Hemorrhagic complications during long-term postoperative warfarin administration in patients undergoing lower extremity arterial bypass surgery

Lower extremity bypass procedures restore function and prevent amputation in many patients with severe peripheral arterial occlusive disease. The regular postoperative use of aspirin offers the dual benefit of extending bypass patency and patient survival. Previous trials of adjunctive oral anticoagulant therapy with warfarin have infrequently combined warfarin with aspirin. We hypothesized that the addition of oral anticoagulant therapy would further enhance the benefits of aspirin but may increase the risk of clinically important bleeding. Eligible patients (N = 831) scheduled for elective lower extremity arterial bypass surgery were randomized to receive either warfarin plus aspirin (WA) (n = 418) or aspirin alone (n = 413). At monthly intervals, the warfarin dose was adjusted to a target international normalized ratio (INR) of 1.4 to 2.8; both groups received aspirin (325 mg/d). The end point of major hemorrhagic events, defined as intracranial hemorrhage or bleeding that required intervention, is reported, and INR values and compliance with warfarin therapy are presented. Major hemorrhagic events occurred more frequently in the WA group (35 in the WA group vs 15 in the aspirin group; p = .02) during a mean follow-up of 38 months. In the WA group, an intracranial hemorrhage occurred in six patients (two had an INR > 3.0), of whom four died; one subdural hemorrhage occurred in the aspirin group. Transfusions and interventions for bleeding were more frequent in the WA group, as were minor bleeding events. Of the 8,946 INR determinations, 58% were in the target range, whereas a higher value occurred in 10% and a lower value in 32%. Compliance with warfarin was maintained in 65% of the patients after the first year of observation. In patients with elective lower extremity bypass procedures, the postoperative adjunctive use of warfarin with aspirin increased the risk of major hemorrhagic events. Most of these events occurred when the INR was in the target range.     

Elevated high-sensitivity C-reactive protein levels are associated with local inflammatory findings in patients with osteoarthritis

OBJECTIVE: C-reactive protein (CRP) has been associated with disease progression in patients with osteoarthritis (OA), but the reasons for this remain unclear. We hypothesized that higher CRP would be related to local inflammatory findings in the joints of patients with OA. METHODS: Plasma and synovial membrane specimens from 54 OA patients undergoing total hip or knee arthroplasty or arthroscopy were obtained. Synovial fluid was obtained from 25 of these patients. Hematoxylin and eosin stained synovial membrane sections were scored for degree of inflammatory cell infiltration. Plasma high-sensitivity CRP (hsCRP) levels, and serum and synovial fluid interleukin (IL)-6 and IL-1beta levels were measured by enzyme-linked immunosorbent assay. RESULTS: Fifty-seven percent of patients with idiopathic OA had inflammatory infiltrates within the synovial membrane. The mean hsCRP level in patients with inflammatory infiltrates was significantly higher than those without inflammation (4.7 +/- 5.0 mg/L vs 1.7 +/- 3.6 mg/L, P = 0.003). There were significant correlations between hsCRP levels and synovial fluid IL-6 (r = 0.64, P = 0.0006), degree of synovial inflammatory infiltration (r = 0.43, P = 0.002), and body mass index (r = 0.31, P = 0.02). Multivariate analysis indicated that only degree of inflammatory infiltrate was significantly associated with hsCRP level (P = 0.026). CONCLUSION: These results suggest that systemic hsCRP levels reflect synovial inflammation in OA patients, perhaps by means of synovial IL-6 production. Future studies are needed to clarify how these infiltrates and their products may contribute to disease pathogenesis.     

Red blood cell transfusions in patients undergoing lower extremity artery bypass surgery.

BACKGROUND AND AIMS: The purpose of this study was to search predictors of red blood cell transfusions in peripheral vascular surgical patients. MATERIAL AND METHODS: All the patients who undergone infrainguinal bypass surgery at Helsinki University Hospital in the year 2000 were included. Of 266 records 261 (98%) were available for data review. Multiple stepwise regression model was created to identify independent predictors of blood use. RESULTS AND CONCLUSIONS: 174 (67%) of the patients received red blood cell transfusion. The lowest measured mean (SD) haemoglobin was 94 (11) g/l intraoperatively and 92 (+/- 10) g/l on the first two postoperative days. The median (range) number of units was 3 (1-19). Multivariate analysis showed that high age (p = 0.019), small body surface area (p = 0.017), low preoperative haemoglobin (p < 0.001), blood loss (p < 0.001), long lasting surgery (p<0.001), reoperation (p=0.018), femoro-distal reconstruction (p=0.048) and chronic obstructive pulmonary disease (p = 0.023) increased the risk to receive red blood cell transfusion. The frequent use of antithrombotic medication (72% of the patients) did not significantly increase red blood cell administration. The generous use of red blood cells despite relative safe haemoglobin levels indicates a need for a standardized multidisciplinary transfusion strategy in this patient population. Otherwise, most of the predictors for red blood cell administration were nonmodifiable.     

