Fibrinogen concentrate vs. fresh frozen plasma for the management of coagulopathy during thoraco-abdominal aortic aneurysm surgery: a pilot randomised controlled trial.

Major vascular surgery is frequently associated with significant blood loss and coagulopathy. Existing evidence suggests hypofibrinogenaemia develops earlier than other haemostatic deficiencies during major blood loss. The purpose of this study was to assess whether the use of an infusion of fibrinogen concentrate to prevent and treat hypofibrinogenaemia during surgery resulted in satisfactory haemostasis, removing or reducing the need for blood component transfusion. Twenty patients undergoing elective extent-4 thoraco-abdominal aortic aneurysm repair were randomly allocated to receive either fresh frozen plasma or fibrinogen concentrate to treat hypofibrinogenaemia during surgery. Coagulation was assessed during and after surgery by point-of-care and laboratory testing, respectively, and treatment was guided by pre-defined transfusion triggers. Despite blood losses of up to 11,800 ml in the patients who received the fibrinogen concentrate, none required fresh frozen plasma during surgery, and only two required platelet transfusions. The median (IQR [range]) allogeneic blood component administration during surgery and in the first 24 h postoperatively was 22.5 (14-28 [2-41]) units in patients allocated to fresh frozen plasma vs. 4.5 (3-11[0-17]) in patients allocated to fibrinogen concentrate (p = 0.011). All patients in both groups were assessed by the surgeon to have satisfactory haemostasis at the end of surgery. Mean (SD) postoperative fibrinogen concentrations were similar in patients allocated to fresh frozen plasma and fibrinogen concentrate (1.6 (0.3) g.l-1 vs. 1.6 (0.2) g.l-1 ; p = 0.36) but the mean (SD) international normalised ratio and activated partial thromboplastin time ratio were lower in patients allocated to fresh frozen plasma (1.1 (0.1) vs. 1.8 (0.3); p < 0.0001 and 1.1 (0.2) vs. 1.7 (0.5); p = 0.032, respectively). Fibrinogen concentrate may be used as an alternative to fresh frozen plasma in the treatment of coagulopathy during thoraco-abdominal aortic aneurysm repair.

Long-term renal outcomes of consecutive patients undergoing open type IV thoracoabdominal aneurysm repair.

OBJECTIVE: To evaluate long-term renal outcomes after open type IV thoracoabdominal aneurysm (TAAA) repair. DESIGN: Retrospective analysis of a prospectively collected database of consecutive operated non-ruptured type IV TAAAs (2007-2011). METHODS: Renal function was analysed by serum creatinine concentration, estimated glomerular filtration rate (eGFR) and Kidney Disease Outcomes Quality Initiative (KDOQI) stage. The primary outcome was the change in creatinine concentration from before surgery to defined time points after surgery: peak postoperative; discharge; at follow-up (>1 year postoperatively). Secondary outcomes were change in eGFR, change in KDOQI stage, dialysis requirement, and 30-day mortality. RESULTS: Between 2007 and 2011, 53 open type IV TAAA repairs were performed. Median creatinine levels significantly increased in the immediate postoperative period, but returned to baseline by discharge. Thirteen patients (28.2%) had an improvement in follow-up eGFR of at least 20% compared with pre-operative eGFR or improved by one KDOQI stage. Twelve patients (26.1%) had a decline in eGFR of at least 20% or one KDOQI stage at follow-up. Three patients (7.5%) required temporary dialysis and one patient (1.9%) required permanent dialysis. The 30-day mortality was 1.9%. CONCLUSIONS: This study demonstrates acceptable renal outcomes following open type IV TAAA repair. Open type IV repair remains the standard against which newer techniques should be compared.

Ruptured thoracoabdominal aneurysm in a 27-year-old with hyper IgE syndrome.

Hyperimmunoglobulin E syndrome is a rare primary immunodeficiency disorder defined by high serum immunoglobulin E titers and associated with characteristic infectious, dermatologic, skeletal, and dental abnormalities. We present the case of a 27-year-old man presenting acutely with a ruptured type IV thoracoabdominal aortic aneurysm. He was successfully treated by open operative repair and discharged with long-term prophylactic antibiotics. To our knowledge, this is the first such case reported in the English literature.

Randomized clinical trial of tranexamic acid-free fibrin sealant during vascular surgical procedures.

