Prospective evaluation of post-implantation inflammatory response after EVAR for AAA: influence on patients' 30 day outcome.

OBJECTIVES: The aim was to prospectively evaluate post-implantation syndrome (PIS) after elective endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) and to investigate its association with clinical and laboratory parameters and the clinical outcome of the patients. METHODS: From January 2010 till June 2013, 214 consecutive patients treated electively by EVAR for AAA were prospectively included. PIS was defined according to systemic inflammatory response syndrome criteria. Adverse events included any major adverse cardiovascular events (MACE), acute renal failure, re-admission and death from any cause. RESULTS: PIS was diagnosed in 77 (34%) patients. Pre-operative white blood cell (WBC) count values (p < .001), endograft material (polyester) (p < .001), and heart failure (p = .03) were independent predictors of PIS. Mean post-operative temperature (p < .001), length of hospital (p < .001) and intensive care unit (p = .008) stay, as well as maximum post-operative WBC count (p < .001) and hs-CRP values (p < .001) were significantly higher in the PIS group. Post-operative hs-CRP (p = .001) and duration of fever (p = .02) independently predicted the occurrence of MACE. Post-operative hs-CRP (p = .004), maximum temperature (p = .03), and the presence of PIS (p = .01) were independent predictors of an adverse event during the first 30 days. A threshold of post-operative hs-CRP value of 125 mg/L was highly associated with the occurrence of MACE, with a sensitivity of 82% and specificity of 75%. CONCLUSIONS: A systematic inflammatory response is observed in a significant number of patients after EVAR. The type of endograft material seems to play a significant role in this inflammatory process. The intensity of inflammation, as assessed mainly by the post-operative hs-CRP values, correlates with the presence of a cardiovascular or any other adverse event during the first 30 days after the procedure.

A comparative study of sutured versus bovine pericardium mesh abdominal closure after open abdominal aortic aneurysm repair.

BACKGROUND: Open abdominal aortic aneurysm (AAA) repair is followed by a high rate of incisional herniation. The purpose of this study was to evaluate whether this postoperative complication could be avoided by a prophylactic implantation of a biological mesh. METHODS: In a prospective randomized clinical study, patients electively treated by open AAA repair were allocated equally to routine abdominal suture closure or to prophylactic placement of bovine pericardium mesh above the fascia. The study end points were postoperative complications and incidence of incisional hernia at a 3-year follow up. RESULTS: Forty patients with a mean age of 74.3 (SD ± 5.8) years were studied. All patients had a successful operation and a quite uneventful postoperative course. The mean operative time in the mesh group was longer compared to the control group (p < 0.001). Two patients in the mesh group developed wound seroma postoperatively. Six patients (30%) in the control group developed incisional hernia comparing to none in the mesh group. Cumulative proportion of freedom from incisional hernia was 100% for mesh group at 3 years and 74.4% (SE 9.9%) for control group at 2 years (p < 0.008). In five patients (83%), the incisional hernia was diagnosed by the second postoperative year. One patient underwent incisional hernia repair. CONCLUSION: The bovine pericardium mesh reinforcement of fascia closure in patients undergoing open AAA repair showed effectiveness and low complication rate in prophylaxis from incisional herniation. It should be considered as an alternative mesh material in selected patients.

Surgical and endovascular intervention on internal carotid artery near occlusion.

Therapeutic strategy for treating carotid artery near occlusion (CANO) has been controversial. The aim of this study was to review the literature concerning the invasive treatment of atherosclerotic CANO. A review was conducted of the English medical literature from 1980 to 2013 using PubMedand EMBASE database to find studies involving open or endovascular management of CANO. The search identified 20 reports describing invasive treatment of CANO encompassing 770 patients (77.7% men; mean age 66.3±5.2 years). A typical appearance of string sign was noted in nearly 60% of the patients. The vast majority (92.6%) were symptomatic. 479 (62.2%) patients underwent an open procedure, while 291 (38.8%) were treated endovascularly. The technical success rate for the endovascular procedures was 99%, while distal embolic protection devices were applied in most patients (66%). The 30 days procedural stroke rate was 2.1% and 2.4% for open and endovascular repair respectively. During a follow-up period spanning an average of approximately two years the ipsilateral cerebrovascular event rate was 5% and 1.2% for open and endovascular treatmentrespectively. Twenty five (5.2%) restenosis or occlusions were reported for the open procedures, while 13 (5.4%) were also documented for endovascular repair. The current literature concerning the invasive treatment of CANO is weak and cannot support any evidence based recommendation. The necessity to intervene as well as the best therapeutic strategy remains controversial. This review shows that the interventionon symptomatic CANO may consist a relatively safe and effective therapeutic strategy with low perioperative cerebrovascular morbidity for both treatment modalities, although durability and long-term outcomes should be further affirmed. The low incidence of this entity and the dearth of clear evidence support the need for a large multicenter registry to clarify the absolute indications for intervention and define the best therapeutic approach.

The impact of direction of great saphenous vein total stripping on saphenous nerve injury.

