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Park YS, Moon YJ, Jun IG, Song JG, Hwang GS. Application of the Revised Cardiac Risk Index to the Model for End-Stage Liver Disease Score Improves the Prediction of Cardiac Events in Patients Undergoing Liver Transplantation. Transplant Proc 2018; 50:1108-1113. [PMID: 29731076 DOI: 10.1016/j.transproceed.2018.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/22/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Although the revised cardiac risk index (RCRI) is a useful tool for estimating the risk of postoperative cardiac events, whether it improves the prediction of cardiac events in patients undergoing liver transplantation (LT) has not been sufficiently demonstrated. METHODS We retrospectively analyzed 1429 patients who underwent LT. Cardiac events were defined as myocardial infarction, death, or combined events within 30 days after surgery. The RCRI was defined as the number of independent predictors including high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin treatment, and creatinine level >2 mg/dL. Multivariate logistic regression analysis was performed to identify factors independently associated with cardiac events. The additive predictability of RCRI for the Model for End-Stage Liver Disease (MELD) score was assessed using receiver operating characteristic curve analysis. RESULTS Forty-four (3.1%) cardiac events occurred within 30 days after surgery. Both the MELD score (adjusted odds ratio [aOR], 1.05; P = .005) and RCRI (aOR, 4.35; P < .001 for RCRI score 2; aOR, 6.27; P = .009 for RCRI score 3 compared with RCRI score 1) independently predicted postoperative 30-day cardiac events. The model with MELD score plus RCRI was significantly more predictive for postoperative 30-day cardiac events than the model with MELD score alone (C-statistics 0.800 vs 0.757; P = .030). CONCLUSIONS For preoperative risk stratification, RCRI showed additive value to MELD score in predicting postoperative 30-day cardiac events after LT.
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Affiliation(s)
- Y-S Park
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Y-J Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - I-G Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - J-G Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - G-S Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Is carotid revascularization worthwhile in patients waiting for kidney transplantation? Transplant Rev (Orlando) 2018; 32:79-84. [DOI: 10.1016/j.trre.2017.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/03/2017] [Accepted: 11/08/2017] [Indexed: 11/18/2022]
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Kong J, Li J, Ye Z, Fan X, Wen J, Zhang J, Liu P. Carotid Endarterectomy with Routine Shunt for Patients with Contralateral Carotid Occlusion. Ann Thorac Cardiovasc Surg 2017; 23:227-232. [PMID: 28794387 DOI: 10.5761/atcs.oa.17-00017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This study aimed to report the clinical features and early and long-term outcomes of patients treated with carotid endarterectomy (CEA) combined with a routine shunt for carotid stenosis with the occlusion of the contralateral carotid artery (CCO), and to compare them with patients without contralateral occlusion (NO-CCO). A retrospective analysis included 301 patients who had carotid artery stenosis treated with CEA using a routine shunt. Of these patients, 35 patients and 266 patients were categorized into a CCO group and NO-CCO group, respectively. Demographics and short-term and long-term outcomes were documented and compared. The demographic characteristics were not significantly different between the two groups. The periprocedural mortality, stroke rate, and rate of periprocedural myocardial infarction were not significantly different between both groups. The mean follow-up period for long-term outcomes was 34.45 ± 22.99 months, and the Kaplan-Meier analysis showed no statistical difference between both groups regarding stroke, myocardial infarction, and mortality. CEA combined with the routine shunt is an effective and durable procedure for carotid artery stenosis patients with CCO.
