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Hamelin T, Bouziane Z, Settembre N, Malikov S. Elective open repair with the debranch, perfuse, reconstruct technique to treat suprarenal or type IV thoracoabdominal aortic aneurysms. J Vasc Surg 2024:S0741-5214(24)01775-0. [PMID: 39181339 DOI: 10.1016/j.jvs.2024.08.025] [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: 03/21/2024] [Revised: 05/19/2024] [Accepted: 08/11/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Open surgical repair of suprarenal abdominal aortic aneurysm (SRAAA) and type IV thoracoabdominal aortic aneurysm (TAAA) remains a surgical challenge because of the inducted intraoperative visceral and renal ischemia. We report a novel three-step technique named debranch, perfuse, reconstruct (DPR), using debranching and passive arterial shunt to decrease these ischemic complications. The main aim of this study was to evaluate the 30-day and 1-year mortality rates associated with these DPR technique. The secondary aim was to evaluate the impact on renal function and the primary patency of the repaired arteries. METHODS This retrospective study included all consecutive patients who underwent elective surgery for SRAAA or type IV TAAA using the DPR technique between January 2011 and June 2022. In debranching, using partial side clamping, a multibranch graft was implanted side-to-end into the descending thoracic aorta. The left renal artery was anastomosed end-to-end to the graft. As needed, the superior mesenteric artery (SMA), the celiac trunk, and the right renal artery could also be anastomosed to the graft. In the perfusion step, cannulas were connected to the last branch of the multibranch graft to perfuse other arteries during aortic cross-clamping. For repair, a tube or bifurcated graft was used for the aortic repair. The branch used as a passive temporary arterial shunt was ligated at the end of the intervention. Clinical, radiological, and biological preoperative and postoperative factors were reviewed using a standardized database. Procedural complications and reinterventions were analyzed, as well as artery patency. RESULTS There were 40 patients who underwent DPR technique. The mean patient age was 67 ± 13 years and two were women. Twenty-three patients presented with a SRAAA and 17 with a type IV TAAA. The 30-day and 1-year mortality rates were 2.5% (one patient). Two respiratory complications (5%) and three mesenteric ischemic complications (7%) have been recorded. No patient developed signs of cardiac or spinal cord dysfunction. We did not observe a significant change in postoperative renal function. The celiac trunk, superior mesenteric artery, left renal artery, and right renal artery bypass patency rates at 1 year were 95%, 100%, 90%, and 100%, respectively. CONCLUSIONS The SRAAA and type IV TAAA repair with DPR technique provides short visceral and renal ischemia times with a low mortality rate. This technique could be an option to consider for visceral and renal protection during open surgical repair.
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Affiliation(s)
- Thibaud Hamelin
- Department of Vascular Surgery, Nancy Regional University Hospital, Nancy, France.
| | - Zakariyae Bouziane
- Department of Vascular Surgery, Nancy Regional University Hospital, Nancy, France
| | - Nicla Settembre
- Department of Vascular Surgery, Nancy Regional University Hospital, Nancy, France; Université de Lorraine, INSERM UMR_S 1116 DCAC, Nancy, France
| | - Sergueï Malikov
- Department of Vascular Surgery, Nancy Regional University Hospital, Nancy, France; Université de Lorraine, INSERM UMR_S 1116 DCAC, Nancy, France
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Doukas P, Hartmann O, Frankort J, Arlt B, Krabbe H, Jacobs MJ, Greiner A, Frese JP, Gombert A. Postoperative bioactive adrenomedullin is associated with the onset of ARDS and adverse outcomes in patients undergoing open thoracoabdominal aortic surgery. Sci Rep 2024; 14:12795. [PMID: 38834580 PMCID: PMC11150250 DOI: 10.1038/s41598-024-63412-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/28/2024] [Indexed: 06/06/2024] Open
Abstract
Cytokine-mediated systemic inflammation after open thoracoabdominal aortic aneurysm (TAAA) repairs plays a pivotal role in disrupting circulatory homeostasis, potentially leading to organ dysfunction. The bioactive form of adrenomedullin (bio-ADM) is a peptide hormone with immunomodulatory and vasomotor effects, making it a potential diagnostic agent in these cases. This retrospective, bicentric study, conducted between January 2019 and December 2022, recruited 36 elective open TAAA repair patients in two German centres. Serum and plasma samples were collected at multiple time points to measure bio-ADM levels. The primary objective was to evaluate the association of bio-ADM levels with the onset of acute respiratory distress syndrome (ARDS), with secondary endpoints focusing on mortality and SIRS-related morbidity. Results showed a significant association between postoperative bio-ADM levels (12-48 h after surgery) and the onset of ARDS (p < .001), prolonged ventilation (p = .015 at 12h after surgery), atrial fibrillation (p < .001), and mortality (p = .05 at 24h). The biomarker was also strongly associated with sepsis (p = .01 at 12 h) and multi-organ dysfunction syndrome (MODS) (p = .02 at 24 h after surgery). The study underscores the potential utility of bio-ADM as a diagnostic tool for identifying patients at risk of postoperative complications following open TAAA repairs.