BACKGROUND: This study evaluated the safety and haemostatic effectiveness of a fibrin sealant (EVICEL(™) Fibrin Sealant (Human)) during vascular surgery. METHODS: This prospective randomized controlled trial compared the haemostatic effectiveness of fibrin sealant (75 patients) or manual compression (72) in polytetrafluoroethylene (PTFE) arterial anastomoses. The primary endpoint was the absence of bleeding at the anastomosis at 4 min after randomization. Secondary endpoints included haemostasis at 7 and 10 min, treatment failures and the incidence of complications potentially related to bleeding. Adverse events were recorded. RESULTS: A higher percentage of patients who received fibrin sealant versus manual compression achieved haemostasis at 4 min (85 versus 39 per cent respectively; odds ratio 11·34, 95 per cent confidence interval 4·67 to 27·52; P < 0·001). Similarly, a higher percentage of patients who received fibrin sealant achieved haemostasis at 7 and 10 min (both P < 0·001). The incidence of treatment failure was lower in the fibrin sealant group (P < 0·001). The rate of complications potentially related to bleeding was similar (P = 0·426). Some 64 per cent of patients who received fibrin sealant experienced at least one adverse event, compared with 71 per cent who received manual compression. CONCLUSION: This fibrin sealant was safe, and significantly shortened the time to haemostasis in vascular procedures using PTFE. REGISTRATION NUMBER: NCT00154141 (http://www.clinicaltrials.gov).

Natural history of thoraco-abdominal aneurysm in high-risk patients.

INTRODUCTION: There is considerable interest in the role of novel endovascular techniques for the treatment of patients with complex aneurysms who are unsuitable for standard interventions. Knowledge of the natural history of these lesions, as well as other co-morbidities, is required in order that these techniques may be applied correctly in this high-risk group. METHOD: This study reviews the outcome of patients deemed to be unfit for surgery following assessment under the Scottish National Thoraco-abdominal aneurysm service (TAAA) service (2002-2008). RESULTS: Of 216 patients assessed, 89 (41%) patients were considered to be unfit for intervention. The median (interquartile range, IQR) age of patients was 75 (70-80) years and there were 39 men (44%). Median (IQR) aneurysm size was 6 (5.6-7.0) cm. The median (IQR) follow-up time was 12 (7-26) months. There were 49 (55%) deaths during the follow-up period of which 23 (47%) cases were due to ruptured TAAA and 26 (53%) were not aneurysm-related. Comparing patients with aneurysms <6 cm (33 patients) with those aneurysms > or =6 cm (56 patients) there was no difference in aneurysm-related death (p = 0.32) or all-cause mortality (p = 0.147). CONCLUSION: Aneurysm-related mortality amongst patients unsuitable for open TAAA surgery is considerable and evolving endovascular techniques may permit intervention in selected patients. However any intervention can only be justified if the patient's life expectancy is sufficient to allow benefit to accrue.

Contemporary results for open repair of suprarenal and type IV thoracoabdominal aortic aneurysms.

BACKGROUND: Endovascular and hybrid procedures are not yet widely established in the management of type IV thoracoabdominal aortic aneurysm (TAAA). Open surgery remains the treatment of choice until the long-term outcomes of these novel techniques are known. METHODS: This study reviewed a 10-year experience of open repair of non-ruptured type IV and suprarenal TAAA. All procedures were performed using a totally abdominal approach with supracoeliac clamping of the aorta. RESULTS: There were 53 patients (31 men; 58 per cent) of median age 69 (range 54-82) years. Forty-four patients had a type IV TAAA and nine a suprarenal aneurysm. Three patients (6 per cent) died within 30 days and the 12-month mortality rate for patients followed for at least 1 year was 6 per cent (three of 49). Ten patients (19 per cent) had a cardiac complication, 20 (38 percent) a respiratory complication, three (6 percent) required early reoperation, and one patient (2 percent) developed permanent paraplegia. There was one late death resulting from an aneurysm-related complication. CONCLUSION: Open repair of suprarenal aneurysms and type IV TAAA may be undertaken using a totally abdominal approach with acceptable levels of morbidity and mortality.

Carotid endarterectomy: are we meeting the two week target?