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Affiliation(s)
- Jie Kong
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jinyong Li
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhidong Ye
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xueqiang Fan
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianyan Wen
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianbin Zhang
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Peng Liu
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
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Mortality in patients with end-stage renal disease and the risk of returning to the operating room after common General Surgery procedures. Am J Surg 2017; 213:395-398. [DOI: 10.1016/j.amjsurg.2016.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 03/20/2016] [Accepted: 03/30/2016] [Indexed: 01/26/2023]
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Arhuidese IJ, Obeid T, Hicks CW, Yin K, Canner J, Segev D, Malas MB. Outcomes after carotid artery stenting in hemodialysis patients. J Vasc Surg 2016; 63:1511-6. [DOI: 10.1016/j.jvs.2016.02.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/10/2016] [Indexed: 10/21/2022]
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Clinical Outcomes after Carotid Endarterectomy in Patients with Contralateral Carotid Occlusion. Ann Vasc Surg 2016; 32:83-7. [DOI: 10.1016/j.avsg.2015.10.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/15/2015] [Accepted: 10/23/2015] [Indexed: 11/18/2022]
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Affiliation(s)
- Marcello Tonelli
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
| | - S. Ananth Karumanchi
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
| | - Ravi Thadhani
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
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Huber M, Ozrazgat-Baslanti T, Thottakkara P, Efron PA, Feezor R, Hobson C, Bihorac A. Mortality and Cost of Acute and Chronic Kidney Disease after Vascular Surgery. Ann Vasc Surg 2015; 30:72-81.e1-2. [PMID: 26187703 DOI: 10.1016/j.avsg.2015.04.092] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 04/21/2015] [Accepted: 04/30/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Both acute kidney injury (AKI) and chronic kidney disease (CKD) are common yet underappreciated risk factors for adverse perioperative outcomes. We hypothesize that AKI and CKD are associated with similar increases in 90-day mortality and cost in patients undergoing major vascular surgery. METHODS We used multivariable regression analyses to evaluate the associations between AKI and CKD and incremental 90-day mortality and hospital cost in a single-center cohort of 3646 adult patients undergoing major vascular surgery. We defined AKI using Kidney Disease: Improving Global Outcomes criteria as change in creatinine ≥ 0.3 mg/dL or ≥ 50% increase from the reference value. CKD was determined from medical history. Regression models were adjusted for demographic and socioeconomic characteristics, comorbid conditions, surgery type, and postoperative complications. RESULTS The prevalence of kidney disease among vascular surgery patients is high with 49% of patients developing AKI during hospitalization and 17% presenting with CKD on admission. In risk-adjusted logistic regression analysis, perioperative AKI (odds ratio 2.2, 95% confidence interval 1.5-3.3) was the most significant predictor of 90-day mortality. The risk-adjusted average cost was significantly higher for patients with any type of kidney disease. The incremental cost of having any type of kidney disease ranged from $9100 to $19,100, even after adjustment for underlying comorbidities and other postoperative complications. CONCLUSIONS Kidney disease after major vascular surgery is associated with significant increases in 90-day mortality and cost with the highest risk observed among patients with AKI regardless of previous CKD.
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Affiliation(s)
- Matthew Huber
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | | | - Paul Thottakkara
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, FL
| | - Robert Feezor
- Department of Surgery, University of Florida, Gainesville, FL
| | - Charles Hobson
- Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL; Department of Health Services Research, Management, and Policy, University of Florida, Gainesville, FL
| | - Azra Bihorac
- Department of Anesthesiology, University of Florida, Gainesville, FL.
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Avgerinos ED, Go C, Ling J, Makaroun MS, Chaer RA. Survival and Long-Term Cardiovascular Outcomes after Carotid Endarterectomy in Patients with Chronic Renal Insufficiency. Ann Vasc Surg 2015; 29:15-21. [DOI: 10.1016/j.avsg.2014.07.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/10/2014] [Accepted: 07/27/2014] [Indexed: 11/15/2022]