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Affiliation(s)
- Panagiotis Doukas
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, 52074, Aachen, Germany.
| | | | - Jelle Frankort
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, 52074, Aachen, Germany
| | - Birte Arlt
- SphingoTec GmbH, Hennigsdorf, Berlin, Germany
| | - Hanif Krabbe
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, 52074, Aachen, Germany
| | - Michael Johan Jacobs
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, 52074, Aachen, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Paul Frese
- Department of Vascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Gombert
- Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, RWTH University Hospital Aachen, 52074, Aachen, Germany
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Doukas P, Bassett C, Krabbe H, Frankort J, Jacobs MJ, Elfeky M, Gombert A. IFABP levels predict visceral malperfusion in the first hours after open thoracoabdominal aortic repair. Front Cardiovasc Med 2023; 10:1200967. [PMID: 37441698 PMCID: PMC10333487 DOI: 10.3389/fcvm.2023.1200967] [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: 04/05/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Intestinal ischemia after open thoracoabdominal aortic repairs, is a rare but devastating complication, associated with high mortality. Notoriously challenging to diagnose, visceral malperfusion necessitates immediate surgical attention. Intestinal fatty acid-binding protein (IFABP) has been proposed as a biomarker for the diagnosis of intestinal wall damage. In this prospectively conducted, observational study we evaluated the diagnostic capacity of IFABP levels in patients' serum and their correlation with visceral malperfusion. Methods 23 patients undergoing open thoracoabdominal aortic repairs were included in this study and 8 of them were diagnosed postoperatively with visceral malperfusion-defined as a partial or complete thrombotic occlusion of the superior mesenteric artery and/or the coeliac trunk. IFABP levels and laboratory parameters often associated with intestinal ischemia (leucocytes, CRP, PCT and lactate) were measured at baseline, directly postoperatively, and at 12, 24 and 48 h after surgery. Postoperative visceral malperfusion-as revealed in CT angiography-was assessed and the predictive ability of IFABP levels to detect visceral malperfusion was evaluated with receiver-operator curve analysis. Results Patients with visceral malperfusion had a relevant risk for a fatal outcome (p = .001). IFABP levels were significantly elevated directly postoperatively and at 12 h after surgery in cases of visceral malperfusion. High IFABP concentrations in serum detected visceral malperfusion accurately during the first 12 h after surgery, with the maximum diagnostic ability achieved immediately after surgery (AUC 1, Sensitivity 100%, Specificity 100%, p < .001). Conclusion We conclude, that IFABP measurements during the first postoperative hours after open thoracoabdominal aortic surgery can be a valuable tool for reliable and timely detection of visceral malperfusion.
