Postoperative Myocardial Injury and Inflammatory Biomarkers in Patients Undergoing Vascular Surgery: A Subanalysis of the Platelet Reactivity and Postoperative Myocardial Injury after Major Vascular Surgery (PROMISE) Study.

BACKGROUND: Postoperative myocardial injury (PMI) is associated with morbidity and mortality, but the aetiology remains unclear. We studied whether PMI is associated with perioperative systemic inflammation. The objective is the examination of the relationship between inflammatory biomarkers (Interleukin 6[IL-6], C-reactive protein [CRP]) and PMI, detected by elevated cardiac troponin (cTn), in patients undergoing elective open abdominal aortic surgery. METHODS: This prospective, single-center, observational cohort study included 54 patients undergoing elective open abdominal aortic surgery between March 2018 and April 2021. Patients were routinely treated with aspirin. IL-6 and CRP were measured preoperatively, directly after surgery, 24 hr and 48 hr postoperatively. The primary outcome was cTn release assessed by a fifth-generation high-sensitive cTn assay. Multivariable generalized linear regression models were used to evaluate the association between inflammatory biomarkers and cTn concentrations. RESULTS: Fifteen patients (27.8%) developed PMI. IL-6 directly and 24 hr postoperatively was associated with elevated cTn concentrations (1.28 [1.07-1.54], P = 0.009) and 1.75 [1.18-2.59], P = 0.006, respectively). Also, CRP directly and 24 hr postoperatively was associated with elevated cTn concentrations (1.25 [1.06-1.47], P = 0.009) and 1.61 [1.1-2.33], P = 0.013, respectively). No association was found between IL-6 or CRP and cTn concentrations when measured at 48 hr postsurgery. CONCLUSIONS: Biomarkers of inflammation are associated with elevated postoperative cTn concentrations in the early postoperative period in patients undergoing elective open abdominal aortic surgery.

A Statistical Shape Model of Infrarenal Aortic Necks in Patients With and Without Late Type Ia Endoleak After Endovascular Aneurysm Repair.

PURPOSE: Hostile aortic neck characteristics, including short length, severe suprarenal and infrarenal angulation, conicity, and large diameter, have been associated with increased risk for type Ia endoleak (T1aEL) after endovascular aneurysm repair (EVAR). This study investigates the mid-term discriminative ability of a statistical shape model (SSM) of the infrarenal aortic neck morphology compared with or in combination with conventional measurements in patients who developed T1aEL post-EVAR. MATERIALS AND METHODS: The dataset composed of EVAR patients who developed a T1aEL during follow-up and a control group without T1aEL. Principal component (PC) analysis was performed using a parametrization to create an SSM. Three logistic regression models were created. To discriminate between patients with and without T1aEL, sensitivity, specificity, and the area under the receiver operating characteristic (ROC) curve (AUC) were calculated. RESULTS: In total, 126 patients (84% male) were included. Median follow-up time in T1aEl group and control group was 52 (31, 78.5) and 51 (40, 62.5) months, respectively. Median follow-up time was not statistically different between the groups (p=0.72). A statistically significant difference between the median PC scores of the T1aEL and control groups was found for the first, eighth, and ninth PC. Sensitivity, specificity, and AUC values for the SSM-based versus the conventional measurements-based logistic regression models were 79%, 70%, and 0.82 versus 74%, 73%, and 0.85, respectively. The model of the SSM and conventional measurements combined resulted in sensitivity, specificity, and AUC of 81%, 81%, and 0.92. CONCLUSION: An SSM of the infrarenal aortic neck determines its 3-dimensional geometry. The SSM is a potential valuable tool for risk stratification and T1aEL prediction in EVAR. The SSM complements the conventional measurements of the individual preoperative infrarenal aortic neck geometry by increasing the predictive value for late type Ia endoleak after standard EVAR. CLINICAL IMPACT: A statistical shape model (SSM) determines the 3-dimensional geometry of the infrarenal aortic neck. The SSM complements the conventional measurements of the individual pre-operative infrarenal aortic neck geometry by increasing the predictive value for late type Ia endoleaks post-EVAR. The SSM is a potential valuable tool for risk stratification and late T1aEL prediction in EVAR and it is a first step toward implementation of a treatment planning support tool in daily clinical practice.

A Statistical Shape Model of the Morphological Variation of the Infrarenal Abdominal Aortic Aneurysm Neck.

Hostile aortic neck characteristics, such as short length and large diameter, have been associated with type Ia endoleaks and reintervention after endovascular aneurysm repair (EVAR). However, such characteristics partially describe the complex aortic neck morphology. A more comprehensive quantitative description of 3D neck shape might lead to new insights into the relationship between aortic neck morphology and EVAR outcomes in individual patients. This study identifies the 3D morphological shape components that describe the infrarenal aortic neck through a statistical shape model (SSM). Pre-EVAR CT scans of 97 patients were used to develop the SSM. Parameterization of the morphology was based on the center lumen line reconstruction, a triangular surface mesh of the aortic lumen, 3D coordinates of the renal arteries, and the distal end of the aortic neck. A principal component analysis of the parametrization of the aortic neck coordinates was used as input for the SSM. The SSM consisted of 96 principal components (PCs) that each described a unique shape feature. The first five PCs represented 95% of the total morphological variation in the dataset. The SSM is an objective model that provides a quantitative description of the neck morphology of an individual patient.

