The Value of Troponin Measurement in Carotid Revascularization: A Scoping Review.

PURPOSE: Patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) are at substantially increased risk of short-term and long-term cardiac complications. Still, the role of perioperative troponin in predicting cardiac events remains unclear. The objective was to systematically summarize the existing evidence on the topic and provide directions for further research. MATERIALS AND METHODS: Studies that examined perioperative troponin values and its association with myocardial injury, and/or myocardial infarction (MI), and/or major adverse cardiac events (MACE) and postoperative mortality in exclusively CEA/CAS patients, published in English until March 15, 2022, were retrieved through a systematic search of MEDLINE and Web of Science. The study selection process was independently performed by 2 authors, while the third researcher resolved disagreements. RESULTS: Four studies with 885 participants met the inclusion criteria. Age, chronic kidney disease, presentation of carotid disease, type of closure (primary closure/venous patch/Dacron/polytetrafluoroethylene patch), coronary artery disease, chronic heart failure, and the long-term use of calcium channel blockers represent risk factors for troponin elevation, which occurred in 11% to 15.3%. Myocardial infarction and MACE occurred in 23.5% to 40%, that is, 26.5% of patients with troponin elevation, respectively, during the first 30 postoperative days. Elevated postoperative troponin levels were significantly associated with adverse cardiac events during the long-term surveillance period. The rates of cardiac-related and all-cause mortality were higher in patients with postoperative troponin elevation. CONCLUSION: Troponin measurement could be helpful in the prediction of adverse cardiac events. The predictive role of preoperative troponin, the patient population in whom routine troponin sampling should be used, and a comparison of different treatment methods/anesthesia techniques in carotid patients should be further examined. CLINICAL IMPACT: The present scoping review critically appraises the extent and nature of the existing literature data on the predictive value of troponin on the occurrence of cardiac complications in patients undergoing CEA and CAS. In particular, it provides clinicians with essential insights by systematically summarizing the core evidence and identifying knowledge gaps that may direct future research. This, in turn, may significantly alter the current clinical practice and perhaps even reduce the incidence of cardiac complications in patients undergoing CEA/CAS.

Comparison of Methods for Monitoring Intra-operative Cerebral Perfusion in Patients Undergoing Carotid Endarterectomy with Selective Shunting: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials and Cohort Studies.

OBJECTIVE: This study aimed to analyse the influence of different methods of monitoring cerebral perfusion (MCP) on stroke, death, and use of intraluminal shunt during carotid endarterectomy (CEA). METHODS: A systematic review and network meta-analysis was conducted and registered in the PROSPERO registry (CRD42021246360). Medline, Embase, CENTRAL, and Web of Science were searched. Randomised controlled trials (RCTs) and cohort studies with > 50 participants that compared clinical outcomes for different MCP in patients undergoing CEA were included. Papers reporting one or a combination of two of the following MCPs were included in the analysis: awake testing (AT), near infrared spectroscopy (NIRS), electroencephalography (EEG), somatosensory evoked potential (SSEP), motor evoked potential (MEP), transcranial Doppler (TCD), and stump pressure (SP). A random effects network meta-analysis was performed using a binomial likelihood function with a specified logit link for peri-operative stroke or death and shunting as outcomes. Near infrared spectroscopy was excluded due to the lack of studies that could be used for statistical analysis. RESULTS: Of 1 834 publications, 17 studies (15 cohort studies and two RCTs) including 21 538 participants were incorporated in the quantitative analysis. Electroencephalography was used in the largest number of participants (7 429 participants, six studies), while AT was used in the highest number of studies (10 studies). All monitoring modalities had worse outcomes with respect to stroke or death when compared with AT, with ORs ranging between 1.3 (95% credible interval [CrI] 0.2 - 10.9) for SSEP + MEP and 3.1 (CrI 0.3 - 35.0) for patients monitored with a combination of EEG and TCD. However, the wide CrI indicated that there is no statistically significant difference between the monitoring methods. Patients monitored with a combination of EEG and TCD had the lowest odds of being shunted, while SP had the highest odds of being shunted, also with no statistically significant difference. CONCLUSION: There is a lack of high quality data on this topic in the literature. The present study showed no significant difference between monitoring methods investigated in the network meta-analysis.

Preoperative Anxiety is Associated With Postoperative Complications in Vascular Surgery: A Cross-Sectional Study.

