Myocardial injury in patients after an elective abdominal aortic aneurysm repair.

BACKGROUND: The aim of the study was to study the frequency of cTnI release in patients undergoing an elective abdominal aortic aneurysm repair (AAA) and examine the relationship between an early perioperative myocardial injury, as detected by an increased serum levels of cTnI, and a clinical outcome (postoperative cardiac and non-cardiac complications, mortality). METHODS: A prospective observational study of 90 patients undergoing an elective AAA repair. SETTING: University hospital. Blood samples were obtained from 90 patients for cTnI assays, 8 and 24 hours after surgery. RESULTS: 74.5 % of patients faced a high and medium perioperative risk (ASA III-IV). Peak postoperative cTnI concentrations above the lower detection limit of the immunoassay occurred in 22 patients. 15 of these patients (cTnI levels: 0.2-10.2 ng/ml) displayed symptoms of clinically significant complications. 9 patients (cTnI levels: 0.48-10.2 ng/ml) had serious complications (3x MI, 3x heart failure, 2x bronchopneumonia - respiratory failure, 1x sepsis), one patient died. Only 5.8 % of patients without cTnI increase had postoperative complications. A Chi-square analysis revealed a significant association between cTi elevation and postoperative complications (chi-square 38.737, p<0.0001). CONCLUSIONS: A quarter of the patients who underwent an elective aortic surgery suffered from myocardial necrosis. A cTnI rise was associated with clinically significant events in 68 %; patients with cTnI release were at a significantly higher risk of cardiac and non-cardiac complications. These data confirm that patients with a postoperative rise in cTnI levels would be classified as patients at a higher risk of complications and a specific cardioprotective treatment, invasive monitoring and a longer ICU stay could be required in these cases (Tab. 6, Ref. 24).

Perioperative haemodynamic monitoring by oesophageal Doppler improves outcome of patients with abdominal aortic aneurysm repair.

BACKGROUND: AAA repair is associated with high rate of mortality and morbidity. Oesophageal Doppler (OED) can offer a less invasive cost-effective tool for intraoperative monitoring of haemodynamic changes. The aim of the study was to confirm the benefits of haemodynamic optimisation in patients undergoing AAA repair using OED monitoring. We assumed that haemodynamic parameters of patients with OED would be better optimised; they would probably get more fluids during the operation, and their ICU and hospital stay would be shorter as a result of having fewer postoperative complications and lower mortality. METHODS: Seventy patients (Doppler group) who underwent AAA operation in 2003-2008 were matched with 70 patients (control group) operated on AAA in 1998-2002. OED was used to estimate the cardiac output, its variations and fluid management. The administered fluids, length of ICU and hospital stay, frequency of postoperative complications and mortality were compared in Doppler and control groups (Mann-Whitney test, Fisher's exact test). RESULTS: No statistically significant difference was found in preoperative parameters. The Doppler group was administered significantly more crystalloids (p<0.001), colloids (p<0.001), sum-up of fluids (4000 ml vs. 3000 ml; p<0.001) in the perioperative period. The Doppler group had a lower incidence of major serious complications (8 vs. 21; p=0.034) and shorter ICU (4 vs. 6 days; p<0.001) and hospital stay (10 vs. 11 days; p=0.012). CONCLUSIONS: The haemodynamic monitoring by oesophageal Doppler can improve the outcome of patients with AAA repair (fewer major complications, shorter ICU and hospital stay) (Tab. 4, Fig. 4, Ref. 25).

Is carotid endarterectomy under the cervical plexus block safe for all patients with various degree of cardiovascular risk?

BACKGROUND: The result of the GALA study did not answer the question whether it is safe to perform carotid endarterectomy (CEA) under the cervical plexus block (CPB) in patients at high cardiovascular (CV) risk. The aim of the study was to compare CV stability and the frequency of cardiovascular and neurological complications in 3 groups of patients with various degree of CV risk who underwent CEA under CPB. METHODS: 60 patients operated on in CPB were divided into the 3 groups according to the degree of their CV risk (I: very high, II: medium, III: low). STATISTICAL ANALYSIS: Chi-square, Kruskal Wallis test. RESULTS: No statistically significant difference was confirmed in the changes of blood pressure (MAP, BP syst, BP diast), heart rate, cardiovascular complications, the rate of the shunt insertion and neurological complications and the level of haemodynamic instability, except for hypotension (p = 0.041) in the three groups. Life threatening CV complications did not occur in any of the groups. The frequency of haemodynamic changes and postoperative complications: hypertension (I--40%, II--60%, III--60%), hypotension (I--35%, II--25%, III--5%), arrhythmias (I--30%, II--15%, III--10%), neurological complications: 2x (TIA), the frequency of shunt insertion: 15 %. CONCLUSION: CPB can be performed in all three groups of patients, even in high-risk cardiac patients. The results will have to be confirmed in a larger group of patients in future (Tab. 3, Fig. 4, Ref. 16).

