Targeted proteomics and metabolomics for biomarker discovery in abdominal aortic aneurysm and post-EVAR sac volume.

BACKGROUND AND AIMS: Abdominal aortic aneurysm (AAA) patients undergo uniform surveillance programs both leading up to, and following surgery. Circulating biomarkers could play a pivotal role in individualizing surveillance. We applied a multi-omics approach to identify relevant biomarkers and gain pathophysiological insights. MATERIALS AND METHODS: In this cross-sectional study, 108 AAA patients and 200 post-endovascular aneurysm repair (post-EVAR) patients were separately investigated. We performed partial least squares regression and ingenuity pathway analysis on circulating concentrations of 96 proteins (92 Olink Cardiovascular-III panel, 4 ELISA-assays) and 199 metabolites (measured by LC-TQMS), and their associations with CT-based AAA/sac volume. RESULTS: The median (25th-75th percentile) maximal diameter was 50.0 mm (46.0, 53.0) in the AAA group, and 55.4 mm (45.0, 64.2) in the post-EVAR group. Correcting for clinical characteristics in AAA patients, the aneurysm volume Z-score differed 0.068 (95 %CI: (0.042, 0.093)), 0.066 (0.047, 0.085) and -0.051 (-0.064, -0.038) per Z-score valine, leucine and uPA, respectively. After correcting for clinical characteristics and orthogonalization in the post-EVAR group, the sac volume Z-score differed 0.049 (0.034, 0.063) per Z-score TIMP-4, -0.050 (-0.064, -0.037) per Z-score LDL-receptor, -0.051 (-0.062, -0.040) per Z-score 1-OG/2-OG and -0.056 (-0.066, -0.045) per Z-score 1-LG/2-LG. CONCLUSIONS: The branched-chain amino acids and uPA were related to AAA volume. For post-EVAR patients, LDL-receptor, monoacylglycerols and TIMP-4 are potential biomarkers for sac volume. Additionally, distinct markers for sac change were identified.

Aneurysm Sac Dynamics and its Prognostic Significance Following Fenestrated and Branched Endovascular Aortic Aneurysm Repair.

OBJECTIVE: This study aimed to assess aneurysm sac dynamics and its prognostic significance following fenestrated and branched endovascular aneurysm repair (F/BEVAR). METHODS: Patients undergoing F/BEVAR for degenerative complex aortic aneurysm from 2008 to 2020 at two large vascular centres with two imaging examinations (30 day and one year) were included. Patients were categorised as regression and non-regression, determined by the proportional volume change (> 5%) at one year compared with 30 days. All cause mortality and freedom from graft related events were assessed using Kaplan-Meier methods. Factors associated with non-regression at one year and aneurysm sac volume over time were examined for FEVAR and BEVAR independently using multivariable logistic regression and linear mixed effects modelling. RESULTS: One hundred and sixty-five patients were included: 122 FEVAR, of whom 34% did not regress at one year imaging (20% stable, 14% expansion); and 43 BEVAR, of whom 53% failed to regress (26% stable, 28% expansion). Following F/BEVAR, after risk adjusted analysis, non-regression was associated with higher risk of all cause mortality within five years (hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.09 - 5.37; p = .032) and higher risk of graft related events within five years (HR 2.44, 95% CI 1.10 - 5.26; p = .029). Following multivariable logistic regression, previous aortic repair (odds ratio [OR] 2.56, 95% CI 1.11 - 5.96; p = .029) and larger baseline aneurysm diameter (OR/mm 1.04, 95% CI 1.00 - 1.09; p = .037) were associated with non-regression at one year, whereas smoking history was inversely associated with non-regression (OR 0.21, 95% CI 0.04 - 0.96; p = .045). Overall following FEVAR, aneurysm sac volume decreased significantly up to two years (baseline vs. two year, 267 [95% CI 250 - 285] cm3vs. 223 [95% CI 197 - 248] cm3), remaining unchanged thereafter. Overall following BEVAR, aneurysm sac volume remained stable over time. CONCLUSION: Like infrarenal EVAR, non-regression at one year imaging is associated with higher five year all cause mortality and graft related events risks after F/BEVAR. Following FEVAR for juxtarenal aortic aneurysm, aneurysm sacs generally displayed regression (66% at one year), whereas after BEVAR for thoraco-abdominal aortic aneurysm, aneurysm sacs displayed a concerning proportion of growth at one year (28%), potentially suggesting a persistent risk of rupture and consequently requiring intensified surveillance following BEVAR. Future studies will have to elucidate how to improve sac regression following complex EVAR, and whether the high expansion risk after BEVAR is due to advanced disease extent.