OBJECTIVES: To examine and compare the effects of downwards versus upwards total stripping of great saphenous vein (GSV) on saphenous nerve (SN) injury using clinical and electrophysiological studies. METHODS: Fifty patients with varicosities were equally and randomly assigned to undergo total, upwards stripping (group A) or downwards stripping (group B) of GSV during saphenectomy. SN function was measured with electroneurogram (ENG) before operation, two weeks and 12 weeks after, in order to record the incidence and type of SN injury. Clinical signs of SN injury were also recorded at the same time points. The results were statistically analysed. RESULTS: There were no statistical significant differences on the occurrence of SN injury between groups A and B at two and 12 weeks, respectively, as confirmed with ENG studies and clinical evaluation. There were no differences between the two techniques with regard to the type of SN injury. SN injury was significantly ameliorated from 34% to 6% during the first three months. CONCLUSION: SN injury was equally observed after downwards or upwards total stripping of the GSV, as confirmed by ENG and clinical evaluation, with no differences in injury type. SN injury tends to be relieved through time in most patients.

Early ischaemic preconditioning of spinal cord enhanced the binding profile of heat shock protein 70 with neurofilaments and promoted its nuclear translocation after thoraco-abdominal aortic occlusion in pigs.

OBJECTIVE(S): Heat shock protein 70 (Hsp70) is detected in substantial amounts in normal neurons and this basal content may protect a cell against harmful conditions without the need for additional synthesis. Herein, we investigate the potential protective role of these basal levels of Hsp70, in an early ischaemic preconditioning (IPC) experimental model, suggesting a possible role of this protein as a first window of protection. DESIGN, MATERIAL AND METHODS: Forty-two pigs were used in an experimental thoraco-abdominal aortic occlusion model. Twelve animals (two groups) were used for neurological evaluation. The remaining 30 animals (five groups) were used for immunoprecipitation and immunohistochemical studies. These were performed to study the binding relationship of Hsp70/cytoskeleton elements and the cellular distribution of Hsp70, respectively. RESULTS: The IPC + ischaemia-group showed significant better neurologic scores compared with those of the ischaemia group, indicating a protective role for IPC (P = 0.003). The immunoprecipitations demonstrated that early IPC increased significantly the binding profile of Hsp70/neurofilaments (P = 0.025). In addition, translocation of Hsp70 into the nucleus was observed, which was conserved until the sustained ischaemia. CONCLUSIONS: These results indicate that Hsp70 may have an important role in early IPC of the spinal cord, by protecting neurofilaments and by ensuring the functionality and the integrity of the nucleus, at the time the intensive insult begins.

Endovascular abdominal aortic aneurysm repair: methods of radiological risk reduction.

AIM: The management of abdominal aortic aneurysm with endovascular repair (EVAR) requires extended exposure to ionizing radiation, before, during and after the intervention. The aim of this study was to quantify the radiological risks to patients and operating team, and to develop strategies to assess and reduce them. METHODS: EVAR was carried out in 97 patients using either a low-power mobile or a high-power stationary fluoroscopic unit. Empirically determined relationships between the indicated dose area product (DAP) and peak skin dose, obtained by direct in vivo dosimetry in a subgroup of patients, were used to predict the peak skin dose. Individual worker monitoring was used to assess personnel radiological burden. RESULTS: The probability for radiation induced biological effects due to the repair itself and the preoperative and life-long surveillance, as carried out, was about 2.4 10-3. The peak skin dose of repairs was linearly correlated with the DAP and did not exceed 1.2 Gy. The collective effective dose of the staff that carried out repairs using the mobile unit was 5.5 and 8 µSv per repair using an angiographic and a surgical table, respectively. The use of the high-power fluoroscopic unit resulted in a many fold higher radiation burden to both patient and personnel. CONCLUSION: The optimum strategy, including equipment-related factors, procedure-conduct factors and follow-up procedures, has to be studied, justified and optimized in each medical facility.

Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study.

OBJECTIVES: To compare aortoenteric fistula (AEF) outcome after endovascular (EV-AEFR) or open repair (O-AEFR). DESIGN: Multicentre retrospective comparative study. MATERIALS/METHODS: 25 patients with AEF (24 secondary, 23 males, median age 75 years) after aortic surgery (median four years). Preoperative sepsis was evident in 19 cases. Eight patients were managed with EV-AEFR and 17 with O-AEFR. RESULTS: The two groups were comparable in preoperative characteristics. In-hospital mortality after EV-AEFR was lower compared to O-AEFR (0% and 35%, respectively, p = 0.13). Similarly, morbidity after EV-AEFR was lower compared to O-AEFR (25% and 77%, respectively, p = 0.028). There was a trend for worse recurrence-free, sepsis-free, re-operation-free and AEF-related death-free rates after EV-AEFR, while the early survival advantage of EV-AEFR was lost after two years and the overall long-term survival rates (perioperative mortality included) of the two groups were similar. Preoperative sepsis had no effect on recurrence and sepsis-free rates (p = 0.94 and p = 0.92, respectively), but it was associated with worse two year overall survival (24% vs 50%, p = 0.32). On multivariate analysis, the number of symptoms (two vs one) at presentation was the single predictor of worse re-operation rates, AEF-related and overall survival. CONCLUSIONS: EV-AEFR was associated with no postoperative mortality in this study and can achieve satisfactory short and long-term results, comparable to O-AEFR. Further trials should focus on the role of EV-AEFR in patients at high risk for O-AEFR, due to shock or co-morbidities, or as a bridging procedure.