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Doukas P, Hellfritsch G, Wendt D, Magliani M, Barbati ME, Jalaie H, Jacobs MJ, Gombert A. Intraoperative Hemoadsorption (Cytosorb™) during Open Thoracoabdominal Aortic Repair: A Pilot Randomized Controlled Trial. J Clin Med 2023; 12:546. [PMID: 36675474 PMCID: PMC9866403 DOI: 10.3390/jcm12020546] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The efficacy of cytokine adsorption in controlling the early inflammation cascade after open thoracoabdominal aortic (TAAA) repair has not been investigated. The aim of this pilot randomized controlled trial was to assess the feasibility and effect of perioperative hemoadsorption during open TAAA repair. METHODS Patients scheduled for open TAAA repair with the use of cardiopulmonary bypass (CPB) were included. The patients were randomized the day before surgery to either intraoperative hemoadsorption during CPB or standard of care. RESULTS A total of 10 patients were randomly assigned to the intervention group, whereas the control group consisted of 17 patients (mean age of the total cohort, 51.1 ± 11.2 years, 67% male, 3 patients not randomized). The majority of baseline and perioperative characteristics were similar, and no device-related adverse events were reported. A trend to shorter ventilation times in the intervention group was observed (median 88 h vs. 510 h, p = 0.08, Δ422). Severe acute respiratory distress syndrome was significantly less in the intervention patients (p = 0.02). CONCLUSIONS This is the first pilot study showing that the intraoperative use of hemoadsorption in open TAAA repair patients may be feasible and safe, yet larger trials are needed to evaluate whether intraoperative hemoadsorption is associated with improved clinical outcomes.
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Affiliation(s)
- Panagiotis Doukas
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, RWTH Aachen, 52074 Aachen, Germany
| | - Gabriel Hellfritsch
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, RWTH Aachen, 52074 Aachen, Germany
| | - Daniel Wendt
- Westgerman Heart & Vascular Center, University Hospital Essen, 45147 Essen, Germany
- CytoSorbents Inc., Princeton, NJ 08540, USA
| | - Mirko Magliani
- Department of Cardiothoracic Surgery, RWTH Aachen, 52074 Aachen, Germany
| | - Mohammad E. Barbati
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, RWTH Aachen, 52074 Aachen, Germany
| | - Houman Jalaie
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, RWTH Aachen, 52074 Aachen, Germany
| | - Michael J. Jacobs
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, RWTH Aachen, 52074 Aachen, Germany
| | - Alexander Gombert
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, RWTH Aachen, 52074 Aachen, Germany
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Onset of Adverse Abdominal Events Due to Intestinal Ischemia-Reperfusion Injury after Aortic Cross-Clamping Is Associated with Elevated HSP70 Serum Levels in the Early Postoperative Phase. Int J Mol Sci 2022; 23:ijms232315063. [PMID: 36499389 PMCID: PMC9736142 DOI: 10.3390/ijms232315063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Abstract
Tissue injury of the viscera during open thoracoabdominal aortic (TAA) reconstructions has been reported as the aftermath of the ischemia-reperfusion mechanism following supracoeliac aortic cross-clamping. Abdominal complications after open aortic reconstructions, although rare through the intraoperative implementation of selective visceral artery blood perfusion, are associated with high rates of reinterventions and a poor prognosis. Recent animal experiments demonstrated that provoking mesenteric ischemia in rats induces the leukocyte-mediated transcription of heat-shock protein 70 (HSP70), a chaperone belonging to the danger-associated molecular pattern proteins (DAMPs). Translating these findings clinically, we investigated the serum levels of HSP70 in patients undergoing open aortic reconstructions with supracoeliac clamping. We postoperatively observed a relevant induction of HSP70, which remained significantly elevated in cases of postoperative abdominal complications (paralytic ileus, abdominal compartment syndrome, and visceral malperfusion). The receiver-operator curve analysis revealed the reliable prognostic accuracy of HSP70 as a biomarker for these complications as soon as 12 h post-operation (AUC 0.908, sensitivity 88.9%, specificity 83.3%). In conclusion, measuring HSP70 serum levels in the early postoperative phase may serve as a further adjutant in the diagnostic decision making for both the vascular surgeon and intensivist for the timely detection and management of abdominal complications following open TAA surgery.
