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Lammy S, Blackmur JP, Perkins JMT. Intravenous heparin during ruptured abdominal aortic aneurysmal repair. Cochrane Database Syst Rev 2016; 2016:CD011486. [PMID: 27541335 PMCID: PMC8485975 DOI: 10.1002/14651858.cd011486.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There have been enormous advances in the screening, diagnosis, intervention and overall prognosis of abdominal aortic aneurysms (AAAs) in the last decade, but despite these, ruptured AAAs (rAAAs) still cause around 3500 to 6000 deaths in England and Wales each year. Open repair remains standard treatment for rAAA in most centres but increasingly endovascular aneurysm repair (EVAR) is being adopted. This has a 30-day postoperative mortality of 40%. This has remained static despite surgical, anaesthetic and critical care advances.One significant change to current practice for elective repairs of AAAs, as opposed to emergency repairs of rAAAs, has been the introduction of intravenous heparin. This provides a protective effect against cardiac and thrombotic disease in the postoperative period. This practice has not gained widespread acceptance for emergency repairs of rAAA even though a reduction in mortality and morbidity has been demonstrated in elective repairs. OBJECTIVES The primary objective was to assess the effect of intravenous heparin on all-cause mortality in ruptured abdominal aortic aneurysm (rAAA) management in people undergoing an emergency repair.The secondary objectives were to assess the effect of intravenous heparin in rAAA management on the incidence of general arterial disease, for example, cardiovascular, cerebral, pulmonary and renal pathologies, in people undergoing emergency repair. SEARCH METHODS The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (December 2015). In addition the CIS searched CENTRAL;2015, Issue 11). The CIS searched clinical trials registries for details of ongoing or unpublished studies. SELECTION CRITERIA We sought all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of intravenous heparin in rAAA repairs (including parallel designs). DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies identified for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. MAIN RESULTS We identified no RCTs or CCTs that satisfied the inclusion criteria. AUTHORS' CONCLUSIONS We identified no RCTs or CCTs of intravenous heparin in rAAA repairs (including parallel designs). Therefore, we were unable to assess the effect of intravenous heparin on all-cause mortality and incidence of general arterial disease, for example, cardiovascular, cerebral, pulmonary and renal pathologies in rAAA management in people undergoing an emergency repair. It is clear that an RCT is needed to address this question in rAAA management as there is no high quality evidence.
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Affiliation(s)
- Simon Lammy
- Queen Elizabeth University Hospital (The Southern General Hospital)Institute of Neurological Sciences1345 Govan RoadGlasgowScotlandUKG51 4TF
- University of OxfordNuffield Department of Surgical SciencesHeadley WayHeadingtonOxfordUKOX3 9DU
| | - James P Blackmur
- University Hospital AyrDepartment of Urological SurgeryDalmellington RoadAyrUKDA6 6KD
| | - Jeremy MT Perkins
- John Radcliffe HospitalDepartment of Vascular & Endovascular SurgeryHeadley WayHeadingtonOxfordUKOX3 9DU
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Graham AP, Fitzgerald O'Connor E, Hinchliffe RJ, Loftus IM, Thompson MM, Black SA. The use of heparin in patients with ruptured abdominal aortic aneurysms. Vascular 2012; 20:61-4. [PMID: 22454548 DOI: 10.1258/vasc.2011.ra0051] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The use of systemic heparin in patients with ruptured abdominal aortic aneurysms (rAAAs) remains a contentious issue with no clear guidelines. This review reports the current understanding, at a molecular and clinical level, of the possible benefits and risks of heparin in emergency aneurysm repair (both open and endovascular). MEDLINE, EMBASE, AMED, SCOPUS, CINAHL and Cochrane Library were searched for all articles containing the keywords 'rupture', 'abdominal', 'aneurysm' and 'heparin'. Current experience, indications and outcomes were analyzed. Articles were searched for both endovascular and open repair of AAAs. A total of eight studies were included for analysis in the systematic review. Of these, only one paper focused specifically on heparin use in open repair of ruptures and suggested a benefit. Of the remaining seven, two were self-reporting retrospective studies assessing individual surgeons' practice, one was a case report and the remaining four included mention of heparin use but with no outcome data. The evidence available suggests that a pro-coagulable state exists in rAAAs. This may be responsible for the morbidity and mortality postprocedure, which arises predominantly from multiple organ failure and cardiac compromise rather than outright hemorrhage. This diathesis may respond well to heparin administration, suggesting that heparin administration in ruptured aneurysms is appropriate.
