Adverse effects following anti-COVID-19 vaccination with mRNA-based BNT162b2 are alleviated by altering the route of administration and correlate with baseline enrichment of T and NK cell genes.

Ensuring high vaccination and even booster vaccination coverage is critical in preventing severe Coronavirus Disease 2019 (COVID-19). Among the various COVID-19 vaccines currently in use, the mRNA vaccines have shown remarkable effectiveness. However, systemic adverse events (AEs), such as postvaccination fatigue, are prevalent following mRNA vaccination, and the underpinnings of which are not understood. Herein, we found that higher baseline expression of genes related to T and NK cell exhaustion and suppression were positively correlated with the development of moderately severe fatigue after Pfizer-BioNTech BNT162b2 vaccination; increased expression of genes associated with T and NK cell exhaustion and suppression reacted to vaccination were associated with greater levels of innate immune activation at 1 day postvaccination. We further found, in a mouse model, that altering the route of vaccination from intramuscular (i.m.) to subcutaneous (s.c.) could lessen the pro-inflammatory response and correspondingly the extent of systemic AEs; the humoral immune response to BNT162b2 vaccination was not compromised. Instead, it is possible that the s.c. route could improve cytotoxic CD8 T-cell responses to BNT162b2 vaccination. Our findings thus provide a glimpse of the molecular basis of postvaccination fatigue from mRNA vaccination and suggest a readily translatable solution to minimize systemic AEs.

Transvaginal versus transabdominal specimen extraction in minimally invasive surgery: a systematic review and meta-analysis.

AIM: Natural orifice specimen extraction (NOSE) is an alternative to conventional transabdominal retrieval. We aimed to compare outcomes following transvaginal specimen extraction (TVSE) and transabdominal specimen extraction (TASE) in minimally invasive abdominal surgery. METHODS: An electronic database search of PubMed, Embase and CENTRAL was performed from inception until March 2023. Comparative studies evaluating TVSE versus TASE in adult female patients were included. Studies involving transanal NOSE, endoluminal surgery, or TVSE with concomitant hysterectomy were excluded. Weighted mean differences (WMD) and odds ratio were estimated for continuous and dichotomous outcomes respectively. Primary outcomes were postoperative day 1 (POD1) pain and length of stay (LOS). Secondary outcomes were operative time, rescue analgesia, morbidity, and cosmesis. A review of sexual, oncological, and technical outcomes was performed. RESULTS: Thirteen studies (2 randomised trials, 11 retrospective cohort studies), involving 1094 patients (TASE 583, TVSE 511), were included in the analysis. Seven studies involved colorectal disease and six assessed gynaecological conditions. TVSE resulted in significantly decreased POD1 pain (WMD 1.08, 95% CI: 0.49, 1.68) and shorter LOS (WMD 1.18 days, 95% CI: 0.14, 2.22), compared to TASE. Operative time was similar between both groups, with fewer patients requiring postoperative rescue analgesia with TVSE. Overall morbidity rates, as well as both wound-related and non-wound related complication rates were better with TVSE, while anastomotic morbidity rates were comparable. Cosmetic scores were higher with TVSE. TVSE did not result in worse sexual or oncological outcomes. CONCLUSION: TVSE may be feasible and beneficial compared to TASE when performed by proficient laparoscopic operators, using appropriate selection criteria. Continued evaluation with prospective studies is warranted.

Effect of preoperative oral antibiotics and mechanical bowel preparation on the prevention of surgical site infection in elective colorectal surgery, and does oral antibiotic regime matter? a bayesian network meta-analysis.

PURPOSE: Surgical site infection (SSI) impacts 5-20% of patients after elective colorectal surgery. There are varying reports on the effectiveness of oral antibiotics (OAB) with preoperative mechanical bowel preparation (MBP) in preventing SSI. We aim to determine the role of OAB and MBP in preventing SSI after elective colorectal surgery. We also determine if a specific OAB regimen will be more effective than others. METHODS: This study investigated the impact of OAB and MBP in patients undergoing elective colorectal surgery. PubMed, MEDLINE, Ovid, Cochrane Central Register of Controlled Trials, ACP Journal Club, and Embase databases were searched for randomized clinical trials (RCTs) published by June 2022. All RCTs comparing various preoperative bowel preparation regimens, including pairwise or multi-intervention comparisons, were included. To establish the role of OAB and MBP in preventing SSI, we conducted a Bayesian network meta-analysis on all RCTs. We further performed subgroup analysis to determine the most effective OAB regimen. RESULTS: Among included 46 studies with a total of 12690 patients, patients in the MBP + OAB group were less likely to have SSI than those having MBP-only (OR 0.55, 95% CrI 0.39-0.76), and without MBP and OAB (OR 0.52, 95% CrI 0.32-0.84). OAB regimen C (kanamycin + metronidazole) and A (neomycin + metronidazole) demonstrated a significantly reduced incidence of SSI, compared to regimen B (neomycin + erythromycin) with OR 0.24 (95% CrI 0.07-0.79) and 0.26 (95% CrI 0.07-0.99) respectively. CONCLUSIONS: OAB with MBP reduces the risk of SSI after elective colorectal surgery. Providing adequate aerobic and anaerobic coverage with OAB may confer better protection against SSI.