BACKGROUND: Preoperative anxiety is associated with increased morbidity and/or mortality in surgical patients. This study investigated the incidence, predictors, and association of preoperative anxiety with postoperative complications in vascular surgery. METHODS: Consecutive patients undergoing aortic, carotid, and peripheral artery surgery, under general and regional anesthesia, from February until October 2019 were included in a cross-sectional study. Anesthesiologists assessed preoperative anxiety using a validated Serbian version of the Amsterdam Preoperative Anxiety and Information Scale. Patients were divided into groups with low/high anxiety, both anesthesia- and surgery-related. Statistical analysis included multivariate linear logistic regression and point-biserial correlation. RESULTS: Of 402 patients interviewed, 16 were excluded and one patient refused to participate (response rate 99.7%). Out of 385 patients included (age range 39-86 years), 62.3% had previous surgery. High-level anesthesia- and surgery-related anxieties were present in 31.2 and 43.4% of patients, respectively. Independent predictors of high-level anesthesia-related anxiety were having no children (OR = 0.443, 95% CI: 0.239-0.821, p = 0.01), personal bad experiences with anesthesia (OR = 2.294, 95% CI: 1.043-5.045, p = 0.039), and time since diagnosis for ≥ 4 months (OR = 1.634, 95% CI: 1.023-5.983, p = 0.04). The female sex independently predicted high-level surgery-related preoperative anxiety (OR = 2.387, 95% CI: 1.432-3.979, p = 0.001). High-level anesthesia-related anxiety correlated with postoperative mental disorders (rpb = 0.193, p = 0.001) and pulmonary complications (rpb = 0.104, p = 0.042). Postoperative nausea (rpb = 0.111, p = 0.03) and postoperative mental disorders (rpb = 0.160, p = 0.002) correlated with high-level surgery-related preoperative anxiety. CONCLUSIONS: Since preoperative anxiety affects the postoperative course and almost every third patient experiences anxiety preoperatively, routine screening might be recommended in vascular surgery.

Identification of Risk Factors and Development of Predictive Risk Score Model for Mortality after Open Ruptured Abdominal Aortic Aneurysm Repair.

Background and Objectives: Despite the relatively large number of publications concerning the validation of these models, there is currently no solid evidence that they can be used with absolute precision to predict survival. The goal of this study is to identify preoperative factors that influenced 30-day mortality and to create a predictive model after open ruptured abdominal aortic aneurysm (RAAA) repair. Materials and Methods: This was a retrospective single-center cohort study derived from a prospective collected database, between 1 January 2009 and 2016. Multivariate logistic regression analysis was used to identify all significant predictive factors. Variables that were identified in the multivariate analysis were dichotomized at standard levels, and logistic regression was used for the analysis. To ensure that dichotomized variables were not overly simplistic, the C statistic was evaluated for both dichotomized and continuous models. Results: There were 500 patients with complete medical data included in the analysis during the study period. Of them, 37.6% were older than 74 years, and 83.8% were males. Multivariable logistic regression showed five variables that were predictive of mortality: age > 74 years (OR = 4.01, 95%CI 2.43−6.26), loss of consciousness (OR = 2.21, 95%CI 1.11−4.40), previous myocardial infarction (OR = 2.35, 95%CI 1.19−4.63), development of ventricular arrhythmia (OR = 4.54, 95%CI 1.75−11.78), and DAP < 60 mmHg (OR = 2.32, 95%CI 1.17−4.62). Assigning 1 point for each variable, patients were stratified according to the preoperative RAAA mortality risk score (range 0−5). Patients with 1 point suffered 15.3% mortality and 3 points 68.2% mortality, while all patients with 5 points died. Conclusions: This preoperative RAAA score identified risk factors readily assessed at the bedside and provides an accurate prediction of 30-day mortality after open repair of RAAA.

Patients' Fears and Perceptions Associated with Anesthesia.

Background and Objectives: It has been suggested that intense feelings of fear/anxiety and significant patient concerns may affect the perioperative course. Those findings emphasize the importance of surgical patients' preoperative feelings. Still, current knowledge in this area is based on a limited number of studies. Thus, we think that there is a need to further explore patients' preoperative fears, better characterize risk factors and reasons for their occurrence, and evaluate patients' perspectives associated with anesthesia. Materials and Methods: A total of 385 patients undergoing vascular surgery were preoperatively interviewed using a questionnaire that included demographics and questions related to patients' fears and perceptions of anesthesia. Statistical analyses included descriptive statistics, Pearson's χ2 and McNemar tests, and multivariate ordinal logistic regression. Results: The main causes of patients' preoperative fear were surgery (53.2%), potential complications (46.5%), and anesthesia (40%). Female sex was a predictor of surgery and anesthesia-related fear (OR = 3.07, p = 0.001; OR = 2.4, p = 0.001, respectively). Previous experience lowered the fear of current surgery (OR = 0.65, p = 0.031) and anesthesia (OR = 0.6, p = 0.017). Type of surgery, type of anesthesia, educational and socioeconomic status, and personal knowledge of an anesthesiologist affected specific anesthesia-related fears. Over 25% of patients did not know that an anesthesiologist is a physician, and only 17.7% knew where anesthesiologists work. Level of education and place of residence influenced patients' perceptions of anesthesia. Conclusions: Anesthesia-related fears are affected by the type of surgery/anesthesia, experience with previous surgery, and personal knowledge of an anesthesiologist. Women, patients with lower education levels, and patients with poorer socioeconomic status are at higher risk of developing those fears. The perception of anesthesiologists is inadequate, and knowledge of anesthesia is poor. Promotion of patient education regarding anesthesia is needed to alleviate those fears and increase understanding of anesthesia.

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.

Hybrid repair of aortic arch with zone zero endografting-Case series with review of the literature.