Circulating biomarkers of cardiovascular disease are related to aneurysm volume in abdominal aortic aneurysm.

BACKGROUND: Surveillance programs in abdominal aortic aneurysms (AAA) are mainly based on imaging and leave room for improvement to timely identify patients at risk for AAA growth. Many biomarkers are dysregulated in patients with AAA, which fuels interest in biomarkers as indicators of disease progression. We examined associations of 92 cardiovascular disease (CVD)-related circulating biomarkers with AAA and sac volume. METHODS: In a cross-sectional analysis, we separately investigated (1) 110 watchful waiting (WW) patients (undergoing periodic surveillance imaging without planned intervention) and (2) 203 patients after endovascular aneurysm repair (EVAR). The Cardiovascular Panel III (Olink Proteomics AB, Sweden) was used to measure 92 CVD-related circulating biomarkers. We used cluster analyses to investigate protein-based subphenotypes, and linear regression to examine associations of biomarkers with AAA and sac volume on CT scans. RESULTS: Cluster analyses revealed two biomarker-based subgroups in both WW and EVAR patients, with higher levels of 76 and 74 proteins, respectively, in one subgroup versus the other. In WW patients, uPA showed a borderline significant association with AAA volume. Adjusting for clinical characteristics, there was a difference of -0.092 (-0.148, -0.036) loge mL in AAA volume per SD uPA. In EVAR patients, after multivariable adjustment, four biomarkers remained significantly associated with sac volume. The mean effects on sac volume per SD difference were: LDLR: -0.128 (-0.212, -0.044), TFPI: 0.139 (0.049, 0.229), TIMP4: 0.110 (0.023, 0.197), IGFBP-2: 0.103 (0.012, 0.194). CONCLUSION: LDLR, TFPI, TIMP4, and IGFBP-2 were independently associated with sac volume after EVAR. Subgroups of patients with high levels of the majority of CVD-related biomarkers emphasize the intertwined relationship between AAA and CVD.ClinicalTrials.gov Identifier: NCT03703947.

Mortality and neurologic complications after repair of aortic arch pathology with elephant trunk procedures: a systematic review with meta-analysis.

INTRODUCTION: Frozen elephant trunk (FET) technique was developed as an alternative to the conventional elephant trunk (cET) procedure for the repair of complex aortic arch pathology. However, short term results between these different procedures are sparsely described. This systematic review with meta-analysis aimed to compare short term outcomes between FET and cET in the repair of aortic arch pathology. EVIDENCE ACQUISITION: PubMed, Web of Science and Scopus electronic databases were searched for studies comparing performance of FET and cET procedures in patients with aortic arch pathology. The primary outcome of interest was early mortality, defined as 30-day or in-hospital mortality. Secondary outcomes were stroke, and spinal cord ischemia (SCI). Meta-analysis utilizing the random-effects model was performed using Review Manager (RevMan) software, version 5.4. EVIDENCE SYNTHESIS: Ten studies, comprising 1481 patients with aortic arch pathology, were included. Meta-analysis demonstrated statistically significant reduction of early mortality (odds ratio [OR], 0.63; 95% CI, 0.41-0.97) in the FET group. For neurologic outcomes, no significant differences were noted in stroke risk between both groups (OR, 1.21; 95% CI, 0.83-1.75), but an increased risk of SCI was present in FET patients (OR, 2.07; 95% CI, 1.05-4.10). CONCLUSIONS: FET appears to be associated with a significant lower early mortality, at costs of greater SCI risk. Larger studies are needed to provide confident recommendations towards preferential use of either procedure.

