Influence of perioperative risk factors on the development of transmural colonic ischemia after open repair of ruptured abdominal aortic aneurysm.

BACKGROUND: Development of colonic ischemia (CI) after ruptured abdominal aortic aneurysm (RAAA) treatment is a lethal complication with perioperative mortality reported to be high as 50%. Therefore, the main goal of this study was to identify pre-, intra- and postoperative risk factors associated with CI in patients undergoing open repair (OR) due to RAAA, that might help to select patients who are more prone to develop CI. METHODS: This was a single-center prospective cohort study on patients with RAAA undergoing OR between January 1st 2018 and July 1st 2019, at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia. During this period 89 patients were treated due to RAAA and all were included in the study. The primary endpoint was grade III CI, or transmural necrosis, diagnosed by laparotomy. RESULTS: Out of 89 patients operated due to RAAA, CI was diagnosed in 14 (15.73%). During the operation, patients with CI had a longer duration of hypotension (42.86±35.82 vs. 24.13±23.48, P=0.021) and more common significant hypotension (54.54% vs. 14.66%, P=0.024). In the postoperative course, patients with CI had more common signs of abdominal compartment syndrome (71.42% vs. 25.33%, P=0.001) and higher mortality rate (78.57% vs 29.33%, P=0.001). The univariate regression model showed that one of the most significant factors that were associated with CI were age higher than 75 years, significant hypotension lasting more than one hour, organ lesion, development of abdominal compartment syndrome and higher potassium values on third and fourth quartile. CONCLUSIONS: Grade III colon ischemia (transmural) remains the important cause of mortality after ruptured abdominal aortic aneurysm repair. We identified pre- and intraoperative and postoperative risk factors that could improve the selection of patients for primary open abdomen treatment or early exploratory laparotomy in order to prevent or timely diagnose colon ischemia.

Open Surgical Treatment of Acute Spontaneous Isolated Abdominal Aortic Dissection.

BACKGROUND: The aim of this paper is to report our single-center experience in the open surgical treatment of acute spontaneous infrarenal isolated abdominal aortic dissection (siIAAD). METHODS: This was a single center retrospective study. Between January 2015 and 2020 ten patients were treated due to acute siIAAD with open surgery. There were no patients treated for chronic siIAAD in this time period. Patients who had concomitant thoracic aortic involvement were excluded from this report. RESULTS: The group consisted of 7 male and 3 female patients. History of hypertension was present in nine patients and six were active smokers. The abdominal/back pain was described in 9 patients, two had acute limb ischemia and three had aortic rupture. Median dissection length was 91 mm (65.7 - 106), median distance from the lowest renal artery was 30 mm (20.7 - 49.3) and median abdominal aortic diameter was 58.5 mm (32.5 - 66.2). Supracoeliac clamp was used in three cases with a ruptured aorta and suprarenal in two patients. The mean duration of proximal clamping time was 24.3 ± 7.49 min. One patient died of postoperative acute myocardial infarction, one suffered nonfatal pulmonary embolism and one had deep venous thrombosis. No aortic-related deaths and/or reinterventions occurred during the median follow-up of 32 months. CONCLUSIONS: Acute siIAAD is a rare event which affects mostly male smokers with hypertension. Open surgery is a technically demanding procedure with acceptable complication rates and should be performed in specialized high-volume centers for the treatment of aortic disease. Future efforts to establish a multicenter registry to evaluate the prevalence of the disease and treatment options could provide better and more comprehensive guidelines for the treatment of acute siIAAAD.

Influence of preoperative statins and aspirin administration on biological and magnetic resonance imaging properties in patients with abdominal aortic aneurysm.