Frailty scoring in vascular and endovascular surgery: A systematic review.

One in 10 independently living adults aged 65 years old and older is considered frail, and frailty is associated with poor postoperative outcomes. This systematic review aimed to examine the association between frailty assessments and postoperative outcomes in patients with vascular disease. Electronic databases - MEDLINE, Embase, and the Cochrane Library - were searched from inception until January 2022, resulting in 648 articles reviewed for potential inclusion and 16 studies selected. Demographic data, surgery type, frailty measure, and postoperative outcomes predicted by frailty were extracted from the selected studies. The risk of bias was assessed using the Newcastle-Ottawa Scale. The selected studies (mean age: 56.1-76.3 years) had low-to-moderate risk of bias and included 16 vascular (elective and nonelective) surgeries and eight frailty measures. Significant associations (p < 0.05) were established between mortality (30-day, 90-day, 1-year, 5-year), 30-day morbidity, nonhome discharge, adverse events, failure to rescue, patient requiring care after discharge, and amputation following critical limb ischaemia. The strongest evidence was found between 30-day mortality and frailty. Composite 30-day morbidity and mortality, functional status at discharge, length of stay, spinal cord deficit, and access site complications were found to be nonsignificantly associated with frailty. With frailty being significantly associated with several adverse postoperative outcomes, preoperative frailty assessments can potentially be clinically useful in helping practitioners predict and guide the pre-, peri-, and postoperative management of frail with vascular disease.

Surgery for chronic arthropathy in people with haemophilia.

BACKGROUND: Chronic arthropathy is a potentially debilitating complication for people with haemophilia - a genetic, X-linked, recessive bleeding disorder, characterised by the absence or deficiency of a clotting factor protein. Staging classifications, such as the Arnold-Hilgartner classification for haemophilic arthropathy of the knee, radiologically reflect the extent of knee joint destruction with underlying chronic synovitis. Management of this highly morbid disease process involves intensive prophylactic measures, and chemical or radioisotope synovectomy in its early stages. However, failure of non-surgical therapy in people with progression of chronic arthropathy often prompts surgical management, including synovectomy, joint debridement, arthrodesis, and arthroplasty, depending on the type of joint and extent of the damage. To date, management of people with mild to moderate chronic arthropathy from haemophilia remains controversial; there is no agreed standard treatment. Thus, the benefits and disadvantages of non-surgical and surgical management of mild to moderate chronic arthropathy in people with haemophilia needs to be systematically reviewed.  OBJECTIVES: To assess the efficacy and safety of surgery for mild to moderate chronic arthropathy in people with haemophilia A or B. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, and two trial registers to August 2022. We also handsearched relevant journals and conference abstract books. SELECTION CRITERIA: Randomized controlled trials (RCTs) and quasi-RCTs comparing surgery and non-surgical interventions, for any joint with chronic arthropathy, in people with haemophilia, who were at least 12 years old. DATA COLLECTION AND ANALYSIS: The review authors did not identify any trials to include in this review. MAIN RESULTS: The review authors did not identify any trials to include in this review. AUTHORS' CONCLUSIONS: The review authors did not identify any trials to include in this review. Due to a lack of research in this particular area, we plan to update the literature search every two years, and will update review if any new evidence is reported. There is a need for a well-designed RCT that assesses the safety and efficacy of surgical versus non-surgical interventions for chronic arthropathy in people with haemophilia.

Robotic ICG guided anatomical liver resection in a multi-centre cohort: an evolution from "positive staining" into "negative staining" method.

BACKGROUND: Laparoscopic major anatomical liver resection is challenging. The robotic liver resection (RLR) approach, with Firefly indocyanine green (ICG) imaging, was proposed to overcome the limitations of laparoscopy. The aim of this multi-centre international study was to evaluate the use of Firefly ICG imaging in anatomical RLR. METHODS: A retrospective study of consecutive patients undergoing RLR anatomical resection with intra-operative ICG administration from January 2015 to July 2018 were enrolled. Patients who underwent simultaneous or en-bloc resections of other organs were excluded. RESULTS: A total of 52 patients were recruited of which 32 patients were healthy donors, 17 with malignancy and 3 for benign conditions. 12 patients had cirrhosis. 28 patients underwent a right hepatectomy (53.8%) with left hepatectomy performed with 18 patients. 40 patients underwent negative staining and 12 patients via direct portal vein injection for positive staining. ICG demarcation line was visualized in 43 patients and was clearer than the ischaemic demarcation line in 29 patients. All resections for malignancy had clear margins. There were no 30-day/inpatient mortalities. CONCLUSION: Robotic ICG guided hepatectomy technique for anatomical liver resection is safe, feasible and has the benefit for improved visualization in healthy donors and cirrhotic patients.