Arterial thrombotic complications in COVID-19 patients.

The coronavirus disease 2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been described to predispose to thrombotic disease in both the venous and arterial circulations. We report four cases of an acute arterial occlusion in COVID-19 patients and literature review on the occurrence of arterial thrombosis in patients with COVID-19. Our findings demonstrate that physicians should be vigilant for signs of thrombotic complications in both hospitalized and new COVID-19 patients.

Outcomes of open repair of postdissection abdominal aortic aneurysms.

BACKGROUND: Evidence to guide management of postdissection abdominal aortic aneurysms (PDAAA) is lacking. This study describes the outcomes of open repair of PDAAA. METHODS: A retrospective cohort study was conducted of all consecutive patients treated with open repair for PDAAA after a Stanford type A or type B thoracic aortic dissection between January 2006 and December 2017 in two vascular referral centers. Preceding type B dissection treatment could include conservative or surgical management. Primary outcomes were 30-day mortality, complication rates, survival, and reintervention-free survival. Survival and reintervention-free survival were analyzed using the Kaplan-Meier method. Reintervention was defined as any endovascular or surgical intervention after the index procedure. RESULTS: Included were 36 patients (27 men [75%]) with a median age of 64 years (range, 35-81 years). The 30-day mortality was 2.7%. The median follow-up was 16 months (range, 0-88 months). The postoperative course was uneventful in 21 patients (58%). The most frequent complications were postoperative bleeding requiring repeat laparotomy (n = 4), pneumonia (n = 3), congestive heart failure (n = 2), new-onset atrial fibrillation (n = 2), mesenteric ischemia requiring left hemicolectomy (n=1), and ischemic cerebrovascular accident (n = 1). Renal failure requiring hemodialysis developed in one patient. The overall survival at 1 year was 88.8%. Reintervention-free survival was 95.5% after 1 year and 88.6% after 2 years. CONCLUSIONS: Open repair of PDAAA can be performed with a low mortality rate and an acceptable complication rate, comparable with elective open repair of abdominal aortic aneurysms without dissection.

Popliteal artery aneurysms differ from abdominal aortic aneurysms in cellular topography and inflammatory markers.

OBJECTIVE: Popliteal artery aneurysms (PAAs) and abdominal aortic aneurysms (AAAs) frequently coincide; however, symptoms differ. We systematically assessed aneurysm cellular wall composition and inflammatory markers to compare both anatomic locations. METHODS: Aneurysmal walls of 38 PAAs and 198 AAAs were harvested from patients undergoing elective open surgical repair. Elastin, collagen, smooth muscle cells, iron, and inflammatory cells were quantified by immunohistochemistry. In addition, protease and cytokine levels were measured. RESULTS: Aneurysmal degradation resulted in similarly degraded media. The location of inflammation differed: the focus for T and B lymphocytes and plasma cells was the intima in PAAs (all P < .001) and the adventitia for AAAs (all P < .001). Iron was more often observed in PAAs than in AAAs (68% vs 1%; P < .001), indicating more previous intramural hemorrhages. Matrix metalloproteinase 2 activity was higher in PAAs than in AAAs (median [interquartile range], 0.363 [0.174-0.556] vs 0.187 [0.100-0.391]; P = .008), whereas matrix metalloproteinase 9 showed no difference. Walls of AAAs were richer in tested cytokine levels than were walls of PAAs. CONCLUSIONS: PAAs showed more signs of previous intramural hemorrhages compared with AAAs. In addition, inflammation in PAAs is mainly located in the intima, whereas its focus in AAAs is the adventitia. These results suggest important differences in the pathophysiologic mechanism of aneurysm formation between these locations and might explain the differences in presentation on diagnosis.

Association of sex with long-term outcomes after popliteal artery aneurysm repair.

BACKGROUND: We compared initial and long-term outcomes between men and women after endovascular and open repair of popliteal artery aneurysms (PAAs). METHODS: Between January 1993 and July 2011, 202 patients (185 men [92%]), underwent open (n = 186) or endovascular (n = 16) repair of a PAA. Data were retrospectively analyzed. RESULTS: Significant differences in baseline characteristics were determined between men and women with regard to aneurysm diameter (men: 30 mm [range: 14-90]; women: 26 mm [range: 13-70]; P = 0.02) and age (men: 66 ± 10 years; women: 71 ± 9 years; P = 0.05). The 30-day mortality rate was 0% in both groups. No significant differences were determined concerning 30-day complications. The median follow-up was 55 months (range: 1-121 months) in men, compared with 35 months (range: 1-183 months) in women (P = 0.74). The primary patency rates at 1, 3, and 5 years were 88%, 82%, and 76% in men compared with 64%, 64%, and 48% in women, respectively (P = 0.007). The limb salvage rates in men at 1, 3, and 5 years were 97%, 97%, and 96%, and in women were 87%, 87%, and 87%, respectively (P = 0.07). When correcting for potential confounders with multivariable regression analysis, sex was independently associated with primary patency (hazard ratio: 2.98 [95% confidence interval: 1.39-6.42]; P = 0.005). CONCLUSIONS: No significant differences between men and women were observed in 30-day mortality and morbidity rates after PAA repair. In the long run, women are associated with lower primary patency rates and a trend toward lower limb salvage rates compared to men.

