Inflammatory Response, Immunosuppression and Arginase Activity after Cardiac Surgery Using Cardiopulmonary Bypass.

Background: Major surgeries suppress patients' cellular immunity for several days, but the mechanisms underlying this T-cell dysfunction are not well understood. A decreased L-Arginine (L-Arg) level may inhibit T-cell function. Arginase 1 (Arg 1) is induced after traumatic injury, leading to molecular changes in T cells, including decreased expression of cell surface T-cell receptors (TCRs) and a loss in CD3ζ chain expression. In this study, we examined the temporal patterns of CD3ζ expression and Arg 1 activity in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Methods: We determined the CD3ζ chain expression; the Arg 1 activity; and the leukocyte, neutrophil and lymphocyte levels of patients on the day before surgery and at 24, 48 and 72 h after surgery. Results: Fifty adult patients scheduled for elective cardiac surgery with CPB were eligible for enrolment. Arginase activity was significantly increased between the day before surgery and at 24, 48 and 72 h after surgery (p < 0.01), and CD3ζ expression was significantly decreased between the day before surgery and at 24, 48 and 72 h after surgery (p < 0.001). We observed significant leukocytosis, neutrophilia and lymphopenia after surgery. Conclusions: The decreased CD3ζ chain expression could be due to the increased Arg 1 activity secondary to the activation of neutrophils in cardiac surgery under CPB. These findings could explain the limited immune-system-mediated organ damage resulting from systemic inflammatory response to major cardiac surgery with CPB.

Early and late results of open surgical and endovascular treatment of infrarenal abdominal aortic aneurysms, selected according to surgical risk.

BACKGROUND: Open surgical repair (OSR) and endovascular aneurysm repair (EVAR) surgery are alternative treatments for infrarenal abdominal aortic aneurysm (IRAAA). OBJECTIVES: To compare OSR and EVAR for the treatment of IRAAA. METHODS: 119 patients with IRAAA were electively operated by the same surgeon between January 1, 2006 and December 31, 2015, following selection for OSR or EVAR according to surgical risk. Complications, reinterventions, failures, and early and late mortality were analyzed. RESULTS: 63 OSR and 56 EVAR patients were analyzed. They were similar in terms of age (70 years), gender (92% men), and average diameter of IRAAA (6.5 cm), but with different comorbidities, surgical risk, and anatomy. EVAR was better than OSR regarding time in the operating theatre (177.5 vs. 233.3 minutes), need for transfusion (25 vs. 73%), and length of stay in ICU (1.3 vs. 3.3 days) and hospital (8.1 vs. 11.1 days). OSR allowed more associated procedures to be conducted simultaneously (19.0 vs. 1.8%). There were no significant differences between the groups with respect to complications (25.4 vs. 25.1%), reinterventions (3.2 vs. 5.2%), or early mortality (1.6 vs. 0%). During follow-up, OSR was associated with fewer revisions (3.13 vs. 4.21), angio-CTs (0.22 vs. 3.23), complications (6.4 vs. 37.5%), reinterventions (3.2 vs. 23.2%), and failures (1.6 vs. 10.7%), and had better survival (78.2 vs. 63.2%). CONCLUSIONS: Correct selection of patients achieves excellent results because it avoids OSR in patients at high risk and avoids EVAR in patients with high anatomical complexity, achieving similar results in the perioperative period, but better results for OSR over the course of follow-up.

