Endovascular repair of abdominal aortic aneurysm reduces intraoperative cortisol and perioperative morbidity

Preoperative Assessment of Patients with Vascular Disease

Patients with vascular disease represent a particularly high-risk surgical population. Many of the comorbidities that contribute to their vascular presentation impact a number of vascular beds or other organ systems. As a result, these patients have the highest rates of cardiac and pulmonary complications among patients with noncardiac surgery. The vascular surgeon is in a unique position to help evaluate and treat many of these conditions to not only reduce the perioperative risk but also to improve the patient's overall health. This article presents a comprehensive review of the common preoperative evaluations that have a high impact on patients with vascular disease.

Hormonal Stress Response and Hemodynamic Stability in Patients Undergoing Endovascular vs. Conventional Abdominal Aortic Aneurysm Repair

Background and Aims:

To investigate the effect of two different surgical techniques with different anesthetic modes on intraoperative and postoperative hormonal stress response, hemodynamic stability, fluid loading and renal function in patients scheduled for elective infrarenal abdominal aortic aneurysm (AAA) repair.

Materials and Methods:

Forty consecutive patients scheduled for elective infrarenal AAA repair were allocated without randomizing into two groups: an endovascular (EVAR, n=20) and a conventional (CAR, n=20) aneurysm repair group according to aneurysm morphology as determined by pre-operative computed tomography and angiography. The EVAR group were operated under spinal anesthesia and the CAR group using general anesthesia with epidural blockade.

Results:

Patients undergoing CAR showed lower intraoperative mean arterial pressure and significantly higher plasma norepinephrine before aortic cross-clamping and significantly higher lactate after aortic declamping and postoperatively than patients in the EVAR group. Postoperatively, vasopressin and serum cortisol were also significantly higher in the CAR group. Fluid loading and estimated blood loss were more excessive in the CAR group.

Conclusions:

Stress response was lower and hemodynamic stability and lower body perfusion superior and renal function also better maintained in patients undergoing EVAR under spinal anesthesia as compared to those undergoing CAR using general anesthesia with epidural blockade.

Preoperative methylprednisolone enhances recovery after endovascular aortic repair: a randomized, double-blind, placebo-controlled clinical trial

OBJECTIVE

To evaluate effects of preoperative high-dose glucocorticoid on the inflammatory response and recovery after endovascular aortic aneurysm repair (EVAR).

BACKGROUND

The postimplantation syndrome after EVAR may delay recovery due to the release of proinflammatory mediators. Glucocorticoids may reduce postoperative inflammatory responses and enhance recovery, but with limited information on EVAR.

METHODS

A single-center, randomized, double-blind, placebo-controlled trial of 153 patients undergoing elective EVAR between November 2009 and January 2013. Patients received 30 mg/kg of methylprednisolone (MP) (n = 77) or placebo (n = 76) preoperatively. Primary outcome was a modified version of the systemic inflammatory response syndrome. Secondary outcome measures were the effect on inflammatory biomarkers, morbidity, and time to meet discharge criteria.

RESULTS

Of 153 randomized patients, 150 (98%) were evaluated for the primary outcome. MP reduced systemic inflammatory response syndrome from 92% to 27% (P < 0.0001) (number needed to treat = 1.5), maximal plasma interleukin 6 from 186 pg/mL [interquartile range (IQR) = 113-261 pg/mL] to 20 pg/mL (IQR = 11-28 pg/mL) (P < 0.001) and fulfillment of discharge criteria was shorter [2 days (IQR = 2-4 days) vs 3 days (IQR = 3-4 days)] (P < 0.001). C-reactive protein, temperature, interleukin 8, and soluble tumor necrosis factor receptor were also reduced (P < 0.001) by MP. Myeloperoxidase, D-dimer, and matrix metalloproteinase 9 were not modified. No differences in 30-day medical (23% vs 36%) (P = 0.1) or surgical (20% vs 21%) morbidity were found in the active group versus the placebo group.

CONCLUSIONS

Preoperative MP attenuates the inflammatory response with a faster recovery after EVAR for abdominal aortic aneurysms. Further safety and dose-response studies are required to allow recommendations for general practice.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00989729.

