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Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
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Ansah Owusu F, Javed H, Saleem A, Singh J, Varrassi G, Raza SS, Ram R. Beyond the Scalpel: A Tapestry of Surgical Safety, Precision, and Patient Prosperity. Cureus 2023; 15:e50316. [PMID: 38205460 PMCID: PMC10776504 DOI: 10.7759/cureus.50316] [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: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 01/12/2024] Open
Abstract
In modern surgical practice, the focus extends beyond simply making and closing incisions. We aim to investigate the various complex aspects that redefine the criteria for achieving effective surgical outcomes. This narrative combines current knowledge, integrating practical experiences and academic viewpoints to comprehend the changing field of surgical care thoroughly. The tapestry explores the detailed aspects of surgical safety, examining the most recent progress in protocols, technology, and team dynamics that strive to reduce procedural risks. Examining precision in surgery, this narrative goes beyond conventional limits to explore the incorporation of advanced technologies, such as robotics and navigational systems. The complex interplay between the surgeon's proficiency and these technology aids is crucial in attaining unparalleled accuracy and favorable patient results. The focal point of this investigation is the patient's well-being, encompassing postoperative care, rehabilitation, and long-term health. Actual accounts from surgical procedures highlight the significant influence of comprehensive patient-centered methods, emphasizing the crucial need for empathy, communication, and individualized care plans in promoting healing and adaptability. As we explore this complex situation, the combination of real-life stories and academic discussions creates a clear and detailed image of a surgical environment that goes far beyond the boundaries of the operating room. "Beyond the Scalpel" seeks to engage practitioners, scholars, and stakeholders in a conversation that redefines the criteria for surgical success. It aims to establish a new benchmark that combines safety, precision, and patient well-being, ultimately shaping the future of surgical practice.
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Affiliation(s)
| | - Herra Javed
- Surgery, Shifa College of Medicine, Islamabad, PAK
| | - Ayesha Saleem
- General Surgery, Hayatabad Medical Complex (HMC), Peshawar, PAK
| | - Jagjeet Singh
- Internal Medicine, Lahore General Hospital, Lahore, PAK
| | | | - Syed S Raza
- Physiology, Gajju Khan Medical College, Swabi, PAK
- Physiology, Khyber Medical College/Teaching Hospital, Peshawar, PAK
- Robert and Suzanne Tomsich Department of Cardiothoracic Surgery, Cleveland Clinic Florida, Peshawar, PAK
- Physiology, Gandhara University, Peshawar, PAK
| | - Raja Ram
- Medicine, MedStar Washington Hospital Center, Washington, USA
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Hussain AK, Kakakhel MM, Ashraf MF, Shahab M, Ahmad F, Luqman F, Ahmad M, Mohammed Nour A, Varrassi G, Kinger S. Innovative Approaches to Safe Surgery: A Narrative Synthesis of Best Practices. Cureus 2023; 15:e49723. [PMID: 38161861 PMCID: PMC10757557 DOI: 10.7759/cureus.49723] [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: 11/26/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
By encompassing a wide range of best practices within the ever-changing realm of modern surgical care, this exhaustive narrative compendium attempts to unravel the complex tapestry of novel approaches to safe surgery. Within the context of a dynamic surgical environment, this research endeavors to illuminate and integrate state-of-the-art methods that collectively methodically improve patient safety. The narrative elucidates a diverse array of practices that seek to revolutionize the paradigm of safe surgery, emphasizing technological progress, patient-centric approaches, and global viewpoints. The combined effectiveness of these methods in fostering an all-encompassing culture of safety, improving surgical precision, and decreasing complications is revealed by the results obtained from their implementation. The recognition of the dynamic interplay among multiple components, including the active participation of patients, the integration of cutting-edge technologies, and the establishment of comprehensive quality improvement programs, is fundamental to this narrative. By their collective composition, these components support the notion that secure surgical practices are intricate and interrelated. The present synthesis functions as a fundamental resource for healthcare professionals, policymakers, and researchers, providing an enlightening examination of the current condition of secure surgical practices. By emphasizing the promotion of innovation, continuous development, and the utmost quality of patient care, it offers a strategic guide for navigating the complex terrain of safe surgery. In the ever-evolving landscape of surgical care, this narrative synthesis serves as a guiding principle for stakeholders striving to understand better and implement safe surgical procedures in various healthcare environments.