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Visceral and renal protection in thoracoabdominal aortic surgery. Indian J Thorac Cardiovasc Surg 2022; 38:157-162. [PMID: 35463708 PMCID: PMC8980969 DOI: 10.1007/s12055-020-01129-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022] Open
Abstract
Ischemic renal failure and visceral ischemia are two serious complications of the surgery for thoracoabdominal aortic aneurysm. The introduction of left atrial bypass, partial bypass, total circulatory arrest, and selective visceral perfusion has reduced the incidence of these complications over the past two decades. Yet these complications still persist, suggesting the sub-optimal nature of the available strategies.
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Pergel A, Demiral G, Tümkaya L, Mercantepe T, Özdemir A, Kalcan S, Çolakoğlu MK, Yılmaz A, Bedir R, Karakaya A. The protective effects of topiramate on intestinal injury induced with infrarenal aortic occlusion via oxidative stress and apoptosis. Clin Exp Hypertens 2021; 43:604-609. [PMID: 33966542 DOI: 10.1080/10641963.2021.1925680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: Prolonged surgical procedures and some clinical conditions such as surgeries of thoracoabdominal aorta, mesenteric ischemia, cardiopulmonary bypass, strangulated hernias and neonatal necrotizing enterocolitis may cause decreased perfusion and injury of relevant organs and tissues. After reperfusion, injuries may get worse, leading to ischemia-reperfusion (I/R) injury. Reperfusion following arterial clamping allows oxygen to ischemic tissues and produce injury by multiple mechanisms, including neutrophilic infiltration, intracellular adhesion molecules, and generation of reactive oxygen radicals. In this study with the analysis of SOD, MDA and Caspase-3 levels, we aimed to investigate the effect of topiramate on the outcome of I/R occured after abdominal aorta clamping on rats.Materials and Methods: Totaly 24 Sprague-Dawley male rats were randomly divided into three experimental groups; the control group (n = 8), I/R (n = 8) and I/R+ topiramate (n = 8). Topiramate (100 mg/kg/day); 50 mg/kg (single dose) was administered intraperitoneally after being diluted with saline 5 days before I/R.Results: The intestinal tissue of the ischemia group displayed hemorrhage, Crypts of Lieberkuhn degeneration, ulceration, vascular congestion and edematous fields as a result of aortic occlusion. We also observed that MDA levels and Caspase-3 positivity increased and SOD levels decreased in the small intestine. However, topiramate administration decreased Crypts of Lieberkuhn degeneration, ulceration, vascular congestion and edematous fields, Caspase-3 positivity, and MDA levels.Conclusion: Our findings suggest that topiramate is effective against aortic occlusion-induced intestinal injury by reducing oxidative stress and apoptosis.
