The effect of body mass index on major outcomes after vascular surgery.

OBJECTIVE: Obesity has been associated with an increased risk for cardiovascular morbidity and mortality, although pooled evidence in patients undergoing vascular surgery are lacking. The aim of this systematic review was to evaluate the effect of body mass index (BMI) on major postoperative outcomes in patients undergoing vascular surgery. METHODS: A systematic literature review conforming to established criteria to identify eligible articles published before May 2016 was conducted. Eligible studies evaluated major postoperative outcomes in vascular surgery patients of different BMI groups according to the weight classification of the National Institutes of Health criteria: underweight (UW), BMI ≤18.5 kg/m2; normal weight (NW), BMI of 18.6 to 24.9 kg/m2; overweight (OW), BMI of 25 to 29.9 kg/m2; and obese (OB), BMI ≥30 kg/m2. Major outcomes included 30-day mortality, cardiac complications, and respiratory complications. Secondary outcomes included wound and cerebrovascular complications, renal complications, deep venous thrombosis/pulmonary embolism, and other complications. RESULTS: Overall, eight retrospective studies were eligible including a total of 92,525 vascular surgery patients (2223 UW patients, 29,727 NW patients, 34,517 OW patients, and 26,058 OB patients). Pooled data were as follows: mortality rate, 2.5%; cardiac events, 2.1%; respiratory events, 8.6%; wound complications, 6.4%; cerebrovascular events, 6.4%; renal complications, 3.9%; other infections, 5.3%; deep venous thrombosis/pulmonary embolism, 1.2%; and other complications, 3.7%. Meta-analysis showed that OB patients were associated with lower mortality (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.541-0.757; P < .0001), cardiac morbidity (OR, 0.81; 95% CI, 0.708-0.938; P = .004), and respiratory morbidity (OR, 0.87; 95% CI, 0.802-0.941; P = .0006) after vascular surgery compared with NW patients. However, OB patients were associated with a higher wound complication rate (OR, 2.39; 95% CI, 1.777-3.211; P < .0001) compared with NW patients. In contrast, UW patients were associated with a higher mortality (OR, 1.71; 95% CI, 1.177-2.505; P = .005) and respiratory morbidity (OR, 1.84; 95% CI, 1.554-2.166; P < .0001) compared with NW patients. CONCLUSIONS: The "obesity paradox" does exist in patients undergoing vascular surgery. This paradox refers not only to 30-day overall mortality but also to 30-day cardiac and respiratory complications. However, obesity seems to be associated with more wound complications. Surprisingly, UW patients are associated with higher mortality as well as respiratory events postoperatively.

Conservative treatment of patients with thromboangiitis obliterans or cannabis-associated arteritis presenting with critical lower limb ischaemia.

BACKGROUND: Proper management of patients with thromboangiitis obliterans (TAO) or cannabis-associated arteritis (CAA), presenting with critical lower limb ischaemia (CLI) remains controversial, and data are limited. PATIENTS AND METHODS: Patients with TAO or CAA presenting with CLI between 2011 and 2016 were retrospectively evaluated. Patients requiring primary intervention were excluded. Conservative treatment included: (a) weight-adjusted bemiparin plus six hours/day intravenous iloprost for 28 days, (b) aspirin (100 mg/day) plus cilostazol (100 mg twice/day) after discharge, and (c) strict recommendations/monitoring for smoking cessation. Main outcomes included symptom recession, ankle-brachial index (ABI) improvement, and healing of lesions at the time of discharge as well as amputation, revascularization, and abstinence rate during follow-up. RESULTS: Overall, 23 patients (TAO: 15; CAA: 8) were included within six years, none of the patients reported any other factor than smoking. All patients presented with rest pain and 12 patients with ulcer or necrotic lesions. Mean ABI measurement at presentation was 0.46 ± 0.2, after 28 days of treatment, all patients showed improvement regarding clinical picture and ABI measurement (0.54 ± 0.1; p < 0.05). During follow-up, only three patients underwent bypass surgery and two patients underwent major amputation, although the smoking abstinence rate was very low (13 %). CONCLUSIONS: Intravenous iloprost plus bemiparin for 28 days together with per os aspirin plus cilostazol seem to produce promising results in patients with TAO/CAA, treated for CLI, even with a low smoking abstinence rate. However, larger series are needed to further evaluate inter-group differences and potential prognostic factors.

Thrombolysis in peripheral artery disease.

Peripheral artery disease (PAD) has been associated with severe morbidity and mortality worldwide, affecting the quality of life for millions of patients. Acute thrombosis has been identified as a major complication of PAD, with proper management including both open as well as endovascular techniques. Thrombolysis has emerged as a reasonable option in the last decades to treat such patients although data produced by randomized trials have been limited. This review aims to present major aspects of thrombolysis in PAD regarding its indications and contraindications, technique tips as well as to review literature data in order to produce useful conclusions for everyday clinical practice.