INTRODUCTION: We present single-institution results of types I and II hybrid procedures for aortic arch disease with 30-day and long-term results and review of the literature. MATERIALS AND METHODS: This is a retrospective study of all patients that underwent zone 0 endografting and open bypass from ascending aorta to the arch vessels at our institution between January 2013 and 2020. The following data for the systematic review were extracted from eligible studies: 30-day/in-hospital mortality, stroke rate, spinal cord ischemia (SCI) rate, renal failure requiring dialysis, development of retrograde dissection, early (<30 days) types I and III endoleak, follow-up length, late (>30 days) endoleak, and late (>30 days) mortality. RESULTS: Twelve patients underwent hybrid aortic arch treatment in our institution. The most common aortic arch pathology was degenerative aortic aneurysm. The rate of retrograde dissection and SCI was 8.33%. Regarding the literature data, a total of 768 patients undergoing types I and II hybrid aortic arch debranching procedure. The pooled rate of 30-day/in-hospital mortality was 10.96% (95% confidence interval [CI], 8.21-14.06), SCI pooled rate was 2.91% (95% CI, 1.76%-4.33%), and retrograde dissection pooled rate was 3.22% (95% CI, 1.99-4.72). CONCLUSION: Hybrid arch techniques provide safe alternative to open repair with acceptable short- and midterm results.

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.

The influence of gender on 30-day adverse clinical outcomes in patients undergoing carotid surgery.

BACKGROUND: We aimed to further evaluate sex differences of perioperative and 30-day complications after carotid surgery in patients with both asymptomatic and symptomatic carotid artery stenosis. METHODS: This was a single-center prospective cohort study including 2013 consecutive patients, who were treated surgically due to extracranial carotid artery stenosis and prospectively followed. Patients who underwent carotid artery stenting and who were treated conservatively were excluded. The primary endpoints for this study were hospital stroke/transitory ischemic attack (TIA) and overall survival rates. Secondary outcomes included all other hospital adverse events, 30-day stroke/TIA, and 30-day mortality rates. RESULTS: Hospital mortality was higher in female patients with symptomatic carotid stenosis (3% vs. 0.5%, P=0.018). Bleeding requiring re-intervention occurred more often in female patients with both asymptomatic (1.5% vs. 0.4%, P=0.045) and symptomatic carotid stenosis (2.4% vs. 0.2%, P=0.022). 30-day stroke/TIA and mortality rates were higher in female patients with both asymptomatic (stroke/TIA 4.4% vs. 2.5%, P=0.041; mortality 3.3% vs. 1.6%, P=0.046) and symptomatic carotid stenosis (stroke/TIA 8.3% vs. 4.2%, P=0.040; mortality 4.1% vs. 0.7%, P=0.006). After adjusting for all confounding factors, female gender remained an important predicting factor for 30-day stroke/TIA in asymptomatic (OR=1.4, 95%CI 1.0-4.7, P=0.041) and symptomatic patients (OR=1.7, 95%CI 1.1-5.3, P=0.040), as well as for 30-day all-cause mortality in patients with asymptomatic (OR=1.5, 95%CI 1.1-4.1, P=0.030) and symptomatic carotid artery disease (OR=1.2, 95%CI 1.0-5.2, P=0.048). CONCLUSIONS: Female gender is important predicting factor for stroke/TIA and all-cause mortality, both perioperative and during the first 30 days after carotid surgery.

Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center.

BACKGROUND: The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma. METHODS: This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience. RESULTS: Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009). CONCLUSIONS: Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.

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.

Translation and validation of the Amsterdam preoperative anxiety and information scale (APAIS) in Serbia.

OBJECTIVES: Preoperative anxiety is common and might affect surgical treatment outcomes. The aim was to translate and validate the Serbian version of the Amsterdam Preoperative Anxiety and Information Scale (APAIS). METHODS: Following translation and initial evaluation, the Serbian version (S-APAIS) was administered to 385 patients. Internal consistency, construct validity, prognostic criteria validity, and concurrent validity between S-APAIS and Visual Analogue Scale for Anxiety (VAS-A) were evaluated. RESULTS: Factor analysis revealed two factors: APAIS-anesthesia (items 1, 2, 3) and APAIS-procedure (items 4, 5, 6). The whole scale, APAIS-anesthesia, and APAIS-procedure subscales showed an adequate level of internal consistency (Cronbach's αs: 0.787, 0.806, and 0.805, respectively). High concurrent validity was observed between APAIS-anesthesia and VAS-A (ρ = 0.628, p < .001). A moderate correlation was found between APAIS-procedure and VAS-A scale (ρ = 0.537, p < .001). At the cut-off point of 9, the area under the curve (AUC) of APAIS-anesthesia was 0.815 (95% CI: 0.77-0.85, p < .001). For the APAIS-procedure, AUC was 0.772 (95% CI: 0.73-0.81, p < .001) at the cut-off point of 8. CONCLUSION: The structure of S-APAIS substantially differs from the original and allows separate measurement of anesthesia- and procedure-related anxieties. S-APAIS is a comprehensive, valid, and reliable instrument for the measurement of preoperative anxiety.