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Affiliation(s)
- Ahmet Pergel
- Department of General Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Gökhan Demiral
- Department of General Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Levent Tümkaya
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Tolga Mercantepe
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Ali Özdemir
- Department of General Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Süleyman Kalcan
- Department of General Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Muhammed Kadri Çolakoğlu
- Department of General Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Adnan Yılmaz
- Department of Biochemistry, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Recep Bedir
- Department of Pathology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Ahmet Karakaya
- Department of General Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
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Palmier M, Bubenheim M, Chiche L, Chaufour X, Koskas F, Fadel E, Magnan PE, Ducasse E, Chakfe N, Steinmetz E, Dusseaux MM, Ricco JB, Plissonnier D. Protocol of supra-visceral aortic ischemic preconditioning for open surgical repair of thoracoabdominal aortic aneurysm : The EPICATA study (Evaluation of the Efficacy of Ischemic PreConditioning on morbidity and mortality in open ThoracoAbdominal Aortic surgery). BMC Surg 2020; 20:193. [PMID: 32854681 PMCID: PMC7457237 DOI: 10.1186/s12893-020-00851-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background Open surgical repair (OSR) for thoracoabdominal aortic aneurysms (TAA) is associated with a high pulmonary and renal morbidity rate. Ischemic preconditioning (IPC) is a mechanism of protection against the deleterious effects of ischemia-reperfusion. To our knowledge IPC has never been tested during OSR for TAA. Methods The primary objective of the study is to evaluate the efficacy of IPC during OSR for TAA with respect to acute kidney injury (AKI) according to KDIGO and pneumonia/prolonged ventilation-time during the first 8 postoperative days. The secondary objectives are to compare both arms with respect to cardiac complications within 48 h, renal and pulmonary complications within 21 days and mortality at 60 days. To assess the efficacy of IPC with respect to pulmonary and renal morbidity, a cox model for competing risks will be used. Assuming that the event occurs among 36% of the patients when no IPC is performed, the allocation of 55 patients to each arm should allow detecting a hazard ratio of at least 2.75 with a power of 80% when admitting 5% for an error of first kind. This means that 110 patients, enrolled in this multicenter study, may be randomised within 36 months of the first randomization. Randomization will be performed to allocate patients either to surgery with preconditioning before aortic cross clamping (Arm 1) or to surgery without preconditioning before aortic cross clamping (Arm 2). Randomization takes place during the intervention after intravenous injection of heparin, or after the start of femoral assistance. The procedure for IPC will be a supra-visceral thoracic aortic cross clamping for 5 min followed by an unclamping period of 5 min. This procedure will be repeated twice before starting thoracic aortic cross clamping needed to perform surgery. Conclusions Our hypothesis is that ischemic preconditioning could reduce clinical morbidity and the incidence of lung damage associated with supra-visceral aortic clamping. Trial registration EPICATAStudy registered in ClinicalTrial.gov / number: NCT03718312 on Oct.24.2018 URL number
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Affiliation(s)
- Mickael Palmier
- Department of vascular surgery and Inserm U1096, Rouen University Hospital, 1 rue de Germont, 76031, Rouen Cedex, France
| | - Mickael Bubenheim
- Department of Clinical research and Innovation, Rouen University Hospital, Rouen, France
| | - Laurent Chiche
- Department of vascular surgery, Pitié-Salpétrière University Hospital, Paris, France
| | - Xavier Chaufour
- Department of vascular surgery, Rangueil University Hospital, Toulouse, France
| | - Fabien Koskas
- Department of vascular surgery, Pitié-Salpétrière University Hospital, Paris, France
| | - Elie Fadel
- Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | | | - Eric Ducasse
- Department of vascular surgery, Pellegrin University Hospital, Bordeaux, France
| | - Nabil Chakfe
- Department of vascular surgery, Nouvel Hopital Civil, University of Strasbourg, Strasbourg, France
| | - Eric Steinmetz
- Department of vascular surgery, Dijon University Hospital, Dijon, France
| | | | - Jean Baptiste Ricco
- Department of Clinical Research and Innovation, University Hospital, Poitiers, France
| | - Didier Plissonnier
- Department of vascular surgery and Inserm U1096, Rouen University Hospital, 1 rue de Germont, 76031, Rouen Cedex, France.
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New Large Animal Model for Aortic Aneurysms in the Viscerorenal Segment. J Surg Res 2019; 240:156-164. [PMID: 30933829 DOI: 10.1016/j.jss.2019.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/23/2019] [Accepted: 02/25/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Aortic aneurysms in the viscerorenal-segment are nowadays treatable by endovascular means. Previously, new endograft techniques were only tested in healthy animals. We aimed to establish a new large animal model for testing complex endovascular stent techniques preclinically. METHODS In sheep, four juxtarenal and two type IV thoracoabdominal aortic aneurysms were surgically created via a retroperitoneal approach. Two pieces out of a 10 × 15-cm bovine pericardial patch were sewn with the healthy aorta longitudinally. The viscerorenal segment was clamped, and the aorta was incised longitudinally. Then, the patches were longitudinally sewn together. In the meantime, antegrade flow through the native part of the aorta was already established by tangential clamping. Computed tomography angiography was performed after 4, 8, and 52 wk. RESULTS Technical success was 100%. The median surgical procedure time was 3 h, the median blood loss was 210 mL, and the viscerorenal-segment clamping time was 2-4 min. The animals started drinking 1 h after arousal from anesthesia. One animal died after 1 wk because of delayed bleeding and another died after 1 y because of aneurysm rupture by a secondary bacterial infection. Four animals survived. The proximal landing zone diameter and the clock position of the vessel were stable over 52 wk. CONCLUSIONS Surgical creation of an aortic aneurysm in the viscerorenal-segment in sheep was successful, without an ischemia/reperfusion injury. This animal model offers a new platform for evaluating innovative endovascular therapy options in vivo.