CONTEXTO: A cirurgia aberta (CA) e o reparo endovascular de aneurisma (REVA) são tratamentos alternativos para o aneurisma da aorta abdominal infrarrenal (AAAIR). OBJETIVOS: Comparar CA e REVA no tratamento do AAAIR. MÉTODOS: Foram incluídos 119 pacientes com AAAIR, operados eletivamente pelo mesmo cirurgião entre 1 de janeiro de 2006 e 31 de dezembro de 2015, após seleção para CA ou REVA de acordo com o risco cirúrgico. Complicações, reintervenções, falhas e mortalidade precoce e tardia foram analisadas. RESULTADOS: Foram analisados 63 pacientes de CA e 56 de REVA, com semelhanças de idade (70 anos), sexo (92% homens) e diâmetro médio do AAAIR (6,5 cm), mas com diferentes comorbidades, riscos cirúrgicos e anatomias. O REVA foi melhor que a CA em relação ao tempo na sala de cirurgia (177,5 vs. 233,3 minutos), necessidade de transfusão (25 vs. 73%) e tempo de permanência na unidade de terapia intensiva (1,3 vs. 3,3 dias) e no hospital (8,1 vs. 11,1 dias). A CA permitiu que mais procedimentos associados fossem realizados simultaneamente (19,0 vs. 1,8%). Não houve diferenças significativas entre os grupos em relação a complicações (25,4 vs. 25,1%), reintervenções (3,2 vs. 5,2%) e mortalidade precoce (1,6 vs. 0%). Durante o acompanhamento, a CA apresentou menos revisões (3,13 vs. 4,21), angiotomografias (0,22 vs. 3,23), complicações (6,4 vs. 37,5%), reintervenções (3,2 vs. 23,2%) e falhas (1,6 vs. 10,7%), além de ter melhor sobrevida (78,2 vs. 63,2%). CONCLUSÕES: A seleção correta dos pacientes proporciona excelentes resultados porque evita pacientes com alto risco para CA e com complexidade anatômica para REVA. Os resultados são semelhantes no período perioperatório, mas melhores para CA durante o acompanhamento.

The First Aortic Endoaneurysmorrhaphy: Ricardo Lozano Monzón (1872-1934).

In 1888, Rudolph Matas described and performed a procedure (endoaneurysmorrhaphy) that revolutionized the treatment of aneurysms, which for centuries had been untreatable or simply involved treatment by ligation and other marginal techniques. In 1940, during the annual meeting of the American Surgical Association, Matas presented the excellent results he had obtained with 98 endoaneurysmorrhaphies, although none of these cases involved an aortic aneurysm. On November 4, 1904, a Spanish surgeon called Ricardo Lozano Monzón was the first person in the world to perform an endoaneurysmorrhaphy on a patient suffering from an abdominal aortic aneurysm. The case was reported in a local journal called La Clínica Moderna in 1905. Despite the journal's limited circulation, Matas and others acknowledged that Lozano was the practitioner of the first, although admittedly unsuccessful, endoaneurysmorrhaphy on an abdominal aorta. Lozano's attempt was followed by other equally unsuccessful ones until Isaac A. Bigger performed the first successful procedure in 1938. The different kinds of endoaneurysmorrhaphy that Matas used, which proved to be effective in the treatment of peripheral aneurysms, did not perform in the same way in aortic aneurysms. Nonetheless, the procedure paved the way for new ideas and contributions (Creech technique).

Early and late results of open surgical and endovascular treatment of infrarenal abdominal aortic aneurysms, selected according to surgical risk / Resultados precoces e tardios dos tratamentos aberto e endovascular de aneurismas da aorta abdominal infrarrenal, selecionados de acordo com o risco cirúrgico

Abstract Background Open surgical repair (OSR) and endovascular aneurysm repair (EVAR) surgery are alternative treatments for infrarenal abdominal aortic aneurysm (IRAAA). Objectives To compare OSR and EVAR for the treatment of IRAAA. Methods 119 patients with IRAAA were electively operated by the same surgeon between January 1, 2006 and December 31, 2015, following selection for OSR or EVAR according to surgical risk. Complications, reinterventions, failures, and early and late mortality were analyzed. Results 63 OSR and 56 EVAR patients were analyzed. They were similar in terms of age (70 years), gender (92% men), and average diameter of IRAAA (6.5 cm), but with different comorbidities, surgical risk, and anatomy. EVAR was better than OSR regarding time in the operating theatre (177.5 vs. 233.3 minutes), need for transfusion (25 vs. 73%), and length of stay in ICU (1.3 vs. 3.3 days) and hospital (8.1 vs. 11.1 days). OSR allowed more associated procedures to be conducted simultaneously (19.0 vs. 1.8%). There were no significant differences between the groups with respect to complications (25.4 vs. 25.1%), reinterventions (3.2 vs. 5.2%), or early mortality (1.6 vs. 0%). During follow-up, OSR was associated with fewer revisions (3.13 vs. 4.21), angio-CTs (0.22 vs. 3.23), complications (6.4 vs. 37.5%), reinterventions (3.2 vs. 23.2%), and failures (1.6 vs. 10.7%), and had better survival (78.2 vs. 63.2%). Conclusions Correct selection of patients achieves excellent results because it avoids OSR in patients at high risk and avoids EVAR in patients with high anatomical complexity, achieving similar results in the perioperative period, but better results for OSR over the course of follow-up.