The role of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers: a systematic review with meta-analysis of randomized controlled trials on limb amputation and ulcer healing.

INTRODUCTION: Hyperbaric oxygen therapy (HBOT) is increasingly being used in the treatment of as diabetic foot ulcers (DFU). However, definitive evidence regarding its beneficial effects is still scarce. The present systematic review aims to analyze the role of HBOT in the prevention of limb amputation along with improvement of ulcer healing in patients with lower limbs DFU. EVIDENCE ACQUISITION: Three databases were searched: PubMed, Scopus, and ISI Web of Knowledge. The search was enrolled during October 2020. Both titles and abstracts were examined by two independent reviewers. Only randomized controlled trials (RCTs) reporting a comparison between standard DFU treatment and standard treatment associated with HBOT were included. In all studies eligibility was assessed and data regarding studies characteristics, methods and considered outcomes was obtained. Odds ratio (OR) was used to evaluate amputation and complete ulcer healing rates. Percentage of ulcer reduction at two weeks was evaluated using the inverse variance method, and the values were compared using mean difference values. Meta-analysis was done using a fixed-effect model if I2 values were under 50%, and a random-effects model if not. EVIDENCE SYNTHESIS: Eleven RCTs were included, with a total of 668 patients studied. Patients undergoing HBOT had lower risk of amputation (OR 0.53 95% CI 0.32-0.90, I2=31%). No difference was found in minor amputations (OR 0.89 95% CI 0.35-2.24, I2=69%). Regarding, healing rates, HBOT patients had greater chances of ulcer healing (OR 4,00 95% CI 1.54-10.44, I2=70%). It has also shown higher percentage of ulcer area reduction after two weeks of treatment in the HBOT group (mean difference 23.19%; 95% CI 14.86-31.52; I2=0%). CONCLUSIONS: The present review offers evidence that adjuvant HBOT decreases risk of major amputation while promoting wound healing when combined to standard treatment in the management of DFU. These findings may have clinical relevance in a selected group of patients, yet further larger studies are still needed.

Long Term Outcomes of Post-Implantation Syndrome After Endovascular Aneurysm Repair.

OBJECTIVE: The aim of this study was to investigate the association between post-implantation syndrome (PIS) and long term outcomes, with emphasis on cardiovascular prognosis. METHODS: One hundred and forty-nine consecutive patients undergoing EVAR in a tertiary institution were previously included in a study investigating the risk factors and short term consequences of PIS (defined as tympanic temperature ≥ 38°C and CRP > 10 mg/L, after excluding complications with an effect on inflammatory markers). This study was based on a prospectively maintained database. Survival status was derived from inquiry of civil registry database information and causes of death from the Dutch Central Bureau of Statistics. The primary endpoint was cardiovascular events. Secondary endpoints were overall and specific cause mortality (cardiovascular, ischaemic heart disease, AAA, and cancer related mortality). Aneurysm sac dynamics and occurrence of endoleaks were also analysed. Survival estimates were obtained using Kaplan-Meier plots and a multivariable model was constructed to correct for confounders. RESULTS: The PIS incidence was 39% (58/149). At the time of surgery, patients had a mean age of 73 ± 7 years and were predominantly male. There were no baseline differences between the PIS and non-PIS groups. The median follow up was 6.4 years (3.2 - 8.3), similar in both groups (p = .81). There was no difference in cardiovascular events for PIS and non-PIS patients (p = .63). However, Kaplan-Meier plots suggest a trend towards a higher rate of cardiovascular events in PIS patients during the first years: freedom from cardiovascular events at one year was 94% vs. 89% and at three years 90% vs. 82%. No differences were found in overall and specific cause mortality. There was a higher rate of type II endoleaks for non-PIS patients (28% vs. 9%, p = .005). Sac dynamics were similar in both groups. CONCLUSION: The results suggest that PIS is not associated with a statistically significantly higher risk of cardiovascular events. PIS had no impact on mortality. Lastly, PIS patients had fewer type II endoleaks, but sac dynamics were analogous.