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Keschenau PR, Klingel H, Reuter S, Foldenauer AC, Vieß J, Weidener D, Andruszkow J, Bluemich B, Tolba R, Jacobs MJ, Kalder J. Evaluation of the NMR-MOUSE as a new method for continuous functional monitoring of the small intestine during different perfusion states in a porcine model. PLoS One 2018; 13:e0206697. [PMID: 30388139 PMCID: PMC6214547 DOI: 10.1371/journal.pone.0206697] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/17/2018] [Indexed: 12/31/2022] Open
Abstract
Objective The study aim was to evaluate a small low-field NMR (nuclear magnetic resonance) scanner, the NMR-MOUSE®, for detecting changes in intestinal diffusion under different (patho-) physiological perfusion states. Methods Laparotomy was performed on 8 female landrace pigs (body weight 70±6 kg) and the feeding vessels of several intestinal loops were dissected. Successively, the intestinal loops were examined using O2C (oxygen to see, LEA Medizintechnik GmbH, Giessen, Germany) for microcirculatory monitoring and the NMR-MOUSE® for diffusion measurement (fast and slow components). On each loop the baseline measurement (physiological perfusion) was followed by one of the following main procedures: method 1 –ischemia; method 2 –flow reduction; method 3 –intraluminal glucose followed by ischemia; method 4 –intraluminal glucose followed by flow reduction. Additionally, standard perioperative monitoring (blood pressure, ECG, blood gas analyses) and histological assessment of intestinal biopsies was performed. Results There was no statistical overall time and method effect in the NMR-MOUSE measurement (fast component: ptime = 0.6368, pmethod = 0.9766, slow component: ptime = 0.8216, pmethod = 0.7863). Yet, the fast component of the NMR-MOUSE measurement showed contrary trends during ischemia (increase) versus flow reduction (decrease). The slow-to-fast diffusion ratio shifted slightly towards slow diffusion during flow reduction. The O2C measurement showed a significant decrease of oxygen saturation and microcirculatory blood flow during ischemia and flow reduction (p < .0001). The local microcirculatory blood amount (rHb) showed a significant mucosal increase (pClamping(method 1) = 0.0007, pClamping(method 3) = 0.0119), but a serosal decrease (pClamping(method 1) = 0.0119, pClamping(method 3) = 0.0078) during ischemia. The histopathological damage was significantly higher with increasing experimental duration and at the end of methods 3 and 4 (p < .0001,Fisher-test). Conclusion Monitoring intestinal diffusion changes due to different perfusion states using the NMR-MOUSE is feasible under experimental conditions. Despite the lack of statistical significance, this technique reflects perfusion changes and therefore seems promising for the evaluation of different intestinal perfusion states in the future. Beforehand however, an optimization of this technology, including the optimization of the penetration depth, as well as further validation studies under physiological conditions and including older animals are required.
