Preoperative Supervised Exercise Improves Outcomes After Elective Abdominal Aortic Aneurysm Repair: A Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to assess the impact of a preoperative medically supervised exercise program on outcomes after elective abdominal aortic aneurysm (AAA) repair. BACKGROUND: Functional capacity is an important predictor of postoperative outcomes after elective AAA repair. Improving patients' preoperative fitness with exercise has the potential to positively influence recovery. METHODS: A randomized controlled trial was performed at a tertiary vascular unit. Patients scheduled for open or endovascular AAA repair were randomized to either 6 weeks of preoperative supervised exercise or standard treatment using sealed envelopes. The primary outcome measure was a composite endpoint of cardiac, pulmonary, and renal complications. Secondary outcome measures were 30-day mortality, lengths of hospital and critical care stay, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, reoperation, and postoperative bleeding. RESULTS: One hundred twenty-four patients were randomized (111 men, mean [SD] age 73 [7] y). Fourteen patients sustained postoperative complications in the exercise group (22.6%), compared with 26 in the nonexercise group (41.9%; P = 0.021). Four patients (2 in each group) died within the first 30 postoperative days. Duration of hospital stay was significantly shorter in the exercise group (median 7 [interquartile range 5-9] vs 8 [interquartile range 6-12.3] d; P = 0.025). There were no significant differences between the groups in the length of critical care stay (P = 0.845), APACHE II scores (P = 0.256), incidence of reoperations (P = 1.000), or postoperative bleeding (P = 0.343). CONCLUSIONS: A period of preoperative supervised exercise training reduces postoperative cardiac, respiratory, renal complications, and length of hospital stay in patients undergoing elective AAA repair.

Endovascular versus Open Repair of Asymptomatic Popliteal Artery Aneurysms: A Systematic Review and Meta-Analysis.

This systematic review compared outcomes between endovascular and open repair of asymptomatic popliteal artery aneurysms (PAAs). Endovascular repair was associated with increased 30-day graft occlusion (odds ratio [OR] = 3.14; 95% confidence interval [CI], 1.43-6.92) and increased 30-day reintervention (OR = 4.09; 95% CI, 2.79-6.00). The 12-month primary patency rate was significantly higher in the open repair group (hazard ratio = 1.95; 95% CI, 1.14-3.33). Endovascular repair was associated with shorter length of hospital stay (mean difference = -3 d; 95% CI, -4.09 to -1.91; P < .001). Endovascular repair is associated with inferior perioperative and postoperative outcomes compared with open repair.

Outcomes after open repair of ruptured abdominal aortic aneurysms in octogenarians: a 20-year, single-center experience.

BACKGROUND: The purpose of this study was to evaluate morbidity, mortality, and survival in octogenarians undergoing open repair of ruptured abdominal aortic aneurysms (RAAAs) in comparison to younger patients. METHODS: This investigation was a retrospective analysis of a prospectively maintained database from a tertiary referral center. We included all consecutive RAAA patients who underwent open repair from 1990 to 2011. Univariate and multivariate analyses were used to identify predictors of inferior short- and long-term outcomes. RESULTS: Overall, 463 patients were identified, of whom 138 (30%) were octogenarians (group 2), with a mean age of 84 ± 0.47 years. There were 96 (69%) men and 42 women (31%). There were more women in group 2 (31%) compared with the <80-year-old patients of group 1 (14%) (P < 0.001). The 30-day mortality for group 2 was 43.5% compared with 28.0% for group 1 (P < 0.001). Preoperatively, 63% of group 1 patients presented with shock compared with 65% of those in group 2 (P = 0.751). There was no difference between the two groups in terms of preoperative systolic blood pressure (SBP), duration of operation, and intraoperative blood loss (P > 0.05). Median preoperative hemoglobin (P < 0.001) and creatinine (P = 0.031) levels were significantly different between the groups. There was no significant difference between the two groups in terms of postoperative complications and length of hospital stay. Median long-term survival for octogenarians (group 2) was 5.4 years compared with 12.4 years for the younger patient group (group 1) (P < 0.001). Multivariate analysis identified age as an independent predictor of 30-day mortality (odds ratio [OR] = 1.154, 95% confidence interval [CI] 1.037-1.285) and inferior long-term survival (OR = 1.074, 95% CI 1.011-1.141). History of cigarette smoking also predicted worse long-term outcomes (OR = 3.044, 95% CI 1.318-7.032) as did multiorgan failure in the postoperative course (OR = 1.363, 95% CI 1.080-14.130). CONCLUSIONS: Advanced age is associated with high surgical mortality; however, for octogenarians surviving surgical repair, long-term outcome is acceptable. Therefore, with responsible decision-making, surgical intervention is justifiable in the elderly. Smoking and multiorgan failure were both predictive of worse survival.

