Association of neutrophil-to-lymphocyte ratio with outcomes after elective abdominal aortic aneurysm repair

Prognostic Significance of Preoperative Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio in Patients with Ruptured Abdominal Aortic Aneurysm Undergoing Endovascular Aneurysm Repair

BACKGROUND

Ruptured abdominal aortic aneurysm (RAAA) is a fatal disease. This study aimed to assess the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in patients with RAAA undergoing endovascular aneurysm repair (EVAR).

MATERIALS AND METHODS

This retrospective study included patients with RAAA who underwent EVAR from 2012 to 2022. NLR and PLR were measured when patients were first admitted to the hospital before receiving any treatment. Risk factors associated with overall survival in this patient group were identified through univariate and multivariate analyses. Nomograms and artificial neural networks were developed to evaluate the prognosis of these patients.

RESULTS

A total of 50 patients were included in this study. The optimal cut-off points for predicting overall survival were an NLR of 19.6 and a PLR of 190.5. Univariate and multivariate analyses revealed that NLR (hazard ratio 0.271, p = 0.024) and PLR (hazard ratio 0.272, p = 0.041). Were independent risk factors for overall survival. Nomograms and artificial neural networks also showed the prognostic value of preoperative NLR and PLR in this patient group.

CONCLUSION

Preoperative NLR and PLR are independent and valid predictors of prognosis in patients with RAAA undergoing EVAR. The higher the preoperative NLR and PLR of the patients, the worse their prognosis.

The prognostic value of preoperative systemic inflammation-based scoring in patients undergoing endovascular repair of abdominal aortic aneurysm

OBJECTIVE

Abdominal aortic aneurysm (AAA) is a common condition that is predominantly managed in the United Kingdom by endovascular aneurysm repair (EVAR). Activation of the systemic inflammatory response (SIR) appears to offer prognostic value in patients with vascular disease. The present study examines the relationship between the SIR and survival in patients undergoing standard and complex endovascular aneurysm repair (EVAR and fenestrated/branched [F/B]-EVAR).

METHODS

Consecutive patients undergoing elective EVAR and F/B-EVAR were retrospectively identified from three tertiary vascular centers over a 5-year period. Neutrophil:lymphocyte ratio and modified Glasgow Prognostic Score were calculated from preoperative blood results and combined into the systemic inflammatory grade (SIG). The primary outcome was all-cause mortality during the follow-up period, which was compared between subgroups of SIGs.

RESULTS

There were 506 patients included in the final study, with a median follow-up of 68.0 months (interquartile range, 27.3 months), and there were 163 deaths during the follow-up period. Mean survival in the SIG 0 vs SIG 1 vs SIG 2 vs SIG 3 vs SIG 4 subgroups was 80.7 months (95% confidence interval [CI], 76.5-85.0 months) vs 78.7 months (95% CI, 72.7-84.7 months) vs 61.0 months (95% CI, 51.1-70.8 months) vs 65.1 months (95% CI, 45.0-85.2 months) vs 54.9 months (95% CI, 34.4-75.3 months) (P < .05). In the entire cohort, age (P < .001), body mass index (P < .05), high creatinine (P < .05), and SIG (P < .05) were associated with survival on univariate analysis, with retained independent association for age (hazard ratio, 1.72; 95% CI, 1.29-2.31; P < .001) and SIG (hazard ratio, 1.20; 95% CI, 1.02-1.40; P < .05) on multivariate analysis. Increasing SIG (area under the curve, 0.68; 95% CI, 0.58-0.78; P < .01) predicted 1-year mortality.

CONCLUSIONS

Markers of the SIR such the SIG may be used to identify patients at higher risk of adverse outcome in patients undergoing EVAR and F/B-EVAR for abdominal aortic aneurysms. These findings warrant further investigation in large prospective cohort studies.