Resumo Contexto A cirurgia aberta (CA) e o reparo endovascular de aneurisma (REVA) são tratamentos alternativos para o aneurisma da aorta abdominal infrarrenal (AAAIR). Objetivos Comparar CA e REVA no tratamento do AAAIR. Métodos Foram incluídos 119 pacientes com AAAIR, operados eletivamente pelo mesmo cirurgião entre 1 de janeiro de 2006 e 31 de dezembro de 2015, após seleção para CA ou REVA de acordo com o risco cirúrgico. Complicações, reintervenções, falhas e mortalidade precoce e tardia foram analisadas. Resultados Foram analisados 63 pacientes de CA e 56 de REVA, com semelhanças de idade (70 anos), sexo (92% homens) e diâmetro médio do AAAIR (6,5 cm), mas com diferentes comorbidades, riscos cirúrgicos e anatomias. O REVA foi melhor que a CA em relação ao tempo na sala de cirurgia (177,5 vs. 233,3 minutos), necessidade de transfusão (25 vs. 73%) e tempo de permanência na unidade de terapia intensiva (1,3 vs. 3,3 dias) e no hospital (8,1 vs. 11,1 dias). A CA permitiu que mais procedimentos associados fossem realizados simultaneamente (19,0 vs. 1,8%). Não houve diferenças significativas entre os grupos em relação a complicações (25,4 vs. 25,1%), reintervenções (3,2 vs. 5,2%) e mortalidade precoce (1,6 vs. 0%). Durante o acompanhamento, a CA apresentou menos revisões (3,13 vs. 4,21), angiotomografias (0,22 vs. 3,23), complicações (6,4 vs. 37,5%), reintervenções (3,2 vs. 23,2%) e falhas (1,6 vs. 10,7%), além de ter melhor sobrevida (78,2 vs. 63,2%). Conclusões A seleção correta dos pacientes proporciona excelentes resultados porque evita pacientes com alto risco para CA e com complexidade anatômica para REVA. Os resultados são semelhantes no período perioperatório, mas melhores para CA durante o acompanhamento.

Decision-making and therapeutic options in intact splenic artery aneurysms: single-center experience and literature review.

BACKGROUND: Splenic artery aneurysms are rare, potentially serious, and usually asymptomatic. Several methods are currently available to treat them, each with their own advantages and drawbacks. Therefore, its therapeutic paradigm has changed. METHODS: We review our database of splenic aneurysms (2009-2019) and undertake an exhaustive literature review. Demographic, clinical, diagnostic, therapeutic, early and follow-up outcome data were examined. Our experience comprised: 15 patients with 19 splenic aneurysms. 11 women (average age, 59.4 years) and 4 men (average age, 61.7 years). All asymptomatic. RESULTS: At diagnosis, aneurysms had a mean cross-sectional diameter of 3.4 cm (3.2 and 3.9 for women and men, respectively), the largest measuring 8.5 cm. Two independent aneurysms were detected in four patients. Diagnoses were always incidental to a CT scan. Treatments consisted of open surgery (2 patients), endovascular surgery (10 patients: 7 embolizations, 3 covered stent) and observation/follow-up (3 patients). The cases of open surgery (with splenectomy) were carried out without postoperative morbidity. One embolization failed (requiring subsequent open surgery) and two suffered localized splenic infarction, but without further complications. In patients treated with a covered stent, the aneurysm was always excluded, without complications. There was no 30-day or follow-up (average 26.2 months) mortality. Splenic aneurysms are diagnosed more frequently and earlier (in the asymptomatic phase), albeit incidentally, than in the past. CONCLUSIONS: The correct indication (identifying patients at risk) and individualization of treatment, in which endovascular techniques are the first-line option, have significantly improved morbidity and mortality outcomes in our hospital.