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AbuRahma AF, Srivastava M, Stone PA, Chong B, Jackson W, Dean LS, Mousa AY. The effect of chronic renal insufficiency by use of glomerular filtration rate versus serum creatinine level on late clinical outcome of carotid endarterectomy. J Vasc Surg 2014; 61:675-82. [PMID: 25499714 DOI: 10.1016/j.jvs.2014.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/13/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several studies have reported mixed results after carotid endarterectomy (CEA) in patients with chronic renal insufficiency (CRI), and we previously reported the perioperative outcome in patients with CRI by use of serum creatinine (Cr) level and glomerular filtration rate (GFR). However, only a few of these studies used GFR by the Modification of Diet in Renal Disease equation in their analysis of long-term outcome. METHODS During the study period, 1000 CEAs (926 patients) were analyzed; 940 of these CEAs had Cr levels and 925 had GFR data. Patients were classified into normal (GFR ≥60 mL/min/1.73 m(2) or Cr <1.5 mg/dL), moderate CRI (GFR ≥30-59 or Cr ≥1.5-2.9), and severe CRI (GFR <30 or Cr ≥3). RESULTS At a mean follow-up of 34.5 months and a median of 34 months (range, 1-53 months), combined stroke and death rates for Cr levels (867 patients) were 9%, 18%, and 44% for Cr <1.5, ≥1.5 to 2.9, and ≥3 (P = .0001) in contrast to 8%, 14%, and 26% for GFR (854 patients) of >60, ≥30 to 59, and <30, respectively (P = .0003). Combined stroke and death rates for asymptomatic patients were 8%, 17%, and 44% (P = .0001) for patients with Cr levels of <1.5, ≥1.5 to 2.9, and ≥3, respectively, vs 7%, 13%, and 24% for a GFR of ≥60, ≥30 to 59, and <30 (P = .0063). By Kaplan-Meier analysis, stroke-free survival rates at 1 year, 2 years, and 3 years were 97%, 94%, and 92% for Cr <1.5; 92%, 85%, and 81% for Cr ≥1.5 to 2.9; and 56%, 56%, and 56% for Cr ≥3 (P < .0001); vs 98%, 95%, and 93% for a GFR ≥60; 93%, 90%, and 86% for a GFR of ≥30 to 59; and 86%, 77%, and 73% for a GFR <30 (P < .0001). These rates for asymptomatic patients at 1 year, 2 years, and 3 years were 97%, 95%, and 93% for Cr <1.5; 94%, 87%, and 82% for Cr ≥1.5 to 2.9; and 56%, 56%, and 56% for Cr ≥3 (P < .0001); vs 98%, 95%, and 94% for a GFR ≥60; 95%, 91%, and 86% for a GFR of ≥30 to 59; and 84%, 80%, and 75% for a GFR <30 (P = .0026). A univariate regression analysis for asymptomatic patients showed that the hazard ratio (HR) of stroke and death was 6.5 (P = .0003) for a Cr ≥3 and 3.1 for a GFR <30 (P = .0089). A multivariate analysis showed that Cr ≥3 had an HR of stroke and death of 4.7 (P = .008), and GFR <30 had an HR of 2.2 (P = .097). CONCLUSIONS Patients with severe CRI had higher rates of combined stroke/death. Therefore, CEA for these patients (particularly in asymptomatic patients) must be considered with caution.
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, WVa.
| | - Mohit Srivastava
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Patrick A Stone
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Benny Chong
- Department of Surgery, West Virginia University, Charleston, WVa
| | - Will Jackson
- Department of Surgery, University of Alabama, Birmingham, Ala
| | - L Scott Dean
- CAMC Health Education and Research Institute, Charleston, WVa
| | - Albeir Y Mousa
- Department of Surgery, West Virginia University, Charleston, WVa
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Squires MH, Lad NL, Fisher SB, Kooby DA, Weber SM, Brinkman A, Scoggins CR, Egger ME, Cardona K, Cho CS, Martin RCG, Russell MC, Winslow E, Staley CA, Maithel SK. The effect of preoperative renal insufficiency on postoperative outcomes after major hepatectomy: a multi-institutional analysis of 1,170 patients. J Am Coll Surg 2014; 219:914-22. [PMID: 25260685 DOI: 10.1016/j.jamcollsurg.2014.05.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 05/15/2014] [Accepted: 05/20/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Renal insufficiency adversely affects outcomes after cardiac and vascular surgery. The effect of preoperative renal insufficiency on outcomes after major hepatectomy is unknown. STUDY DESIGN All patients who underwent major hepatectomy (≥3 segments) at 3 institutions from 2000 to 2012 were identified. Resections were performed using low central venous pressure anesthesia. Renal function was analyzed by preoperative serum creatinine (sCr) level. Primary outcomes were major complications (Clavien grade III to V), respiratory failure, renal failure requiring hemodialysis, and 90-day mortality. RESULTS One thousand one hundred and seventy patients had preoperative sCr levels available. Renal function was analyzed using sCr dichotomized at 1.8 mg/dL, 1 SD higher than the mean value (0.97 ± 0.79 mg/dL) for the cohort. Twenty-two patients had sCr ≥1.8 mg/dL. Major complications occurred in 279 patients (23.8%), respiratory failure in 62 (5.3%), and renal failure in 31 (2.6%). Ninety-day mortality rate was 5.4%. On multivariate analysis, patients with sCr ≥1.8 mg/dL remained at significantly increased risk for major complications (hazard ratio = 3.94; 95% CI, 1.48-10.49; p = 0.006), respiratory failure (hazard ratio = 4.43; 95% CI, 1.33-14.80; p = 0.014), and renal failure (hazard ratio = 4.75; 95% CI, 1.19-18.97; p = 0.028). Serum Cr ≥1.8 mg/dL was not independently associated with 90-day mortality on multivariate analysis (p = 0.27). CONCLUSIONS Preoperative serum creatinine ≥1.8 mg/dL identifies patients at significantly increased risk of postoperative major complications, respiratory failure, and renal failure requiring dialysis. Patients are well selected for major hepatectomy, and few patients with substantial renal insufficiency are deemed operative candidates.