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Affiliation(s)
- Paula R. Keschenau
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, Aachen, Germany
| | - Hanna Klingel
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, Aachen, Germany
| | - Silke Reuter
- Institut für Technische und Makromolekulare Chemie, RWTH University Aachen, Aachen, Germany
| | | | - Jochen Vieß
- Institut für Technische und Makromolekulare Chemie, RWTH University Aachen, Aachen, Germany
| | - Dennis Weidener
- Institut für Technische und Makromolekulare Chemie, RWTH University Aachen, Aachen, Germany
| | - Julia Andruszkow
- Institute for Pathology, RWTH University Hospital Aachen, Aachen, Germany
| | - Bernhard Bluemich
- Institut für Technische und Makromolekulare Chemie, RWTH University Aachen, Aachen, Germany
| | - René Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, RWTH University Aachen, Aachen, Germany
| | - Michael J. Jacobs
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, Aachen, Germany
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, AZM University Hospital Maastricht, Maastricht, The Netherlands
| | - Johannes Kalder
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, Aachen, Germany
- * E-mail:
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A 30-Minute Supraceliac Aortic Clamping in the Rat Causes Death Due to an Inflammatory Response and Pulmonary Lesions. Ann Vasc Surg 2018; 52:192-200. [PMID: 29673584 DOI: 10.1016/j.avsg.2017.12.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/30/2017] [Accepted: 12/01/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The treatment of thoracoabdominal aortic aneurysms through an open approach has general and pulmonary consequences of multiple etiologies. Our assumption was that the supraceliac aortic clamping needed for this operation causes a systemic inflammatory response associated with a pulmonary attack. METHODS We developed a model of 30-min supraceliac aortic clamping in Wistar rats weighing 300 g. After 90 min of reperfusion, the rats were sacrificed. The effects on the digestive tract wall were analyzed by measurement of the mucosal thickness/total thickness ratio. The effects on the mesenteric endothelial function were determined by an ex situ measurement of the arterial pressure/volume curves (third branch). The systemic consequences of the procedure were analyzed by dosing tumor necrosis factor alpha (TNFα), interleukin (IL)1β, and IL10 in the blood. The pulmonary consequences were analyzed by the measurement of macrophages, polymorphonuclear neutrophils (PNs), T lymphocyte infiltration, pulmonary apoptosis (TUNEL) and active caspase 3. The experimental scheme included 20 rats with ischemia-reperfusion (IR) and 20 control rats. An analysis of survival was carried out on 20 other rats (10 IR and 10 controls). RESULTS The results were expressed as average ± standard error of the mean. The statistical tests were Student's t-test and Mann-Whitney test. This visceral IR model decreased the ratio of the thickness of the intestinal mucosa compared with that of the control rats (0.77 ± 0.008 vs. 0.82 ± 0.009 [P < 0.001]). This local effect was not accompanied by any mesenteric endothelial dysfunction (P = 0.91). On a systemic level, IR increased TNFα (37.9 ± 1.5 vs. 28.2 ± 0.6 pg/mL; P < 0.0001), IL1β (67.1 ± 9.8 vs. 22.5 ± 5.6 pg/mL; P < 0.001), and IL10 (753.3 ± 96 vs. 3.7 ± 1.7 pg/mL; P < 0.0001). As regards the lungs, IR increased the parenchymal cellular infiltration by macrophages (6.8 ± 0.8 vs. 4.5 ± 0.4 cells per field; P < 0.05) and PNs (7.4 ± 0.5 vs. 6.2 ± 03 cells per field; P < 0.05). There was no increase in the pulmonary cellular apoptosis measured by TUNEL (P = 0.77) or in the caspase 3 activity (P = 0.59). The mortality of the visceral IR rats was 100% at 36 hr vs. 0% in the animals without IR. CONCLUSIONS This work showed that the inflammatory response to visceral IR had systemic and pulmonary effects which always results in the death in the rat.
