Postoperative myocardial injury and platelet reactivity in patients undergoing vascular surgery: The platelet reactivity and postoperative myocardial injury after major vascular surgery (PROMISE) study.

BACKGROUND: Postoperative myocardial injury (PMI) after major vascular surgery, detected by elevated cardiac troponin (cTn), has been associated with morbidity and mortality. It is unclear whether the pathophysiology of PMI is determined by increased platelet activity. OBJECTIVE: To examine the relationship between platelet activation (P-selectin expression) and PMI in patients undergoing elective open abdominal aortic surgery. METHODS: This prospective, single-centre, observational, cohort study included 33 patients undergoing elective open abdominal aortic surgery between March 2018 and April 2021. Patients were routinely treated with aspirin. Unstimulated platelet activation was measured by platelet bound P-selectin expression (range 0-100 %). Explorative coagulation measurements were: stimulated platelet aggregation measured with the VerifyNow® assay (aspirin cartridge), with the Multiplate® analyzer (ASPI, ADP and TRAP) and stimulated coagulation status evaluated by the TEG® Hemostasis Analyzer System (global hemostasis cartridge). The primary outcome was cTn release assessed by the fifth generation high-sensitive cTn assay. Multivariable generalized linear mixed models were used to evaluate the association between platelet function and cTn concentrations over time. RESULTS: Ten patients (30.3 %) developed PMI. Increased P-selectin expression directly after surgery was associated with the cTn concentrations over 48 h (ß = 1.39 (1.1-1.75), P = 0.0064). No association was found between P-selectin measured later after surgery (at 24 h or 48 h) and cTn concentrations. Furthermore, there was no association between the explorative coagulation parameters and cTn release. CONCLUSION: Platelet reactivity, assessed by P-selectin expression measured directly after surgery is associated with PMI, assessed by elevated cTn concentrations in the early postoperative period in patients undergoing elective open abdominal aortic surgery.

[Elderly patients with an abdominal aortic aneurysm; preoperative frailty-screening and a multidisciplinary approach]. / Ouderen met een aneurysma van de abdominale aorta.

Aneurysm of the abdominal aorta is common and can be treated with endovascular repair, open surgical repair or conservative treatment. Risk-stratification and treatment decision-making can be complex in frail patients and depends largely on anatomy, life-expectancy and functional capacity. Currently, risk-stratification in the Netherlands is primarily based on comorbidities and age. Insight in a patient's resilience could provide important additional information. For this reason, St. Antonius hospital has implemented an Anaesthesia Geriatric Evaluation (AGE) to screen for frailty in high risk vascular surgery patients. Results of frailty-screening are discussed in a multi-disciplinary team (MDT) to assess perioperative risk and compose a personal treatment plan. This paper presents a case-series of three patients to illustrate the additional value of MDT care and frailty-screening in a high-risk vascular surgery population.

CT angiography to evaluate hemodynamic changes in popliteal artery aneurysms during flexion and extension of the knee joint.

AIM: The aim of this study was to find out which characteristics of an asymptomatic popliteal artery aneurysm (PAA) will increase the risk for acute thrombosis. METHODS: This was a single-center prospective study of consecutive patients with asymptomatic PAAs presenting from January 2010 to April 2012. Computed tomography angiography was used to perform measurements of the PAA during 0º extension and 90º flexion of the knee. After semi-automated segmentation of the popliteal artery (PA) lumen, a center lumen line (CLL) was automatically constructed. RESULTS: The study included 16 asymptomatic PAAs. Median lumen area of the PA was directly proximal and distal of the PAA 57 mm2 (IQR, 44-87 mm2) and 46 mm2 (IQR, 32-66 mm2) in extension vs. 51 mm2 (IQR, 38-73 mm2) and 38 mm2 (IQR, 30-62 mm2) during 90º flexion, respectively (P=0.007) and (P=0.03). The median of the greatest decrease in lumen area after flexion and extension of the knee was 36 mm (IQR, 28-48 mm) in PAAs≥30 mm compared with 11 mm (IQR, 4-18 mm) in PAAs<30 mm (P<0.05). The proximal angulation was a median 48° in extension (IQR, 27-61º) and 75° during flexion (IQR, 46-99º; P=0.02). Distal angulation was a median of 31° (IQR, 21-42º) after extension vs. 62° (IQR, 33-81º) during flexion (P=0.03). CONCLUSION: Knee bending in patients with PAAs will lead to a reduction in the lumen area of the PAA and a change in the degree of angulation of the PAA. A significant decrease in lumen area was seen in PAAs≥30 mm compared with PAAs<30 mm after flexion of the knee.

Clinical outcome of acute leg ischaemia due to thrombosed popliteal artery aneurysm: systematic review of 895 cases.