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Affiliation(s)
- Malcolm H Squires
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Neha L Lad
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sarah B Fisher
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - David A Kooby
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Adam Brinkman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Charles R Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Michael E Egger
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Kenneth Cardona
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Emily Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Charles A Staley
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
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Merkler AE, Saini V, Kamel H, Stieg PE. Preoperative steroid use and the risk of infectious complications after neurosurgery. Neurohospitalist 2014; 4:80-5. [PMID: 24707336 DOI: 10.1177/1941874413510920] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE The association between preoperative corticosteroid use and infectious complications after neurosurgical procedures is unclear. We aim to determine whether corticosteroids increase the risk of infectious complications after neurosurgery. METHODS We examined the association between preoperative corticosteroid use and postoperative infectious complications in a cohort of adults who underwent a neurosurgical procedure between 2005 and 2010 at centers participating in the National Surgical Quality Improvement Program. Corticosteroid use was defined as at least 10 days of oral or parental therapy in the 30 days prior to surgery. Our primary outcome was a composite of any infectious complications occurring within 30 days of surgery. We used propensity score analysis to examine the independent association between preoperative corticosteroid use and postoperative infections. RESULTS Among 26 634 neurosurgical procedures, 1228 (4.61%, 95% confidence interval [CI], 4.36-4.86) were preceded by preoperative corticosteroid use and 1469 (5.52%; 95% CI, 5.24-5.79) were followed by postoperative infections. In a propensity score analysis controlling for comorbidities, illness severity, and preexisting preoperative infections, corticosteroid use was independently associated with subsequent postoperative infections (odds ratio, 1.38; 95% CI, 1.11-1.70). Our results were unchanged in sensitivity analyses controlling for central nervous system tumors or active treatment with chemotherapy. CONCLUSION Our results suggest that preoperative corticosteroid use is associated with an increased risk of infectious complications after neurosurgery. These findings may aid physicians with preoperative treatment decisions and risk stratification. Future randomized trials are needed to guide preoperative use of corticosteroids in this population.
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Affiliation(s)
| | - Vaishali Saini
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, USA
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Long-term Morbidity and Mortality of Carotid Endarterectomy in Patients with End-stage Renal Disease Receiving Hemodialysis. J Stroke Cerebrovasc Dis 2014; 23:545-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/07/2013] [Accepted: 05/10/2013] [Indexed: 11/21/2022] Open
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Impact of chronic renal insufficiency on the early and late clinical outcomes of carotid artery stenting using serum creatinine vs glomerular filtration rate. J Am Coll Surg 2014; 218:797-805. [PMID: 24655873 DOI: 10.1016/j.jamcollsurg.2013.12.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 12/12/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study analyzed the impact of chronic renal insufficiency (CRI) on early and late clinical outcomes of carotid artery stenting (CAS) using serum creatinine and glomerular filtration rate (GFR). STUDY DESIGN There were 313 CAS patients classified into 3 groups: normal (serum creatinine <1.5 mg/dL or GFR ≥ 60 mL/min/1.73 m(2)); moderate CRI, and severe CRI (serum creatinine ≥ 3 or GFR < 30 mL/min/1.73 m(2)). Major adverse events ([MAE] stroke, death, and myocardial infarction) were compared for all groups. RESULTS Using serum creatinine, perioperative stroke rates for normal, moderate, and severe CRI were: 5%, 0%, and 25%, respectively, (p = 0.05) vs 4.6%, 3.7%, and 11.1%, respectively, (p = 0.44) using GFR. The perioperative MAE rates for symptomatic patients were 9.3% and 0% (p = 0.355) and 2% and 5.9% (p = 0.223) for asymptomatic patients for normal and moderate/severe CRI, respectively, using serum creatinine vs 8.1% and 7.8%, respectively, for symptomatic patients and 2.5% and 3%, respectively, for asymptomatic patients using GFR. At a mean follow-up of 21 months, late MAE rates in normal vs moderate/severe CRI patients were 8.2% and 14%, respectively, (p = 0.247) using serum creatinine vs 6.6% and 13.3%, respectively, (p = 0.05) using GFR. Late MAE rates for symptomatic patients in normal vs moderate/severe CRI were: 8.7% vs 27%, respectively, (p = 0.061) using serum creatinine and 5.7% vs 18.8%, respectively, (p = 0.026) using GFR. Late death rate was 0.55% in normal vs 7.6% (p = 0.002) for moderate/severe CRI. Freedom from MAE at 3 years in symptomatic patients was 81% in normal and 46% in moderate/severe CRI (p = 0.0198). A multivariate Cox regression analysis showed that a GFR of < 60 mL/min/1.73 m(2) had an odds ratio of 1.6 (p = 0.222) of having a MAE after CAS. CONCLUSIONS The GFR was more sensitive in detecting late MAE after CAS. Carotid artery stenting in moderate CRI patients can be done with a satisfactory perioperative outcome; however, late death was significant.