C-reactive protein in patients undergoing cardiac surgery

Among 25 patients undergoing cardiac surgery with the aid of cardiopulmonary bypass, 13 who recovered uneventfully all had normal (less than 2 mg/litre) levels of serum C-reactive protein pre-operatively. In contrast, 10 of the 12 patients who suffered from various postoperative complications, including two who died, had abnormally raised levels of C-reactive protein pre-operatively. All patients showed a major acute phase response to surgery with peak C-reactive protein levels at about 46 hours but, whereas the uncomplicated cases showed a characteristic smooth biphasic pattern of declining levels thereafter, the complicated cases all exhibited significant alterations of this pattern. The occurrence during the postoperative period of a secondary rise in C-reactive protein or the failure of the level to continue falling, generally preceded clinical evidence of intercurrent infection. Pre-operative measurement of serum C-reactive protein may thus make a valuable contribution to the assessment of patients requiring elective cardiac surgery; regular postoperative monitoring can provide early warning of serious complications.     

Elevated preoperative C-reactive protein levels are a risk factor for the development of postoperative infectious complications following elective colorectal surgery

Purpose

The present study was designed to evaluate the relationship between the preoperative C-reactive protein levels and the incidence of postoperative infectious complications in patients undergoing colorectal surgery.

Methods

This study was a retrospective cohort study of a consecutive series of 464 patients who underwent elective colorectal resection between April 2010 and March 2012. We evaluated the patients’ preoperative conditions, including the preoperative C-reactive protein levels, surgical content, and incidence of postoperative infectious complications.

Results

Postoperative infectious complications occurred in 133 patients (28.7 %). In the univariate analysis, male gender, rectal surgery, open surgery, elevated preoperative white blood cell counts, elevated preoperative C-reactive protein levels, extended operative times, large amounts of blood loss during surgery, and ostomy formation were found to be significantly associated with the incidence of postoperative infectious complications. In the multivariate analysis, elevated preoperative C-reactive protein levels (OR per mg/dl?=?1.17, 95 % CI?=?1.02–1.37, P?=?0.02) and large amounts of blood loss during surgery (OR per 100 g?=?1.13, 95 % CI?=?1.06–1.23, P?<?0.01) were found to be independently associated with the incidence of postoperative infectious complications.

Conclusions

This study provides evidence of an association between the preoperative C-reactive protein level and the incidence of postoperative infectious complications following colorectal surgery, which should be further confirmed in prospective and appropriately designed studies.     

Elevated serum levels of C-reactive protein in hemodialysis patients

Serum C-reactive protein (CRP) levels were measured by nephelometry in 30 healthy subjects (controls) and in 99 patients with uncomplicated terminal uremia on conservative therapy (group 1, n = 30) or chronic hemodialysis (group 2, n = 69). Whereas there was no difference between controls and group 1, both the mean concentration of CRP and the incidence of elevated levels were significantly higher in group 2 in comparison with both controls and group 1. Moreover, the degree of increase in these patients was directly correlated with the duration of hemodialysis. The abnormality, therefore, is somehow related to chronic hemodialysis per se. From a practical standpoint, we concluded that this test cannot be recommended as an acute-phase reactant in this clinical setting.     

Intercurrent clinical events are predictive of plasma C-reactive protein levels in hemodialysis patients

BACKGROUND: In chronic hemodialysis (HD) patients, the repetitive induction of the acute phase response (APR) may induce a chronic micro-inflammatory state, leading to various long-term complications. METHODS: The present prospective study was designed to assess the alterations in the APR in 74 patients who were randomized to HD with a high-flux polysulfone (PS; F 60S), a super-flux PS (F 500S), or a super-flux cellulosic tri-acetate (CTA and CTA with filtered dialysate, CTA(f)) dialyzer. Blood samples collected at the start of the study and after twelve weeks were analyzed for interleukin-6 (IL-6) and C-reactive protein (CRP). In addition to the microbiological quality of the dialysate, the appearance of a "clinical event" was assessed. RESULTS: At baseline, mean IL-6 levels were within the reference range whereas mean CRP levels were slightly elevated. Mean values did not change after 12 weeks of HD with either modality. After subdividing the patients in quartiles with increasing change in plasma CRP, 23.0% of the patients showed a change of more than 8.0 mg/L. In a multiple regression analysis, CRP levels appeared to be independent of the degree of dialysate contamination, the material and the flux characteristics of the devices. In fact, the variable "clinical events" was the only significant predictor of the plasma CRP levels (P < 0.001). CONCLUSIONS: Based on these results, both PS and CTA super-flux dialyzers appear safe for clinical use. Whether changes in CRP values, which are associated with intercurrent clinical events, influence the long-term prognosis of chronic HD patients remains to be established.     