Risk Factors, Dynamics, and Clinical Consequences of Aortic Neck Dilatation after Standard Endovascular Aneurysm Repair.

OBJECTIVE: Aortic neck dilatation (AND) occurs after endovascular aneurysm repair (EVAR) with self expanding stent grafts (SESs). Whether it continues, ultimately exceeding the endograft diameter leading to abdominal aortic aneurysm (AAA) rupture, remains uncertain. Dynamics, risk factors, and clinical relevance of AND were investigated after EVAR with standard SESs. METHODS: All intact EVAR patients treated from 2000 to 2015 at a tertiary institution were included. Demographic, anatomical, and device related characteristics were investigated as risk factors for AND. Outer to outer diameters were measured at a single standardised aortic level on reconstructed computed tomography (CT) images. RESULTS: A total of 460 patients were included (median follow up 5.2 years, interquartile range [IQR] 3.0, 7.7 years; CT imaging follow up 3.3 years, IQR 1.3, 5.4). Baseline neck diameter was 24 mm (IQR 22, 26) and increased 11.1% (IQR 1.5%, 21.9%) at last CT imaging. Endograft oversizing was 20.0% (IQR 13.6, 28.0). AND was greater during the first year (5.2% [IQR 0, 11.7]) decreasing subsequently (two to four years to 1.4%/year [IQR 0.0, 4.5%], p ≤ .001) and was associated with suprarenal fixation endografts (t value = 7.9, p < .001) and oversizing (t value = 4.4, p < .001). AND exceeding the endograft was 3.5% (95% CI 2.2% - 4.8%) and 14.4% (95% CI 11.0% - 17.8%) at five and eight years, respectively. Excessive AND was associated with baseline neck diameter (OR 1.2/mm, 95% CI 1.05 - 1.41) while the Excluder endograft had a protective effect (OR 0.15, 95% CI 0.04 - 0.58). Excessive AND was associated with type 1A endoleak (HR 3.3, 95% CI 1.1 - 9.7) and endograft migration > 5 mm (HR 3.1, 95% CI 1.4 - 6.9). CONCLUSION: AND after EVAR with SES is associated with endograft oversizing and radial force but decelerates after the first post-operative year. Baseline aortic neck diameter and suprarenal stent bearing endografts were associated with an increased risk of AND beyond nominal stent graft diameter. However, it remains unclear whether patient selection, differences in endograft radial force or the suprarenal stent are accountable for this difference.

THE IMPACT OF NEUTROPHIL-TOLYMPHOCYTE RATIO AND PLATELETTO- LYMPHOCYTE RATIO IN CAROTID ARTERY DISEASE.

INTRODUCTION: Inflammation is a common underlying feature of atherosclerosis. Several inflammatory biomarkers have been reported to have prognostic value, in several areas, including in vascular surgery. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) may permit to identify patients at greater risk for cerebrovascular events, tailor patient management, improve preoperative status and possibly develop target anti-atherosclerotic therapy. However, studies reporting usefulness of these hematological biomarkers in the context of carotid artery disease are still scarce. The aim of this study was to review the literature concerning the prognostic ability of NLR and PLR in the subpopulation of vascular patients with carotid artery disease. METHODS: A Medline search was performed in order to identify publications focused on the physiopathology of NLR and PLR and their impact in the management of patients with carotid artery disease. RESULTS: The study identified 18 articles with a total of 5339 patients. NLR is associated with carotid intima-media thickness, carotid plaques, carotid stenosis, symptomatic stenosis and intra-stent restenosis after carotid artery stenting and cognitive dysfunction after carotid endarterectomy. PLR is associated with carotid stenosis, symptomatic stenosis and predicts post-operative outcomes after carotid artery revascularization, including post-operative stroke, acute coronary syndrome and all-cause mortality. CONCLUSIONS: The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have the ability to predict sub-clinic atherosclerosis, atherosclerosis progression in carotid artery disease and propensity for carotid stenosis to become symptomatic along with morbidity following CEA and carotid stenting. Consequently, these parameters may be considered to tailored therapy and improve patient management.