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Squires MH, Mehta VV, Fisher SB, Lad NL, Kooby DA, Sarmiento JM, Cardona K, Russell MC, Staley CA, Maithel SK. Effect of preoperative renal insufficiency on postoperative outcomes after pancreatic resection: a single institution experience of 1,061 consecutive patients. J Am Coll Surg 2014; 218:92-101. [PMID: 24211054 PMCID: PMC6002849 DOI: 10.1016/j.jamcollsurg.2013.09.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 09/04/2013] [Accepted: 09/04/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is known to adversely affect cardiac and vascular surgery outcomes. We examined the effect of preoperative renal insufficiency on postoperative outcomes after pancreatic resection. STUDY DESIGN All patients who underwent pancreatic resection between January 2005 and July 2012 were identified. Glomerular filtration rate (eGFR) was estimated by the Modification of Diet in Renal Disease formula. Severe CKD (stages 4-5) was defined as eGFR < 30 mL/min/1.73 m(2). Renal function also was analyzed using serum creatinine (sCr) dichotomized at 1.8 mg/dL. Primary outcomes were any complication, major complications, and respiratory failure. Multivariate models for each endpoint were constructed by including all variables with p value ≤ 0.10 on univariate analysis. RESULTS There were 1,061 patients identified; 709 underwent pancreaticoduodenectomy, 307 distal pancreatectomy, and 45 central or total pancreatectomy. Median sCr value was 0.86 mg/dL (range 0.30 to 14.1 mg/dL). Eighteen patients (1.7%) had severe CKD and 31 (2.9%) had sCr ≥ 1.8 mg/dL. Complications occurred in 622 patients (58.6%), major complications in 198 (18.7%), and respiratory failure in 48 (4.5%). Both severe CKD and sCr ≥ 1.8 mg/dL were associated with any complication, major complications, and respiratory failure on univariate analysis. On multivariate analysis, severe CKD was associated with increased complications (odds ratio [OR] 5.5; 95% CI 1.3 to 25.5; p = 0.02) and respiratory failure (OR 6.1; 95% CI 1.8 to 20.5; p = 0.03), but not major complications. Using sCr ≥ 1.8 mg/dL as a surrogate marker for renal insufficiency, patients with sCr ≥ 1.8 mg/dL had increased risk of any complication (OR 3.5; 95% CI 1.3 to 9.3; p = 0.01), major complications (OR 2.2; 95% CI 1.04 to 4.8; p = 0.04), and respiratory failure (OR 4.7; 95% CI 1.8 to 12.6; p = 0.002). CONCLUSIONS Few patients with significant renal insufficiency are candidates for pancreatic resection. Severe CKD (stages 4-5) is associated with increased risk of complication and respiratory failure. Serum creatinine ≥ 1.8 mg/dL may serve as a useful marker of renal insufficiency and identifies patients at significantly increased risk of any complication, major complication, and respiratory failure after pancreatic resection.
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Affiliation(s)
- Malcolm H Squires
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Vishes V Mehta
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sarah B Fisher
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Neha L Lad
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - David A Kooby
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Juan M Sarmiento
- Division of General and GI Surgery, Emory University, Atlanta, GA
| | - Kenneth Cardona
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Charles A Staley
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
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Van den Brande P, Van Heymbeeck I, Debing E, Aerden D, von Kemp K, Moerman L, Verborgh C, Haentjens P. Discharge on the first postoperative day after elective carotid endarterectomy. Ann Vasc Surg 2013; 28:901-7. [PMID: 24362259 DOI: 10.1016/j.avsg.2013.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 09/20/2013] [Accepted: 10/06/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Medical complications may prolong the hospital stay after elective carotid endarterectomy (CEA). We prospectively assessed the social and medical feasibility and safety of patient discharge on the first postoperative day after elective CEA and unplanned readmissions. METHODS Between June 2011 and January 2012, 57 consecutive patients scheduled for elective CEA were enrolled with the aim of discharge on the first postoperative day if there were no medical contraindications and on the condition that the patient should not be left alone during the first day and night at home. CEA was carried out under local or general anesthesia. After discharge, the patients were contacted to ascertain the occurrence of arterial hypertension, cerebral hyperperfusion, focal cerebral ischemia, or hospital readmission. RESULTS Sixty-two CEA were carried out in 57 patients (33 men and 24 women ranging in age from 51-89 years). The indications for CEA were: asymptomatic high grade stenosis in 27, hemispheric transient ischemic attack in 12, amaurosis fugax in 6, recovered stroke in 16, and nonlateralizing signs in 1. There were no cases of perioperative stroke or death. Discharge on the first postoperative day was achieved in 45 cases (73%). In 15 cases (24%), discharge was on the second postoperative day because of the absence of a relative (12 cases) or for medical reasons (3 cases). Discharge was on day 3 in 1 case, and on day 10 in another, both for medical reasons. No cases of severe arterial hypertension, stroke, mortality, or readmission for reasons related to the CEA procedure were recorded up to postoperative day 30. CONCLUSION In this study, the majority of patients undergoing elective CEA were discharged safely on the first postoperative day. Social reasons, rather than medical reasons, underlied most cases of later discharge. There were no unplanned readmissions for complications of CEA.