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Orthopedic Surgery Causes Gut Microbiome Dysbiosis and Intestinal Barrier Dysfunction in Prodromal Alzheimer's Disease Patients: A Prospective Observational Cohort Study. Ann Surg 2022; 276:270-280. [PMID: 35766370 PMCID: PMC9259038 DOI: 10.1097/sla.0000000000005489] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: To investigate gut microbiota and intestinal barrier function changes after orthopedic surgery in elderly patients with either normal cognition (NC) or a prodromal Alzheimer disease phenotype (pAD) comprising either subjective cognitive decline (SCD) or amnestic mild cognitive impairment (aMCI). Background: Homeostatic disturbances induced by surgical trauma and/or stress can potentially alter the gut microbiota and intestinal barrier function in elderly patients before and after orthopedic surgery. Methods: In this prospective cohort study, 135 patients were subject to preoperative neuropsychological assessment and then classified into: NC (n=40), SCD (n=58), or aMCI (n=37). Their gut microbiota, bacterial endotoxin (lipopolysaccharide), tight junction (TJ) protein, and inflammatory cytokines in blood were measured before surgery and on postsurgical day 1, 3, and 7 (or before discharge). Results: The short-chain fatty acid (SCFA)-producing bacteria were lower while the gram-negative bacteria, lipopolysaccharide and TJ were higher preoperatively in both the SCD and aMCI (pAD) groups compared with the NC group. After surgery, a decrease in SCFA-producing bacteria, and an increase in both gram-negative bacteria and plasma claudin were significant in the pAD groups relative to the NC group. SCFA-producing bacteria were negatively correlated with TJ and cytokines in pAD patients on postsurgical day 7. Furthermore, surgery-induced perioperative metabolic stress and inflammatory responses were associated with gut microbiota alterations. Conclusions: Surgery exacerbates both preexisting microbiota dysbiosis and intestinal barrier dysfunction in pAD patients, all of which may be associated with systemic inflammation and, in turn, may lead to further cognitive deterioration.
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Lin Y, Chen M, Peng Y, Chen Q, Li S, Chen L. Feeding intolerance and risk of poor outcome in patients undergoing cardiopulmonary bypass surgery. Br J Nutr 2021; 126:1340-1346. [PMID: 33468265 PMCID: PMC8505710 DOI: 10.1017/s0007114521000167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/19/2020] [Accepted: 01/07/2021] [Indexed: 12/12/2022]
Abstract
We conducted a prospective, observational study to determine the incidence of feeding intolerance (FI) within 7 d of initiating enteral nutrition (EN) in patients undergoing cardiopulmonary bypass (CPB) and to evaluate the association between FI and a poor prognosis. Patients who underwent CPB surgery at Fujian Medical University Union Hospital between March 2020 and June 2020 were enrolled. According to the presence or absence of FI within 7 d after EN, patients were divided into FI and non-FI groups. According to the occurrence of a poor prognosis (death, gastrointestinal haemorrhage, acute kidney injury, liver insufficiency, neurological events (cerebral infarction, cerebral haemorrhage and epilepsy) and prolonged mechanical ventilation (> 48 h)), patients were divided into poor prognosis and good prognosis groups. The mean age of the 237 CPB patients, including 139 men and ninety-eight women, was 53·80 (sd 12·25) years. The incidence of FI was 64·14 %. Multivariate logistic regression analysis showed factors independently associated with poor prognosis after CPB included FI (OR 2·138; 95 % CI 1·058, 4·320), age (OR 1·033; 95 % CI 1·004, 1·063), New York Heart Association (NYHA) class III/IV cardiac function (OR 2·410; 95 % CI 1·079, 5·383), macrovascular surgery (OR 5·434; 95 % CI 1·704, 17·333) and initial sequential organ failure assessment score (OR 1·243; 95 % CI 1·010, 1·530). Thus, the incidence of FI within 7 d of EN after CPB was high, which was associated with a poor prognosis.