Ruptured AAA: suitability for endovascular repair is associated with lower mortality following open repair

OBJECTIVES

Perioperative mortality of open repair of ruptured abdominal aortic aneurysms (rAAA) remains unacceptably high: 30-day mortality ≈ 40 %. This study aimed to assess, quantify, and determine the consequences of anatomic suitability for endovascular repair of rAAA.

DESIGN

A retrospective analysis of the prospectively maintained database identified patients with rAAA.

METHODS

Preoperative CT scans were assessed for anatomic suitability for emergency EVAR and precluding factors recorded. Demographic information was collected and analysed for all patients.

RESULTS

A total of 141 patients underwent open surgical repair of rAAA. Forty-six patients had preoperative CT scans suitable for reconstruction. Morphological measurements indicated that 41 % would have been anatomically suitable for EVAR. Suitability was associated with lower mortality rates than unsuitability: 0, 11, and 20 % (24 h, 30 days, and 1 year respectively) versus 11, 33, and 59 % (statistically significant at 1 year; p = 0.02). The groups were comparable excepting diabetes incidence, which was higher in those suitable for EVAR (p = 0.003).

CONCLUSIONS

A minority of patients with ruptured AAA are anatomically suitable for EVAR. Anatomical suitability appears to identify patients at low risk from open surgery. Whether this is due to technically less demanding open surgery is unknown. This may be resolved by the IMPROVE trial results, which are eagerly awaited.

Risk stratification by pre-operative cardiopulmonary exercise testing improves outcomes following elective abdominal aortic aneurysm surgery: a cohort study

BACKGROUND

In 2009, the NHS evidence adoption center and National Institute for Health and Care Excellence (NICE) published a review of the use of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). They recommended the development of a risk-assessment tool to help identify AAA patients with greater or lesser risk of operative mortality and to contribute to mortality prediction.A low anaerobic threshold (AT), which is a reliable, objective measure of pre-operative cardiorespiratory fitness, as determined by pre-operative cardiopulmonary exercise testing (CPET) is associated with poor surgical outcomes for major abdominal surgery. We aimed to assess the impact of a CPET-based risk-stratification strategy upon perioperative mortality, length of stay and non-operative costs for elective (open and endovascular) infra-renal AAA patients.

METHODS

A retrospective cohort study was undertaken. Pre-operative CPET-based selection for elective surgical intervention was introduced in 2007. An anonymized cohort of 230 consecutive infra-renal AAA patients (2007 to 2011) was studied. A historical control group of 128 consecutive infra-renal AAA patients (2003 to 2007) was identified for comparison.Comparative analysis of demographic and outcome data for CPET-pass (AT ≥ 11 ml/kg/min), CPET-fail (AT < 11 ml/kg/min) and CPET-submaximal (no AT generated) subgroups with control subjects was performed. Primary outcomes included 30-day mortality, survival and length of stay (LOS); secondary outcomes were non-operative inpatient costs.

RESULTS

Of 230 subjects, 188 underwent CPET: CPET-pass n = 131, CPET-fail n = 35 and CPET-submaximal n = 22. When compared to the controls, CPET-pass patients exhibited reduced median total LOS (10 vs 13 days for open surgery, n = 74, P < 0.01 and 4 vs 6 days for EVAR, n = 29, P < 0.05), intensive therapy unit requirement (3 vs 4 days for open repair only, P < 0.001), non-operative costs (£5,387 vs £9,634 for open repair, P < 0.001) and perioperative mortality (2.7% vs 12.6% (odds ratio: 0.19) for open repair only, P < 0.05). CPET-stratified (open/endovascular) patients exhibited a mid-term survival benefit (P < 0.05).

CONCLUSION

In this retrospective cohort study, a pre-operative AT > 11 ml/kg/min was associated with reduced perioperative mortality (open cases only), LOS, survival and inpatient costs (open and endovascular repair) for elective infra-renal AAA surgery.