Survival Advantage of Laparoscopic Versus Open Resection For Colorectal Liver Metastases: A Meta-analysis of Individual Patient Data From Randomized Trials and Propensity-score Matched Studies.

OBJECTIVE: To perform an individual participant data meta-analysis using randomized trials and propensity-score matched (PSM) studies which compared laparoscopic versus open hepatectomy for patients with colorectal liver metastases (CLM). BACKGROUND: Randomized trials and PSM studies constitute the highest level of evidence in addressing the long-term oncologic efficacy of laparoscopic versus open resection for CLM. However, individual studies are limited by the reporting of overall survival in ways not amenable to traditional methods of meta-analysis, and violation of the proportional hazards assumption. METHODS: Survival information of individual patients was reconstructed from the published Kaplan-Meier curves with the aid of a computer vision program. Frequentist and Bayesian survival models (taking into account random-effects and nonproportional hazards) were fitted to compare overall survival of patients who underwent laparoscopic versus open surgery. To handle long plateaus in the tails of survival curves, we also exploited "cure models" to estimate the fraction of patients effectively "cured" of disease. RESULTS: Individual patient data from 2 randomized trials and 13 PSM studies involving 3148 participants were reconstructed. Laparoscopic resection was associated with a lower hazard rate of death (stratified hazard ratio = 0.853, 95% confidence interval: 0.754-0.965, P = 0.0114), and there was evidence of time-varying effects (P = 0.0324) in which the magnitude of hazard ratios increased over time. The fractions of long-term cancer survivors were estimated to be 47.4% and 18.0% in the laparoscopy and open surgery groups, respectively. At 10-year follow-up, the restricted mean survival time was 8.6 months (or 12.1%) longer in the laparoscopy arm (P < 0.0001). In a subgroup analysis, elderly patients (≥65 years old) treated with laparoscopy experienced longer 3-year average life expectancy (+6.2%, P = 0.018), and those who live past the 5-year milestone (46.1%) seem to be cured of disease. CONCLUSIONS: This patient-level meta-analysis of high-quality studies demonstrated an unexpected survival benefit in favor of laparoscopic over open resection for CLM in the long-term. From a conservative viewpoint, these results can be interpreted to indicate that laparoscopy is at least not inferior to the standard open approach.

A systematic review of the impact of preoperative exercise for patients with abdominal aortic aneurysm.

BACKGROUND: Abdominal aortic aneurysm (AAA) surgery carries significant risk of morbidity and mortality. Preoperative exercise may improve the physical fitness capacity of patients with AAA as well as postoperative outcomes. METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search was performed on MEDLINE, Embase, and Cochrane Library for relevant studies. A methodologic assessment of included studies was conducted using the Physiotherapy Evidence Database (PEDro) scale. RESULTS: Seven studies (six randomized controlled trials and one retrospective cohort study) were included. The overall quality of studies was assessed to range from fair to good. Three studies included AAA patients without indication for surgery, whereas four other studies included AAA patients awaiting surgical repair. One study implemented an inspiratory muscle training program; five studies implemented a continuous moderate-intensity exercise regimen; one study implemented a high-intensity interval training program. Overall compliance with the exercise regimen was high (94% in those not waiting for surgery; 75.8% to 82.3% in those waiting for surgery). In patients not awaiting surgery, preoperative exercise may improve physical fitness parameters including ventilatory threshold (P = .016 at 12 weeks; P = .09 at 12 months) and anaerobic threshold (10% increase; P = .007) but not peak oxygen consumption (P = .183 at 12 weeks; P = .29 at 12 months). In patients awaiting surgery, one study demonstrated a statistically significant improvement in peak oxygen consumption (difference, 1.6 mL/kg/min; P = .004) and anaerobic threshold (difference, 1.9 mL/kg/min; P = .012) for patients who exercised. In terms of postoperative outcomes, exercise may reduce the risk of cardiac, renal, and respiratory complications, although only in those who undergo open surgery. Only patients who underwent endovascular repair had a shorter length of hospital stay when preoperative exercise was conducted. CONCLUSIONS: Despite the encouraging evidence of preoperative exercise for AAA patients, it remains premature to recommend it as a preoperative intervention. Given the heterogeneity of reported outcomes, future studies should consider conducting well-designed randomized controlled trials with standardized reporting outcomes and definitions.