Pre-operative high sensitivity C-reactive protein and postoperative outcome in patients undergoing elective orthopaedic surgery

High-sensitivity C-reactive protein (hsCRP) adds important prognostic information, not reflected by traditional risk factors, to the prediction of both the development and outcome of cardiovascular pathology. HsCRP levels also correlate inversely with cardiorespiratory fitness, an important determinant of peri-operative outcome. We hypothesised that pre-operative hsCRP should be associated with excess peri-operative morbidity and longer length of stay. Pre-operative hsCRP was measured blinded to standardised postoperative outcomes in 129 elective orthopaedic patients. HsCRP levels were divided into high (> 3 mg x l(-1)) or low (< 3 mg x l(-1)) groups (Center for Disease Control stratification). High-CRP patients had significant cardiovascular history, received cardiac medication or steroid therapy (p < 0.05). Higher pre-operative hsCRP was associated with longer length of stay: mean 7.5 days (95% CI: 6.2-8.8) vs 6.0 days (95% CI: 5.5-6.5; p = 0.03; log rank test). In 21 patients with > 8 days length of stay, high pre-operative hsCRP patients were over-represented (p = 0.04). Pre-operative hsCRP is related to length of stay and delayed postoperative complications.     

Obesity in diabetic patients undergoing coronary artery bypass graft surgery is associated with increased postoperative morbidity

BACKGROUND: Despite the fact that obesity is a known risk factor for cardiovascular disease, many studies have failed to demonstrate that obesity is independently associated with an increased risk of cardiovascular morbidity and mortality in nondiabetic patients undergoing coronary artery bypass graft surgery. The authors investigated the influence of obesity on adverse postoperative outcomes in diabetic and nondiabetic patients after primary coronary artery bypass surgery. METHODS: A retrospective cohort study of patients undergoing primary coronary artery bypass surgery (n = 9,862) between January 1995 and December 2004 at the Texas Heart Institute was performed. Diabetic (n = 3,374) and nondiabetic patients (n = 6,488) were classified into five groups, according to their body mass index: normal weight (n = 2,148), overweight (n = 4,257), mild obesity (n = 2,298), moderate obesity (n = 785), or morbid obesity (n = 338). Multivariate, stepwise logistic regression was performed controlling for patient demographics, medical history, and preoperative medications to determine whether obesity was independently associated with an increased risk of adverse postoperative outcomes. RESULTS: Obesity in nondiabetic patients was not independently associated with an increased risk of adverse postoperative outcomes. In contrast, obesity in diabetic patients was independently associated with a significantly increased risk of postoperative respiratory failure (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.41-3.61; P < 0.001), ventricular tachycardia (OR, 2.27; 95% CI, 1.18-4.35; P < 0.02), atrial fibrillation (OR, 1.56; 95% CI, 1.03-2.38; P < 0.04), atrial flutter (OR, 2.38; 95% CI, 1.29-4.40; P < 0.01), renal insufficiency (OR, 1.66; 95% CI, 1.10-3.41; P < 0.03), and leg wound infection (OR, 5.34; 95% CI, 2.27-12.54; P < 0.001). Obesity in diabetic patients was not independently associated with an increased risk of mortality, stroke, myocardial infarction, sepsis, or sternal wound infection. CONCLUSION: Obesity in diabetic patients is an independent predictor of worsened postoperative outcomes after primary coronary artery bypass graft surgery.     

下肢静脉造影在下肢静脉曲张患者中的应用及阻塞性下肢静脉曲张发生的预测因素

目的 探讨下肢静脉造影检查在下肢静脉曲张中应用的临床意义,并分析阻塞性下肢静脉曲张可能相关的预测因素.方法 选取2019年1月至2021年12月因下肢静脉曲张于海军军医大学第二附属医院诊治的74例患者(111条患肢)为研究对象,对所有患肢行下肢静脉造影检查,采用病例报告表形式记录患者相关信息,根据有无深静脉阻塞表现分为...     

Autogenous reversed vein bypass for lower extremity ischemia in patients with absent or inadequate greater saphenous vein

This report has presented the results of 329 reversed vein bypasses performed for lower extremity ischemia over a 6 3/4 year period. One hundred eighty-nine bypasses were formed from intact ipsilateral greater saphenous veins of adequate size and length. One hundred forty bypasses were formed in patients in whom the ipsilateral greater saphenous vein was absent or of inadequate size or length to complete the bypass. The grafts in these patients were accomplished using a variety of techniques including distal graft origin, use of arm veins and lesser saphenous veins, and use of vein splicing. The patency rates of these grafts were equivalent to those achieved using adequate intact ipsilateral greater saphenous vein. In view of these results, we conclude that the absence of a greater saphenous vein does not preclude successful autogenous lower extremity vein bypass and that prosthetic bypass is rarely justified.     