Supervised exercise program improves aerobic fitness in patients awaiting abdominal aortic aneurysm repair.

BACKGROUND: Aerobic fitness is an important predictor of postoperative outcome in major surgery. In this study, we assess the effects of a period of preoperative exercise on aerobic fitness as measured by cardiopulmonary exercise testing (CPET) in patients scheduled for abdominal aortic aneurysm (AAA) repair. METHODS: As part of a randomized trial, the first patients recruited in the intervention group were enrolled in a supervised exercise program of six week duration. Treadmill CPET parameters were measured before and after exercise preoperatively for these patients. These parameters were as follows: peak oxygen uptake (VO2 peak), anaerobic threshold (AT), and ventilator equivalents for oxygen and carbon dioxide (VE/VO2 and VE/VCO2, respectively). Total exercise time and the time at which AT was achieved were also recorded. A comparison between pre- and postexercise parameters was made to detect for a possible improvement in aerobic fitness. RESULTS: Twenty patients with AAA (17 men; mean age: 74.9 ± 5.9 years) were included in this study. Thirty-five percent of patients had a history of ischemic heart disease, 25% of obstructive airway disease, and 15% of cerebral vascular events. Seventy percent were previous smokers, and 15% were current smokers. Fifty-five percent of patients were taking aspirin and 75% were undergoing statin therapy. The median (interquartile range) VO2 peak at baseline was 18.2 (15.4-19.9) mL/kg/min, and after exercise was 19.9 (17.1-21.1; P = 0.048). Median AT at baseline was 12.2 (10.5-14.9), and 14.4 (12.3-15.4) after exercise (P = 0.023). Time of exercise tolerated also improved from a median of 379 to 604 sec (P = 0.001). No significant changes were seen in VE/VO2, VE/VCO2, or the time at which AT was achieved. CONCLUSION: This study shows that cardiopulmonary aerobic fitness improves after a period of supervised exercise in patients scheduled for AAA repair. This is justification for a randomized trial to assess whether this affects morbidity and mortality after AAA repair.

Role of pre-operative multiple gated acquisition scanning in predicting long-term outcome in patients undergoing elective abdominal aortic aneurysm repair.

OBJECTIVE: To determine whether resting pre-operative left ventricular ejection fraction (LVEF) estimated by multiple gated acquisition scanning (MUGA) predicts long-term survival in patients undergoing elective abdominal aortic aneurysm (AAA) repair. METHODS: A retrospective study of MUGA scans which were performed to estimate pre-operative resting LVEF in 127 patients [106 (83 %) males, mean age 74 ± 7.6 years] who underwent elective AAA repair over a period of 4 years from March 2007. We compared outcomes and long-term survival between patients who had a pre-operative LVEF ≤ 40 % (Group 1, n = 60) and LVEF > 40 % (Group 2, n = 67). RESULTS: Overall 19 (15 %) patients died during the follow-up period (13 patients in group 1 and 6 patients in group 2). 30-day mortality was 8 %. There was no significant difference between group 1 and 2 in terms of patients' mean age or median length of hospital stay (8 days for both groups, p = 0.61). However, group 2 had more females than group 1(18 vs. 3, p = 0.001). Median survival for patients in group 2 was significantly higher than patients in group 1 (1,258 days vs. 1,000 days, p = 0.03). In a Cox regression model which included age, sex, smoking status and LVEF as covariates, only smoking status and LVEF predicted survival [Hazard ratio (HR) = 1.06, p = 0.04 and HR = 0.93, p = 0.00, respectively]. CONCLUSION: This study shows that there is a role for pre-operative MUGA scan assessment of resting LVEF in predicting long-term survival post elective AAA repair and that the lower the pre-operative LVEF the poorer the long-term outcome.