A systematic review, meta-analysis, and meta-regression of the efficacy and safety of endovascular arteriovenous fistula creation.

OBJECTIVE: The percutaneous endovascular approach to arteriovenous fistula (AVF) creation is a minimally invasive alternative to surgical AVF creation. This systematic review and meta-analysis aimed to investigate the efficacy and safety of endovascular AVF creation in patients with end-stage renal disease. METHODS: This study conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search was performed on major databases to identify relevant articles. Meta-analysis of proportions and meta-regression were conducted. RESULTS: Seven studies totaling 300 patients were included, of which four evaluated the everlinQ (TVA Medical, Austin, Tex) and three employed the Ellipsys (Avenu Medical, San Juan Capistrano, Calif) systems. The overall technical success rate was 97.50% (95% confidence interval [CI], 94.98-99.31%; I2 = 0.00%; P = .487). The 90-day maturation rate was 89.27% (95% CI, 84.00-93.66%; I2 = 21.29%; P = .283), and the 6-month patency and 12-month patency were 91.99% (95% CI, 87.98-95.35%; I2 = 0.00%; P = .780) and 85.71% (95% CI, 79.90-90.71%; I2 = 0.00%; P = NS), respectively. The overall procedure-related complication rate was 5.46% (95% CI, 0.310-14.42%; I2 = 81.21%; P = .000). Meta-regression was conducted on the pooled rates of technical success and complication, showing that age, diabetes, white race, hypertension, on dialysis, and body mass index were not significant sources of heterogeneity. CONCLUSIONS: Current endovascular AVF systems appear to be effective and safe. However, given the lack of head-to-head comparative analyses with surgical AVF creation, superiority cannot be established.

Systematic Review and Meta-analysis on Colorectal Cancer Findings on Colonic Evaluation After CT-Confirmed Acute Diverticulitis.

BACKGROUND: CT findings of acute diverticulitis can overlap with features of malignancy, and current guidelines recommend colonic evaluation after acute diverticulitis. However, the benefits of routine colonic evaluation have been questioned. OBJECTIVE: We review 30 studies, composed of 29,348 subjects, to evaluate the role of routine colonic evaluation after CT-proven acute diverticulitis. DATA SOURCES: Medline, EMBASE, and the Cochrane Library were searched for articles published up to July 2018 to identify all relevant articles. STUDY SELECTION: A combination of both Medical Subject Headings and non-Medical Subject Headings key terms using Boolean operators were used on Medline, including colonic neoplasms, colorectal cancer, colon cancer, colonic cancer, colonoscopy, and diverticulitis. Any randomized or nonrandomized, English-language article that specifically analyzed incidence of colorectal cancer after performing colonoscopy in patients with previous diverticulitis was included. MAIN OUTCOME MEASURES: The desired outcome was to evaluate for incidence of colonic malignancy in cases of acute colonic diverticulitis. Subgroup analyses for incidence of malignancy in uncomplicated and complicated diverticulitis, and Asian population studies were also performed. RESULTS: Findings of colonic malignancy occurred in 1.67% (95% CI, 1.24-2.14) of patients with CT-diagnosed diverticulitis. The risk of malignancy in cases with uncomplicated diverticulitis was 1.22% (95% CI, 0.63-1.97) as compared with 6.14% (95% CI, 3.20-9.82) in cases with complicated diverticulitis, with a relative risk of 5.033 (95% CI, 3.194-7.930; p < 0.001). LIMITATIONS: Significant variability in design and methodology of the individual studies contributed to the heterogeneity of this study, but these were addressed by using the random-effects model analysis. CONCLUSIONS: Colonic evaluation is worth considering for patients with diverticulitis because of the small but serious risk of underlying malignancy. The risk of malignancy is higher for patients of advanced age and with complicated diverticulitis.

Computational Fluid Dynamics Modeling of Hemodynamic Parameters in the Human Diseased Aorta: A Systematic Review.

BACKGROUND: The analysis of the correlation between blood flow and aortic pathology through computational fluid dynamics (CFD) shows promise in predicting disease progression, the effect of operative intervention, and guiding patient treatment. However, to date, there has not been a comprehensive systematic review of the published literature describing CFD in aortic diseases and their treatment. METHODS: This review includes 136 published articles which have investigated the application of CFD in all types of aortic disease (aneurysms, dissections, and coarctation). We took into account case studies of both, treated or untreated pathology, investigated with CFD. We also graded all studies using an author-defined Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach based on the validation method used for the CFD results. RESULTS: There are no randomized controlled trials assessing the efficacy of CFD as applied to aortic pathology, treated or untreated. Although a large number of observational studies are available, those using clinical imaging tools as independent validation of the calculated CFD results exist in far smaller numbers. Only 21% of all studies used clinical imaging as a tool to validate the CFD results and these were graded as high-quality studies. CONCLUSIONS: Contemporary evidence shows that CFD can provide additional hemodynamic parameters such as wall shear stress, vorticity, disturbed laminar flow, and recirculation regions in untreated and treated aortic disease. These have the potential to predict the progression of aortic disease, the effect of operative intervention, and ultimately help guide the choice and timing of treatment to the benefit of patients and clinicians alike.