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Affiliation(s)
- Yanjuan Lin
- Department of Nursing, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou City, Fujian Province, People’s Republic of China
| | - Meihua Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou City, Fujian Province, People’s Republic of China
| | - Yanchun Peng
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou City, Fujian Province, People’s Republic of China
| | - Qiong Chen
- Fujian Medical University, 88 Jiaotong Road, Fuzhou City, Fujian Province, People’s Republic of China
| | - Sailan Li
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou City, Fujian Province, People’s Republic of China
| | - Liangwan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou City, Fujian Province, People’s Republic of China
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Chen R, Li W, Qiu Z, Zhou Q, Zhang Y, Li WY, Ding K, Meng QT, Xia ZY. Ischemic Postconditioning-Mediated DJ-1 Activation Mitigate Intestinal Mucosa Injury Induced by Myocardial Ischemia Reperfusion in Rats Through Keap1/Nrf2 Pathway. Front Mol Biosci 2021; 8:655619. [PMID: 33996908 PMCID: PMC8119885 DOI: 10.3389/fmolb.2021.655619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/12/2021] [Indexed: 01/23/2023] Open
Abstract
Intestinal mucosal barrier dysfunction induced by myocardial ischemia reperfusion (IR) injury often leads to adverse cardiovascular outcomes after myocardial infarction. Early detection and prevention of remote intestinal injury following myocardial IR may help to estimate and improve prognosis after acute myocardial infarction (AMI). This study investigated the protective effect of myocardial ischemic postconditioning (IPo) on intestinal barrier injury induced by myocardial IR and the underlying cellular signaling mechanisms with a focus on the DJ-1. Adult SD rats were subjected to unilateral myocardial IR with or without ischemic postconditioning. After 30 min of ischemia and 120 min of reperfusion, heart tissue, intestine, and blood were collected for subsequent examination. The outcome measures were (i) intestinal histopathology, (ii) intestinal barrier function and inflammatory responses, (iii) apoptosis and oxidative stress, and (iv) cellular signaling changes. IPo significantly attenuated intestinal injury induced by myocardial IR. Furthermore, IPo significantly increased DJ-1, nuclear Nrf2, NQO1, and HO-1 expression in the intestine and inhibited IR-induced apoptosis and oxidative stress. The protective effect of IPo was abolished by the knockdown of DJ-1. Conversely, the overexpression of DJ-1 provided a protective effect similar to that of IPo. Our data indicate that IPo protects the intestine against myocardial IR, which is likely mediated by the upregulation of DJ-1/Nrf2 pathway.
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Affiliation(s)
- Rong Chen
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wei Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhen Qiu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qin Zhou
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuan Zhang
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wen-Yuan Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ke Ding
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qing-Tao Meng
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhong-Yuan Xia
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
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Keschenau PR, Simons N, Klingel H, Reuter S, Foldenauer AC, Vieß J, Weidener D, Andruszkow J, Blümich B, Tolba R, Jacobs MJ, Kalder J. Perfusion-related changes in intestinal diffusion detected by NMR-MOUSE® monitoring in minipigs. Microvasc Res 2019; 125:103876. [DOI: 10.1016/j.mvr.2019.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 04/22/2019] [Accepted: 04/28/2019] [Indexed: 02/07/2023]
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Memet O, Zhang L, Shen J. Serological biomarkers for acute mesenteric ischemia. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:394. [PMID: 31555708 DOI: 10.21037/atm.2019.07.51] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute mesenteric ischemia (AMI) defines a complex of conditions characterized by an interruption of the splanchnic circulation, leading to insufficient oxygen delivery or utilization to fill the metabolic needs of the visceral organs. Early diagnosis and immediate therapy are the cornerstones of early ischemia to reach a successful outcome and are necessary to reduce the high mortality. Although there is still lack of specific biomarkers to assist the diagnosis of AMI in clinical practice, there are several biomarkers with high specificity, may become a potential tools in early diagnosis of AMI, including intestinal fatty acid binding protein (I-FABP), a-glutathione S-transferase (a-GST), D-dimer, L- and D-lactate, citrulline, ischemia modified albumin, procalcitonin (PCT). However, they use in clinical limited duo to the many studies about these makers finished with small patient populations, and heterogeneous among these populations. This review describes the etiology of AMI, the current most studied promising biomarkers, the current research situation and future of biomarker research.