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Waked K, Schepens M. State-of the-art review on the renal and visceral protection during open thoracoabdominal aortic aneurysm repair. J Vis Surg 2018; 4:31. [PMID: 29552513 DOI: 10.21037/jovs.2018.01.12] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/10/2018] [Indexed: 12/13/2022]
Abstract
During open thoracoabdominal aortic aneurysm repair (OTAAAR), there is an inevitable organ ischemic period that occurs when the abdominal arteries are being reattached to the aortic graft. Despite various protective techniques, the incidence of renal and visceral complications remains substantial. This state-of-the-art review gives an overview of the current and most evidence-based organ protection methods during OTAAAR, based on the most recent publications and personal experience. An electronic search was performed in four medical databases, using the following MeSH terms: thoracoabdominal aneurysm, TAAAR, visceral protection, renal protection, kidney, perfusion, and intestines. Every publication type was considered. The literature search was ended on August 31st, 2017. The left heart bypass (LHB) is currently the most frequent adjunct to provide distal aortic perfusion (DAP) during aortic clamping. Together with systemic hypothermia, it forms the cornerstone in organ protection during aortic clamping. Further renal protection can be obtained by selective renal perfusion (SRP) with cold blood or cold crystalloid solution, the latter enriched with mannitol. The perfusion should be administered in a volume- and pressure-controlled way and, if possible, by use of a pulsatile pump. Selective visceral perfusion (SVP) is not routinely used, as it does not provide adequate blood flow for visceral protection. The best way to protect the intestines is by minimizing the ischemic time. The preservation of renal and visceral function after OTAAAR can only be obtained with specific strategies before, during, and after the operation. This involves a series of measures, including selective digestive decontamination (SDD), avoidance of nephrotoxic drugs, minimizing the renal and intestinal ischemic time, systemic cooling, avoidance of hemodynamic instability, and regional protective perfusion of the kidneys. Future innovations in catheters, cardiac bypass flow types, mechanical components, hybrid vascular grafts, and pharmaceutical protection measures will hopefully further reduce organ complications.
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Affiliation(s)
- Karl Waked
- Department of Cardiovascular Surgery, AZ Sint Jan Hospital, Brugge, Belgium
| | - Marc Schepens
- Department of Cardiovascular Surgery, AZ Sint Jan Hospital, Brugge, Belgium
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Rocha de Sousa PT, Breithaupt-Faloppa AC, de Jesus Correia C, Simão RR, Ferreira SG, Fiorelli AI, Moreira LFP, Sannomiya P. 17β-Estradiol prevents mesenteric injury induced by occlusion of the proximal descending aorta in male rats. J Vasc Surg 2018; 67:597-606. [DOI: 10.1016/j.jvs.2016.12.125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 12/17/2016] [Indexed: 02/07/2023]
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Wasicek PJ, Shanmuganathan K, Teeter WA, Gamble WB, Hu P, Stein DM, Scalea TM, Brenner ML. Assessment of Blood Flow Patterns Distal to Aortic Occlusion Using CT in Patients with Resuscitative Endovascular Balloon Occlusion of the Aorta. J Am Coll Surg 2017; 226:294-308. [PMID: 29248608 DOI: 10.1016/j.jamcollsurg.2017.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 12/03/2017] [Accepted: 12/03/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to decrease hemorrhage below the level of aortic occlusion (AO); however, the amount of collateral blood flow below the level of occlusion is unknown. Our aim was to investigate blood flow patterns during complete AO in patients who underwent CT scan after REBOA. STUDY DESIGN Between February 2013 and January 2017, patients who received REBOA and underwent CT scan with intravenous contrast during full AO were included. Patients were excluded if they had a CT scan performed with the balloon partially or fully deflated. RESULTS Nine patients (8 men) were included; all had blunt trauma. Mean Injury Severity Score (±SD) was 48 ± 8 and mean age was 45 ± 19 years. Four had supra-celiac AO, and 5 had infra-renal AO. Arterial contrast enhancement was noted below the level of AO in all patients, and distal to REBOA sheath placement in 5. Collateralization from arteries above and below the AO was identified in all patients. Contrast extravasation distal to AO was identified in 4 patients, and hematomas in 8. Distal vascular enhancement patterns varied by level of AO and contrast administration site. CONCLUSIONS Aortic occlusion appears to dramatically decrease, but does not completely impede, distal perfusion during REBOA due to multiple pathways of collateralization. Active extravasation and hematomas can still be detected in the setting of full AO, with purposefully timed contrast and image acquisition. Blood flow persists below the level of both the AO and in-dwelling sheath. Dynamic flow studies are needed to determine the contribution of AO and sheath placement to distal tissue ischemia.