A systematic review and meta-analysis on the quality of life after hepatic resection.

BACKGROUND: Quality of life (QoL) after hepatic resection is a pertinent issue that has been poorly studied. The aim of this study was to compare changes in QoL before and after hepatic resection. METHODS: A systematic review was performed using Medline, EMBASE, and the Cochrane library. Whenever possible, pooled mean differences of survey scores pre- and post-operatively were calculated. RESULTS: 22 studies were included comprising a total of 1785 participants. Using the EORTC-QLQ 30C survey, patients with benign disease tend to have better QoL post-surgery than those with malignant disease. There were post-operative improvements in the following FACT-HEP domains: physical at 9 months (MD 3.14, 95%CI 2.70 to 3.58, P < 0.001), social and family at 3 (MD 1.45, 95%CI 0.12 to 2.77, p = 0.030), 6 (MD 1.12, 95%CI 0.21 to 2.04, p = 0.020), 9 (MD 0.66, 95%CI 0.03 to 1.28, p = 0.040), and 12 (MD 0.58, 95%CI 0.12 to 1.03, p = 0.010) months, emotional at 9 (P < 0.001) and 24 months (P < 0.001), hepatobiliary at 24 months (p < 0.001), and global health status at 9 months (p = 0.002). CONCLUSION: QoL scores tend to deteriorate post-surgery, but recover to baseline in the long-term at 9-months. Patients with malignant disease, and those who underwent major hepatectomy, have poorer QoL scores.

Pouch Versus No Pouch Following Total Gastrectomy: Meta-analysis of Randomized and Non-randomized Studies.

OBJECTIVE: The aim of the study was to assess the impact of pouch reconstruction on perioperative outcomes, postprandial symptoms, nutritional and anthropometric parameters, and overall quality of life after total gastrectomy for gastric malignancy. SUMMARY BACKGROUND DATA: The short-term perioperative risks and longer term functional value of creating a small-bowel reservoir after total gastrectomy are contended. METHODS: A search for randomized and non-randomized studies comparing reconstruction with or without a pouch was conducted. Treatment effects were computed using pairwise random-effects meta-analysis and meta-regression, and the systematic review was conducted in accordance with PRISMA and MOOSE guidelines. RESULTS: A total of 17 randomized trials and 8 observational studies involving 1621 participants were included. Pouch creation is associated with an increased operation time [259.3 vs 235.8 min; weighted mean difference (WMD) 23.5, 95% confidence interval (CI) 9.8-37.2], but not hospitalization duration. There was no difference in overall postsurgical complications, including anastomotic leak and abdominal abscess. Pouch formation markedly reduces the risk of dumping syndrome at 3 to 6 months [8.1% vs 32.4%; risk ratios (RR) 0.36, 95% CI, 0.21-0.60] and 12 to 24 months (2.8% vs 23.6%; RR 0.27, 95% CI, 0.16-0.46). The functional advantages of pouch reconstruction persist at 1 to 2 years, with aggregated data indicating considerably lower risks of esophagitis and heartburn (63% relative reduction), dumping syndrome (73% relative reduction), and food intake disturbance (50% relative reduction). At 12 to 24 months, albumin levels (40.5 vs 37.9 g/L; WMD 2.59, 95% CI, 1.35-3.84) and body mass index (22.2 vs 20.9 kg/m; WMD 1.28, 95% CI, 0.61-1.94) are significantly higher among participants with a pouch. CONCLUSIONS: Pouch creation improves long-term functional and nutritional outcomes after total gastrectomy, without greater perioperative morbidity.

A systematic review and meta-analysis of surgical versus endovascular thrombectomy of thrombosed arteriovenous grafts in hemodialysis patients.

