Frail patients having vascular surgery during the early COVID-19 pandemic experienced high rates of adverse perioperative events and amputation

BACKGROUND

Frailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision-making about vascular surgery in the resource constrained COVID-19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes.

METHODS

The COVID-19 Vascular Service in Australia (COVER-AU) prospective cohort study evaluates 30-day and six-month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March-July 2020. The primary outcome was mortality, with secondary outcomes procedure-related outcomes and hospital utilization. Frailty was assessed using the nine-point visual Clinical Frailty Score, scores of 5 or more considered frail.

RESULTS

Of the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non-frail patients (OR 1.68, 95%CI 0.79-3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non-frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non-frail patients, after adjustment (OR 2.01; 95% CI 1.17-3.78), driven by a high rate of amputation during the period of reduced surgical activity.

CONCLUSION

Our findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.

Acute subclavian artery occlusion with associated clavicle fracture managed with bypass graft alone

Subclavian artery injury is a rare consequence of clavicle fracture. It most often results from penetrating trauma but can result from blunt trauma with adjacent bone fragments causing rupture, pseudoaneurysm, dissection or thrombosis of the artery. If flow through the subclavian artery is compromised there is a risk of ipsilateral upper limb ischaemia. Life-threatening haemorrhage may result in cases of laceration, and cerebral infarction may result from dissection. Vascular injury in association with clavicle fracture is typically regarded as an indication for internal fixation of the fracture. We present a case of subclavian artery thrombosis in association with a comminuted midshaft clavicle fracture causing limb ischaemia managed by carotid to brachial artery bypass without internal fracture fixation. The fracture united at 4 weeks and there was no sustained vascular or neurological impairment at follow-up. We advocate urgent vascular intervention in subclavian artery injury. There is little discussion in the literature regarding non-operative management of clavicle fractures with subclavian artery injury. We suggest that select clavicle fractures with subclavian artery injury can be safely managed non-operatively.

Has carotid artery stenting found its place? A 10-year regional centre perspective

INTRODUCTION

The post-Carotid Revascularization Endarterectomy versus Stenting Trial era has seen a dramatic decline in the practice of carotid artery stenting (CAS). A retrospective review of prospectively collected CAS outcomes over a 10-year period by a single operator was undertaken to determine if this change in practice is justified and to identify the place of carotid stenting in current practice.

METHODS

One hundred fifty-nine carotid stent procedures were undertaken on 137 patients from 2002 to 2012. Cases were selected for CAS only if they fulfilled the inclusion criteria for the SAPPHIRE trial. Post-procedural outcomes were compared against those of a contemporaneous cohort of patients undergoing carotid endarterectomy (CEA) by the same operator and against published meta-analyses. The measure of CAS durability was need for re-intervention, based on the presence of ultrasound-detected re-stenosis >70%.

RESULTS

No significant difference was identified in 30-days' complication rates between patients undergoing CAS and those having CEA. Compared to published meta-analyses of CAS, our practice was accompanied by a significantly lower rate of peri-procedural stroke (1.26% versus 6%, P = 0.014) while carrying equivalent 30-days' death and myocardial infarction. Four stented arteries had re-intervention, due to asymptomatic in-stent stenosis of >70%. Further intervention was declined in a fifth case. This represents a re-stenosis rate of 3.1% over a mean follow-up of 40.2 ± 27.6 months.

DISCUSSION

CAS can provide a safe and durable treatment option for selected patients with carotid artery disease, in the hands of appropriately trained proceduralists who meet accepted standards of practice.

Ischaemic preconditioning of the liver: a preliminary study

BACKGROUND

A phenomenon of 'preconditioning' exists for the heart, but has not been described for the liver. This study was undertaken to determine whether a brief episode of ischaemia (3 or 5 min) followed by a short reperfusion time (5 or 10 min) would precondition the liver to reduce subsequent injury from prolonged ischaemia (30 to 90 min).

METHODS

Male Wistar rats were allocated into five control (no preconditioning) and five preconditioned groups, each having a liver resection. The preconditioning times were 3 min ischaemia followed by 5 min reperfusion with a prolonged ischaemia of 60 or 90 min for the first two groups, and 5 min ischaemia followed by 10 min reperfusion with prolonged ischaemia times of 30 or 45 min for the other three groups.

RESULTS

Of rats resected with 3-5-60 min time sequence designed to assess survival, 9/10 died. However 9/10 died also in the matching control group with 60 min ischaemia. With a 5-10-45 min sequence, 9/10 survived more than 24 h in the preconditioned group and 1/10 in the non-preconditioned controls. With a 5-10-30+ sequence designed to measure liver function tests, the prothrombin time was significantly improved; bilirubin, serum alkaline phosphatase and the alanine aminotransferase improved but these did not reach significance.

CONCLUSION

A brief episode of ischaemia followed by an episode of reperfusion before a prolonged period of ischaemia ameliorated the effects of ischaemia-reperfusion injury in a rat liver resection model. If hepatic preconditioning is confirmed in humans, ischaemic preconditioning will have an important role for all liver surgery.

Two cases of idiopathic acute gastric necrosis

Two cases of acute hemorrhagic gastric necrosis are presented. The first patient was a 62 yr old man with a past history of chronic gastritis, Parkinson's disease and dementia. The second case was a 25 yr old woman with recent abuse of oral analgesic agents. Both presented with an acute abdomen and peritonitis, and underwent urgent gastrectomy for gastric necrosis with perforation. The first patient died, whereas the second recovered. Histology of the gastrectomy specimens showed severe hemorrhagic transmural gastric necrosis with minimal inflammatory changes. Only occasional Gram positive rods were seen in case 1, and microbiological cultures were negative. The etiology of the gastric necrosis in these 2 cases is unclear.