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Affiliation(s)
- Philip J Wasicek
- Program in Trauma/Critical Care RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
| | | | - William A Teeter
- Program in Trauma/Critical Care RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - William B Gamble
- Program in Trauma/Critical Care RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Peter Hu
- Program in Trauma/Critical Care RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Deborah M Stein
- Program in Trauma/Critical Care RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas M Scalea
- Program in Trauma/Critical Care RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Megan L Brenner
- Program in Trauma/Critical Care RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Impact of arterial cross-clamping during vascular surgery on arterial stiffness measured by the augmentation index and fractal dimension of arterial pressure. HEALTH AND TECHNOLOGY 2016. [DOI: 10.1007/s12553-016-0141-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Monnot A, Dusseaux MM, Godier S, Plissonnier D. Passive Temporary Visceral Shunt from the Axillar Artery as an Adjunct Method during the Open Treatment of Thoracoabdominal Aortic Aneurysm. Ann Vasc Surg 2016; 36:127-131. [PMID: 27427350 DOI: 10.1016/j.avsg.2016.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 03/23/2016] [Accepted: 03/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Distal aortic retrograde perfusion systems like the left heart bypass or femoro-femoral extracorporeal circulation are the methods of reference for organ protection during direct approaches to thoracoabdominal aortic aneurysms. The aim of this work was to evaluate the use of a passive arterial shunt to reduce visceral ischemia during aortic operations when occlusive diseases of the iliac arteries make distal aortic retrograde perfusion inappropriate. METHODS Ten patients affected by a Crawford type III thoracoabdominal aneurysm (TAA) were operated on between January 2013 and January 2015 with the use of a temporary shunt inserted onto the left axillar artery that allows visceral perfusion immediately after the aorta is opened. The operation was performed after a single dose of heparin (50 UI/kg). The sera lactate levels were measured 2 hr after the last aortic clamp was removed and compared with those obtained from a group of 19 patients operated on for a Crawford type IV TAA during the same period without any arterial shunt. RESULTS Neither mortality nor paraplegia occurred. The sera lactate levels were lower in the group of patients operated on for a type III TAA (2.57 ± 1) than for a type IV TAA (3.68 ± 1) (P < 0.01, Student's t-test). CONCLUSION This method was effective for low mesenteric ischemia, easy to perform, and did not require high doses of anticoagulants.
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Affiliation(s)
- Antoine Monnot
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | | | - Sylvie Godier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Didier Plissonnier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
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Keschenau PR, Ribbe S, Tamm M, Hanssen SJ, Tolba R, Jacobs MJ, Kalder J. Extracorporeal circulation increases proliferation in the intestinal mucosa in a large animal model. J Vasc Surg 2015; 64:1121-33. [PMID: 26190050 DOI: 10.1016/j.jvs.2015.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/29/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Extracorporeal circulation induces ischemia/reperfusion injury in the small intestinal wall. One reason for this damage is a perfusion shift from the muscular toward the mucosal layer. This study investigated the effect of this perfusion shift on the small-intestinal apoptosis and proliferation. METHODS Twenty-eight pigs were randomly assigned to the following cohorts and underwent a thoracolaparotomy and a 1 hour main procedure: cohort I: control; cohort II: thoracic aortic cross-clamping (TAC) without perfusion; cohort III: TAC and distal aortic perfusion (DAP); cohort IV: TAC, DAP, and selective visceral perfusion. The main procedure was followed by 2 hours of reperfusion in all cohorts. Tissue samples were taken during the experiment, stained, and analyzed for apoptosis and proliferation (caspase-3, annexin-V, terminal deoxynucleotide transferase-mediated deoxy uridine triphosphate nick-end labeling, and proliferating cell nuclear antigen). Six animals died unexpectedly during the experiment and were excluded from the analysis. RESULTS Extensive tissue damage and necrosis was only found in cohort II after the main procedure. In the mucosa, the proliferation was increased in cohort III at the end of the experiment (P = .0157 cohort I vs II). In contrast, the annexin-V/proliferating cell nuclear antigen ratio was significantly higher in cohorts II and IV than in cohorts I and II at the end of the experiment (P = .0034). Furthermore, the caspase-3/annexin-V ratio was increased in all cohorts at the end of the experiment (P = .0015). CONCLUSIONS Mucosal proliferation is the early repair mechanism of the limited small intestinal ischemia/reperfusion injury after DAP. Furthermore, the extensive surgical trauma shifted the mucosal apoptosis into an advanced state.