Elective infrainguinal lower extremity bypass for claudication is associated with high postoperative intensive care utilization

BackgroundThe overall use of intensive care units (ICUs) in the United States has been steadily increasing and is associated with tremendous health care costs. We suspect that the burden of ICU utilization after elective infrainguinal lower extremity bypass (LEB) procedures is high, despite relatively low risks of complications in the immediate postoperative period. We sought to identify the burden of ICU utilization after elective LEB in patients with claudication.MethodsWe queried the Premier Healthcare Database for all adult patients undergoing first recorded elective infrainguinal LEB for claudication from 2009 to 2015. Baseline characteristics and ICU utilization on postoperative day 0 (POD 0) were identified for each patient using Premier room and board chargemaster codes. A bivariate logistic regression was performed and postestimation concordance statistics were calculated to identify predictors of postoperative ICU vs regular surgical floor admission immediately after surgery.ResultsThere were 6010 patients who met the selection criteria, of whom 2772 (46.1%) were admitted to the ICU and 3238 (53.9%) to the regular surgical floor on POD 0. Whereas patient-level factors were responsible for minor differences found in postoperative admission to the ICU after elective LEB, hospital characteristics made up the majority of variation in admission practices. Specifically, patients undergoing elective infrainguinal LEB in rural, nonteaching, small hospitals and those in certain geographic regions were more likely to be admitted to the ICU than to the floor (all, P < .001). Patient-level factors were poorly predictive of admission to the ICU immediately postoperatively, with C statistics ranging from 0.50 to 0.53. In contrast, hospital-level factors had higher C statistics ranging from 0.51 to 0.66, with geographic location being the strongest predictor of post-LEB ICU admission. There were no significant differences in the incidence of postoperative wound complications, major adverse limb events, major adverse cardiac events, or in-hospital mortality between groups (all, P ≥ .32). The median total hospital cost was $2340 higher for ICU compared with floor admission ($13,273 [interquartile range, $10,136-$17,883] vs $10,927 [interquartile range, $8342-$14,523]; P < .001).ConclusionsNearly half of patients are admitted to an ICU directly after elective infrainguinal LEB for claudication. This practice is associated with significantly higher hospital cost and is predominantly influenced by hospital-level rather than by patient-level factors. Perioperative morbidity and mortality were similar regardless of postoperative disposition. To minimize ICU utilization, postoperative care intensity should be determined by clinical severity of the patient rather than by hospital routine.     

Treatment of failed lower extremity bypass grafts with new autogenous vein bypass grafting

During the last 9 years we performed 111 bypass procedures for lower extremity ischemia, which occurred after failed infrainguinal bypass grafting. An all autogenous reversed vein bypass was achieved in 103 of 111 operations (93%). Five-year primary and secondary patency of bypasses placed as treatment for one or more failed prior bypass(es) was 57% and 71%, respectively, as compared to 80% and 83%, respectively, for 5-year primary and secondary patency of simultaneously placed first time leg bypasses. Five-year limb salvage for bypass procedures performed as treatment for failed bypass was 90%, which was identical to that achieved for first time bypasses.     

Increasing obesity is associated with lower postoperative bleeding in coronary bypass patients

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普通外科恶性肿瘤患者术后下肢深静脉血栓形成预测模型的构建

背景与目的：下肢深静脉血栓形成（LDVT）是普通外科恶性肿瘤患者术后常见的并发症之一,严重影响患者的术后康复。目前的评估工具无法对LDVT患者进行更加细致的风险分层。因此,本研究探讨普通外科恶性肿瘤患者术后发生LDVT的影响因素,并建立可靠的预测工具,从而为LDVT的诊断和防治提供帮助。方法：回顾性分析2021年1月1日—2022年10月31日中南大学湘雅医院普通外科手术治疗恶性肿瘤患者的临床资料,根据良好设计的纳入、排除标准对病例进行严格的质量控制。使用已经较明确的LDVT的影响因素和一些重要临床特征作为分析变量,单变量分析和多变量分析用以评估LDVT的影响因素以及筛选模型的预测因子。应用编程软件制作基于Logistic回归的列线图并通过受试者工作特征曲线（ROC）评估列线图的预测性能,校准曲线用以评估预测模型与数据的拟合程度。使用决策曲线分析（DCA）比较预测模型与其他单一指标临床应用价值的差异。结果：本研究共纳入342例患者,其中LDVT组167例,对照组175例。单变量分析显示,1个月内有手术创伤史、高血压史、吸烟史、饮酒史、放疗史、ICU住院时间、红细胞（RBC）、血红蛋白（...