The Neutrophil-to-Lymphocyte Ratio’s Predictive Utility in Acute Pulmonary Embolism: Systematic Review

Acute pulmonary embolism is a cardiovascular emergency with a significant morbidity and mortality. In the last decade, attempts have been made to find prognostic markers for pulmonary embolism. We conducted a systematic review of the literature for studies that assess the relationship between the neutrophil-to-lymphocyte ratio (NLR) and disease progression in patients with pulmonary embolism. We included a total of seven studies published between 2016 and 2021, reporting on a total of 4,272 patients. The mean NLR observed in these studies was 5.93, with values ranging from 5.12 to 7.3. Elevated NLR was significantly associated with an increased rate of mortality in all studies. Furthermore, the collected data revealed a 2-to-15 times higher mortality rate in the group with NLR values higher than the mean. Due to its accessibility and the simplicity with which it can be calculated, as well as the outcomes revealed in this review, we strongly emphasize that NLR should be used more in medical practice.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio Impact on Predicting Outcomes in Patients with Acute Limb Ischemia

Acute Limb Ischemia (ALI) of the lower limb is defined as a sudden drop in arterial limb perfusion, which is a medical emergency requiring prompt intervention with high amputation and mortality rates in the absence of revascularization. This observational, analytical, and retrospective cohort study with longitudinal follow-up aimed to confirm the relevance of the preoperative inflammatory biomarkers neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting the 30-day poor prognosis of patients with Rutherford classification (RC) grades II and III ALI. The ROC analysis found a strong association of an NLR > 4.33 with all studied outcomes, while a PLR > 143.34 was associated with all studied outcomes, except the composite endpoint in all RC stages. Depending on the optimal cut-off value, the ROC analysis found a higher incidence of all adverse outcomes in all high NLR (>4.33) and high PLR (>143.34) groups. A multivariate analysis showed that a high baseline value for NLR and PLR was an independent predictor of amputation (OR:11.09; 95% CI: 5.48−22.42; p < 0.0001; and OR:8.97; 95% CI: 4.44−18.16; p < 0.0001), mortality (OR:22.24; 95% CI: 9.61−51.47; p < 0.0001; and OR:8.32; 95% CI: 3.90−17.73; p < 0.0001), and composite endpoint (OR:21.93; 95% CI: 7.91−60.79; p < 0.0001; and OR:9.98; 95% CI: 3.89−25.55; p < 0.0001), respectively. Furthermore, for all hospitalized patients, the RC grade III (OR:7.33; 95% CI: 3.73−14.26; p < 0.0001) was an independent predictor of amputation (OR:7.33; 95% CI: 3.73−14.26; p < 0.0001), mortality (OR:8.40; 95% CI: 4.08−17.31; p < 0.0001), and composite endpoint (OR: 10.70; 95% CI: 4.48−25.56; p < 0.0001), respectively. The NLR and PLR are excellent predictors of risks associated with ALI for primary and secondary prevention. Our study showed that increased pre-operative values for NLR and PLR are indicators of a poor outcome in patients with RC grades II and III ALI.

The Predictive Role of NLR and PLR in Outcome and Patency of Lower Limb Revascularization in Patients with Femoropopliteal Disease

BACKGROUND

Peripheral arterial disease (PAD) changes the arterial structure and function, and is the most common manifestation of the atherosclerotic process, except for the coronary and cerebral arterial systems. Inflammation is well known to have a role in the progression of atherosclerosis and, by extension, in PAD. Among the recently studied markers in the literature, we list the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR). This study aims to analyze the preoperative role of NLR and PLR in the medium-term outcome of patients surgically revascularized for femoropopliteal disease.

METHODS

A retrospective study included patients admitted to the Vascular Surgery Clinic of the County Emergency Clinical Hospital of Târgu-Mureș, Romania, between January 2017 and December 2019, diagnosed with femoropopliteal disease and having presented an indication for surgical revascularization. The patients included in the study were classified according to the 12 months primary patency in two groups: "patency" and "nonpatency".

RESULTS

Depending on the Rutherford classification (RC), there was a higher incidence of stages II and III in the patency group and a higher incidence of stage V in the nonpatency group. Depending on the optimal cut-off value according to ROC for the 12 months primary patency, obtained from Youden's index (3.95 for NLR (82.6% sensitivity and 89.9% specificity), and 142.13 for PLR (79.1% sensitivity and 82.6% specificity)), in all high-NLR and high-PLR groups, there was a higher incidence of all adverse outcomes. Moreover, a multivariate analysis showed that a high baseline value for NLR and PLR was an independent predictor of all outcomes for all recruited patients. Furthermore, for all hospitalized patients, RC 5 was an independent predictor of poor prognosis.

CONCLUSIONS

Our findings establish that a high value of preoperative NLR and PLR determined at hospital admission is strongly predictive of primary patency failure (12 months after revascularization). Additionally, elevated ratio values are an independent predictor for a higher amputation rate and death for all patients enrolled in the study, except for mortality in RC 2, and both amputation and mortality in RC 5.