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Affiliation(s)
- Amer Kamal Hussain
- Urology, Sandwell and West Birmingham Hospitals National Health Service (NHS) Trust, Birmingham, GBR
| | - Muhammad Maaz Kakakhel
- Trauma and Orthopaedics, Liverpool University Hospitals National Health Service (NHS) Foundation Trust, Liverpool, GBR
| | | | | | - Fahad Ahmad
- Upper Gastrointestinal Surgery, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Birmingham, GBR
| | - Faizan Luqman
- Ophthalmology, Khyber Medical College, Peshawar, PAK
- Ophthalmology, Medical Teaching Institution (MTI) Khyber Teaching Hospital, Peshawar, PAK
| | - Mahmood Ahmad
- Trauma and Orthopaedics, Royal College of Surgeons, Dublin, IRL
| | - Ayman Mohammed Nour
- Urology, Sandwell and West Birmingham Hospitals National Health Service (NHS) Trust, Birmingham, GBR
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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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Lester LC, Kostibas MP. Anesthetic Management for Open Thoracoabdominal and Abdominal Aortic Aneurysm Repair. Anesthesiol Clin 2022; 40:705-718. [PMID: 36328624 DOI: 10.1016/j.anclin.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Open thoracoabdominal and abdominal aortic aneurysm repairs are some of the most challenging cases for anesthesiologists because of the potential for rapid blood loss combined with clamping and reperfusion, potential use of left heart bypass, the potential need for lung isolation, and potential placement and management of a spinal drain. In addition, patients often present with other significant comorbidities and a detailed understanding of the disease process, the complex physiology throughout the case, and the intricacies of organ protection are critical.
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Affiliation(s)
- Laeben Chola Lester
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Zayed 6212, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Megan P Kostibas
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Zayed 6212, 1800 Orleans Street, Baltimore, MD 21287, USA.
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Ertugay S, Apaydin AZ, Karaca S, Ergi DG, Posacioglu H. Distal Perfusion With Modified Centrifugal Pump Circuit in Thoracic and Thoracoabdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2022; 56:737-742. [PMID: 35694966 DOI: 10.1177/15385744221108049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The left heart bypass is currently the most frequent adjunct to provide distal aortic perfusion during aortic clamping. However, closed-circuits cannot respond to sudden hemodynamic fluctuations during aortic clamping which may lead to complications. In this report, we aim to give the technical aspects of reservoir-added centrifugal pump circuit system, its implementation and the clinical outcomes. METHODS Between 2002 and 2020, the data of 35 patients underwent aortic aneurysm repair with the use of modified pump circuit were analyzed. The mean age was 53.4 years (range 24-73) and 91.4% of all was male. Preoperative demographics, intraoperative pump data and postoperative clinical outcomes were reported. RESULTS Thoracoabdominal incision was used in 22 patients (62.9%) and cerebrospinal fluid (CSF) drainage catheter was placed in 15 patients (42.9%). The left inferior pulmonary vein for outflow and the left femoral artery for inflow cannulation were used preferably. Median duration of pump support was 50 mins (13-121) in the cohort. The median transfusion of red packed cells was 2 units. Renal failure was observed in two patients and permanent paraplegia in one patient. Only one patient died in the elective group (1/34) and one patient in the emergent. CONCLUSIONS The reservoir-added centrifugal pump is an effective, practical, and flexible perfusion system which should be in the armamentarium of surgeons in order to solve difficult problems during open repair of descending and thoracoabdominal aortic aneurysms.
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Affiliation(s)
- Serkan Ertugay
- Department of Cardiovascular Surgery, 60521Ege University School of Medicine, Izmir, Turkey
| | - Anil Z Apaydin
- Department of Cardiovascular Surgery, 60521Ege University School of Medicine, Izmir, Turkey
| | - Sedat Karaca
- Department of Cardiovascular Surgery, 60521Ege University School of Medicine, Izmir, Turkey
| | - Defne G Ergi
- Department of Cardiovascular Surgery, 60521Ege University School of Medicine, Izmir, Turkey
| | - Hakan Posacioglu
- Department of Cardiovascular Surgery, 60521Ege University School of Medicine, Izmir, Turkey
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Jang AY, Oh PC, Kang JM, Park CH, Kang WC. Extensive complex thoracoabdominal aortic aneurysm salvaged by surgical graft providing landing zone for endovascular graft: A case report. World J Clin Cases 2022; 10:5005-5011. [PMID: 35801037 PMCID: PMC9198850 DOI: 10.12998/wjcc.v10.i15.5005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/07/2022] [Accepted: 03/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Surgical repair of complex abdominal aortic aneurysm is associated with a higher perioperative mortality and morbidity. The advent of endovascular aortic repair (EVAR) has reduced perioperative complications, although the utilization of such techniques is limited by lesion characteristics, such as involvement of the visceral or renal arteries (RA) and/or presence of a sealing zone.