OBJECTIVE: It has been recommended that carotid endarterectomy should be carried out within fourteen days of the index event if maximum stroke prevention benefit is to be achieved. The aim of this study was to see whether this target was being met in our region and where in the pathway delays occurred. METHODS: This was a retrospective review of all patients (n=75) undergoing carotid endarterectomy in 2006 in a regional vascular unit. Eleven patients were excluded as the timing of onset of symptoms was unclear, leaving 64 patients for further analysis. RESULTS: The median time-interval from onset of symptoms to surgery was 47 days (interquartile range 32-65 days). Five of 64 patients (4.5%) had a carotid endarterectomy within 14 days. Median time from onset of symptoms to presentation to health services was one day (IQR 0-7 days), from presentation to health services to neurovascular clinic was 16 days (IQR 10-23 days), from neurovascular clinic to vascular surgery clinic was 13 days (IQR 9-24 days), and from vascular surgery clinic to operation was 13 days (IQR 8-22 days). Fifteen of the 51 patients (29%) attending a neurovascular clinic and five of the 57 patients (9%) attending a vascular surgery clinic were seen within 14 days. CONCLUSION: The fourteen-day target is difficult to achieve due to the number of steps in the referral pathway. This delay may be jeopardising outcome. Reduction in the delay to surgery would require a multi-disciplinary approach and should involve education of the general public.

Successful management of both early and delayed-onset neurological deficit following extent II thoracoabdominal aneurysm repair.

INTRODUCTION: Delayed-onset paraplegia is an uncommon but devastating complication of thoracoabdominal aneurysm repair. REPORT: We report the successful use of repeat cerebrospinal fluid drainage in the management of both immediate- and delayed-onset (21 days) paraplegia in the same patient undergoing open Type II thoracoabdominal aneurysm repair. DISCUSSION: Few studies have looked specifically at preventing delayed onset of symptoms. We advocate continued attention to blood pressure management and hydration for the duration of hospital stay and recommend repeat CSF drainage if symptoms occur.

Influence of sex on expansion rate of abdominal aortic aneurysms.

BACKGROUND: The UK Small Aneurysm Trial suggested that female sex is an independent risk factor for rupture of abdominal aortic aneurysm (AAA). This study assessed the effect of sex on the growth rate of AAA. METHODS: Between January 1985 and August 2005 all patients who were referred to the Royal Infirmary of Edinburgh with an AAA who were not considered for early aneurysm repair were assessed by serial abdominal ultrasonography. Maximum anteroposterior and transverse diameters of the AAAs were measured. RESULTS: A total of 1255 patients (824 men and 431 women) were followed up for a median of 30 (range 6-185) months. A median of six examinations (range 2-37) was performed for each patient. Median diameter on initial examination was 41 (range 25-83) mm. Median growth rate overall was 2.79 (range - 4.80-37.02) mm per year. Median growth rate of AAA was significantly greater in women than men (3.67 (range - 1.2-37.02) versus 2.03 (range - 4.80-21.00) mm per year; P < 0.01). Weighted linear regression analysis revealed that large initial anteroposterior AAA diameter and female sex were significant predictors of faster aneurysm growth rate (P < 0.001 and P = 0.006 respectively). CONCLUSION: The growth rate of AAA was significantly greater in women than in men. This may have implications for the frequency of follow-up and timing of repair of AAA in women.

Regional versus general anaesthesia for carotid endarterectomy: impact of change in practice.

BACKGROUND: Local anaesthesia (LA) for carotid endarterectomy (CEA) may offer advantages over general anaesthesia (GA). AIM: Our aim was to compare outcome from CEA before and after changing our anaesthetic technique from GA to LA. METHODS: Sequential patients who underwent CEA between January 1997 and December 2001 were identified from a prospectively collected database. GA was used during the first two years of this period and LA was used exclusively over the last three years. Differences in the incidence of intraoperative shunting, perioperative stroke and transient ischaemic attack (TIA), cranial nerve injury, neck haematoma, perioperative death and duration of hospital stay were assessed. RESULTS: Three hundred and seventy one CEAs were carried out in 363 patients, 179 under GA and 192 under LA. Indications were TIAs (140), stroke with recovery (134), amaurosis fugax (85) and asymptomatic high-grade stenosis (12). Intraoperative shunting was used in 66 (37%) GA operations and 36 (18.8%) LA operations (p<0.01). There were nine strokes and four transient neurological events; 10 (5.5%) patients developed such problems with GA and three (1.6%) with LA (p<0.05). There were four deaths, three (1.7%) after GA and one (0.5%) after LA (p=NS). Duration of hospital stay was less in the LA group at a median (range) of three days (2-10) compared with 4.5 (3-14) days in the GA group (p<0.001). CONCLUSION: Employing LA rather than GA for CEA has been associated with a reduction in intraoperative shunting and perioperative stroke, and the duration of hospital stay. LA appears to offer clinical and possible cost advantages over GA.