OBJECTIVES: A systematic review was performed to summarise outcomes of acute thrombosed popliteal artery aneurysms (PAAs) treated with thrombolysis or thrombectomy followed by bypass. METHODS: A systematic review was conducted of data on acute thrombosed PAAs dated 1 January 1990 through 30 June 2008 using the Cochrane Library, MEDLINE and EMBASE databases. Primary endpoint was limb salvage; secondary endpoints were mortality and patency of the bypasses. RESULTS: Eight prospective studies and 25 retrospective studies with 895 patients presenting with acute ischaemia were included. No randomised trials were included. The mortality rate after surgical repair was 3.2% (95% confidence interval (C.I.) 1.8-4.6). The amputation rate was 14.1% (95% C.I. 11.8-16.4). Thrombolysis before surgery did not result in a significant reduction of the number of amputations, compared with surgery (thrombectomy and bypass) alone. The mean primary patency rates of the bypasses at 1, 3 and 5 years were 79%, 77% and 74%, respectively, in the 'thrombolysis' group and 71% (P=0.026), 54% (P=0.164) and 45% (P=0.249) in the 'thrombectomy' group. No distinction could be made regarding secondary patency and limb-salvage rates between the groups owing to insufficient data. CONCLUSIONS: Preoperative and intra-operative thrombolyses result in a significant improvement in 1-year primary graft patency rates, but do not result in a significant reduction for amputations compared with surgery alone.

Surgical and endovascular treatment of atherosclerotic popliteal artery aneurysms.

Popliteal artery aneurysms are the most common peripheral aneurysms. Patients with unrecognized aneurysms may present with acute limb ischemia and considerable threat for limb loss due to thromboembolic complications. This article reviews short-term and long-term results of surgical and endovascular treatment for mainly elective repair of popliteal artery aneurysms. A systemic review was conducted of data in the English literature from 1990. The review included 1 prospective randomized trial, 6 prospective studies, and 42 retrospective studies on the management of popliteal artery aneurysms. These studies contained 2 197 patients with 2 882 popliteal artery aneurysms. Short-term results are acceptable, with average 1-year patency rates of 90% for surgical treatment and 75% for endovascular treatment, and respective limb salvages rates of 95% and 100%. Endovascular treatment lacks long-term follow-up, whereas venous surgical repair has an average 5-year patency rate of up to 85% (prosthetic grafts, 40-80%). There is a need for randomized trials comparing long-term results of surgical versus endovascular treatment of popliteal artery aneurysms. So far, long-term results of elective surgical repair for popliteal artery aneurysms are acceptable if venous grafts are used. In any case, acute repair of popliteal artery aneurysms must be avoided.

Preoperative radiation therapy for locally advanced rectal cancer: a comparison between two different time intervals to surgery.

BACKGROUND: Although it is now considered a standard treatment to irradiate an advanced mid or low rectal tumor before surgical total mesorectal excision (TME), the optimal time interval between radiation therapy and surgery remains controversial. MATERIALS AND METHODS: Between 1995 and 2005, patients undergoing preoperative radiation therapy and TME for locally advanced mid and low rectal tumors treated in the VU Medical Center or the Zaans Medical Center were entered into this study. All patients received identical radiation treatment in the VU Medical Center and were subsequently operated on within 2 weeks in the Zaans Medical Center (SI group) and after 6-8 weeks in the VU Medical Center (LI group). Preoperative tumor staging, operative data, postoperative complications, pathology results, and follow-up were compared. RESULTS: The SI group (N=57) underwent surgery after a median delay of 4 days and the LI group (N=51) after 45 days. Operative data and short-term morbidity were comparable for both groups. However, significantly higher numbers of complete remissions (12 vs 0%), tumor downstaging (55 vs 26%), and less lymph-node metastases (22 vs 44%) were found in the LI group. No significant differences were found regarding local control or long-term survival after a median follow-up of 34 months. CONCLUSION: Several advantages, such as complete remissions and downstaging in the LI group, do not appear to have expression in a better survival or less local recurrences after a median follow-up of 34 months. Although larger (randomized) studies will be needed for definite conclusions, this may indicate that patients can be operated on within 2 weeks after radiation therapy.

Long-term results of percutaneous transluminal angioplasty for symptomatic iliac in-stent stenosis.

OBJECTIVE: This study describes the long-term results of endoluminal therapy for iliac in-stent obstructions. DESIGN: This is a retrospective study. MATERIALS AND METHODS: From 1992 to 2005, 68 patients (22 women), with a mean age of 61+/- 13 years and 16 bi-iliac in-stent obstructions, underwent 84 endovascular interventions for focal iliac in-stent stenoses (n = 61) or occlusions (n = 23). Primarily, only uncovered stents were placed. All patients were symptomatic: 70% had disabling intermittent claudication, 23% had resting pain, and 7% had trophic changes. All had in-stent diameter reduction exceeding 50% that was confirmed by duplex scanning and angiography. Procedures were performed under local anesthesia via the femoral route. RESULTS: All interventions were initially technically successful, with a minor complication of pneumonia in one patient (2%). Initial clinical success was achieved in 86% of patients. PTA alone was used to treat 72 (86%) in-stent obstructions, the other 12 (14%) had PTA and renewed stent placement. The 30-day mortality rate was 0%. Mean follow-up was 35 months (range, 3 months to 10 years) and included duplex scanning. Primary clinical patency was 88% at 1 year, 62% at 3 years, and 38% at 5 years follow-up. During follow-up, 28 (33%) of 84 extremities required secondary reinterventions because of symptomatic renewed in-stent stenosis, and 11 were treated successfully with repeated endovascular interventions. Secondary patency at 1 year was 94%, 78% at 3 years, and 63% at 5 years. Surgical intervention was eventually needed in 17 (20%) of the 84 extremities. CONCLUSIONS: Endoluminal therapy for iliac focal in-stent obstructive disease seems to be a safe technique with acceptable long-term outcome and therefore a true alternative to primary surgical reconstruction.