Perioperative, Postoperative, and Long-Term Outcomes Following Open Surgical Repair of Ruptured Abdominal Aortic Aneurysm.

We investigated factors that affected perioperative, postoperative, and long-term outcomes of patients who underwent open emergency surgical repair of ruptured abdominal aortic aneurysms (RAAA). All patients who underwent open emergency surgical repair from 1990 to 2011 were included (463 patients; 374 [81%] male; mean age 74.7 ± 8.7years). Logistic and Cox regression analyses were performed to explore the association of variables with outcomes. Preoperatively, median (interquartile range) hemoglobin was 11.2 (9.5-12.8) g/dL, and median creatinine level was 140 (112-177) µmol/L. Intraoperatively, the median operative time was 2.25 (2-3) hours, and median estimated blood loss was 1.5 (0.5-3) L; 250 (54%) patients required intraoperative inotropes, and a median of 6 (4-8) units of blood was transfused. Median length of hospital stay was 11 (7-20) days. In-hospital mortality rate was 35.6%, and 5-year mortality was 48%. Age, distance traveled, operation duration, postoperative myocardial infarction (MI), and multi-organ failure (MOF) were predictors of in-hospital mortality and long-term outcome. Additionally, postoperative acute renal failure predicted in-hospital mortality. In patients with RAAA undergoing open surgical repair, the strongest predictors of in-hospital mortality and long-term outcome were postoperative MOF and MI and operative duration.

Attitudes towards the surgical safety checklist and factors associated with its use: A global survey of frontline medical professionals.

BACKGROUND: The Surgical Safety Checklist (SSC) has been shown to reduce perioperative errors and complications and its implementation is recommended by the World Health Organisation (WHO). However, it is unknown how widely this intervention is used. We investigated attitudes and factors associated with use of WHO SSC in frontline medical professionals across the globe using a survey distributed through social networks. METHODS: A survey of usage and opinions regarding the SSC was posted on the Facebook and Twitter pages of a not-for-profit surgical news website for one month (March 2013). Respondents were grouped into four groups based on their country's Gross National Income: high, upper middle, lower middle and low income. Univariate and multivariate analyses were performed to investigate how different factors were associated with the use of the SSC. RESULTS: 6269 medical professionals from 69 countries responded to the survey: most respondents were from lower middle (47.4%) countries, followed by: high (35.0%), upper middle (14.6%), and low (3.0%) income countries. In total, 57.5% reported that they used the WHO SSC perioperatively. Fewer respondents used the WHO SSC in upper middle, lower middle and low income countries (LMICs) compared to high income countries (43.5% vs. 83.5%, p < 0.001). Female (61.3% vs. 56.4% males, p = 0.001), consultant surgeons (59.6% vs. 53.2% interns, p < 0.001) and working in university hospitals (61.4% vs. 53.7% non-university hospitals, p < 0.001) were more likely to use the SSC. Believing the SSC was useful, did not work or caused delays was independently associated with the respondents reported use of the SSC (OR 1.22 95% CI 1.07-1.39; OR 0.47 95% CI 0.36-0.60; OR 0.64 95% CI 0.53-0.77, respectively). CONCLUSION: This study suggests the use of the WHO SSC is variable across countries, especially in LMICs where it has the most potential to improve patient safety. Critical appraisal of the documented benefits of the WHO SSC may improve its adoption by those not currently using it.

The Vicorder device compared with SphygmoCor in the assessment of carotid-femoral pulse wave velocity in patients with peripheral arterial disease.