Survival After Mitral Valve Replacement for Leaflet Escape in a Contemporary On-X Mechanical Valve.

Leaflet escape in contemporary mechanical valves is an extremely rare and potentially lethal condition. We report the case of a 77-year-old man who presented with embolization of a leaflet from an On-X mitral valve (CryoLife, Kennesaw, GA) with Conform-X Sewing Ring prosthesis (CryoLife) after exercise. The patient recovered completely 6 months after surgery, and he is currently asymptomatic.

Disruption in "Nonanastomotic Section" of an Axillofemoral Bypass: A Thorough Critical Review of the Literature.

This work is a thorough nonsystematic critical review (PubMed/MEDLINE 1950-September 2016) of "disruption in nonanastomotic section of an axillofemoral bypass." Fourteen cases were selected (including that provided by the authors of this publication) dating from 1963 to 2016 (53 years). This type of disruption is a very unusual complication in the axillofemoral bypass. The cases described reveal that this disorder is more frequent in unifemoral bypass (9 cases), in ringed polytetrafluorethylene, in blunt trauma, and at costal level especially on the left side. The mean age of the patients was 65.2 (38-83) years, and the men:women ratio was 2:2. The usual symptom was a false aneurysm (10 cases). Although the imaging diagnosis of the first cases was done by arteriography, computed tomography is currently more used. The usual treatment (7 cases) consisted in the resection of the affected segment and the interposition of the new prosthesis. Furthermore, 2 cases treated with coated stent have been described, as well as 1 case of femorofemoral bypass, 1 of suture, and 1 of exeresis without revascularization. One patient refused surgery, and there was as a case where the treatment was unknown. The evolution in the short term is satisfactory, with no perioperative mortality registered.

Comparative study of bacterial translocation control with nitric oxide donors and COX2 inhibitor.

OBJECTIVE AND DESIGN: To evaluate the beneficial effects of exogenous NO and an inhibitor of the COX2, and their action levels in a model of SIRS/bacterial translocation (BT) induced by Zymosan A(®). MATERIAL AND METHODS: Ninety Wistar rats were submitted to different treatments, and after 12h and 24h they were anaesthetized in order to collect blood, mesenteric lymph nodes, and kidney for subsequent biochemical analyses and microbiological examinations. TREATMENTS: A nitric oxide donor, Molsidomine(®), was compared with a COX2 inhibitor, Celecoxib(®). METHODS: Zymosan A(®) was administered to Wistar rats. The animals were divided into 6 groups: one group for survival study, Group (1) No manipulation (BASAL); Group (2) vehicle of Zymosan A(®) given intraperitoneally (SHAM); Group I (control), with Zymosan A(®) (0.6g/kg) intraperitoneally; Group II (Molsidomine), with Molsidomine(®) (4mg/kg) through the penis dorsal vein, 30min prior to administration of the Zy(®) (0.6g/kg); Group III (Celecoxib), with Celecoxib(®) (400mg/kg) orally through a stomach tube, 6h prior to administration of the Zy (0.6g/kg). DETERMINATIONS: The parameters survival, bacterial translocation, renal function, neutrophil accumulation, oxygen free radicals (OFR), detoxifying enzymes, and cytokines were measured at different times after Zymosan administration. RESULTS: The model established induced a mortality rate of 100% and generated BT and systemic inflammatory response syndrome (SIRS) in all samples. It also significantly increased all variables, with p<.001 for MPO and all pro-inflammatory cytokines, and p<.01 for all OFR. Treatment with Molsidomine reduced mortality to 0%, decreased BT, MPO, pro-inflammatory cytokines and OFR (p<.001) significantly and increased IL-10 and IL-6 production. Moreover, the Celecoxib(®) showed a lower capacity for SIRS regulation. CONCLUSIONS: The exogenous administration of NO prevented BT and controlled SIRS. Therefore these results suggest that Molsidomine could be used as a therapeutic strategy to protect against BT.