Mid-term patency of iliac venous stenting for post-thrombotic syndrome.

INTRODUCTION: Post-thrombotic syndrome (PTS) is the most common chronic complication of deep vein thrombosis. Recent studies suggested that iliac stenting in chronic obstructive venous disease is safe and effective. However, systematic reviews focusing on mid-term efficacy of iliac stenting in post-thrombotic syndrome are lacking. This systematic review aimed to analyze mid-term stent patency rates and clinical outcomes of iliac stenting in post-thrombotic syndrome. EVIDENCE ACQUISITION: Two databases were searched: Pubmed/Medline and Scopus. Articles published between January 2000 and July 2020 were selected and titles and abstracts were independently reviewed. Eighteen articles were included for the qualitative analysis. From this initial set of articles, fourteen articles were included for the quantitative analysis. EVIDENCE SYNTHESIS: Overall, 1008 patients were included in this study. The pooled technical success rate was 96%. The pooled primary and secondary patency rates were 98.2% and 100% at 30 days, 78.1% and 94.5% at 12 months and 66.3% and 89.4% at 36 months, respectively. The rates of ulcer healing, pain and edema relief were 78.1%, 53.4% and 48.8%, respectively. The pooled rate of complications including intraoperative venous injury, back pain and stent fracture were 28%, 57.1%, and 5.9%, respectively. CONCLUSIONS: Iliac venous stenting in PTS presents durable mid-term patency rates, as well as significant symptomatic improvement. Therefore, endovascular treatment should be considered in symptomatic patients with PTS.

Myocardial injury after non-cardiac surgery (MINS) in EVAR patients: a retrospective single-centered study.

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) stands for myocardial injury due to ischemia that occurs during or within 30-days after non-cardiac surgery. Although MINS is known to be independently associated with 30-day mortality after intervention, little is described about the impact of MINS after vascular procedures, particularly after endovascular aneurysm repair (EVAR). METHODS: This is an observational, retrospective, single-centered study. All patients underwent elective standard EVAR between January 2008 and June 2017, and them with at least one postoperative measurement of troponin I in the first 48 h after surgery, were retrospectively included. MINS was defined as the value exceeding the 99th percentile of a normal reference population with a coefficient of variation <10%. Primary outcomes include the prevalence of MINS in this subset of EVAR patients, as well as its impact in mid-term all-cause mortality. As secondary aim, the preoperative predictors of MINS were also assessed. RESULTS: One-hundred and thirty-six patients with postoperative troponin measurements were included (95.6% male; mean age 75.51years). MINS was diagnosed in 16.2% (N.=22) of the patients, and in 86.4% of the cases (N.=19) it was completely asymptomatic. Heart failure (31.8% vs. 10.5%, P=0.016), ASA Score ≥3 (95.5% vs. 67.5%, P=0.004), pre-operative (P=0.036) and postoperative (P=0.04) hemoglobin concentrations ≤12 g/dL were found to be significantly associated with MINS. Regarding remaining baseline characteristics, anesthesia and femoral access, no further differences were observed. Survival at 1, 3 and 5 years was 92% (95% CI: 4.6-6.9, standard error [SE] 0.023), 81% (95% CI: 5.6-7.6, SE=0.034) and 71% (95% CI: 6.9-8.7, SE=0.04), with two deaths reported at 30 days follow-up. MINS was found to be significantly associated with increased mid-term all-cause mortality after EVAR at 24 months follow-up (84.2±3.4% vs. 63.6±10.3%, P=0.001), with a 2.12-fold risk increase of death. CONCLUSIONS: MINS is a common complication after EVAR and negatively impacts the mid-term prognosis of such interventions. In the majority of cases, it is asymptomatic and, therefore, not detectable unless routine postoperative troponin measurements are performed.

Aneurysm Volumes After Endovascular Repair of Ruptured vs Intact Aortic Aneurysms: A Retrospective Observational Study.