Background: Main objective of this study was to evaluate the influence of statins and/or acetylsalicylic acid on biochemical characteristics of abdominal aortic aneurysm (AAA) wall and intraluminal thrombus (ILT). Patients and methods: Fifty patients with asymptomatic infrarenal AAA were analyzed using magnetic resonance imaging on T1w sequence. Relative ILT signal intensity (SI) was determined as a ratio between ILT and psoas muscle SI. Samples containing the full ILT thickness and aneurysm wall were harvested from the anterior surface at the level of the maximal diameter. The concentration of enzymes such as matrix metalloproteinase (MMP) 9, MMP2 and neutrophil elastase (NE/ELA) were analyzed in ILT and AAA wall; while collagen type III, elastin and proteoglycan 4 were analyzed in harvested AAA wall. Oxidative stress in the AAA wall was assessed by catalase and malondialdehyde activity in tissue samples. Results: Relative ILT signal intensity (1.09 ± 0.41 vs 0.89 ± 0.21, p = 0.013) were higher in non-statin than in statin group. Patients who were taking aspirin had lower relative ILT area (0.89 ± 0.19 vs 1.13. ± 0.44, p = 0.016), and lower relative ILT signal intensity (0.85 [0.73-1.07] vs 1.01 [0.84-1.19], p = 0.021) compared to non-aspirin group. There were higher concentrations of elastin in AAA wall among patients taking both of aspirin and statins (1.21 [0.77-3.02] vs 0.78 (0.49-1.05) ng/ml, p = 0.044) than in patients who did not take both of these drugs. Conclusions: Relative ILT SI was lower in patients taking statin and aspirin. Combination of antiplatelet therapy and statins was associated with higher elastin concentrations in AAA wall.

Vascular Injuries in Intravenous Drug Addicts-A Single-Center Experience.

BACKGROUND: Infected false aneurysms (IFA) caused by intravenous drug abuse are uncommon but challenging lesions. The best approach for the surgical management of this condition is still unknown. The aim is to present a single-center 14-year experience in the IFA treatment in intravenous drug abusers, thus providing additional data regarding the treatment options and outcome in these patients. METHODS: A retrospective analysis of 32 consecutive patients with vascular injuries secondary to intravenous drug abuse, during the period from January 2004 to April 2018, was performed. Data of interest were extracted from patients' medical history records, anesthesia charts, and database implemented in daily practice, or were obtained by personal contact. The diagnosis was set based on history, physical examination and/or color Doppler sonography, multidetector computed tomographic angiography, and digital subtraction angiography. The outcome included graft patency, limb amputation, and mortality. RESULTS: During study period, 32 heroin abusers, predominantly males (81%), were surgically treated due to vascular injuries, with mean age of 35.2 years. The vast majority of patients have had an injury of the lower extremity blood vessels (84.3%) and the common femoral artery was the most common site of injury (59.4%). Three-quarters of patients underwent resection of the false aneurysm and ligation of the artery without reconstruction of the blood vessel. In 7 cases (21.9%), arterial reconstruction was performed with overall failure rate of 42.86%. The overall mortality rate was 6.25% and the rate of extremity salvage was 96.7%. CONCLUSIONS: The best treatment option is yet to be found, but based on the results of the present study, ligation of affected artery without revascularization seems to be an efficient, safe, and optimal treatment method, with minor risk of the extremity loss.

An Isolated Aneurysm of the Abdominal Aorta in a Patient with Marfan Syndrome-A Case Report.

We present a case of successfully treated abdominal aortic aneurysm in a 24-year-old patient with Marfan syndrome. After initial physical and ultrasound examination, the multislice computed tomography (MSCT) scan revealed infrarenal aortic aneurysm of 6 cm in diameter, 10 cm long, along with slightly dilated iliac arteries. However, dimensions of aortic root, aortic arch, and descending suprarenal aorta were within normal limits. Further on, because the patient presented with signs of impending rupture, an urgent surgical intervention was performed. The patient was discharged in good general medical condition 7 days after surgery. After 6 months of follow-up, the patient's condition was satisfying and no MSCT signs of further aortic dissection/aneurysm were identified. To the best of our knowledge, a case of successful management of a patient with Marfans syndrome and truly isolated infrarenal and symptomatic abdominal aortic aneurysm has not been described in the literature before.

Risk factors for intraoperative bradycardia during ear, nose, throat and maxillofacial surgery.

Intraoperative bradycardia (IOB) is one of the most common cardiac arrhythmias observed in clinical anaesthetic practice. Controlled hypotension, as a strategy of lowering patient's blood pressure during anesthesia has been practiced for decades in head and neck surgery. The aim of our study was to determine the incidence and the risk factors for intraoperative bradycardia in maxillofacial, ear, nose and throat surgery, as well as to determine whether controlled hypotension affects the occurrence of IOB. The retrospective study included 2304 patients who underwent maxillofacial, ear, nose or throat surgery. We studied the influence of: sex, age, comorbidity, type of surgery, duration of anesthesia and controlled hypotension on the occurrence of IOB. IOB was registered in 473 patients (20.5%). Patients with controlled hypotension had IOB significantly more often than patients without controlled hypotension (33.9 vs 15.1%) (p = 0.000). The significant predictors of IOB were: age (OR = 1.158; 95% CI = 1.068-1.256; p = 0.000), sex (OR = 0.786; 95% CI = 0.623-0.993; p = 0.043), ischemic heart disease (OR = 2.016; 95% CI = 1.182-3.441; p = 0.010); ear surgery (OR = 1.593; 95% CI = 1.232-2.060; p = 0.000), anesthesia duration, (OR = 1.006; 95% CI = 1.004-1.007; p = 0.000) and controlled hypotension (OR = 2.204; 95% CI = 1.761-2.758; p = 0.000). IOB is common in maxillofacial, ear, nose and throat surgery, particularly in male, older age and patients with ishemic heart disease. The ear surgery, longer anesthesia duration and controlled hypotension raise the risk for occurrence of IOB.