CASE SUMMARY A 60-year-old male presented with a Crawford type IV complex thoracoabdominal aortic aneurysm (CAAA) starting directly distal to the diaphragm extending to both common iliac arteries (CIAs). The CAAA consist of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level. Due to the poor performance of the patient and the expansive disease, we planned a stepwise-combined surgery and EVAR to minimize invasiveness. A branched graft was implanted after surgical debranching of the visceral and RA. Since the patient had renal and liver injury after surgery, the second stage EVAR was performed 10 mo later. The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR. The patient has been uneventful for 5-years after discharge and is being followed in the outpatient clinic.
CONCLUSION The current case demonstrates that the surgical graft can provide a landing zone for second stage EVAR to avoid aggressive surgery in patients with poor performance with a long hostile CAAA.
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Affiliation(s)
- Albert Youngwoo Jang
- Department of Cardiology, Gachon University Gil Medical Center, Incheon 1198, South Korea
| | - Pyung Chun Oh
- Department of Internal Medicine, Gil Medical Center, Gachon Cardiovascular Research Institute, Gachon University College of Medicine, Incheon 1198, South Korea
| | - Jin Mo Kang
- Division of Vascular Surgery, Gachon University Gil Medical Center, Incheon 1198, South Korea
| | - Chul Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Incheon 1198, South Korea
| | - Woong Chol Kang
- Division of Cardiology, Gil Medical Center, Gachon University of Medicine and Science, Incheon 1198, South Korea
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Mannitol Use is Renal Protective in Patients with Chronic Kidney Disease Requiring Suprarenal Aortic Clamping. Ann Vasc Surg 2022; 85:77-86. [PMID: 35452789 DOI: 10.1016/j.avsg.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Objective: Mannitol is often administered during open juxtarenal or suprarenal aortic surgery to prevent ischemic injury to the kidneys. Prior evidence evaluating the benefits of intraoperative mannitol in reducing ischemia/reperfusion injury is conflicting and largely based on small, retrospective series. The aim of this study was to evaluate the effect of mannitol in preventing postoperative hemodialysis in patients undergoing open abdominal aortic aneurysm (AAA) repair where proximal control involved temporary renal ischemia. METHODS Methods: The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. Patients were included in the current analysis if the proximal aortic clamp was placed above at least one renal artery. Chronic kidney disease (CKD) was defined as Cr >1.8mg/dL. Primary endpoints were 30-day major morbidity (myocardial infarction, respiratory complications, lower extremity or intestinal ischemia, and the need for temporary or permanent hemodialysis) and mortality. Comparisons were made between the mannitol and non-mannitol cohorts and stratified by the presence of pre-existing CKD. RESULTS Results: During the study period, 4,156 patients underwent elective open AAA repair requiring clamp placement above one (32.7%) or both (67.3%) renal arteries; 182 patients (4.4%) had pre-existing CKD. Overall, 69.8% of patients received mannitol during their surgery. Mannitol was more frequently used in cases involving clamp placement above both renal arteries (70.3%) than one renal artery (61.5%). While prolonged ischemia time (greater than 40 minutes) was associated with higher risk of post-operative dialysis in patients without CKD, it was not significant in patients with baseline CKD. On univariate analysis, mannitol use in patients with CKD was associated with lower risk of post-operative dialysis (p=0.005). This remained significant on multivariate analysis (p=0.008). Mannitol use did not appear to confer renal protective effects in patients without baseline CKD. CONCLUSIONS Conclusion: Mannitol use was associated with a decreased risk of need for post-operative hemodialysis in patients with CKD undergoing suprarenal aortic clamping for open aneurysm repair. In appropriately selected patients, particularly those with underlying renal insufficiency, mannitol may confer a renal protective effect in open repair of pararenal AAA requiring suprarenal clamping.