[Surgical management of the abdominal aortic aneurysm in a patient with left-sided inferior vena cava and a functional solitary left kidney]. / Chirurgické resní aneuryzmatu abdominální aorty u pacientky s levostrannou dolní dutou zilou a funkcne solitárni levou ledvinou.

In a polymorbid female patient, an aneurysm of the abdominal aorta was discovered incidentally, necessitating admission to an angiosurgical department. On surgery, an additional problem was found, the left-sided inferior vena cava (a congenital anomaly of the venous system) as well as the juxtarenal aneurysm of the abdominal aorta. As the patient had a solitary functioning kidney, the resection of the aortic aneurysm was considered to be associated with unacceptable risk if performed at a standard department. Therefore, the patient was transferred to the Centre of Cardiovascular Surgery and Transplantations Brno where a resection of the aneurysm was performed. On resection, the perfusion of the solitary functioning kidney was maintained with organ preservation solution used in organ transplantations. The operation was uneventful, the postoperative course was complicated only by insignificant wound healing problems.

[Aortointestinal fistula--a serious complication of surgery on aortic and pelvic arteries]. / Aorto-intestinální pístel--závazná komplikace chirurgie aorty a pánevních tepen.

Aortoenteral fistula (AEF) is a rare, but a serious complication in the vascular surgery. It may occur as a primary or a secondary fistula. The principal sign of the condition is bleeding from the gastrointestinal tract (GIT), which, depending on its severity, may present with various symptoms (anemia, melena, hematemesis). The authors describe three cases of patients who experienced AEF. In all the cases, signs of massive GIT bleeding were present with a rapid development of hemorrhagic shock. In a single case, the primary fistula was concerned, in two cases the fistula was secondary. The perioperative mortality rate reached 66%. The surgical management approach is discussed in the article, and early diagnosis and prevention of the complication is emphasized.

[Combined surgical treatment of portal hypertension]. / Kombinovaná chirurgická lécba portální hypertenze.

The bleeding from esophageal varices is at 85-90% cases stopped by conservative (i.e. non surgical) approach. The method of choice is endoscopic sclerotisation or ligation. Less often is necessary to perform TIPS. The rest of cases is necessary to resolve by one of surgical techniques of hemorrhage control--devascularisation operation or perform emmergently porto-systemic shunt. The authors stress the importance of devascularisation operations for theirs simplicity. On the case report they illustrate the advantage of combination of both surgical techniques.

[Coagulopathy as an unusual manifestation of splenic artery aneurysm. Case report]. / Manifestní koagulopatie jako neobvyklý projev aneuryzmatu lienální arterie. Kazuistika.

Meticulous examination of patient treated for infertility with clinical signs of coagulopathy reveals lienal artery aneurysm. Such presentation of mentioned pathology is very rare. Surgical resection of aneurysm enabled to cure coagulopathy and very probably infertility as well.

[Retroperitoneoscopy--a new era]. / Retroperitoneoskopie--nová éra.

Retroperitoneoscopy is a minimal invasive surgical technique enabling the diagnostics of the disease, as well as operative treatment of retroperitoneal organs. It is a very promising method especially for urologist, but of interest for general, vascular surgeon or gynecologist. The method is known since the end of sixties. Its routine introduction was enabled by technical advancement of laparoscopic surgery.

[Retroperitoneoscopic lumbar sympathectomy]. / Retroperitoneoskopická lumbální sympatektomie.

The development of revascularization techniques of the distal lower extremity dramatically diminished the need of lumbar sympathectomy. Which is indicated when patient with rest pain or with a profound gangrene of toes (which does not exceed the line of metatarsal articulation) could not be treated by vascular reconstruction. Lumbar sympathectomy could be done surgically or chemically, the efficiency of which is about 50%. The second to the fourth lumbar sympathetic ganglion could be resected with minimal invasivity, retroperitoneoscopically. This approach to lumbar sympathectomy opens further possibilities for operating in retroperitoneal space. Retroperitoneoscopy is well tolerated by patients.

[Peroperative autotransfusion using a cell saver in ruptured aneurysms of the abdominal aorta]. / Vyuzití peroperacní autotransfuze cell saverem u ruptury aneuryzmatu brisní aorty.

The authors present five cases where a cell saver was used in rupture of an aneurysm of the abdominal aorta. During the peroperative collection they obtained 830 +/- 150 ml of autologous red cell concentrate. They assume that this blood is an invaluable source of volume replacement during urgent operations on the abdominal aorta.