The Prognostic Significance of Neutrophil to Lymphocyte Ratio (NLR), Monocyte to Lymphocyte Ratio (MLR) and Platelet to Lymphocyte Ratio (PLR) on Long-Term Survival in Off-Pump Coronary Artery Bypass Grafting (OPCAB) Procedures

BACKGROUND

Cardiovascular diseases, apart from commonly known risk factors, are related to inflammation. There are several simple novel markers proposed to present the relation between inflammatory reactions activation and atherosclerotic changes. They are easily available from whole blood count and include neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), and platelets to lymphocyte ratio (PLR). The RDW results were excluded from the analysis.

METHOD AND RESULTS

The study based on retrospective single-centre analysis of 682 consecutive patients (131 (19%) females and 551 (81%) males) with median age of 66 years (60-71) who underwent off-pump coronary artery bypass grafting (OPCAB) procedure. During the median 5.3 +/- 1.9 years follow-up, there was a 87% cumulative survival rate. The laboratory parameters including preoperative MLR > 0.2 (HR 2.46, 95% CI 1.33-4.55, p = 0.004) and postoperative NLR > 3.5 (HR 1.75, 95% CI 1.09-2.79, p = 0.019) were found significant for long-term mortality prediction in multivariable analysis.

CONCLUSION

Hematological indices NLR and MLR can be regarded as significant predictors of all-cause long-term mortality after OPCAB revascularization. Multivariable analysis revealed preoperative values of MLR > 0.2 and postoperative values of NLR > 3.5 as simple, reliable factors which may be applied into clinical practice for meticulous postoperative monitoring of patients in higher risk of worse prognosis.

Preoperative HbA1c and Outcomes Following Lower Extremity Vascular Procedures

OBJECTIVES

Limited data exist evaluating pre-operative hemoglobin A1c (HbA1c) in patients undergoing vascular procedures for peripheral arterial disease (PAD). This study evaluated the relationship of preoperative HbA1c on outcomes after open and endovascular lower extremity (LE) vascular procedures for PAD.

METHODS

We selected patients with PAD admitted for elective LE procedures between September 2008 and December 2015 from the Cerner Health Facts® database using ICD-9-CM diagnosis and procedure codes. Bivariable analysis and multivariable logistic models examined the association of patient characteristics, procedure type, and preoperative HbA1c (normal < 6.5%, high ≥ 6.5%) with postsurgical outcomes that included infection, renal failure, respiratory or cardiac complications, length of stay (LOS), in-hospital mortality, and readmission.

RESULTS

Of 4,087 patients who underwent a LE vascular procedure for PAD, 2,462 (60.2%) had a preoperative HbA1c recorded. The cohort was mostly male (60%), white (73%), and underwent endovascular intervention (77%). Patients with high HbA1c levels were more likely of black race (p < .02) and had significantly higher comorbidities (p < .0001). Elevated HbA1c was associated with diabetes (p < .0001) and cellulitis (p = .05) on unadjusted analysis. Multivariable logistic regression (adjusting for patient, hospital, comorbidity and procedural characteristics) revealed that elevated HbA1c was significantly associated with 30-day readmission (OR = 1.06, 95% CI = 1.00-1.12), but was not associated with the other outcomes. An independent diagnosis of diabetes was not predictive of complications or readmission.

CONCLUSIONS

Historic glucose control, as evidenced by a high preoperative HbA1c level, is not associated with adverse outcome, other than readmission, in patients undergoing LE procedures for PAD. Given the known association of high perioperative glucose levels with poor outcome following vascular procedures, this is suggestive of a more important effect of perioperative, as opposed to chronic, glucose control upon outcome. Thus, we suggest focusing efforts on creating standardized goal-directed guidelines for glucose control in the perioperative period for LE vascular procedures to potentially mitigate complications.