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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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Barsuk AL, Nekaeva ES, Lovtsova LV, Urakov AL. Selective Intestinal Decontamination as a Method for Preventing Infectious Complications (Review). Sovrem Tekhnologii Med 2021; 12:86-95. [PMID: 34796022 PMCID: PMC8596238 DOI: 10.17691/stm2020.12.6.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Indexed: 11/14/2022] Open
Abstract
Infectious complications are the most common cause of death in patients with severe burns. To date, there is no generally accepted method for preventing such complications in burn injury. One of the possible prevention options is selective intestinal decontamination (SID). This method is based on the enteral administration of non-absorbable antimicrobial agents. The preventive effect of SID involves inhibition of intestinal microflora translocation through the mucous membranes, inasmuch as studies demonstrate that endogenous opportunistic microorganisms are a common cause of infectious complications in various critical conditions. The SID method was originally developed in the Netherlands for patients suffering from mechanical injury. Antimicrobial drugs were selected based on their high activity in relation to the main endogenous opportunistic pathogens and minimal activity against normal intestinal microflora components. The combination of polymyxin (B or E), tobramycin, and amphotericin B with intravenous cefotaxime was chosen as the first SID regimen. Other regimens were proposed afterwards, and the application field of the method was expanded. In particular, it became the method of choice for prevention of infectious complications in patients with severe burn injury. Clinical studies demonstrate efficacy of some SID regimens for preventing infectious complications in patients with thermal injury. Concomitant administration of SID and systemic preventive antibiotics and addition of oropharyngeal decontamination increases the method efficacy. SID is generally well-tolerated, but some studies show an increased risk of diarrhea with this preventive option. In addition, SID increases the risk of developing antibiotic resistance like any other antibiotic regimens.
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Affiliation(s)
- A L Barsuk
- Associate Professor, Department of General and Clinical Pharmacology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - E S Nekaeva
- Head of Admission and Consultation Department, Clinical Pharmacologist, University Clinic; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - L V Lovtsova
- Associate Professor, Head of the Department of General and Clinical Pharmacology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A L Urakov
- Professor, Head of the Department of General and Clinical Pharmacology; Izhevsk State Medical Academy, 281 Kommunarov St., Izhevsk, 426034, Udmurt Republic, Russia; Leading Researcher, Department of Modeling and Synthesis of Technological Processes Udmurt Federal Research Center, Ural Branch of the Russian Academy of Sciences, 34 Tatyany Baramzinoy St., Izhevsk, 426067, Udmurt Republic, Russia
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Busch A, Wolk S, Lutz B, Zimmermann C, Ankudinov M, Klenk D, Ehehalt F, Rössel T, Ludwig S, Reeps C. [Open thoracic and thoracoabdominal aortic repair vs. f/bTEVAR - complementary or competitive?]. Zentralbl Chir 2021; 146:470-478. [PMID: 34666359 DOI: 10.1055/a-1562-2770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The classical approach of open repair (OR) for thoracic and thoracoabdominal aortic pathologies, including aneurysms and dissection, has been outnumbered by the use of fenestrated/branched (thoracic) endovascular aortic repair (f/b[T]EVAR) in recent years. Providing OR for complex cases in an aortic service requires a dedicated surgical setup and a huge body of expertise in this particular field.In order to reduce specific complications, such as perioperative mortality, kidney failure, spinal cord ischemia, stroke or bowel ischemia, it is necessary to apply cerebrospinal-spinal fluid drainage, point-of-care coagulation therapy, distal and retrograde aortic perfusion and sequential clamping. Despite the predominance of endovascular solutions, the specific OR expertise is still needed for specific indications, such as young patients, connective tissue disorder or aortic graft infections.Currently, the short and mid term results for f/b(T)EVAR outweigh those for OR, including the shorter hospital stay and less invasive procedures. However, OR provides better long-term results for overall mortality, re-intervention rates and secondary complications.In conclusion, in our opinion OR is a service that is still necessary for dedicated aortic centres, but will most likely become more frequent again in the years to come.