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Affiliation(s)
| | - Isolde Van Heymbeeck
- Department of Vascular Surgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Erik Debing
- Department of Vascular Surgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Dimitri Aerden
- Department of Vascular Surgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Karl von Kemp
- Department of Vascular Surgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Leslie Moerman
- Department of Vascular Surgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Chris Verborgh
- Department of Anesthesiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Patrick Haentjens
- Center for Outcome Research, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Johansson T, Fritsch G, Flamm M, Hansbauer B, Bachofner N, Mann E, Bock M, Sönnichsen AC. Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review. Br J Anaesth 2013; 110:926-39. [PMID: 23578861 DOI: 10.1093/bja/aet071] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Elective surgery is usually preceded by preoperative diagnostics to minimize risk. The results are assumed to elicit preventive measures or even cancellation of surgery. Moreover, physicians perform preoperative tests as a baseline to detect subsequent changes. This systematic review aims to explore whether preoperative testing leads to changes in management or reduces perioperative mortality or morbidity in unselected patients undergoing elective, non-cardiac surgery. We systematically searched all relevant databases from January 2001 to February 2011 for studies investigating the relationship between preoperative diagnostics and perioperative outcome. Our methodology was based on the manual of the Ludwig Boltzmann Institute for Health Technology Assessment, the Scottish Intercollegiate Guidelines Network (SIGN) handbook, and the PRISMA statement for reporting systematic reviews. One hundred and one of the 25 281 publications retrieved met our inclusion criteria. Three test grid studies used a randomized controlled design and 98 studies used an observational design. The test grid studies show that in cataract surgery and ambulatory surgery, there are no significant differences between patients with indicated preoperative testing and no testing regarding perioperative outcome. The observational studies do not provide valid evidence that preoperative testing is beneficial in healthy adults undergoing non-cardiac surgery. There is no evidence derived from high-quality studies that supports routine preoperative testing in healthy adults undergoing non-cardiac surgery. Testing according to pathological findings in a patient's medical history or physical examination seems justified, although the evidence is scarce. High-quality studies, especially large randomized controlled trials, are needed to explore the effectiveness of indicated preoperative testing.
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Affiliation(s)
- T Johansson
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.
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AbuRahma AF, Srivastava M, Chong B, Dean LS, Stone PA, Koszewski A. Impact of Chronic Renal Insufficiency Using Serum Creatinine vs Glomerular Filtration Rate on Perioperative Clinical Outcomes of Carotid Endarterectomy. J Am Coll Surg 2013; 216:525-32; discussion 532-3. [DOI: 10.1016/j.jamcollsurg.2012.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 12/07/2012] [Indexed: 11/28/2022]
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19
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20
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Herzog CA, Asinger RW, Berger AK, Charytan DM, Díez J, Hart RG, Eckardt KU, Kasiske BL, McCullough PA, Passman RS, DeLoach SS, Pun PH, Ritz E. Cardiovascular disease in chronic kidney disease. A clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2011; 80:572-86. [PMID: 21750584 DOI: 10.1038/ki.2011.223] [Citation(s) in RCA: 611] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD) is high, and the presence of CKD worsens outcomes of cardiovascular disease (CVD). CKD is associated with specific risk factors. Emerging evidence indicates that the pathology and manifestation of CVD differ in the presence of CKD. During a clinical update conference convened by the Kidney Disease: Improving Global Outcomes (KDIGO), an international group of experts defined the current state of knowledge and the implications for patient care in important topic areas, including coronary artery disease and myocardial infarction, congestive heart failure, cerebrovascular disease, atrial fibrillation, peripheral arterial disease, and sudden cardiac death. Although optimal strategies for prevention, diagnosis, and management of these complications likely should be modified in the presence of CKD, the evidence base for decision making is limited. Trials targeting CVD in patients with CKD have a large potential to improve outcomes.