Preoperative Neutrophil to Lymphocyte Ratio, Platelet to Lymphocyte Ratio, and Mean Platelet Volume as Predictors of 1-Year Mortality in Patients Undergoing an Open Repair of Abdominal Aortic Aneurysms: A Retrospective Study

Objectives: To investigate if preoperative neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), or mean platelet volume (MPV) could be used to predict 1-year mortality in patients undergoing open abdominal aortic aneurysm (AAA) repair. Methods: We retrospectively reviewed 382 patients who underwent open AAA repair between January 2008 and July 2019. We divided the patients into two groups based on 1-year mortality and compared the preoperative NLR, PLR, and MPV. The patients were then classified into tertiles based on their preoperative NLR (first tertile: <2.41 (n = 111); second tertile: 2.41 ≤ NLR ≤ 6.07 (n = 111); and third tertile: >6.07 (n = 112)). We compared the incidence of mortality and morbidity across the aforementioned tertiles. We performed a stepwise logistic regression analysis to evaluate the predictors for mortality. An additional subgroup analysis was performed by dividing the cases into non-ruptured and ruptured cases. Results: The preoperative NLR was significantly higher in the non-survivor group than in the survivor group (10.53 ± 7.60 vs. 5.76 ± 6.44, respectively, p = 0.003). The PLR and MPV were similar between the groups (145.35 ± 91.11 vs. 154.20 ± 113.19, p = 0.626, 9.38 ± 1.20 vs. 9.11 ± 1.39, p = 0.267, respectively). The incidence of 1-year mortality was 2.7%, 9.0%, and 14.3% in the first, second, and third NLR tertiles, respectively (p = 0.009). Higher NLR (odds ratio 1.085, 95% confidence interval 1.016–1.159, p = 0.015) and ruptured AAA (odds ratio 2.706, 95% confidence interval 1.097–6.673, p = 0.031) were the independent predictors of 1-year mortality in all patients. Moreover, the preoperative NLR was significantly higher in the ruptured AAA than in the non-ruptured AAA group (11.17 ± 7.90 vs. 4.10 ± 4.75, p < 0.001). In subgroup analysis, preoperative NLR (odds ratio 1.144, 95% confidence interval 1.031–1.271, p = 0.012) and PLR (odds ratio 0.986, 95% confidence interval 16 0.975–0.998, p = 0.017) was an independent predictor for 1-year mortality in ruptured cases. Conclusions: We demonstrated an independent relationship between the preoperative NLR and 1-year mortality in patients undergoing open AAA repair, besides PLR and MPV. Furthermore, the NLR and PLR had predictive power for 1-year mortality in ruptured cases.

Neutrophils as Regulators and Biomarkers of Cardiovascular Inflammation in the Context of Abdominal Aortic Aneurysms

Neutrophils represent up to 70% of circulating leukocytes in healthy humans and combat infection mostly by phagocytosis, degranulation and NETosis. It has been reported that neutrophils are centrally involved in abdominal aortic aneurysm (AAA) pathogenesis. The natural course of AAA is growth and rupture, if left undiagnosed or untreated. The rupture of AAA has a very high mortality and is currently among the leading causes of death worldwide. The use of noninvasive cardiovascular imaging techniques for patient screening, surveillance and postoperative follow-up is well established and recommended by the current guidelines. Neutrophil-derived biomarkers may offer clinical value to the monitoring and prognosis of AAA patients, allowing for potential early therapeutic intervention. Numerous promising biomarkers have been studied. In this review, we discuss neutrophils and neutrophil-derived molecules as regulators and biomarkers of AAA, and our aim was to specifically highlight diagnostic and prognostic markers. Neutrophil-derived biomarkers may potentially, in the future, assist in determining AAA presence, predict size, expansion rate, rupture risk, and postoperative outcome once validated in highly warranted future prospective clinical studies.

Elevated neutrophil to lymphocyte ratio is associated with decreased amputation-free survival after femoropopliteal percutaneous revascularization

BACKGROUND

An elevated neutrophil-lymphocyte ratio (NLR) is a biomarker associated with adverse outcomes after cardiovascular surgery. This study evaluates the association of preoperative NLR with clinical outcomes after peripheral vascular intervention (PVI) of the femoropopliteal segments.

METHODS

A retrospective review identified 488 patients who underwent percutaneous interventions of femoropopliteal arteries between 2011 and 2018 and had a pre-procedural complete blood count with differential with normal white blood cell count within 30 days prior to intervention. Amputation-free survival (AFS), survival, and freedom from major amputation were assessed using Kaplan-Meier methods. Cohorts of patients with NLR <3 (Low), 3-4 (Mid), and >4 (High) were compared using univariate and multivariable statistical models. In these analyses NLR was analyzed as a continuous variable to correlate with clinical outcomes.