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Affiliation(s)
- Albert Busch
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Steffen Wolk
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Brigitta Lutz
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Carolin Zimmermann
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Miroslav Ankudinov
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - David Klenk
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Florian Ehehalt
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Thomas Rössel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Stefan Ludwig
- General, Thoracic and Vascular Surgery, University of Dresden, Dresden, Germany
| | - Christian Reeps
- Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
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Loschi D, Melloni A, Kahlberg A, Chiesa R, Melissano G. Kidney protection in thoracoabdominal aortic aneurysm surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:326-338. [PMID: 33307647 DOI: 10.23736/s0021-9509.20.11745-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute kidney injury (AKI) is a common complication of both open and endovascular repair of thoracoabdominal aortic aneurysms (TAAA). Its definition varies across difference studies, some standardized definitions (RIFLE, AKIN, KDIGO) have been proposed but still not uniformly employed in published papers. Acute kidney injury is multifactorial and is associated with increased in-hospital mortality, long-term mortality and late renal function decline. In addition, AKI is also associated with perioperative spinal cord ischemia. No specific pharmacological strategy has received a strong recommendation with high level of evidence as a protective measure. Fenoldopam, methylprednisolone or mannitol use to prevent AKI is commonly employed, but not supported by literature data. Avoiding nephrotoxic drugs and maintaining an adequate MAP, during and after the procedure plays a key role in preserving kidney function. During open TAAA surgery, renal arteries may be reimplanted using different techniques. The choice of the best option must be tailored to the patient, to reduce ischemic time and guarantee long-term patency. Current experience suggests that cold crystalloid solutions are the best substrates in preventing ischemia-reperfusion injury. Renal perfusion using Custodiol® (Dr Franz-Kohler Chemie GmbH; Bensheim, Germany) 4 °C, even if currently considered off-label, represents an encouraging organ protection tool. In endovascular TAAA repair, techniques such as fusion imaging, use of diluted contrast, and CO<inf>2</inf> subtraction angiography have the potential to reduce postoperative AKI. Visceral vessels patency is closely related to the anatomy. Therefore, accurate endograft design according to these characteristics is crucial for long-term preservation of renal function.
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Affiliation(s)
- Diletta Loschi
- Division of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy -
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Strand K, Søreide E, Kirkegaard H, Taccone FS, Grejs AM, Duez CHV, Jeppesen AN, Storm C, Rasmussen BS, Laitio T, Hassager C, Toome V, Hästbacka J, Skrifvars MB. The influence of prolonged temperature management on acute kidney injury after out-of-hospital cardiac arrest: A post hoc analysis of the TTH48 trial. Resuscitation 2020; 151:10-17. [PMID: 32087257 DOI: 10.1016/j.resuscitation.2020.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/27/2019] [Accepted: 01/22/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common after cardiac arrest and targeted temperature management (TTM). The impact of different lengths of cooling on the development of AKI has not been well studied. In this study of patients included in a randomised controlled trial of TTM at 33 °C for 24 versus 48 h after cardiac arrest (TTH48 trial), we examined the influence of prolonged TTM on AKI and the incidence and factors associated with the development of AKI. We also examined the impact of AKI on survival. METHODS This study was a sub-study of the TTH48 trial, which included patients cooled to 33 ± 1 °C after out-of-hospital cardiac arrest for 24 versus 48 h. AKI was classified according to the KDIGO AKI criteria based on serum creatinine and urine output collected until ICU discharge for a maximum of seven days. Survival was followed for up to six months. The association of admission factors on AKI was analysed with multivariate analysis and the association of AKI on mortality was analysed with Cox regression using the time to AKI as a time-dependent covariate. RESULTS Of the 349 patients included in the study, 159 (45.5%) developed AKI. There was no significant difference in the incidence, severity or time to AKI between the 24- and 48-h groups. Serum creatinine values had significantly different trajectories for the two groups with a sharp rise occurring during rewarming. Age, time to return of spontaneous circulation, serum creatinine at admission and body mass index were independent predictors of AKI. Patients with AKI had a higher mortality than patients without AKI (hospital mortality 36.5% vs 12.5%, p < 0.001), but only AKI stages 2 and 3 were independently associated with mortality. CONCLUSIONS We did not find any association between prolonged TTM at 33 °C and the risk of AKI during the first seven days in the ICU. AKI is prevalent after cardiac arrest and TTM and occurs in almost half of all ICU admitted patients and more commonly in the elderly, with an increasing BMI and longer arrest duration. AKI after cardiac arrest is an independent predictor of time to death.
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Affiliation(s)
- Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Norway.
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Emergency Department, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | | | - Anders Morten Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- Research Centre for Emergency Medicine and Emergency Department, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-University, Berlin, Germany
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Finland
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Valdo Toome
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Johanna Hästbacka
- Department of Anaesthesiology, Intensive Care and Paine Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital, Finland
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Affiliation(s)
- Nicholas J. Swerdlow
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Winona W. Wu
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L. Schermerhorn
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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