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Affiliation(s)
- A P Graham
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
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Cruden NL, Harding SA, Flapan AD, Graham C, Wild SH, Slack R, Pell JP, Newby DE. Previous Coronary Stent Implantation and Cardiac Events in Patients Undergoing Noncardiac Surgery. Circ Cardiovasc Interv 2010; 3:236-42. [DOI: 10.1161/circinterventions.109.934703] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Noncardiac surgery performed after coronary stent implantation is associated with an increased risk of stent thrombosis, myocardial infarction, and death. The influence of stent type and period of risk still have to be defined.
Methods and Results—
We linked the Scottish Coronary Revascularisation Register with hospital admission data to undertake a Scotland-wide retrospective cohort study examining cardiac outcomes in all patients who received drug-eluting or bare-metal stents between April 2003 and March 2007 and subsequently underwent noncardiac surgery. Of 1953 patients, 570 (29%) were treated with at least 1 drug-eluting stent and 1383 (71%) with bare-metal stents only. There were no differences between drug-eluting and bare-metal stents in the primary end point of in-hospital mortality or ischemic cardiac events (14.6% versus 13.3%;
P
=0.3) or the secondary end points of in-hospital mortality (0.7% versus 0.6%;
P
=0.8) and acute myocardial infarction (1.2% versus 0.7%;
P
=0.3). Perioperative death and ischemic cardiac events occurred more frequently when surgery was performed within 42 days of stent implantation (42.4% versus 12.8% beyond 42 days;
P
<0.001), especially in patients revascularized after an acute coronary syndrome (65% versus 32%;
P
=0.037). There were no temporal differences in outcomes between the drug-eluting and bare-metal stent groups.
Conclusions—
Patients undergoing noncardiac surgery after recent coronary stent implantation are at increased risk of perioperative myocardial ischemia, myocardial infarction, and death, particularly after an acute coronary syndrome. For at least 2 years after percutaneous coronary intervention, cardiac outcomes after noncardiac surgery are similar for both drug-eluting and bare-metal stents.
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Affiliation(s)
- Nicholas L.M. Cruden
- From the Centre for Cardiovascular Science (N.L.M.C., D.E.N.), University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology (S.A.H.), Wellington Public Hospital, Wellington, New Zealand; Department of Cardiology (A.D.F.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Wellcome Trust Clinical Research Facility (C.G.), University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom; Public Health Sciences (S.H.W.), University of Edinburgh, Edinburgh, United
| | - Scott A. Harding
- From the Centre for Cardiovascular Science (N.L.M.C., D.E.N.), University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology (S.A.H.), Wellington Public Hospital, Wellington, New Zealand; Department of Cardiology (A.D.F.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Wellcome Trust Clinical Research Facility (C.G.), University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom; Public Health Sciences (S.H.W.), University of Edinburgh, Edinburgh, United
| | - Andrew D. Flapan
- From the Centre for Cardiovascular Science (N.L.M.C., D.E.N.), University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology (S.A.H.), Wellington Public Hospital, Wellington, New Zealand; Department of Cardiology (A.D.F.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Wellcome Trust Clinical Research Facility (C.G.), University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom; Public Health Sciences (S.H.W.), University of Edinburgh, Edinburgh, United
| | - Cat Graham
- From the Centre for Cardiovascular Science (N.L.M.C., D.E.N.), University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology (S.A.H.), Wellington Public Hospital, Wellington, New Zealand; Department of Cardiology (A.D.F.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Wellcome Trust Clinical Research Facility (C.G.), University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom; Public Health Sciences (S.H.W.), University of Edinburgh, Edinburgh, United
| | - Sarah H. Wild
- From the Centre for Cardiovascular Science (N.L.M.C., D.E.N.), University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology (S.A.H.), Wellington Public Hospital, Wellington, New Zealand; Department of Cardiology (A.D.F.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Wellcome Trust Clinical Research Facility (C.G.), University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom; Public Health Sciences (S.H.W.), University of Edinburgh, Edinburgh, United
| | - Rachel Slack
- From the Centre for Cardiovascular Science (N.L.M.C., D.E.N.), University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology (S.A.H.), Wellington Public Hospital, Wellington, New Zealand; Department of Cardiology (A.D.F.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Wellcome Trust Clinical Research Facility (C.G.), University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom; Public Health Sciences (S.H.W.), University of Edinburgh, Edinburgh, United
| | - Jill P. Pell