RESULTS

Mean age was 71.7 ± 12.8 years and males constituted 55.5%. The majority of patients presented with chronic limb threatening ischemia (CLTI, 78.5%). Increasing NLR was correlated with increasing rates of comorbidities, except for smoking history. The 30-day mortality rates increased with increasing NLR: 1.4%, 4.3%, and 7.0% for Low (<3), Mid (3-4) and High (>4) NLR groups, respectively (P =.005). Patients with a lower pre-operative NLR achieved significantly greater amputation-free survival at 4-year follow-up: low NLR, 65.5%; mid NLR, 37.5%; and high NLR, 17.6% (P <.0001). By multivariable analysis, increasing NLR, advanced age, CLTI, and dialysis-dependent renal failure reduced AFS.

CONCLUSIONS

Elevated NLR is an independent predictor of decreased AFS following percutaneous interventions of femoropopliteal segments. Further research on identification and modulation of risk factors for high NLR are warranted.

Association of Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratio with Adverse Events in Endovascular Repair for Abdominal Aortic Aneurysm

The association of chronic inflammatory markers with the clinical outcome after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was investigated. We included 230 patients, treated electively with EVAR. The values of neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) were measured pre- and postoperatively. Any major adverse cardiovascular event (MACE) and acute kidney injury (AKI) were recorded. Adverse events occurred in 12 patients (5.2%). Seven patients suffered from MACE and five from AKI. Median NLR and PLR values were significantly increased after the procedure (NLR: from 3.34 to 8.64, p < 0.001 and PLR: from 11.37 to 17.21, p < 0.001). None of the patients or procedure characteristics were associated with the occurrence of either a MACE or AKI. Receiver operating characteristic curve analysis showed that postoperative NLR and PLR were strongly associated with AKI. A threshold postoperative NLR value of 9.9 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 81%. A threshold postoperative PLR value of 22.8 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 83%. Postoperative NLR and PLR have been associated with the occurrence of AKI after EVAR for AAA.

Clinical application values of neutrophil-to-lymphocyte ratio in intracranial aneurysms

Inflammation plays an important role in the pathogenesis and growth of intracranial aneurysms (IAs). We investigated the clinical value of the neutrophil-to-lymphocyte ratio (NLR) as a marker of systemic subclinical inflammation in patients with IAs.

Consecutive patients with IAs who underwent endovascular treatment (EVT) were enrolled in the study. The evaluation indicators were aneurysm size and rupture, a poor outcome at 3 to 6 months, and delayed cerebral ischemia (DCI) during hospitalization.

In total, 532 patients with IAs underwent EVT (mean age, 54.0 years; 62.4% female). Among patients with ruptured IAs, those with a higher NLR had an increased risk of a poor outcome at 3 to 6 months and DCI during hospitalization than those with a lower NLR. A higher NLR was significantly more strongly associated with the size of unruptured aneurysms and aneurysm rupture than a lower NLR. The NLR and C-reactive protein concentration showed similar predictive ability for aneurysm size and treatment prognosis. The NLR was lower at discharge than admission for patients with ruptured IAs and DCI.

An elevated NLR was significantly associated with the size of unruptured IAs, an increased risk of a poor outcome, and DCI in patients with ruptured IAs.

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Biomarkers for Cardiovascular Surgery Procedures: A Literature Review

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) have been studied so far as prognostic factors of cardiovascular diseases. Their role interplayed with endothelial inflammation has emerged as optimal predictors for major cardiovascular disease events and prognostic factors for post-procedural outcomes.

METHODS

A review of the current literature was undertaken to investigate the relationship between NLR and PLR with percutaneous, cardiac surgery, and vascular surgery procedures.

RESULTS

Our findings show that perioperative NLR and PLR levels are significantly correlated with patient morbidity and mortality rates.

CONCLUSION

These biomarkers have several attractive characteristics, as they are inexpensive and quickly available, and they can contribute to the early identification of patients at high risk for periprocedural adverse events.

Correlation of neutrophil-to-lymphocyte ratio with the prognosis of non-ST-segment elevation in patients with acute coronary syndrome undergoing selective percutaneous coronary intervention

OBJECTIVE

We aimed to explore the relationship between neutrophil-to-lymphocyte ratio (NLR) at three timepoints and prognosis of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) undergoing elective percutaneous coronary intervention (PCI) within 1 year of PCI.

METHODS

This retrospective study enrolled 231 patients with NSTE-ACS who received PCI and were followed for 1 year after PCI. The study population was divided into major adverse cardiovascular and cerebrovascular events (MACE) and non-MACE groups.