PURPOSE: To compare changes in abdominal aortic aneurysm (AAA) sac volume between endovascular aneurysm repairs (EVAR) performed for ruptured (rEVAR) vs intact (iEVAR) AAAs and to determine the impact of early volume shrinkage on future complications. MATERIALS AND METHODS: A retrospective analysis was performed of all patients undergoing standard infrarenal EVAR from 2002 to 2016 at a tertiary referral institution. Only patients with degenerative AAAs and with 30-day and 1-year computed tomography angiography (CTA) imaging were included. Early sac shrinkage was defined as a volume sac reduction >10% between the first (<30-day) and the 1-year CTA. The primary endpoint was to compare AAA sac volume changes between patients undergoing rEVAR (n=51; mean age 71.0±8.5 years; 46 men) vs iEVAR (n=393; mean age 72.3±7.5 years; 350 men). Results are reported as the mean difference with the interquartile range (IQR Q1, Q3). The secondary endpoint was freedom from aneurysm-related complications after 1 year as determined by regression analysis; the results are presented as the hazard ratio (HR) and 95% confidence interval (CI). RESULTS: At baseline, the rEVAR group had larger aneurysms (p<0.001) and shorter (p<0.001) and more angulated (p=0.028) necks. Aneurysm sac volume decreased more in the rEVAR group during the first year [-26.3% (IQR -38.8%, -12.5%)] vs the iEVAR group [-11.9% (IQR -27.5%, 0); p<0.001]. However, after the first year, the change in sac volume was similar between the groups [-3.8% (IQR -32.9%, 31.9%) for rEVAR and -1.5% (IQR -20.9%, 13.6%) for iEVAR, p=0.74]. Endoleak occurrence during follow-up was similar between the groups. In the overall population, patients with early sac shrinkage had a lower incidence of complications after the 1-year examination (adjusted HR 0.59, 95% CI 0.39 to 0.89, p=0.01). CONCLUSION: EVAR patients treated for rupture have more pronounced aneurysm sac shrinkage compared with iEVAR patients during the first year after EVAR. Patients presenting with early shrinkage are less likely to encounter late complications. These parameters may be considered when tailoring surveillance protocols.

Ruptured axillary artery pseudoaneurysm following an anterior glenohumeral dislocation: A case report.

Vascular injuries following anterior shoulder dislocations are rare, with an estimated incidence of 1-2%. The formation of an axillary artery pseudoaneurysm secondary to vascular trauma is a possible late complication and frequently underdiagnosed since it may remain asymptomatic for many years. A rupture of a pseudoaneurysm may occur either from the dislocation itself or after forceful reduction attempts. A ruptured pseudoaneurysm of the axillary artery is a medical emergency and may result in significative upper-limb morbidity or even patient mortality. Nowadays, endovascular techniques have progressively gained ground for the treatment of such lesion, especially in an emergency context. In the present article, the authors present the case of a 77-years-old male patient with a rupture of a pseudoaneurysm of the left axillary artery after repeated forceful reductions of an anterior glenohumeral dislocation and its treatment with percutaneous endovascular stenting.

Symptomatic Distal Anastomotic Pseudo-aneurysm After the Bentall Procedure Successfully Treated by Supra-aortic Trunk Debranching and Zone 0 Thoracic Endovascular Aneurysm Repair.

INTRODUCTION: Post-operative anastomotic pseudo-aneurysms are rare but potentially lethal complications after the Bentall procedure. When symptomatic or ruptured, expedited repair is warranted, and open surgery may carry significant bleeding risk, particularly when these lesions project anteriorly. As totally endovascular techniques are frequently limited owing to hostile anatomies, complex hybrid interventions are an alternative option in such scenarios. REPORT: A 53 year old man with a previous Bentall procedure performed 10 years previously for DeBakey type 1 dissection was admitted with chest pain. Computed tomography angiography revealed a distal anastomotic pseudo-aneurysm. Percutaneous pseudo-aneurysm occlusion with a septal occluder plug was performed initially, with significant clinical improvement but without total sac thrombosis. The patient was discharged under strict surveillance, but six months later was re-admitted owing to hoarseness and new onset of chest pain. As the patient developed acute pain and compressive symptoms, urgent treatment was required. As the pseudo-aneurysm projected anteriorly into the posterior aspect of sternum, significantly bleeding risk was anticipated with redo sternotomy. A hybrid repair was then planned, with a full supra-aortic trunk debranching (carotid-carotid and left carotid-subclavian bypass) and zone 0 TEVAR with a single parallel graft to the brachiocephalic trunk. The patient was discharged 10 days later. Total aneurysm exclusion was achieved, with no complications reported after six months follow up. DISCUSSION: Hybrid procedures may represent a safe and feasible alternative to open surgery in symptomatic ascending aortic pseudo-aneurysms. However, long term follow up studies are required to confirm the durability of these procedures.