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21
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van Lammeren GW, Moll FL, Blankestijn PJ, de Kleijn DP, Bots ML, Verhaar MC, de Vries JPP, Pasterkamp G. Decreased Kidney Function. Stroke 2011; 42:307-12. [DOI: 10.1161/strokeaha.110.597559] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Guus W. van Lammeren
- From the Experimental Cardiology Laboratory (G.W.L., G.P.), Department of Vascular Surgery (G.W.L., F.L.M.), Department of Nephrology (P.J.B., M.C.V.), Julius Center for Health and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery (J.P.P.M.V.), St Antonius Hospital, Nieuwegein, The Netherlands
| | - Frans L. Moll
- From the Experimental Cardiology Laboratory (G.W.L., G.P.), Department of Vascular Surgery (G.W.L., F.L.M.), Department of Nephrology (P.J.B., M.C.V.), Julius Center for Health and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery (J.P.P.M.V.), St Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter J. Blankestijn
- From the Experimental Cardiology Laboratory (G.W.L., G.P.), Department of Vascular Surgery (G.W.L., F.L.M.), Department of Nephrology (P.J.B., M.C.V.), Julius Center for Health and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery (J.P.P.M.V.), St Antonius Hospital, Nieuwegein, The Netherlands
| | - Dominique P.V. de Kleijn
- From the Experimental Cardiology Laboratory (G.W.L., G.P.), Department of Vascular Surgery (G.W.L., F.L.M.), Department of Nephrology (P.J.B., M.C.V.), Julius Center for Health and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery (J.P.P.M.V.), St Antonius Hospital, Nieuwegein, The Netherlands
| | - Michiel L. Bots
- From the Experimental Cardiology Laboratory (G.W.L., G.P.), Department of Vascular Surgery (G.W.L., F.L.M.), Department of Nephrology (P.J.B., M.C.V.), Julius Center for Health and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery (J.P.P.M.V.), St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marianne C. Verhaar
- From the Experimental Cardiology Laboratory (G.W.L., G.P.), Department of Vascular Surgery (G.W.L., F.L.M.), Department of Nephrology (P.J.B., M.C.V.), Julius Center for Health and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery (J.P.P.M.V.), St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jean-Paul P.M. de Vries
- From the Experimental Cardiology Laboratory (G.W.L., G.P.), Department of Vascular Surgery (G.W.L., F.L.M.), Department of Nephrology (P.J.B., M.C.V.), Julius Center for Health and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery (J.P.P.M.V.), St Antonius Hospital, Nieuwegein, The Netherlands
| | - Gerard Pasterkamp
- From the Experimental Cardiology Laboratory (G.W.L., G.P.), Department of Vascular Surgery (G.W.L., F.L.M.), Department of Nephrology (P.J.B., M.C.V.), Julius Center for Health and Primary Care (M.L.B.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery (J.P.P.M.V.), St Antonius Hospital, Nieuwegein, The Netherlands
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22
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. J Am Coll Cardiol 2011; 57:e16-94. [PMID: 21288679 DOI: 10.1016/j.jacc.2010.11.006] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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23
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42:e464-540. [PMID: 21282493 DOI: 10.1161/str.0b013e3182112cc2] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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24
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011; 124:e54-130. [PMID: 21282504 DOI: 10.1161/cir.0b013e31820d8c98] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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25
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Chronic Kidney Disease. Perioper Med (Lond) 2011. [DOI: 10.1007/978-0-85729-498-2_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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26
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Bacharach JM, Slovut DP, Ricotta J, Sullivan TM. Octogenarians are not at Increased Risk for Periprocedural Stroke following Carotid Artery Stenting. Ann Vasc Surg 2010; 24:153-9. [DOI: 10.1016/j.avsg.2009.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 05/27/2009] [Indexed: 11/16/2022]
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27
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Kretz B, Abello N, Brenot R, Steinmetz E. The impact of renal insufficiency on the outcome of carotid surgery is influenced by the definition used. J Vasc Surg 2010; 51:43-50. [DOI: 10.1016/j.jvs.2009.08.070] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 08/21/2009] [Accepted: 08/21/2009] [Indexed: 11/30/2022]
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28