To assess the reliability and reproducibility of the Vicorder's carotid-femoral pulse wave velocity (cfPWV) measurements in patients with peripheral arterial disease (PAD) and to compare between cfPWV measurements obtained using the Vicorder with those obtained using the SphygmoCor device as a reference. Some 30 patients with PAD (23 men, mean age 64.9±7.5) underwent cfPWV measurement twice by a single investigator during one visit using the Vicorder and the SphygmoCor according to the manufacturer's instructions. Intra-rater reproducibility for each device was assessed using intraclass correlation coefficients (ICC) and Bland-Altman method. The latter was also used to compare between the two devices. The mean difference (s.d.) between repeated measurements was 0.03±0.92 m s(-1), P=0.85 and 0.01±0.54 m s(-1), P=0.91 for the SphygmoCor and Vicorder, respectively. Measurements of cfPWV were highly reproducible using both devices (ICC=0.94 and 0.92, for the Vicorder and SphygmoCor, respectively). Limits of Agreement using the Bland-Altman method were -1.07 to 1.09 m s(-1) and -1.79 to 1.85 m s(-1) for the Vicorder and the SphygmoCor, respectively. Bland-Altman plots indicated that 90% of the cfPWV measurements using the Vicorder and 93% of the measurements using the SphygmoCor fell within two s.d.s of the mean difference. Transit time (TT) differed significantly between the two devices (mean difference 30±9.2 m s, P<0.001), with the Vicorder recording higher values. Nevertheless, the two devices recorded nearly similar cfPWV measurements (mean difference -0.69±1.6 m s(-1), P=0.02) with 97% of cfPWV values falling within two s.d. values of the mean difference on Bland-Altman plot. Both devices generated highly reproducible cfPWV measurements in patients with PAD and were in good agreement when compared with each other. However, the discrepancy in TT between the two devices lead to the Vicorder producing lower values of cfPWV at high values produced by the SphygmoCor.

Meta-analysis of angiotensin converting enzyme inhibitors effect on walking ability and ankle brachial pressure index in patients with intermittent claudication.

OBJECTIVE: The aim of this meta-analysis was to investigate the effect of angiotensin converting enzyme (ACE) inhibitors on maximum walking distance (MWD), pain-free walking distance (PFWD) and ankle brachial pressure index (ABPI) in patients with intermittent claudication (IC). METHODS: MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to July 2013 on randomised controlled trials (RCTs) that assessed the effect of ACE inhibitors on MWD, PFWD and ABPI in patients with IC. RESULTS: Of 348 publications found, a meta-analysis was conducted of 6 RCTs comprising 821 patients. Treatment with ACE inhibitors improved MWD by mean difference (95 per cent confidence interval) of 120.8 (2.95-238.68) m (P = 0.040), improved PFWD by 74.87 (25.24-124.50) m (P = 0.003) and insignificantly improved ABPI by 0.07 (-0.02-0.17) (P = 0.110) compared to placebo. Heterogeneity across studies was significant. Maximum treatment benefit was achieved after a 6-months treatment period with ramipril as the ACE inhibitor. CONCLUSION: Treatment with ACE inhibitors improved walking ability in patients with IC. However, this was not associated with significant improvement in ABPI. Patients with IC might benefit from treatment with a high tissue affinity ACE inhibitor for a period of 6 months.

Chylous ascites complicating elective abdominal aortic aneurysm repair: case report and review of treatment options.

INTRODUCTION: Chylous ascitis is a rare complication of abdominal aortic aneurysm (AAA) surgery with only 38 cases reported since the early 70s. Due to their anatomical relation with the abdominal aorta, cisterna chyli injury is more common following open AAA repairs when compared to other surgeries; 81% of all postsurgical chylous ascites reported. CASE PRESENTATION: We present a case of severe chylous ascitis following elective AAA repair in a 76-year-old caucasian male who gradually developed abdominal distension following discharge. A conservative approach was followed by a peritoneovenous shunt insertion, but this had no clinical benefit. The site of chyle leak was identified and ligated at relaparatomy to eventually resolve his ascitis. CONCLUSION: Many reports in literature demonstrate successful conservative measures and highlight the importance of nutritional status in the course of persistent postoperative chylous ascitis. In our experience, complete resolution only came after relaparatomy and repair of leaking lymphatics.