- From the Centre for Cardiovascular Science (N.L.M.C., D.E.N.), University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology (S.A.H.), Wellington Public Hospital, Wellington, New Zealand; Department of Cardiology (A.D.F.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Wellcome Trust Clinical Research Facility (C.G.), University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom; Public Health Sciences (S.H.W.), University of Edinburgh, Edinburgh, United
| | - David E. Newby
- From the Centre for Cardiovascular Science (N.L.M.C., D.E.N.), University of Edinburgh, Edinburgh, United Kingdom; Department of Cardiology (S.A.H.), Wellington Public Hospital, Wellington, New Zealand; Department of Cardiology (A.D.F.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Wellcome Trust Clinical Research Facility (C.G.), University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom; Public Health Sciences (S.H.W.), University of Edinburgh, Edinburgh, United
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Hobbs SD, Haggart P, Fegan C, Bradbury AW, Adam DJ. The role of tissue factor in patients undergoing open repair of ruptured and nonruptured abdominal aortic aneurysms. J Vasc Surg 2007; 46:682-6. [PMID: 17764874 DOI: 10.1016/j.jvs.2007.05.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Accepted: 05/23/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ruptured abdominal aortic aneurysm (AAA) is associated with the development of a procoagulant and hypofibrinolytic state. Tissue factor (TF) and its naturally occurring inhibitor, tissue factor pathway inhibitor (TFPI), play a central role in the initiation and progression of such a hypercoagulable state, but their role in patients undergoing open AAA repair has not previously been examined. METHODS A prospective study was conducted of 17 patients undergoing elective AAA repair and 10 patients undergoing emergency AAA repair. Blood was taken before induction, and 5 minutes, 24 hours, and 48 hours after aortic cross-clamp release and assayed for plasma TF, TFPI, tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI), and thrombin-activatable fibrinolysis inhibitor (TAFI) activities. RESULTS TF activity was significantly higher at all time points in patients with ruptured AAA compared with nonruptured AAA. The median (interquartile range, IRQ) TF activity (AU/mL) was 9.9 vs 3.2 (IRQ, 5.9 to 12.6 vs 2.0 to 7.6; P = .005) at preinduction; 10.7 vs 1.5 (IRQ, 9.2 to 18.3 vs 0.1 to 6.6; P = .003) at 5 minutes after clamp release; 9.5 vs 3.3 (IRQ, 7.0 to 13.5 vs 1.0 to 7.9; P = .013) at 24 hours, and 9.6 vs 3.9 (IRQ, 7.6 to 12.6 vs 2.4 to 8.7; P = .006) at 48 hours. TFPI levels were not significantly different between ruptured AAA and nonruptured AAA before or during operation but became significantly elevated at 24 and 48 hours in patients who had undergone repair of ruptured AAA. Ruptured AAA repair was associated with a hypofibrinolytic state compared with nonruptured AAA. CONCLUSIONS The present study has demonstrated for the first time, to our knowledge, that ruptured AAA is associated with significantly higher perioperative levels of circulating TF compared with nonruptured AAA. Furthermore, in the immediate perioperative period, the high levels of TF are not associated with a corresponding rise in TFPI levels, indicating an unopposed prothrombotic state. Direct inhibition of TF by administration of anti-TF antibodies or recombinant TFPI remains to be evaluated in subjects presenting with hemorrhage due to ruptured AAA, but if given early enough, it may attenuate the early deleterious effects of unopposed TF expression and ultimately contribute to improved outcomes.
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Affiliation(s)
- Simon D Hobbs
- University Department of Vascular Surgery, Heart of England National Health Service Foundation Trust, Birmingham, UK
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Abstract
Because of changing demographics, increasing numbers of patients with IHD are presenting for noncardiac surgery, and the risks of perioperative morbidity and mortality are significant. The Lee Cardiac Risk Index is applicable in defining perioperative cardiac risk: however, ACC/AHA guidelines may not be applicable comprehensively. The role of biomarkers in risk stratification still needs to be defined. Structured management protocols that help assess, diagnose, and treat patients with IHD preoperatively are likely to help decrease postoperative morbidity and mortality, but clearly are not applicable to all patients. Augmented hemodynamic control with beta-blockers or alpha-2 agonists and modulating inflammation by statins can play an important role in improving outcomes in many patients with IHD; preoperative coronary revascularization may be of limited value. Intraoperative anesthetic management that minimizes hemodynamic perturbations is important; however, the choice of a particular technique typically is not critical. Of critical importance is the postoperative management of the patient. Postoperative myocardial injury should be identified, evaluated, and managed aggressively. Secondary stresses such as sepsis, extubation, and anemia, which can increase demand on the heart, should be treated or minimized. Clearly, optimal care of the patient with IHD entails closely coordinated assessment and management throughout the preoperative, intraoperative, and postoperative phases, if one is to optimize short- and long-term outcomes.