BACKGROUND: The major pitfall of arteriovenous grafts (AVGs) for hemodialysis patients is thrombosis and occlusion. Prompt intervention with either surgical or endovascular therapy to salvage the vascular access is crucial in maintaining effective hemodialysis. The purpose of this systematic review and meta-analysis was to assess and compare the efficacy of open surgical vs wholly endovascular therapy for the treatment of thrombosed AVGs. METHODS: This review was conducted according to the PRISMA guidelines. Relative risks **(RRs) and pooled proportions for both primary and secondary outcomes were calculated. RESULTS: A total of eight randomized, controlled trials and two retrospective cohort studies were included, comprising 806 (63%) and 466 (37%) participants in the surgical and wholly endovascular treatment arms respectively. There were no significant differences between endovascular and surgical therapy in the 30-, 60-, and 90-day primary nonpatency rates. However, endovascular therapy reported a significantly higher 1-year primary nonpatency rate (rate ratio [RR], 1.22; 95% confidence interval [CI], 1.13-1.33; P < .01) and the 2-year primary nonpatency rate (RR, 1.26; 95% CI, 1.10-1.45; P < .01) as compared with surgical therapy. Similarly, the endovascular arm had a higher pooled proportion of primary nonpatency of 87.7% (95% CI, 81.5%-92.9%; P = .297), as compared with the surgical arm (72.1%; 95% CI, 66.4%-77.4%; P = .289). In terms of secondary nonpatency rates, there were no significant differences between endovascular and surgical procedures at 30, 60, and 90 days. Endovascular procedures reported a significantly higher technical failure rate as compared with surgical thrombectomy (RR, 1.58; 95% CI, 1.06-2.37; P = .03). There was no significant difference in terms of minor and major complications. CONCLUSIONS: Our data suggest that, for thrombectomy of AVGs, wholly endovascular therapy seems to be inferior to open surgery plus adjuncts based on the long-term patency and technical failure rates. However, further research in the form of a well-conducted randomized trial is warranted to establish a firmer conclusion.

Risk factors for distal stent graft-induced new entry in type B aortic dissections: Systematic review and meta-analysis.

BACKGROUND: After the use of thoracic endovascular aortic repair in the management of type B aortic dissection (TBAD), there has been increasing recognition of the phenomenon of stent graft-induced new entry (SINE) as a late complication of thoracic endovascular aortic repair, with risk factors for SINE identified. We performed a meta-analysis of contemporary studies to establish the risk factors for distal SINE (dSINE). METHODS: A systematic search of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to investigate the risk factors for dSINE. Data from population-cohort and case-control studies were extracted to compute a conventional meta-analysis by combining the odds ratio using the generic inverse variance function on RevMan 5.3. Furthermore, a meta-analysis of proportions using the Freeman-Tukey double arcsine transformation was performed to compare the incidence of acute and chronic TBAD. RESULTS: Seventeen studies assessing the data of 3962 patients met the eligibility requirements and were included in the review. The pooled proportion of dSINE in TBAD cases treated with thoracic endovascular aortic repair is 10.1%. The relative risk of incidence of dSINE in chronic TBAD compared to acute TBAD is 3.12. The chronicity of TBAD and excessive distal oversizing ratio was demonstrated to be positively associated with dSINE with odds ratios of 2.25 and 2.06, respectively. Stent grafts with connecting bars were also positively associated with dSINE, but this lacked statistical significance. CONCLUSIONS: This meta-analysis demonstrated that chronic TBAD and an excessive distal oversizing ratio are both positively and independently associated with the incidence of dSINE tears in TBAD. This should be taken into consideration when planning interventions in these patient cohorts.

Forecasting aortic aneurysm rupture: A systematic review of seasonal and atmospheric associations.

BACKGROUND: Abdominal aortic aneurysms (AAAs) represent a significant burden of disease worldwide, and their rupture, without treatment, has an invariably high mortality rate. Whereas some risk factors for ruptured AAAs (rAAAs) are well established, such as hypertension, smoking, and female sex, the impact of seasonal and meteorologic variables is less clear. We systematically reviewed the literature to determine whether these variables are associated with rAAA. METHODS: Review methods were according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We calculated pooled proportions and incidence rate ratios (IRRs) for the different months and seasons. Funnel plots were constructed to assess for publication bias. Given the poor methodologic quality of included studies, a sensitivity analysis was performed on better-quality studies, which scored 6 and above of 9 in the author-modified Newcastle-Ottawa Scale. RESULTS: The pooled proportion of rAAA was highest in the autumn season (incidence rate, 26.6%; 95% confidence interval [CI], 25.6%-27.7%; I2 = 15.4%), followed by winter (incidence rate, 26.2%; 95% CI, 24.1%-28.2%; I2 = 72.4%), and lowest in summer (incidence rate, 21.1%; 95% CI, 19.3%-23.0%; I2 = 70.4%). The IRRs of rAAA were -6.9% (95% CI, -9.8% to -3.9%), -19.5% (95% CI, -22% to -16.8%), +10.5% (95% CI, 7.2%-13.9%), and +18.1% (95% CI, 15%-22%) in spring, summer, autumn, and winter compared with the remaining seasons, respectively (all P < .0001), thus affirming existence of seasonal variation. The pooled proportion of rAAA was highest in December (incidence rate, 8.9%; 95% CI, 7.1%-10.9%; I2 = 54.5%) but lowest in July (incidence rate, 5.7%; 95% CI, 4.2%-7.3%; I2 = 54.5%). The IRR was significantly the highest in January (IRR, 1.14; 95% CI, 1.01-1.29; P = .031) but lowest in July (IRR, 0.75; 95% CI, 0.65-0.87; P < .0001). There is also some evidence for a possible association with atmospheric pressure. Associations with temperature and daylight hours, however, are at best speculative. CONCLUSIONS: Autumn and winter are significantly associated with a higher incidence of rAAAs, and autumn is associated with the highest rupture incidence of all the seasons. However, the inability to appropriately control for other confounding factors known to increase the risk of AAA rupture precludes any additional recommendations to alter current provision of vascular services on the basis of these data.