Risk Factors for Intraoperative Hypertension during Surgery for Primary Hyperparathyroidism.

OBJECTIVE: To investigate the incidence and identify risk factors for the occurrence of intraoperative hypertension (IOH) during surgery for primary hyperparathyroidism (pHPT). SUBJECTS AND METHODS: The study included 269 patients surgically treated between January 2008 and January 2012 for pHPT. IOH was defined as an increase in systolic blood pressure ≥20% compared to baseline values which lasted for 15 min. The investigated influence were demographic characteristics, surgical risk score related to physical status (based on the American Society of Anesthesiologists [ASA] classification), comorbidities, type and duration of surgery, and duration of anesthesia on IOH occurrence. The investigated factors were obtained from the patients' medical history, anesthesia charts, and the daily practice database. Logistic regression analysis was done to determine the predictors of IOH. RESULTS: Of the 269 patients, 153 (56.9%) had IOH. Based on the univariate analysis, age, body mass index, ASA status, duration of anesthesia, and preoperative hypertension were risk factors for the occurrence of IOH. Multivariate analysis showed that independent predictors of IOH were a history of hypertension (OR = 2.080, 95% CI: 1.102-3.925, p = 0.024) and age (OR = 0.569, 95% CI: 0.360-0.901, p = 0.016). CONCLUSION: In this study, a high percentage (56%) of the patients developed IOH during surgery for pHPT, which indicates that special attention should be paid to these patients, especially to the high-risk groups: older patients and those with a history of hypertension. Further, this study showed that advanced age and hypertension as a coexisting disease prior to parathyroid surgery were independent risk factors for the occurrence of IOH.

PREDICTORS OF DIFFICULT AIRWAY MANAGEMENT IN THYROID SURGERY: A FIVE-YEAR OBSERVATIONAL SINGLE-CENTER PROSPECTIVE STUDY.

Difficult tracheal intubation (DI) is more common in thyroid than in other surgical branches due to thyromegaly. Proper preoperative airway evaluation is necessary in order to reduce the potential numerous complications. The study examined the incidence of DI in thyroid surgery and the influence of tracheal dislocation and other risk factors on DI. A prospective study was conducted on 2379 patients who underwent thyroidectomy at the Center for Endocrine Surgery, Clinical Center of Serbia, from 2007 to 2012. Patients were divided into groups with (n = 162) and without DI (n = 2217). Besides tracheal dislocation, another 13 risk factors contained in 13 screening tests and three additional factors of gender, age and diagnosis were defined. The incidence of DI in our study was 6.81%. The presence of tracheal dislocation was statistically significant, but not an independent predictor of DI. The diagnosis, large circumference and small neck length, previous DI, recessive mandible, tooth characteristics and oral anomalies were the most significant and independent predictors of DI. Neck circumference and small neck length had highest sensitivity. Previous DI had highest specificity. Thyromegaly, if causing tracheal dislocation and/or stenosis, represents a significant DI predictor, not individually, but in combination with other factors.

Anaesthesia and the patient with diabetes.

AIMS: To provide updated knowledge regarding the airway management and the possibility of difficult intubation in diabetic patients. MATERIALS AND METHODS: We preformed a systematic literature review of the English language literature, published over the past 10 years which deals with this subject. RESULTS: The vast majority of the modern literature data supports the fact that diabetic population has higher risk for difficult intubation occurrence. The most important characteristics of diabetic patients that are considered to be contributing factors for the difficult intubation are obesity, increased neck circumference and stiff joint syndrome. CONCLUSION: A special attention and thorough preoperative preparation should be given to patients with diabetes. In order to predict and prevent difficult intubation in these patients, further studies are needed to investigate this issue closely.