Negative impact of deep venous thrombosis on chronic venous disease.

INTRODUCTION: There are several conditions that may cause chronic venous disease (CVD). It is not known whether the aetiology of CVD can predict disease severity and quality of life (QoL). Our objective is that the severity and QoL of patients with CVD secondary to DVT is different from those without prior DVT. MATERIAL AND METHODS: We compare patients with CVD caused by DVT (n=125) and patients with non-DVT CVD (n=1435) with respect to disease severity (CEAP and Venous Clinical Severity Score-VCSS) and quality of life (Health Survey Short-Form-SF12 y Chronic Lower Limb Venous Insufficiency Questionnaire-CIVIQ20). RESULTS: Regarding to non-thrombotic CVD, patients with CVD due to DVT showed more severe disease [C6 grade (14.4% vs 3.6%) (p<0.05); score VCSS (1,33±0,65 vs 0,84±0,49) (p<0.05)] and poorer QoL [global score CIVIQ-20 (57,84±15,57 vs 65,75±14,07) (p<0.05); global score SF-12 (45,98±18,79 vs 57,79±19,64) (p<0.05).]. These differences remained statistical significant in all parameters - attributed measured at each severity score and QoL questionnaires. CONCLUSION: A history of DVT leads to worse clinical severity and quality of life in CVD patients. These data support even more the need to implement programs to prevent DVT and/or its evolutionary consequences.

Clinical experience with bemiparin.

Subcutaneous bemiparin has been evaluated for the prevention of venous thromboembolism (VTE) in moderate to high-risk patients undergoing surgery, and for the acute and long-term treatment of established VTE. General and orthopaedic surgery is associated with VTE incidence rates of 15-60% in the absence of thromboprophylaxis and this can be reduced by over 70% with appropriate thromboembolic prophylaxis. Bemiparin was as effective as unfractionated heparin (UFH) in the prevention of VTE, when both were initiated preoperatively, but was associated with significantly fewer bleeding episodes than UFH. Bemiparin prophylaxis initiated postoperatively was at least as effective as bemiparin initiated preoperatively and was associated with a lower incidence of bleeding complications than preoperative initiation. In terms of patients with cancer undergoing abdominal or pelvic surgery, preliminary results from a recent study with bemiparin showed that extended prophylaxis for 4 weeks significantly reduced the rate of major VTE, without increasing bleeding risk, compared with prophylaxis for one week. Bemiparin, initiated postoperatively, was as effective as enoxaparin, initiated preoperatively, in the prevention of VTE in patients undergoing total knee replacement. The incidence of bleeding complications was similar between groups, although the incidence of injection site haematoma was significantly higher with enoxaparin than with bemiparin. Postoperative initiation of bemiparin thromboprophylaxis minimized the risk of spinal haematoma in patients using neuraxial anaesthesia (approximately 93% of patients). In addition, postoperative initiation is likely to reduce the total costs, because patients do not need to be admitted to hospital the day before surgery. Bemiparin was more effective than intravenous UFH in the acute treatment of established deep vein thrombosis (DVT) and was as effective as oral warfarin in the subsequent secondary prevention of VTE over 3 months of therapy, while bleeding complications over 3 months of therapy were similarly low. In a European study, acute treatment of DVT with bemiparin for one week followed by 12 weeks' secondary prevention with bemiparin (i.e. bemiparin/bemiparin) was associated with a cost saving of &U20AC;908 per patient compared with UFH/warfarin. Similarly, bemiparin/warfarin produced a cost saving of &U20AC;769 compared with UFH/warfarin. The savings were predominantly the result of reduced hospital stays during acute treatment with bemiparin. Bemiparin was also associated with increased quality-adjusted life expectancy. Observational studies in routine clinical practice demonstrated that outpatient treatment of acute VTE was as effective as inpatient treatment, but with lower costs, and bemiparin was as effective as vitamin K antagonists over 3 months for secondary prevention, with VTE recurrence rates of 0% and 0.3% over 3 months in separate studies. Bemiparin is thus an effective, well tolerated agent for thromboprophylaxis in surgery, and for the acute and long-term treatment of established VTE, having advantages over UFH and particular benefits as a result of initiating therapy postoperatively.