Aortic trauma in Scotland--a population based study.

OBJECTIVES: This population-based study aims to determine the incidence, mechanisms and outcomes of aortic trauma in patients from Scotland between 1992-2002. METHODS: Patients with aortic trauma were identified from the Scottish Trauma Audit Group database. Demographics, mechanism of injury, initial management and outcome were analysed. RESULTS: 165 (0.3%) patients suffered trauma to the thoracic or abdominal aorta. Of these, 130 (79%) patients had an injury of the thoracic aorta, 33 (20%) an injury of the abdominal aorta and two (1%) had injuries of both. There were 123 (75%) men and 42 (25%) women with a median (range) age of 36 (14-90) years. Blunt trauma was responsible for 121 (73%) injuries, of which road traffic accidents were the most common mechanism. A further 44 (27%) aortic injuries were due to penetrating trauma, of which assault was the most common cause. The median (range) Injury Severity Score was 43 (16-75). Ninety (55%) patients died in the emergency department while 59 (32%) underwent attempted operative repair. The operative mortality was 35 (59%) of 59 patients and overall mortality 141 (86%) of 165 patients. CONCLUSIONS: The incidence of aortic trauma presenting to Scottish hospitals is low. The majority of patients do not survive to surgical repair and operative and overall mortality remain prohibitive.

Cardiac troponin I predicts outcome after ruptured abdominal aortic aneurysm repair.

BACKGROUND: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for myocardial injury that predicts mortality in patients with acute coronary syndromes. This study examined the relationship between perioperative cTnI levels and clinical outcome in patients with ruptured abdominal aortic aneurysm (AAA). METHODS: Consecutive patients who underwent operative repair of a ruptured AAA over a 22-month interval and survived for more than 24 h were entered into a prospective observational cohort study. Levels of cTnI were measured immediately before, and at 24 and 48 h after surgery, and related to clinical outcome. RESULTS: Of 62 patients who underwent attempted operative repair of ruptured AAA, 50 (81 per cent) survived for more than 24 h and were included in this study. Twenty-three (46 per cent) of the 50 had a detectable cTnI level at one or more time points during the first 48 h. Of these, 11 patients had clinical or electrocardiographic evidence of an acute cardiac event and 12 did not; five patients in each of these two groups died. Of 27 patients with no increase in cTnI in the first 48 h, only three died (P = 0.031 and P = 0.043 respectively, relative to the groups with detectable cTnI). CONCLUSION: Approximately half of patients who survived repair of ruptured AAA for more than 24 h sustained a detectable myocardial injury within the first 48 h. A perioperative increase in the level of cTnI, with or without clinically apparent cardiac dysfunction, was associated with postoperative death.

Validity of the Glasgow Aneurysm Score and the Hardman Index in predicting outcome after ruptured abdominal aortic aneurysm repair.

BACKGROUND: The Glasgow Aneurysm Score and the Hardman Index have been recommended as predictors of outcome after repair of ruptured abdominal aortic aneurysm (AAA). This study aimed to assess their validities. METHODS: Patients admitted to a single unit with a ruptured AAA over a 2-year interval (2000-2001) were identified from a prospectively compiled database. Hospital records of all patients undergoing attempted operative repair were reviewed. The Glasgow Aneurysm Score and the Hardman Index were calculated retrospectively and related to clinical outcome. RESULTS: One hundred patients were admitted with a ruptured AAA. Of these, 82 underwent attempted operative repair and were included in the study: 68 men and 14 women, of median age 73 (range 54-87) years. Thirty (37 per cent) patients died after the operation. The Glasgow Aneurysm Score was a poor predictor of postoperative mortality. The area under the Receiver-Operator Characteristic curve was 0.606 (P = 0.112, 95 per cent c.i. 0.483-0.729). Similarly, the Hardman Index failed to predict postoperative mortality accurately (P = 0.211, chi(2) for trend). Of nine patients in this series with three or more Hardman criteria, generally held to be fatal, six survived. CONCLUSION: Contrary to previous reports, The Glasgow Aneurysm Score and the Hardman Index were poor predictors of postoperative mortality after repair of a ruptured AAA in this study.