Variations in anatomy of the popliteal artery and its side branches.

Knowledge of anatomic variations of the popliteal artery is essential for the management of peripheral vascular disease and in orthopedic surgery. The aim of this study was to perform an overview of the literature describing variations of the popliteal artery. To identify relevant literature, we performed a systematic search on MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. We included 4 studies of anatomic dissections and 11 radiologic retrospective series, comprising 7671 limbs, and a variation in popliteal branching was seen in almost 10%. The 3 most frequent variations in branching are a high origin of the anterior tibial artery, the trifurcation of the anterior tibial artery, peroneal artery, and posterior tibial artery, and a hypoplastic or aplastic posterior tibial artery. Awareness of the terminal branching pattern of the popliteal artery before intervention enhances the planning for successful operations and may reduce the incidence of serious, unexpected arterial injury.

Treatment of impacted greenstick forearm fractures in children using bandage or cast therapy: a prospective randomized trial.

BACKGROUND: To evaluate the relative risks and advantages of using soft bandage therapy (BT) for impacted greenstick fractures of the distal forearm compared with cast therapy (CT). METHODS: At a single center from September 2005 to October 2006 all patients with an impacted greenstick fracture were randomized to BT or CT. RESULTS: A total of 92 patients were randomized and assigned. No fracture displacement was seen. Three patients from the BT group were converted to standard treatment. A significant difference in pain was seen between both groups after 1 week in favor of the CT group. Discomfort was significantly less in the BT group compared with the CT group. After 4 weeks, the wrist function was significantly better in the BT group. After 6 weeks, the wrist functions of both the groups were comparable. CONCLUSIONS: BT for impacted greenstick fractures of the distal forearm is a safe technique, patients treated with bandage suffer greater pain at the start of the treatment, are able to return to normal activities sooner, and have less discomfort when compared with the standard CT.

Surgical repair of a gunshot injury to the left carotid artery: case report and review of literature.

We present a case of a 37-year-old man who sustained a single gunshot wound (penetrating zones I and II) and internal carotid artery injury. Optimal evaluation and management of vascular injury remains controversial. Literature on the operative techniques of carotid artery injuries is reviewed.

The medial versus the posterior approach in the repair of popliteal artery aneurysms: a multicenter case-matched study.

OBJECTIVES: This study was conducted to compare the early and mid-term results of the medial and posterior approaches in the surgical treatment of popliteal artery aneurysms (PAAs). METHODS: From 1992 to 2006 in three hospitals, 110 popliteal aneurysms needed surgical repair by a posterior or a medial approach. Of 36 aneurysms repaired by the posterior approach, 33 could be case-matched to a medially excluded PAA according to the criteria of (1) patient age, (2) cardiovascular comorbidity, (3) indication for PAA repair, (4) diameter of PAA at time of surgical repair, (5) number of distal outflow vessels at time of surgical repair, and (6) type of bypass or interposition graft (venous or polytetrafluoroethylene). RESULTS: During the 30-day postoperative period, seven complications (21%) occurred in each group, no patients died, and no amputations were necessary. Two patients in the posterior group vs none in the medial group (P < .05) needed thrombectomy because of occlusion of the reconstruction. The mean follow-up was 47 months (range, 2 to 176). In this period, 13 deaths occurred, but none were related to the previous interventions. The primary patency rates at 6 months and at 1, 3, and 4 years were 84%, 79%, 66%, and 66% in the posterior group and 96% (P < .05), 93% (P < .05), 76% (P = NS), and 69 % (P = NS) for the medial group, respectively. The secondary patency rates at 6 months, and at 1, 3, and 4 years were 100%, 100%, 100%, and 90% in the posterior group and 96%, 96%, 96%, and 90% in the medial group, respectively (P = NS). Limb salvage rates were 97% for the posterior group and 100% for the medial group (P = NS). No neurologic complications or venous damage was seen in either group. Irrespective of approach, venous reconstructions resulted in significantly higher patency rates compared with prosthetic reconstructions at the 3-year follow-up (84% vs 67%, P < .01). During follow-up, which included duplex scanning, two patients in the medial group needed renewed surgical intervention and posterior exclusion because of persistent flow and growth of the native aneurysm. CONCLUSION: Early (<1 year) primary patency rates of the medial approach were significantly better than the posterior approach, possibly because of the limited posterior exposure. However, in the absence of a significant difference in long-term primary and secondary patency rates between the posterior and medial approach, and considering the substantial risk of aneurysm growth after medial approach (up to 22%), the posterior approach might be the surgical method of preference for PAA repair in the long run.