Myocardial injury after aortoiliac revascularization for extensive disease: A survival analysis.

BACKGROUND: This study aims to evaluate the incidence of myocardial injury after non-cardiac surgery for an extensive disease pattern (TASC II type D) and to examine its prognostic value. METHODS: This prospective study included a total of 66 consecutive patients (62 males, 4 females; mean age 62.5±8.2 years) who underwent elective revascularization for aortoiliac TASC II type D lesions in the tertiary setting between January 2013 and March 2019. The patients were scheduled for revascularization either by open surgery or endovascular approach. Cardiac troponins were routinely measured in the postoperative period. Myocardial injury after non-cardiac surgery was defined as the elevation of cardiac troponin for at least one value above the 99th percentile upper reference limit. Myocardial infarction, acute heart failure, stroke, major adverse cardiovascular events, major adverse limb events, and all-cause mortality were assessed both postoperatively and during follow-up. RESULTS: The incidence of myocardial injury after non-cardiac surgery was 25.8%. In the multivariate analysis, chronic heart failure was found to be a significant risk factor for myocardial injury after non-cardiac surgery (odds ratio: 10.3; 95% confidence interval 1.00-106.8, p=0.018). At 12 months after revascularization, the diagnosis of myocardial injury after non-cardiac surgery was significantly associated with myocardial infarction, stroke, major adverse cardiovascular events, major adverse limb events, and all-cause mortality. At 12 months after revascularization, the diagnosis of myocardial injury after non-cardiac surgery was significantly associated with myocardial infarction (log-rank p=0.002), stroke (log-rank p=0.007), major adverse cardiovascular events (log-rank p=0.000), major adverse limb events (log-rank p=0.007), and all-causemortality (log-rank p=0.000). CONCLUSION: Our study results suggest that myocardial injury after non-cardiac surgery plays a role as a predictor of significant cardiovascular comorbidities and mortality after complex aortoiliac revascularization. The presence of chronic heart failure is also associated with a higher incidence of myocardial injury after aortoiliac TASC II type D revascularization. Therefore, preemptive strategies should be adopted to identify and treat these patients.

Efficacy of near-infrared spectroscopy cerebral oximetry on detection of critical cerebral perfusion during carotid endarterectomy under regional anesthesia.

Background: Patients undergoing carotid endarterectomy (CEA) may suffer from cerebral hypoperfusion during the carotid cross-clamping. Near-infrared spectroscopy cerebral oximetry (NIRS) is a non-invasive method of regional cerebral oxygen saturation measurement reflecting changes in cerebral blood flow during CEA. The main goal of the study was to evaluate the accuracy of the NIRS in detecting cerebral hypoperfusion during CEA under regional anesthesia (RA) and compare it with awake neurological testing. Patients and methods: A prospective observational study of 28 patients that underwent CEA in RA and manifested neurologic deficits, and 28 consecutive controls from a tertiary and referral center, was performed. All patients were monitored with NIRS cerebral oximetry and awake testing as the control technique. Subsequently, operating characteristic curve and Cohen's kappa coefficient were determined to evaluate the reliability of the monitoring test. Results: NIRS presented a sensitivity of 27.3% and a specificity of 89.3% in comparison to awake testing. Receiver operating characteristic (ROC) curve analysis demonstrated that a decrease of at least 20% in cerebral oxygen saturation is the best threshold to infer cerebral hypoperfusion. However, the respective area under the curve (AUROC) was 0.606 (95% CI: 0.456-0.756, P = 0.178) with a calculated Cohen's kappa of 0.179, P = 0.093. Regarding 30-days outcomes, only awake testing has shown significant associations with stroke and postoperative complications (P = 0.043 and P = 0.05), which were higher in patients with post-clamping neurologic deficits. Conclusions: NIRS demonstrated a reduced discriminative capacity for critical cerebral hypoperfusion, and does not seem to add substantial clinical benefits to the awake test.