Does immediate operation for symptomatic non-ruptured abdominal aortic aneurysm compromise outcome?

Background. The optimum timing of surgery for acutely symptomatic abdominal aortic aneurysm (AAA) remains a clinical dilemma: should symptomatic aneurysm be operated on urgently for fear of impending rupture, or should there be a period of preoperative evaluation to optimise the patient's medical co-morbidity, with a consequent delay in surgery? Method. Ninety-five patients were diagnosed with acutely symptomatic AAA (back pain, abdominal pain or a tender aneurysmal aorta) between 1995 and 2001 and included in a retrospective case-cohort study. The in-hospital mortality rates for patients undergoing early surgery (within 24h of presentation) were compared to those of patients whose surgery had been delayed to allow further evaluation. Results. Of 95 patients with an acutely symptomatic AAA, 70 had surgery within 24h of admission. The remaining 25 underwent planned delayed surgery after a median of (range) three (2-17) days. The reasons for delay to AAA repair were primarily to allow further cardiorespiratory assessment and radiological imaging. In the early surgery group, there were six postoperative deaths (9%); in the group who were to have delayed surgery, there were three (12%) deaths (P=0.694). Conclusion. Early operation for acutely symptomatic AAA, in selected patients, is not associated with an excessive mortality rate compared to delayed operation.

Quality of life after repair of ruptured abdominal aortic aneurysm.

BACKGROUND: Ruptured abdominal aortic aneurysm (AAA) continues to be associated with high operative mortality. Though survivors can expect to return to a normal life expectancy, their postoperative health related quality of life (HRQoL) remains uncertain. This review examines HRQoL following operative repair of ruptured AAA. METHODS: PreMedline, Medline and Embase databases were searched for clinical studies relating to quality of life following repair of ruptured AAA. Reference lists of relevant papers were also reviewed. RESULTS: Fourteen retrospective-observational studies of postoperative quality of life following repair of ruptured AAA were identified. Both validated and non-validated tools for generic HRQoL assessment were used. All but one study showed no significant difference in overall HRQoL following ruptured AAA repair when compared to both the normal age-adjusted population and patients undergoing elective repair of intact AAA. However, survivors of ruptured AAA did exhibit significant reductions in the isolated domains of physical function, social behaviour and general well-being. CONCLUSIONS: There are few studies of HRQoL following repair of ruptured AAA. These reports are retrospective, have small sample sizes and use generic instruments for HRQoL assessment. The findings suggest that survivors of ruptured AAA may attain a similar functional outcome to patients undergoing elective AAA repair and the age-matched healthy population. However, these results must be interpreted with caution and further prospective study is required.

Non-operative management of high-risk patients with abdominal aortic aneurysm.

OBJECTIVES: to determine the risk of rupture in patients with large non-operated abdominal aortic aneurysms (AAAs). METHODS: in 128 patients admitted over a 5-year period with an intact AAA, and who did not have a surgical repair were included, initial maximum antero-posterior AAA diameter was related to survival and cause of death. RESULTS: at the end of follow-up 27/52 (52%) patients with AAA <55 mm were alive compared to 17/62 (27%) patients with AAA > or =55 mm. Six (12%) in the former and 18 (29%) in the latter group had an AAA-related death. However, non-AAA-related death was commoner in both groups. CONCLUSION: these findings support a role for non-operative management in high-risk patients with large AAAs.

Conservative management of MRSA periaortic graft abscess.

Following repair of ruptured abdominal aortic aneurysm a patient developed methicillin-resistant Staphylococcus aureus perigraft abscess. The patient's clinical condition did not permit conventional open surgical correction. Ultrasound-guided aspiration and insertion of percutaneous drain enabled local antibiotic irrigation accompanied by systemic therapy. At 2 years follow-up the patient remains well with no evidence of sepsis.