RESULTS

In total, 214 patients completed the 1-year follow-up; 32 patients (15.0%) had MACE and 182 (85.0%) had no MACE. The MACE and non-MACE groups differed significantly in age, preoperative neutrophil count, preoperative and postoperative NLR, proportion of three-vessel lesion disease, preoperative lymphocyte count, postoperative lymphocyte count within 24 hours, postoperative lymphocyte count over 24 hours, and left ventricular ejection fraction (LVEF). Multivariate logistic regression analysis showed that preoperative NLR, postoperative NLR within 24 hours, age, and LVEF values were independent risk factors for MACE in patients with NSTE-ACS after elective PCI.

CONCLUSION

Compared with preoperative NLR, postoperative NLR (within 24 hours) may have a stronger ability to predict the occurrence of MACE in NSTE-ACS patients within 1 year after elective PCI.

Leukocyte subsets and abdominal aortic aneurysms detected by screening in men

OBJECTIVE

In the present case-control study, we describe the associations between leukocyte subsets in blood and early, screening-detected AAA in men. An abdominal aortic aneurysm (AAA) may result in a life-threatening rupture of the aortic wall. The trigger for AAA formation remains unknown, but the vascular adventitia of advanced AAAs is infiltrated by various leukocytes, indicating that the pathogenesis may involve inflammation.

METHODS

In Sweden, all 65-year-old men are invited to an ultrasound examination for detection of AAA. At the Gothenburg screening site, 16 256 men were examined in 2013-2017, 1.2% of whom had an AAA (diameter of the infrarenal aorta ≥30 mm). All men with AAA at screening as well as a randomized selection of AAA-free screened men were invited to participate in a case-control study.

RESULTS

The median diameter of AAAs was 33 mm. Men with an AAA (n = 151) had a higher frequency of smoking, hypertension and statin use than controls (n = 224). Blood levels of neutrophils, lymphocytes, monocytes and basophils were higher in individuals with an AAA, but eosinophil count did not differ from controls. Odds ratios (95% confidence interval) for AAA were 8.6 (4.2-17.4), 3.5 (1.9-6.6) and 3.3 (1.8-6.3) for the highest versus lowest quartile of neutrophils, lymphocytes and monocytes, respectively. For neutrophils and lymphocytes, the association with AAA remained significant after adjustment for smoking and other known risk factors/markers.

CONCLUSION

Several, but not all, subsets of circulating leukocytes are associated with screening-detected AAA in men, which is insufficiently explained by associations with smoking and other confounders.

Prognostic role of neutrophil-to-lymphocyte ratio in aortic disease: a meta-analysis of observational studies

OBJECTIVE

Recent studies have reported that neutrophil-to-lymphocyte ratio (NLR) is associated with cardiovascular disease. The aim of the present study was to investigate the prognostic value of NLR in aortic disease.

METHODS

We systematically searched electronic databases (Cochrane, PubMed, Elsevier, Medline, and Embase) from their inception to March 2020. Observational studies that evaluated the relationship between NLR and aortic disease were eligible for critical appraisal. Data were extracted from applicable articles, risk ratio (RR), weighted mean differences (MD) and 95% confidence intervals (CI) were calculated by RevMan 5.3, and statistical heterogeneity was assessed by the I² statistic.

RESULTS

Fourteen studies enrolling 4066 individuals were included in the meta-analysis. Compared with the control group, NLR was significantly higher in the aortic disease group (MD 3.44, 95%CI: 0.81-6.07, P = 0.01, I² = 99%). The NLR was also significantly higher in non-survivors with aortic disease, compared to the survivors (MD 4.62, 95%CI: 2.75-6.50, P < 0.00001, I² = 60%). Compared with the aortic disease patients with a low NLR, mortality was significantly higher in those with a high NLR (RR 2.63, 95%CI: 1.79-3.86, P < 0.00001, I² = 67%).

CONCLUSION

Based on current evidence, an elevated NLR was associated with aortic disease and in-hospital mortality. Raised NLR also demonstrated a significantly increased the risk of mortality after surgical repair in aortic disease patients. NLR may be a good prognostic biomarker in aortic disease and deserve further research in this area.