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Mathew A, Eliasziw M, Devereaux PJ, Merino JG, Barnett HJM, Garg AX. Carotid endarterectomy benefits patients with CKD and symptomatic high-grade stenosis. J Am Soc Nephrol 2009; 21:145-52. [PMID: 20007752 DOI: 10.1681/asn.2009030287] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Endarterectomy is generally recommended for symptomatic high-grade (70 to 99%) stenosis of the internal carotid artery, but whether this procedure is beneficial among patients with chronic kidney disease (CKD) is unknown. In this re-analysis of data from the North American Symptomatic Carotid Endarterectomy Trial, we included patients with symptomatic stenosis and either stage 3 CKD (n = 524) or preserved kidney function (n = 966; estimated GFR > or = 60). For medically treated patients with high-grade stenosis, risk for ipsilateral stroke at 2 yr was significantly higher in patients with CKD than in those with preserved renal function (31.6 versus 19.3%; P = 0.042); carotid endarterectomy significantly reduced this risk by 82 and 51%, respectively. To prevent one ipsilateral stroke, the number needed to treat by endarterectomy was four for patients with CKD and 10 for patients with preserved renal function. Compared with patients with preserved renal function, those with CKD had similar rates of perioperative stroke and death but higher rates of cardiac events. In conclusion, patients with stage 3 CKD and symptomatic high-grade carotid stenosis gain a large benefit in stroke risk reduction after endarterectomy.
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Affiliation(s)
- Anna Mathew
- University of Western Ontario, London, Ontario, Canada
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29
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Wang GJ, Fairman RM, Jackson BM, Szeto WY, Pochettino A, Woo EY. The outcome of thoracic endovascular aortic repair (TEVAR) in patients with renal insufficiency. J Vasc Surg 2009; 49:42-6. [DOI: 10.1016/j.jvs.2008.07.070] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 07/22/2008] [Accepted: 07/23/2008] [Indexed: 11/28/2022]
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30
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Sidawy AN, Aidinian G, Johnson ON, White PW, DeZee KJ, Henderson WG. Effect of chronic renal insufficiency on outcomes of carotid endarterectomy. J Vasc Surg 2008; 48:1423-30. [DOI: 10.1016/j.jvs.2008.07.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 07/07/2008] [Accepted: 07/09/2008] [Indexed: 11/29/2022]
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31
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Govindarajan G, Saab G, Whaley-Connell A. Outcomes of carotid revascularization in patients with chronic kidney disease. Adv Chronic Kidney Dis 2008; 15:347-54. [PMID: 18805380 DOI: 10.1053/j.ackd.2008.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Chronic kidney disease (CKD) carries an increased risk for cardiovascular disease (CVD) including cerebrovascular accidents (CVAs). There are multiple etiologies for CVA, and among them extracranial carotid artery disease accounts for approximately 25% of ischemic strokes. It has been shown that carotid revascularization by carotid endarterectomy and carotid artery angioplasty and stenting can decrease the risk of CVA in appropriately selected population with carotid artery disease. Both these techniques of carotid revascularization have been shown to be safe and clinically effective in many large multicentered randomized clinical trials. However, most of these large trials have predominately excluded the patients with kidney failure. Most of the evidence for the management of carotid disease in CKD is based on small clinical trials and expert opinions. There is an urgent need to conduct large clinical trials in patients with CKD to enable better understanding and to improve techniques of various carotid revascularization therapies in CKD patients.
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Abstract
Patients with chronic kidney disease (CKD) are predisposed to stroke, especially as the estimated glomerular filtration rate decreases. This update reviews the pathologic mechanisms particular to this stroke population. The treatment for primary and secondary prevention of stroke is reviewed with respect to antiplatelet agents, anticoagulants, surgery, and carotid stenting. The control of chronic hypertension is particularly important in reducing stroke risk in CKD. In patients with prior stroke from atherosclerosis, antiplatelet agents are most beneficial in reducing secondary stroke risk. Those with atrial fibrillation and CKD may benefit from warfarin anticoagulation. Statins in CKD for stroke reduction in diabetics receiving dialysis are not useful, and the data are pending for their use in stroke reduction in the general CKD population. In carefully selected cases, carotid endarterectomy can be a treatment. The data on carotid stenting are conflicting.
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33
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Chronic kidney disease and postoperative mortality: A systematic review and meta-analysis. Kidney Int 2008; 73:1069-81. [DOI: 10.1038/ki.2008.29] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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