The association between diabetes and thoracic aortic aneurysms.

OBJECTIVE: The negative correlation between diabetes mellitus (DM) and abdominal aortic aneurysms (AAAs) is well described. The etiologic similarities and differences between AAAs and thoracic aortic aneurysms (TAAs) have also been documented. We aimed to evaluate the relationship between DM and TAA by performing a meta-analysis of contemporary clinical studies. METHODS: A systematic search of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to investigate the relationship of DM and TAA. Data from population cohort and case-control studies were extracted and computed together to determine a pooled unadjusted odds ratio (OR) with corresponding 95% confidence intervals (CIs) using random-effects meta-analysis. RESULTS: Five population cohort studies and five case-control studies involving 1,006,360 patients met eligibility requirement and were included. Unadjusted pooled analysis of all 10 studies demonstrated an inverse association of DM with TAA (OR, 0.77; 95% CI, 0.61-0.98). Primary analysis of the five cohort studies demonstrated a statistically significant negative association between DM and TAA (OR, 0.70; 95% CI, 0.59-0.84). However, primary analysis of the five case-control studies demonstrated a negative association between DM and TAA (OR, 0.86; 95% CI, 0.50-1.47) with no statistical significance. CONCLUSIONS: This meta-analysis demonstrated a statistically significant inverse association between DM and TAA, similar to that of AAA. Further research is required into the potentially protective mechanisms that DM may confer and whether there is biologic plausibility to exploit these mechanisms further to prevent aneurysm expansion and rupture.

A systematic review and meta-regression analysis of nonoperative management of blunt traumatic thoracic aortic injury in 2897 patients.

BACKGROUND: Thoracic endovascular aortic repair has transformed the management of blunt traumatic thoracic aortic injuries (BTTAI). Recent studies have suggested that the nonoperative management (NOM) of BTTAI may be a viable alternative. We investigated the NOM of BTTAI by conducting a systematic review and meta-analysis of the mortality proportions and incidence of complications. METHODS: We searched PubMed through June 22, 2017, and referenced lists of included studies without language restriction, with the assistance of a trained librarian. We included studies that reported the NOM of BTTAI (≥5 participants). Two authors independently screened titles, abstracts, and performed data extraction. Pooled prevalence of mortality (aortic related, in hospital) were obtained based on binomial distribution with Freeman-Tukey double-arcsine transformation and continuity correction. The random-effects model was used for all analyses to account for variation between studies. Meta-regression was performed to explore sources of heterogeneity, including Injury Severity Score, age, and gender. RESULTS: We included 35 studies comprising 2897 participants. The pooled prevalence of all-cause in-patient mortality in the overall, grade I, grade II, grade III, and grade IV populations are as follows: 29.0% (95% confidence interval [CI], 19.3%-39.6%; I2 = 95%; P < .01), 6.8% (95% CI, 0.6%-19.3%; I2 = 52%; P = .03), 0% (95% CI, 0%-2.0%; I2 = 0%; P = .81), 29.2% (95% CI, 17%-42.5%; I2 = 3%; P = .41), and 87.4% (95% CI, 16.4%-100%; I2 = 48%; P = .14), respectively. The combined incidence of aortic-related in-patient mortality in the overall, grade I, grade II, and grade III populations are: 2.4% (95% CI, 0.4%-5.5%; I2 = 60%; P < .01), 0.93% (95% CI, 0%-14.2%; I2 = 65%; P < .01), 0% (95% CI, 0%-1.8%; I2 = 0%; P = .99), and 0.13% (95% CI, 0%-6.4%; I2 = 14%; P = .33), respectively. The total proportion of postdischarge aortic-related mortality is 0% (95% CI, 0%-0.5%; I2 = 0%; P = .91). Meta-regression showed a decreased risk of in-hospital mortality as age increases (ß = .99; 95% CI, 0.98-1.00), an increased risk of in-hospital mortality with a higher Injury Severity Score (ß = 1.02; 95% CI, 1.00-1.04), and a decreased risk of in-hospital mortality among male patients (ß = .54; 95% CI, 0.3-0.90). CONCLUSIONS: This study provides, to our knowledge, the most up-to-date pooled estimate of mortality rates after the NOM of BTTAI. However, its interpretation is limited by the paucity of data and substantial quantitative heterogeneity. If patients are to be managed nonoperatively, we would recommend the judicious use of active surveillance in a select group of patients in the short, mid, and long term.