Staged Endovascular Repair of Isolated Bilateral Internal Iliac Artery Aneurysms: A Case Report.

This report aims to present an unusual case with isolated bilaterally located internal iliac artery aneurysms (IIAAs) that were incidentally detected. Owing to the high surgical risk of the patient and anatomical location of the aneurysms, an endovascular management was preferred. Initially, the patient underwent a percutaneous embolization of the right-sided aneurysm with coiling. A stent-graft deployment covering the orifice of the left-sided internal iliac artery and occluding the ipsilateral aneurysm followed 1 month later. The patient remains asymptomatic after 6 months. Endovascular management has been associated with lower morbidity and hospital stay compared with open repair for IIAAs, although both techniques show satisfying early and mid-term results. Especially for bilaterally located aneurysms, a staged strategy decreases the risk for ischemic complications. Finally, endovascular methods should be preferred when there are no compression symptoms or in cases of higher surgical risk.

Bilateral Type IIIa Endoleak and Disconnection of Both Limbs after Evar with an Endurant II Endograft.

A 75-year-old patient with severe comorbidities was treated with an Endurant® (Medtronic, USA) II endograft due to a ruptured abdominal aortic aneurysm (AAA). After four years of unremarkable follow-up, bilateral limb separation was detected. The patient underwent endovascular bridging without any complication. Although rarely detected in newer grafts, late bilateral type IIIa endoleaks can present and should be promptly repaired. Complex or ruptured AAAs treated with off-label use of endografts should be under closer surveillance using imaging tools for potential endoleaks or aneurysm sac growth.

Iatrogenic and non-iatrogenic arterial injuries in an urban level I trauma center in Greece.

BACKGROUND: Aim of this study is to present the experience of an urban trauma center concerning the management of vascular trauma. METHODS: All data on major arterial injuries of the extremities treated during a 6-year period (August 2008 - August 2014) were retrospectively collected and analyzed. All cases were classified into iatrogenic and non-iatrogenic injuries, and comparisons were made between the two groups. Arterial injuries of the thorax and abdomen as well as venous injuries were not included. RESULTS: Overall, 67 major arterial injuries were managed (22% iatrogenic). Iatrogenic and non-iatrogenic cases showed differences regarding sex, age and injury of adjacent structures. Almost 8% of patients underwent primary amputation, with major nerve, long bone or extensive soft tissue injury being the main risk factors. Most iatrogenic cases underwent endovascular treatment, although open repair with venous grafting was the primary choice for non-iatrogenic injuries. Primary patency was 100% for all open repairs, although secondary patency was 97% after one month of intervention. Eight cases needed secondary amputation, with extensive soft tissue loss being the major risk factor for secondary amputation. CONCLUSIONS: Iatrogenic and non-iatrogenic arterial injuries show different characteristics concerning epidemiology and management. Injury of main adjacent structures remains a major risk factor for primary as well as secondary amputation. Endovascular treatment when indicated remains a therapeutic choice with optimal results.

Multidisciplinary Management of Carotid Body Tumors in a Tertiary Urban Institution.

Objective. Aim of this study is to present the experience of our institution in carotid body tumors (CBTs) treatment. Methods. All cases treated in a Vascular Surgery Department within 2.5 years (03/2013-09/2015) were retrospectively evaluated. Demographics, diagnostic, and treatment strategy were recorded. All patients with known CBT underwent ultrasound and magnetic resonance imaging preoperatively. All cases were classified according to the Shamblin type and evaluated by a radiologist, otolaryngologist, and anesthesiologist before and after surgery. Major outcomes included mortality, stroke, cranial nerve injury, and recurrence. Results. Overall, nine patients (mean age: 59.5 ± 16.3 years) with a total of ten CBTs were treated. There was no gender prevalence and most of the cases (55%) were asymptomatic. There were no functional or familial cases. There was only one bilateral case treated in a staged manner. No preoperative embolization of CBTs was performed. Mortality and stroke rates were null. No severe complication was observed in the early and late setting. No malignancy was recorded. Mean follow-up was 15.6 ± 7.8 months. Conclusions. Multidisciplinary management of patients with CBTs is imperative for optimal results, especially in type III tumors, bilateral or functional cases. After careful treatment planning and intraoperative manipulations, complications could be avoided even without preoperative embolization.

Bioabsorbable stenting in peripheral artery disease.

Arterial stenting has been broadly utilized for the management of peripheral arterial occlusive disease. The evolution of stent materials has led to the introduction of newer bioabsorbable scaffolds that have been extensively evaluated in the treatment of coronary artery disease. However, the utilization of bioabsorbable stents in the lower extremities remains challenging and has not been evaluated in the same degree. There are not many trials focusing on major outcomes of treatment with bioabsorbable stents or comparing them with other therapeutic choices such as surgery or angioplasty only. The aim of this review is to report current status on bioabsorbable stenting in peripheral artery disease treatment as well as to present the results of all major relevant trials. Moreover, future expectations and challenges with this type of stents are discussed as well.