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Affiliation(s)
- Paula Rosalie Keschenau
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Rheinisch-Westfälische Technische Hochschule University Hospital Aachen, Aachen, Germany
| | - Stefanie Ribbe
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Rheinisch-Westfälische Technische Hochschule University Hospital Aachen, Aachen, Germany
| | - Miriam Tamm
- Department of Medical Statistics, Rheinisch-Westfälische Technische Hochschule University Hospital Aachen, Aachen, Germany
| | - Sebastiaan J Hanssen
- European Vascular Center Aachen-Maastricht, Department of Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - René Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, Rheinisch-Westfälische Technische Hochschule University Hospital Aachen, Aachen, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Rheinisch-Westfälische Technische Hochschule University Hospital Aachen, Aachen, Germany; European Vascular Center Aachen-Maastricht, Department of Surgery, Maastricht University Hospital, Maastricht, The Netherlands.
| | - Johannes Kalder
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Rheinisch-Westfälische Technische Hochschule University Hospital Aachen, Aachen, Germany
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Microcirculatory perfusion shift in the gut wall layers induced by extracorporeal circulation. J Vasc Surg 2013; 61:497-503. [PMID: 24275079 DOI: 10.1016/j.jvs.2013.10.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 09/27/2013] [Accepted: 10/10/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Extracorporeal circulation (ECC) is regularly applied to maintain organ perfusion during major aortic and cardiovascular surgery. During thoracoabdominal aortic repair, ECC-driven selective visceral arterial perfusion (SVP) results in changed microcirculatory perfusion (shift from the muscularis toward the mucosal small intestinal layer) in conjunction with macrohemodynamic hypoperfusion. The underlying mechanism, however, is unclear. Therefore, the aim of this study was to assess in a porcine model whether ECC itself or the hypoperfusion induced by SVP is responsible for the mucosal/muscular shift in the small intestinal wall. METHODS A thoracoabdominal aortic approach was performed in 15 healthy pigs divided equally into three groups: group I, control; group II, thoracic aortic cross-clamping with distal aortic perfusion; and group III, thoracic aortic cross-clamping with distal aortic perfusion and SVP. Macrocirculatory and microcirculatory blood flow was assessed by transit time ultrasound volume flow measurement and fluorescent microspheres. In addition, markers for metabolism and intestinal ischemia-reperfusion injury were determined. RESULTS ECC with a roller pump induced a significant switch from the muscularis and mucosal layer of the small intestine, even with adequate macrocirculation (mucosal/muscular perfusion ratio: group I vs II, P = .005; group I vs III, P = .0018). Furthermore, the oxygen extraction ratio increased significantly in groups II (>30%) and III (>40%) in the beginning of the ECC compared with the control (group I vs II, P = .0037; group I vs III, P = .0062). Lactate concentrations and pH values did not differ between groups I and II; but group III demonstrated a significant shifting toward a lactate-associated acidosis (lactate: group I vs III, P = .0031; pH: group I vs III, P = .0001). CONCLUSIONS We demonstrated a significant shifting between the small intestinal gut wall layers induced by roller pump-driven ECC. The shift occurs independently of macrohemodynamics, with a significant effect on aerobic metabolism in the gut wall. Consequently, an optimal intestinal perfusion cannot be guaranteed by a roller pump; therefore, perfusion techniques need to be optimized.
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Karhausen J, Stafford-Smith M. The role of nonocclusive sources of acute gut injury in cardiac surgery. J Cardiothorac Vasc Anesth 2013; 28:379-91. [PMID: 24119676 DOI: 10.1053/j.jvca.2013.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Indexed: 12/16/2022]
Affiliation(s)
- Jörn Karhausen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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