A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm

Background

Several studies have compared outcomes after elective open and endovascular approaches to abdominal aortic aneurysm (AAA) surgery, with varying results.

Methods

A random-effects meta-analysis was undertaken to compare operative outcomes, postoperative complications, 30-day mortality and long-term patient survival after surgery. Endpoints were compared using odds ratios (ORs), weighted mean differences (WMDs) or log hazard ratios (HRs) as appropriate.

Results

Forty-two studies comprising 21 178 patients (10 855 open; 10 323 endovascular) were included. In the elective setting (20 715 patients), the endovascular method was associated with a shorter stay in intensive care (WMD − 36 h; P &lt; 0·001) and a shorter total postoperative stay (WMD − 5·4 days; P &lt; 0·001). Cardiac (OR 1·76; P = 0·002) and respiratory (OR 4·01; P &lt; 0·001) complications were more common after open surgery. In the endovascular group, 30-day mortality was lower (OR 0·46; P &lt; 0·001). Endovascular surgery was also associated with an improved long-term aneurysm-related mortality (HR 0·39; P &lt; 0·001). For ruptured AAA (463 patients), the less invasive operation was associated with a reduced stay in intensive care (WMD − 100·4 h; P = 0·005) and a significantly lower 30-day mortality (OR 0·45; P = 0·005).

Conclusions

The endovascular repair of AAA offers a clear benefit in terms of reduction in postoperative adverse events and 30-day mortality. In the longer term, it is also associated with a reduction in aneurysm-related mortality, but not in all-cause mortality.

Endovascular Ruptured Abdominal Aortic Aneurysm Repair (EVRAR): A Systematic Review

BACKGROUND

To review evidence supporting the use of endovascular ruptured aneurysm repair (EVRAR) for treatment of ruptured abdominal aortic aneurysm (RAAA).

METHODS

A systematic review of the medical literature was performed for relevant studies. We searched a number of electronic databases and hand-searched relevant journals until November 2006 to identify studies for inclusion. We considered studies in which patients with a confirmed ruptured abdominal aortic aneurysm were treated with EVRAR, which reported endpoints of mortality and major complications.

RESULTS

There was 1 randomised controlled trial (RCT), 33 non-randomised case series (24 retrospective and 9 prospective) reports were identified comparing EVRAR (n=891) with conventional open surgical repair for the treatment of RAAA. Whilst no benefit in the primary outcome of mortality was noted in the only RCT, evidence from non-randomised studies suggest that EVRAR is feasible in selected patients, where it may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, early complications, and mortality.

CONCLUSIONS

For the treatment of symptomatic or ruptured abdominal aortic aneurysm, emergency endovascular repair (EVRAR) is feasible in selected patients, with early outcomes comparable to best conventional open surgical repair for the treatment of RAAA.

Preoperative Nutritional Status Predicts the Severity of the Systemic Inflammatory Response Syndrome (SIRS) Following Major Vascular Surgery

OBJECTIVES

This study examined the relationship between pre-operative nutritional status and systemic inflammatory response syndrome (SIRS) or sepsis following major vascular surgery.

DESIGN AND METHODS

Subjects undergoing open AAA repair, EVAR or lower limb revascularisation were studied prospectively. Pre-operative nutrition was assessed clinically using Mini-Nutritional Assessment (MNA) and body composition was measured by dual energy X-ray absorptiometry (DEXA) scanning. SIRS severity was assessed for 5 post-operative days and sepsis noted within 30 days of surgery.

RESULTS

Using MNA, neither SIRS severity nor sepsis occurrence differed significantly between 'well-nourished' subjects and those 'at risk of malnutrition'. Using DEXA, negative associations existed between body mass index and both SIRS score and SIRS duration. Fat free mass (FFM) was negatively associated with SIRS score and duration. Negative associations also existed between skeletal muscle mass (SMM) and SIRS score and duration. SMM was also negatively correlated with post-operative length of stay in hospital. There were no significant correlations between sepsis and any nutritional indices.

CONCLUSIONS

Lower pre-operative nutritional indices, indicating protein energy malnutrition, were associated with more severe systemic inflammatory responses following major vascular surgery.