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Affiliation(s)
- Shamsuddin Akhtar
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP-3, New Haven, CT 06520-8051, USA.
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Hobbs SD, Yapanis M, Burns PJ, Wilmink AB, Bradbury AW, Adam DJ. Peri-operative Myocardial Injury in Patients Undergoing Surgery for Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2005; 29:301-4. [PMID: 15694805 DOI: 10.1016/j.ejvs.2004.11.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2004] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Although up to a half of patients undergoing abdominal aortic aneurysm (AAA) repair suffer myocardial injury, as indicated by a rise in cardiac troponin I (cTnI), this is infrequently accompanied by a rise in creatine kinase (CK)-MB fraction or electrocardiogram (ECG) changes. This study compares for the first time peri-operative cTnI, CK-MB and ECG changes in patients undergoing surgery for critical lower limb ischaemia (CLI). METHODS Twenty-nine patients (20 men, median age 75 [range, 57-95] years) were studied prospectively. cTnI, CK/CK-MB ratio and ECG were performed pre-operatively and on post-operative days 1, 2 and 3. RESULTS Eleven (38%) patients had an elevated cTnI >0.5 ng/ml. Five (17%) patients had an elevated CK-MB fraction >4% and all of these patients had an elevated cTnI. Eleven (38%) patients had ischaemic changes on ECG including seven of 11 (64%) patients with elevated cTnI and all five patients with elevated CK-MB fraction. There was no relationship between pre-operative cardiac status, antiplatelet use or type of anaesthesia and post-operative cTnI rise. Patients with a cTnI rise were younger (p=0.01), and were more likely to have presented with gangrene (p=0.04) and have a longer operation time (p=0.01) than patients who did not demonstrate a cTnI rise. Four patients developed clinically apparent cardiac complications: cardio-pulmonary arrest (n=1), cardiogenic shock (n=1), acute CCF (n=1) and rapid atrial fibrillation (n=1). Survival at 6 months was 26 of 29 (90%) patients. CONCLUSION These data demonstrate that over a third of patients operated for CLI sustain peri-operative myocardial injury, many of which are not clinically apparent. Pre-operative medical optimisation may improve prognosis in this group of patients.
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Affiliation(s)
- S D Hobbs
- University Department of Vascular Surgery, Birmingham Heartlands Hospital, Birmingham, UK
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Adam DJ, Haggart PC, Ludlam CA, Bradbury AW. Coagulopathy and Hyperfibrinolysis in Ruptured Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2004; 18:572-7. [PMID: 15534737 DOI: 10.1007/s10016-004-0087-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Perioperative hemorrhage is one of the principal causes of death in patients with ruptured abdominal aortic aneurysm (AAA). This study examines perioperative coagulation and fibrinolysis in patients undergoing ruptured AAA repair complicated by coagulopathy. Eight patients (8 men of median age 74, range 69-87, years) who developed clinical and laboratory evidence of coagulopathy during attempted repair of ruptured infrarenal AAA were prospectively studied. Platelet count, fibrinogen, clotting times, prothrombin fragment (PF) 1+2, and tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI) activities were measured preoperatively, immediately before, and 5 min and 24 hr after aortic declamping. Six patients died, three intraoperatively, one within 24 hr, and two in the late postoperative period. All patients had thrombocytopenia and prolonged clotting times intraoperatively with evidence of increased thrombin generation (as demonstrated by elevated PF 1+2). Five patients had increased systemic fibrinolysis (as demonstrated by elevated t-PA activity) preoperatively and/or before aortic declamping and all of these patients died. Three patients had perioperative inhibition of systemic fibrinolysis (as demonstrated by elevated PAI activity) and two survived. These data demonstrate that coagulopathy in ruptured AAA repair may be associated with a hyperfibrinolytic state. Further research is required to determine if (a) a causal relationship exists between hyperfibrinolysis and coagulopathy and (b) whether antifibrinolytic agents can improve outcome if targeted at this group of patients.
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Affiliation(s)
- D J Adam
- University Department of Vascular Surgery, Birmingham Heartlands Hospital, Birmingham, UK.
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