Implementation of a perioperative protocol to enhance open aortic repair.

BACKGROUND: Although appreciated for its long-term benefits, open repair of abdominal aortic aneurysms (AAA) is associated with a significant perioperative burden. Enhanced recovery and fast track protocols have improved surgical outcomes in many specialties, but remain scarcely applied in the vascular field. METHODS: Based on the applied perioperative protocol in a single-center experience, three consecutive study groups were identified among 394 consecutive patients undergoing elective AAA open repair in the last 12 years. Group A included 66 patients who underwent traditional surgery, group B comprised 225 patients treated according to a partially adopted perioperative protocol, and group C consisted of 103 patients, operated in line with a complete perioperative protocol. The aim of this study was to evaluate the impact of the perioperative protocol on recovery time by measuring complication rates, analgesic and antiemetic control, and return of bowel function and ambulation, as well as the length of hospitalization. RESULTS: The study groups had similar baseline characteristics. A significant improvement was noted in the complication rates (P = .019) and hospitalization time (P < .001) following a complete implementation of the perioperative protocol, where the median hospitalization time was 3 days. No mortality and no readmissions within 30 postoperative days were recorded in this group. There was an improvement in pain levels, as well as postoperative nausea and vomiting control (P < .001). CONCLUSIONS: Perioperative protocol implementation in AAA open repair is feasible; the clinical outcomes may be improved when strictly adhering to the protocol. All the applied perioperative management interventions seem to have a synergic effect on shortening the recovery time.

Paraplegia Due to Spinal Cord Ischemia after Endovascular Treatment of a Type II Endoleak.

Type II endoleaks are a common complication after endovascular abdominal aortic aneurysm repair, with transarterial embolization using synthetic surgical glue being an established treatment option. We report a case of paraplegia due to spinal cord ischemia after lumbar arteries embolization by Glubran-lipiodol glue for a type II endoleak. Special attention must be given by interventional specialists when applying surgical diluted glues for the treatment of type II endoleaks to avoid distal embolization and subsequent spinal cord ischemia.

Unconventional Endovascular Access for Symptomatic Thoracic Aortic Ulcer with Infrarenal Aortic Occlusion-A Case Report.

BACKGROUND: A man in very poor general condition was admitted for acute thrombosis of the infrarenal aorta associated to a penetrating aortic ulcer (PAU) of the distal thoracic aorta. METHODS: We planned a two-stage procedure: an axillobifemoral revascularization to be followed by thoracic endovascular aortic repair (TEVAR) after rehabilitation. Before the second stage, the patient presented with acute respiratory failure secondary to an abrupt PAU evolution. RESULTS: A properly selected stent graft was successfully deployed in an antegrade manner through a left axillary artery access with the nose of the delivery system pushed over a guidewire deep into the aortic thrombosis. CONCLUSIONS: Inadequate access and paraplegia are the major challenges hampering clinical success of TEVAR. Off-the-shelf stent graft can be used outside its primary use in an unconventional setting. Careful planning, consideration of all comorbidities and vascular anatomy, as well as correct choice of the device are crucial for the successful treatment.

Fibromuscular dysplasia: a rare disease that can mimic vasculitis.

Fibromuscular dysplasia (FMD) is an uncommon angiopathy that occurs mainly in young to middle-aged female individuals. It is an idiopathic, segmental, non-inflammatory and non-atherosclerotic vascular disease leading to stenosis of small- and medium-sized arteries. Clinical manifestations are determined by the artery involved, most commonly hypertension (renal artery) and stroke (carotid artery). When FMD affects multiple vascular beds, it may mimic a systemic vasculitis. Here, we present the case of a young female patient with FMD. The patient had a clinical history of bilateral internal carotid artery dissection that required surgical repair. Since a systemic vascular disease was suspected, abdominal angiography was done, showing evidence of a "string of beads" appearance involving the distal two-thirds of the right renal artery. This lesion is considered to be pathognomonic of the medial FMD that accounts for 70-95% of all cases of FMD. Two years later, a new magnetic resonance angiography confirmed the "string of beads" appearance of the middle to distal part of the right renal artery, with significant hemodynamic stenosis that was successfully dilated with percutaneous transluminal angioplasty.

The effects of exercise on circulating endocannabinoid levels-a protocol for a systematic review and meta-analysis.

BACKGROUND: Increased circulating endocannabinoids levels are typically associated with aerobic exercise. This phenomenon is associated with a "runner's high," a state of euphoria and well-being experienced after a long exercise. We will provide in this review a transparent and standardized methodology following the PRISMA-P and Cochrane Handbook for Systematic Reviews of Interventions for conducting a systematic review and meta-analysis for synthesizing the available evidence about the effects of physical activity on the circulating levels of AEA and 2-AG endocannabinoids in healthy subjects. METHODS: A multi-disciplinary team with basic and clinical expertise in exercise science developed this protocol. PubMed, EMBASE, Web of Science, CINAHL, SPORTDiscus, and Scopus will be the databases. A health sciences librarian was consulted in the development of the research. Search strategies will combine MeSH terms and free text words, including "exercise," "exercise, physical," "exercise training," "physical activity," "endocannabinoids," "2-arachidonoyl-glycerol," "glyceryl 2-arachidonate," "2-AG," "anandamide," "AEA," "n-arachidonoylethanolamide," "adult," "young adult," and "middle-aged." We will select experimental or quasi-experimental studies published through December 2021. The selection of studies, data extraction, assessment of the risk of bias, and the quality of evidence will be carried out in a paired and independent manner, and the consistency will be assessed using the statistics of Cohen Kappa. Methodological quality will be assessed using the Revised Cochrane risk of bias tool for randomized trials (RoB 2) and the Risk Of Bias In Nonrandomized Studies of Interventions (ROBINS-I) risk tool. We will use the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of the evidence, χ2 and I2 tests for heterogeneity, funnel plots, and the Egger test for publication bias. A meta-analysis for each data comparison will be performed whenever possible to determine the effect of physical activity on endocannabinoids' circulating levels. DISCUSSION: This systematic review and meta-analysis will provide an overview of the evidence about physical activity over AEA and 2-AG endocannabinoids, including comparability of variables between studies, critical interpretation of results, and use of accurate statistical techniques. The endocannabinoid is molecules by which muscles communicate with other tissues and organs, mediating the beneficial effects of exercise on health and performance, including increased glucose uptake, improved insulin action, and mitochondrial biogenesis. They are essential to exercise. Thus, this study will review the acute effect of physical exercise on circulating levels of endocannabinoids in healthy individuals. The results of this study will potentially be transferred to doctors, health professionals, and legislators to guide their decision making, as well as will improve future research. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020202886 .

Clampless and Sutureless Hybrid Technique for Aortic Arch Debranching on a Porcelain Aorta.

An innovative hybrid approach to the supraaortic vessels in a porcelain aorta and severe fibrotic tissue reaction at the neck is described. The technique is demonstrated in an 80-year-old woman with previous several carotid operations but still experiencing recurrent transient ischemic attacks. Clinical success was achieved at midterm follow-up, demonstrating the efficacy of hybrid treatment for this high-risk patient. Novel prosthetic vascular grafts that can be applied without cross-clamping may also provide a solution to approaching a porcelain aorta and difficult anatomies.