Complex relationship between low albumin level and poor outcome after lower extremity procedures for peripheral artery disease

OBJECTIVE

A low albumin level has been associated with poor outcome, including death, in surgical patients. The mechanistic relationship, however, is more complex than simply nutritional. As studies are scant in the vascular population, we sought to examine the association of low albumin level with outcomes in patients undergoing open and endovascular lower extremity procedures for peripheral artery disease.

METHODS

Patients with peripheral artery disease undergoing lower extremity procedures (2008-2015) were selected from Cerner Health Facts database (Cerner Corporation, Kansas City, Mo) using International Classification of Diseases, Ninth Revision diagnosis and procedure codes. Age, sex, disease severity, and other comorbidities were captured. Outcomes were identified using codes and encounter data. A χ²analysis and multivariable logistic regression were performed.

RESULTS

There were 6170 patients evaluated; 4562 (74%) underwent endovascular procedures and 1608 (26%) underwent open surgery. Low albumin level (<3.5 g/dL) was associated with age ≥80 years (23.1% vs 16.3% normal; P < .0001), black race (21% vs 11.6% normal; P < .0001), tissue loss (38% vs 16.4% normal; P < .0001), and higher Charlson index (mean, 3.1 vs 2.2 in the normal group; P < .0001). Low albumin level was also associated with longer length of stay (4.9 vs 2.2 days normal; P < .0001), higher in-hospital mortality (1.9% vs 0.3% normal; P < .0001), and higher 30-day readmission (15% vs 12.7% normal; P = .02). Multivariable analysis demonstrated that low albumin level was strongly associated with in-hospital death (odds ratio [OR], 5.23; 95% confidence interval [CI], 2.00-13.70), infection (OR, 2.51; 95% CI, 1.96-3.22), renal failure (OR, 2.61; 95% CI, 1.79-3.79), and cardiac complications (OR, 2.59; 95% CI, 1.69-3.96). After multivariable adjustment, there was no association between albumin level and 30-day readmission.

CONCLUSIONS

Low preoperative albumin levels are associated with in-hospital death, prolonged length of stay, and severe morbidity after open and endovascular lower extremity procedures. As the majority of lower extremity procedures are elective, serious consideration should be given to deferring elective procedures until albumin levels have been optimized. Because of the pleiotropic effects of albumin, including antiplatelet and inflammatory function, study of this complex relationship may offer insights into how best to integrate this novel biomarker into vascular surgery decision-making.

Defining the Term "Elderly" in the Field of Surgery: A Retrospective Study Regarding the Changes in the Immunoinflammatory Indices During the Immediate Perioperative Period of the Elective Uncomplicated Laparoscopic Cholecystectomy

BACKGROUNDS

The term "elderly" seems to have been used as "vulnerable to various stresses" but not well defined. To define the "elderly", we investigated whether the increased age causes unfavorable changes in several immunoinflammatory indices that indicate the increased vulnerability in the surgical field.

PATIENTS AND METHODS

One-hundred forty-two patients undergoing an elective-uncomplicated laparoscopic cholecystectomy (within 60 min and without intraoperative-cholangiography, bile spillage, or open conversion) were retrospectively investigated. Before surgery, immediately after surgery, and on postoperative day (POD)1, whether the patient age correlated the following variables was examined: neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio, lymphocyte-to-C-reactive-protein ratio (LCR), C-reactive-protein-to-albumin ratio (CAR), and others.

RESULTS

The immunoinflammatory indices most unfavorably changed on POD1. The age correlated neither lymphocyte-to-monocyte ratio nor platelet-to-lymphocyte ratio on POD1, when NLR, LCR, and CAR showed the significant correlation with the age. Multiple regression analyses determined the following variables as the independent determinants of these 3 indices on POD1: age, intraoperative minimum body temperature ≥35.5°C (IntMinBT ≥35.5°C), maximum heart rate during POD0-1 (MaxHR) for NLR; age and IntMinBT ≥ 35.5°C for LCR; and age and MaxHR for CAR. The threshold of "elderly" was determined as 102-year-old for NLR, 94-year-old for LCR, and 97-year-old for CAR.

CONCLUSIONS

The increased age causes the unfavorable changes in early postoperative immunoinflammatory indices after the uncomplicated laparoscopic cholecystectomy. Thus, the term "elderly" can be rephrased by the term "vulnerable to various surgical stresses." The thresholds for "elderly" defined herein seem impractical. Namely, the increased vulnerability caused by the aging seems modified by the individual surgical procedures.