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Affiliation(s)
- Obulkasim Memet
- Center of Emergency & Intensive Care Unit, Medical Center of Chemical Injury, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Lin Zhang
- Center of Emergency & Intensive Care Unit, Medical Center of Chemical Injury, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Jie Shen
- Center of Emergency & Intensive Care Unit, Medical Center of Chemical Injury, Jinshan Hospital, Fudan University, Shanghai 201508, China
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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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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: 14] [Impact Index Per Article: 2.3] [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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van Noord D, Kolkman JJ. Functional testing in the diagnosis of chronic mesenteric ischemia. Best Pract Res Clin Gastroenterol 2017; 31:59-68. [PMID: 28395789 DOI: 10.1016/j.bpg.2016.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/03/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Chronic mesenteric ischemia (CMI) results from insufficient oxygen delivery or utilization to meet metabolic demand. Two main mechanisms may lead to mesenteric ischemia: occlusion in the arteries or veins of the gastrointestinal tract, or reduced blood flow from shock states or increased intra-abdominal pressure, so-called non-occlusive mesenteric ischemia. Severe stenoses in the three main mesenteric vessels as demonstrated with CT-angiography or MR-angiography are sufficient to proof mesenteric ischemia, for example in patients who present with weight loss, postprandial pain and diarrhea. Still in many clinical situations mesenteric ischemia is only one of many possible explanations. Especially in patients with a single vessel stenosis in the celiac artery or superior mesenteric artery with postprandial pain, mesenteric ischemia remains a diagnosis of probability or assumption without functional proof of actual ischemia. This review is aimed to provide an overview of all past, present and future ways to functionally proof CMI.
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Affiliation(s)
- Desirée van Noord
- Erasmus MC University Medical Center Rotterdam, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands; Franciscus Gasthuis & Vlietland, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands.
| | - Jeroen J Kolkman
- Medisch Spectrum Twente, Department of Gastroenterology and Hepatology, Enschede, The Netherlands; Universitair Medisch Centrum Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands.
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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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Kalder J, Kokozidou M, Keschenau P, Tamm M, Greiner A, Koeppel TA, Tolba R, Jacobs MJ. Selective renal blood perfusion induces renal tubules injury in a porcine model. J Vasc Surg 2014; 63:778-87. [PMID: 25441670 DOI: 10.1016/j.jvs.2014.08.116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/30/2014] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Extracorporeal circulation is routinely used in thoracoabdominal aortic aneurysm repair to preserve blood perfusion. Despite this protective measure, acute and chronic kidney disorders can develop. Therefore, the aim of this study was to establish a new large-animal model to assess the efficacy of selective renal perfusion (SRP) with extracorporeal circulation in a setting of thoracoabdominal aortic aneurysm repair. METHODS Eighteen pigs underwent a thoracolaparotomy, during with the aorta and renal arteries were exposed. The animals were divided into three cohorts of six pigs each: cohort I--control; cohort II--thoracic aortic clamping with distal aortic perfusion (DAP) using a roller pump; and cohort III--thoracic aortic clamping with DAP plus SRP. Kidney metabolism, kidney injury, and red blood cell damage were measured by oxygen extraction ratio (O2ER), neutrophil gelatinase-associated lipocalin, a marker for acute kidney damage, and serum free hemoglobin. RESULTS With normal mean arterial blood pressures, flow rates in the renal arteries during perfusion decreased to 75% (group II) with DAP and to 50% (group III) with SRP compared with the control animals (group I; P = .0279 for I vs II; P = .0002 for I vs III). Microcirculation, measured by microspheres, did not differ significantly among the groups. In contrast, O2ER (P = .0021 for I vs III) and neutrophil gelatinase-associated lipocalin (P = .0083 for I vs III) levels were significantly increased in group III, whereas free hemoglobin was increased in groups II and III (P = .0406 for I vs II; P = .0018 for I vs III). CONCLUSIONS SRP with a roller pump induces kidney tubule injury. Thus, distal aortic and SRP in our model does not provide adequate kidney protection. Furthermore, the perfusion system provokes red blood cell damage with increased free hemoglobin. Hence, the SRP perfusion technique should be revised and tested.
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Affiliation(s)
- Johannes Kalder
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Aachen, Germany
| | - Maria Kokozidou
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Aachen, Germany
| | - Paula Keschenau
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Aachen, Germany
| | - Miriam Tamm
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Andreas Greiner
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Aachen, Germany
| | - Thomas A Koeppel
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Aachen, Germany
| | - Rene Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, RWTH Aachen University, Aachen, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Aachen, Germany; Department of Surgery, European Vascular Center Aachen-Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands.
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