Myocardial Injury After Noncardiac Surgery (MINS) in Vascular Surgical Patients: A Prospective Observational Cohort Study.

OBJECTIVE: To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients. BACKGROUND: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described. METHODS: This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring. RESULTS: The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%-22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%-20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%-3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46-25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1-29.1) and without an ischemic feature (12.2%; 95% CI, 5.3-25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6-82.4). CONCLUSIONS: Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.

Hybrid repair of symptomatic aberrant right subclavian artery and Kommerell's diverticulum.

INTRODUCTION: An aberrant right subclavian artery (ARSA) with or without an associated Kommerell's diverticulum (KOD) is a rare vascular anomaly. Patients with an ARSA may present with a variety of symptoms, including rupture. Options for repair include open, endovascular, and a hybrid approach, with no clear consensus on which is best because of the rarity of the anomaly. We present 2 cases that underwent hybrid repair and a systematic review of the literature. METHODS: A systematic review of the literature was performed from 2000-2012 searching for patients with ARSA with or without KOD who underwent endovascular repair. Twenty-four articles were identified, including a few case reports and small case series, for a total of 31 patients. A chart review was also performed on 2 patients at our institution who underwent a hybrid repair for symptomatic ARSA. RESULTS: We report the presenting history, management, and follow-up of 2 symptomatic patients with ARSA with associated KOD. Both patients underwent a hybrid approach for repair, with no reported complications. After postoperative imaging and clinical follow-up, both patients remained in good general condition without signs of vascular complications. Our systematic literature review identified 31 reported cases of patients with ARSA who underwent endovascular repair (10 patients without an associated KOD and 21 patients with a KOD). The patients ranged in age from 21-82 years of age (average: 56 years). Of these patients, 17 (55%) were women. The presenting symptoms varied, and some patients had multiple symptoms noted on presentation, including dysphagia, dyspnea, or asymptomatic patients. In those patients with an associated KOD, the average size of the diverticulum was 3.3 cm (range: 2.3-7 cm). A number of operative strategies were used in the reported cases, depending on the presence of absence of an associated KOD. The average reported duration of hospital stay was 5.4 days (range: 1-60 days). Seven patients had postoperative complications (22%). There were 3 mortalities reported (10%). Only 1 of these could be directly related to the surgical procedure. Reported decrease in aneurysm size was between 25-50%, although this was not reported for most patients. Four of 31 patients (13%) had an endoleak (1 type I endoleak, 2 type II endoleaks, and 1 type IV endoleak). The range of reported follow-up varied between 6 weeks and 92 months, with 9 patients having no follow-up reported. CONCLUSION: Hybrid approach to repair of an ARSA with associated KOD appears to be feasible, safe, and effective. Despite the poor quality and heterogeneity of the evidence available in the literature for this rare condition, we believe that this could be the preferred treatment option for an ARSA either with or without KOD.

Mortality and major postoperative complications within 1 year after vascular surgery: a prospective cohort study.

INTRODUCTION: Patients undergoing vascular procedures are prone to developing postoperative complications affecting their short­term mortality. Prospective reports describing the incidence of long­term complications after vascular surgery are lacking. OBJECTIVES: We aimed to describe the incidence of complications 1 year after vascular surgery and to evaluate an association between myocardial injury after noncardiac surgery (MINS) and 1­year mortality. PATIENTS AND METHODS: This is a substudy of a large prospective cohort study Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION). Recruitment took place in 28 centers across 14 countries from August 2007 to November 2013. We enrolled patients aged 45 years or older undergoing vascular surgery, receiving general or regional anesthesia, and hospitalized for at least 1 night postoperatively. Plasma cardiac troponin T concentration was measured before the surgery and on the first, second, and third postoperative day. The patients or their relatives were contacted 1 year after the procedure to assess the incidence of major postoperative complications. RESULTS: We enrolled 2641 patients who underwent vascular surgery, 2534 (95.9%) of whom completed 1­year follow­up. Their mean (SD) age was 68.2 (9.8) years, and the cohort was predominantly male (77.5%). The most frequent 1­year complications were myocardial infarction (224/2534, 8.8%), amputation (187/2534, 7.4%), and congestive heart failure (67/2534, 2.6%). The 1­year mortality rate was 8.8% (223/2534). MINS occurred in 633 patients (24%) and was associated with an increased 1­year mortality (hazard ratio, 2.82; 95% CI, 2.14-3.72; P <0.001). CONCLUSIONS: The incidence of major postoperative complications after vascular surgery is high. The occurrence of MINS is associated with a nearly 3­fold increase in 1­year mortality.

Hypothenar hammer syndrome from ice hockey stick-handling.

Ulnar artery thrombosis and hypothenar hammer syndrome are rare vascular complications that could potentially occur with repeated blows or trauma to the hand. Although initially reported as an occupational hazard among laborers and craftsmen, it has been observed more recently among recreationalists and athletes. Until now, it has never been reported as a complication in ice hockey players. In this case report, a 26-year-old Canadian professional ice hockey player presented with acute dominant right hand paleness, coolness, and pain with hand use. The patient used a wooden hockey stick with a large knob of tape at the end of the handle, which he regularly gripped in the palm of his right hand to help with face-offs and general stick-handling. Sonographic evaluation demonstrated no arterial flow in the distal right ulnar artery distribution, and ulnar artery occlusion with no aneurysmal degeneration was confirmed by magnetic resonance angiogram. Intraarterial thrombolytic therapy was initiated, and subsequent serial angiograms demonstrated significant improvement in distal ulnar artery flow as well as recanalization of right hand deep palmar arch and digital arteries. The patient's symptoms resolved, and he was maintained on therapeutic anticoagulation for 3 months prior to returning to playing ice hockey professionally, but with a padded glove and no tape knob at the handle tip. This case highlights a unique presentation of hockey stick-handling causing ulnar artery thrombosis that was likely from repeated palmar hypothenar trauma. Appropriate diagnostic imaging, early intraarterial thrombolysis, and postoperative surveillance and follow-up were crucial for the successful outcome in this patient.

The use of transcutaneous oximetry to predict complications of chronic wound healing: a systematic review and meta-analysis.

Transcutaneous oximetry (P(tc) O(2) ) has been proposed as a method to predict nonhealing of chronic wounds and the occurrence of healing complications. However, the validity of this method as an independent predictor and an optimal threshold value for this tool are poorly defined. We undertook a systematic review and meta-analysis to address these questions, searching five major medical databases, relevant review articles, and reference lists. We included all studies that used multivariable analysis to evaluate P(tc) O(2) for its ability to predict chronic wound healing complications. Article selection and data abstraction were conducted independently and in duplicate. Four studies, enrolling 901 patients with 910 lower extremity chronic wounds, met our inclusion criteria. These studies showed that a peri-wound P(tc) O(2) level below a cutoff of 20 mmHg or 30 mmHg was an independent predictor of chronic wound healing complications (odds ratio 3.21, 95% confidence interval 1.07-9.69, I(2) = 77%). A threshold value of 20 mmHg was used most frequently in the included studies and showed the strongest association. This review was limited by the small number of studies, a possible reporting bias, and heterogeneity. These results suggest that P(tc) O(2) measurements have independent prognostic value in the assessment of chronic wounds, but further research is required to confirm these findings and define an optimal threshold value.