A systematic review and meta-analysis of drug-coated balloon versus conventional balloon angioplasty for dialysis access stenosis.

BACKGROUND: Arteriovenous fistulas for patients undergoing hemodialysis (HD) are at high risk of stenosis. Despite conventional balloon angioplasty (CBA), restenosis rates are high. The use of a drug-coated balloon (DCB) may offer an alternative to reduce restenosis. METHODS: This study has been performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search on MEDLINE, Embase, and the Cochrane Library was performed to identify articles evaluating DCB angioplasty for patients with HD access stenosis. Risk ratios (RRs) of primary patency were pooled, and relevant subgroup and sensitivity analyses were conducted. RESULTS: There were 17 studies (8 randomized controlled trials [RCTs], 9 cohort studies) included, comprising a total of 1113 stenotic dialysis accesses, of which 54.7% underwent DCB angioplasty and 45.3% underwent CBA. There was a significantly superior 6-month (RR, 0.57; 95% confidence interval [CI], 0.44-0.74; P < .00001; I2 = 62%) and 12-month (RR, 0.73; 95% CI, 0.63-0.84; P < .0001; I2 = 53%) primary patency in the DCB angioplasty group in comparison to the CBA group (71.0% vs 49.2% at 6 months; 44.2% vs 20.6% at 12 months). Subgroup analyses of study design (RCTs, cohort studies) showed similar trends. Sensitivity analyses by excluding one poor-quality RCT and those employing the crossover analysis design also showed similar results. Studies investigating central venous stenosis showed significantly better 6-month (RR, 0.57; 95% CI, 0.41-0.79; P = .0009; I2 = 67%) and 12-month (RR, 0.69; 95% CI, 0.56-0.85; P = .0004; I2 = 64%) primary patency in the DCB angioplasty group in comparison to the CBA group. The pooled rate of minor complications was low in both the DCB (1.1%) and CBA (0.9%) groups. CONCLUSIONS: DCB angioplasty appears to be a better and safe alternative to CBA in treating patients with HD stenosis in terms of 6- and 12-month primary patency. However, a larger trial is warranted to establish these findings.

Closed Incision Negative Pressure Wound Therapy in Vascular Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Closed incision negative pressure wound therapy (CiNPT) may be a valuable treatment option for surgical site infections. This systematic review and meta-analysis sought to compare CiNPT against conventional wound care after vascular procedures. METHODS: This study conformed to the PRISMA guidelines. An electronic search was performed on Medline/Pubmed, EMBASE, and the Cochrane Library. The date of last search was July 11 2018. Relative risks and mean differences for primary and secondary outcomes were calculated. A random effects model was used for substantial heterogeneity (I2 > 30%). The Cochrane Risk of Bias tool was employed to rate the methodological quality of the included studies, whilst the GRADE approach was use to grade the level of evidence for the observed effects. RESULTS: Of 47 studies, five randomised controlled trials (RCTs) were included, comprising 662 patients, of which 47.9% underwent CiNPT and 52.1% received conventional care. The overall risk of infection (RR = 0.31, 95% CI 0.21-0.47) (high quality), Szilagyi Grades I (RR = 0.35, 95% CI 0.20-0.60) (high quality), and III (RR = 0.17, 95% CI 0.04-0.68) (high quality) infections, need for antibiotics (RR = 0.36, 95% CI 0.20-.64) (high quality), and surgical re-intervention (RR = 0.27, 95% CI 0.27-0.98) (high quality) were lower in the CiNPT group. However, there were no significant differences in the risk of Grade II (RR = 0.59, 95% CI 0.10-3.66) (moderate quality), as well as length of hospital stay (mean difference, MD = -0.59, 95% CI -2.48 to 1.31) (moderate quality), and 30 day mortality (RR = 3.95, 95% CI 0.17-94.76) (high quality). CONCLUSION: While there is evidence demonstrating that CiNPT reduces the risk of Grades I and III infections and re-interventions, there was a noticeable lack of difference in other important post-operative outcomes. Further well designed RCTs are needed to corroborate these findings.