[Surgical treatment of carotid paragangliomas]. / Tratamiento quirúrgico de los paragangliomas carotídeos.

The present article reviews the current panorama of the surgical treatment of carotid paragangliomas. The article begins by discussing surgical indications and preoperative aspects (Shamblins classification, the value of genetic study, informed consent, the utility of embolization, etc). Intraoperative aspects (surgical team) and features of the surgical technique (the patients position, incision and exposition, vessel control and identification of nerves, subadventitial or periadventitial tumoral excision, the need for arterial resection and reconstruction, etc.) are discussed in depth. Postoperative aspects, morbidity (neurological and vascular) and mortality, as well as how to follow-up these patients, are discussed at the end of the first part of the article. The second part analyzes special situations concerning carotid paraganglioma (unresectable, malignant, residual [persistent] or recurrent, bilateral and multiple tumors, associated diseases, tumors in children, etc.). The final part of the article, in the form of an appendix, shows the characteristics and results of our series (30 carotid paragangliomas in 26 patients between 1994 and 2008).

[Quality of life and venous thromboembolic disease]. / Calidad de vida y enfermedad tromboembólica venosa.

Health-related quality of life (HRQoL) refers to patients' perceptions of their diseases or the application of specific treatments in various areas of their lives, especially the effects on physical, emotional and social well-being. The present article reviews current knowledge about HRQoL in venous thromboembolic disease (VTED). First, the importance and utility of the concept of HRQoL is discussed and then the instruments used to measure this concept are described. The central argument of this review has three main aims: To present the HRQoL measurement instruments designed specifically for VTED; to evaluate the impact of VTED on HRQoL in these patients; and to determine the changes produced by distinct therapeutic strategies on the already altered HRQoL in these patients. Both in the acute phase (venous thrombosis) and in the chronic phase (postthrombotic syndrome), VTED alters several dimensions of HRQoL. At all stages, treatment of VTED should aim to improve HRQoL. Do achieve this, clinical trials should incorporate HRQoL measurement in the evaluation of results.

Systemic inflammatory response, bacterial translocation and nitric oxide donors.

Abdominal aortic surgery is relatively common and is associated with considerable post-operative morbidity and death. The aortic cross-clamping (supra or infrarenal) necessary for the insertion of a vascular graft, often in circumstances of haemorrhagic shock (e.e. a ruptured aneurysm) elicits a Systemic Inflammatory Response Syndrome (SIRS) and an Ischaemia-Reperfusion syndrome (I-R), with affectation of many organs including the kidneys and the intestine. Experimentally, the exogenous use of nitric oxide donors has proved to be able to control the SIRS, minimising the damage due to I-R and protecting from renal dysfunction and BT. However, clinical experience in these situations is still limited. Here we review the current status and experience of the authors in the use of nitric oxide donors in the control of the SIRS induced by infrarenal, suprarenal aortic cross-clamping, with or without haemorrhagic shock; and the Bacterial Translocation phenomenon (BT) induced by aortic cross-clamping below the mesenteric artery with or without associated hemorrhaging.

Trombofilias: nuevos conocimientos en la TVP / Thrombophilia: new knowledge on DVT

En esta publicación el autor presenta, en tres apartados:1) una actualización del tema. Después de una introducción, se expone el concepto y las características de las trombofilias, una clasificación de las mismas y se pormenoriza el estudio de la antitrombina III y del sistema de la proteína C, de los factores V y II, la hiperhomocistinemia y del síndrome antifosfolípido. Asimismo se presentan las asociaciones posibles de diversas situaciones trombofílicas. 2) la experiencia del autor 3) las consideraciones prácticas del tema y sus recomendaciones