Abdominal compartment syndrome after r-EVAR: a systematic review with meta-analysis on incidence and mortality.

INTRODUCTION: Endovascular aneurysm repair for ruptured abdominal aortic aneurysms (r-EVAR) sometimes complicates with abdominal compartment syndrome (ACS) due to extensive retroperitoneal hematoma, with significant prognostic implications. This systematic review aimed to analyze the incidence of the syndrome and assess the impact of ACS on mortality. Mortality after decompressive laparotomy was also assessed. EVIDENCE ACQUISITION: Two databases were searched: Medline and Web of Science. The search was conducted through October 2019. The titles and abstracts of the retrieved articles were independently reviewed. All studies reporting on the ACS incidence after r-EVAR were initially included. From each study, eligibility was determined and descriptive, methodological, and outcome data was extracted. The incidence was calculated with summary proportion. Odds ratio was used to compare the mortality rate. Meta-analysis was performed with fixed effect model when calculating the ACS incidence in r-EVAR patients and when assessing the impacts of ACS and DL in the mortality rate. EVIDENCE SYNTHESIS: A total of 46 studies were included, with a cumulative cohort of 3064 patients. Two hundred and fifty-two (8.2%) patients developed ACS. The ACS pooled incidence was 9% with a 95% confidence interval of [0.08; 0.11]. Among the 46 included studies, 19 studies reported data on the mortality rate, corresponding to 1825 of the 3064 patients. Of these, 169 (9.3%) had developed ACS and 94 (55.6%) of them died by multi organ failure. Among the 1656 patients without ACS, 328 died (19.8%). The mortality odds ratio meta-analysis was 6.25 with a 95% confidence interval of [4.44, 8.80]. Decompressive laparotomy was performed in 41 patients, decreasing mortality in 47%. CONCLUSIONS: ACS affects approximately 9% of patients submitted to r-EVAR, and significantly increases perioperative mortality. Close postoperative surveillance to clinical signs of ACS is vital in these patients.

Abdominal aortic aneurysm: a review on the role of oral antidiabetic drugs.

INTRODUCTION: A paradoxical negative association between diabetes mellitus and abdominal aortic aneurysm (AAA) prevalence and growth is established. However, so far is not possible to determine whether this protection comes from the disease itself or the medication for Diabetes. The aim of this manuscript is to review the association between oral antidiabetic drugs and AAA incidence and growth. EVIDENCE ACQUISITION: A search was conducted on PubMed and Scopus databases until December 2019 to identify publications reporting on the association between oral antidiabetic drugs (biguanides/metformin, sulfonylureas(SU), thiazolidinediones(TZD), dipeptidyl-peptidase 4(DPP-4) inhibitors, glucagon-like peptide 1(GLP-1) agonists, sodium-glucose transporter protein-2(SGLT2) inhibitors) and the outcomes AAA incidence and growth. Only data from human studies were considered, with a minimum of 3 months follow-up. EVIDENCE SYNTHESIS: Six studies enrolling 25,810 patients were included: one reporting on the AAA risk and five reporting on AAA growth. Metformin prescription was associated with a 28% reduction in AAA occurrence, while SU and TZD were associated with a 18% decrease in AAA risk. Regarding AAA enlargement, results were concordant for a slower expansion rate associated with metformin, with a decrease ranging from -0.30 mm/y to -1.30 mm/y, but not consistent for other antidiabetic drugs. CONCLUSIONS: Metformin seems to be associated with a decrease in AAA risk and enlargement rate. Evidence for the other classes is lacking. Studies evaluating the association between oral antidiabetic drugs and AAA progression, independently of the diabetic status, are needed.