Does intensive perioperative dialysis improve the results of coronary artery bypass grafting in haemodialysed patients?

BACKGROUND: Between January 1996 and April 1998, 17 chronic haemodialysed patients underwent coronary artery bypass grafting (CABG). Two of them simultaneously had valve replacement. METHODS: Except for two cases in which CABG was performed in an emergency, 15 patients (CRF group) received 3 consecutive days of haemodialysis in the preoperative period, intraoperative haemodialysis connected to cardiac pulmonary bypass (CPB) and continuous hemodiafiltration in the early postoperative period. The perioperative clinical parameters of the CRF group were compared with those of 17 age-matched patients with normal renal function undergoing CABG as the control (NRF group). RESULTS: When the perioperative variables were compared, no significant differences were seen in total operation time and CPB time, but we noted significant increases in the mean volume of transfused blood in the 6 perioperative days, postoperative intubation time, postoperative fasting time, and time spent in the intensive care unit. Levels of central venous pressure, systolic blood pressure, respiratory index (PaO2/FiO2) and daily fluid balance of the CRF group were the same as the control group in the early postoperative period. In addition, the levels of serum creatinine, urea nitrogen, potassium and hematocrit of CRF group remained almost constant in the early postoperative period. After all, the hospital morbidity of the CRF group was not more serious than that of the NRF group, and hospital mortality of the CRF and NRF groups was 0%. CONCLUSIONS: Our intensive perioperative dialysis programme could successfully manage the perioperative clinical course of haemodialysed patients undergoing CABG.     

Does kidney transplantation onto the external iliac artery affect the haemodynamic parameters of the cavernosal arteries?

Reduced cavernosal arterial inflow has been hypothesized to be the likely cause of erectile dysfunction after kidney transplants in recipients revascularized through end-to-end anastomosis to the internal iliac artery, suggesting that end-to-side anastomosis at the external iliac artery is preferable. The aim of this study was to prospectively evaluate the effect of the use of the external iliac artery on erectile function, hormone profiles and penile blood flow by evaluating changes in penile colour Doppler ultrasound parameters in a consecutive series of 22 recipients before and after end-to-side external iliac artery transplantation. The mean International Index of Erectile Function-Erectile Function (IIEF-EF) domain score decreased significantly 3 months after transplant (18.09±6.33 vs. 22.50±7.09, P=0.01). The reduction in peak systolic velocity (PSV) was significant for the cavernous artery homolateral to the side of transplant (42.60±18.77 vs. 52.01±19.91, P=0.01). The mean postoperative end diastolic velocity (EDV) did not differ significantly from the preoperative value (P=0.74). No statistical differences were found in the serum levels of testosterone or prolactin. Kidney grafts anastomosed at the external iliac artery produced significant (P=0.01) reductions in arterial inflow at the homolateral cavernosal artery that remained above the normal threshold. Whether these haemodynamic changes can explain the worsening of postoperative erectile function remains to be proven.     

Does below-the-knee placement of drug-eluting stents improve clinical outcomes?

Modern critical limb ischemia management algorithms endorse an "endovascular first" strategy of treatment. The advent of stents coated with anti-restenotic agents that are gradually eluted to the vessel wall has revolutionized modern endovascular therapies. Several single-center, non-randomized cohort series have provided compelling data about the short- to mid-term safety and effectiveness of drug-eluting stents in below-the-knee lesions and have fuelled further large-scale research. Three multicenter randomized trials (the YUKON-BTX, the DESTINY and the ACHILLES trials) are now available and have paved the way for level I-A evidence about infrapopliteal use of drug-eluting stents. Amassed evidence strongly supports the use of olimus-eluting metal stents for focal obstructive infrapopliteal lesions in order to inhibit restenosis, prolong vessel patency and thereby achieve sustained patient improvement, as reflected by the significantly improved Rutherford-Becker classification, reduced number of repeat procedures and a trend towards improved wound healing. The present overview outlines current evidence about clinical outcomes after below-the-knee drug-eluting stent placement compared to more traditional endovascular treatments like conventional old balloon angioplasty and bare metal stents. Available evidence is appraised in the context of clinically meaningful results and relevant unresolved issues are highlighted.     

Hepatic venous outflow obstruction in living donor liver transplantation: balloon angioplasty or stent placement?

Background

The incidence of hepatic venous outflow obstruction (HVOO) has been reported to be 5%-13% when a partial graft is used for orthotopic liver transplantation (OLT). HVOO leads to graft congestion, portal hypertension, and finally cirrhosis, which jeopardizes both graft and recipient survivals. In this study, we sought to identify perioperative factors influencing HVOO and to investigate conditions that require stent placement.

Patients and Methods

From February 1994 to December 2010, we performed 40 living donor liver transplantations (LDLT). HVOO occurred in 5 cases (12.5%), all of which were left lobe grafts. Because HVOO was not observed in patients with body weight (BW) <30 kg, we investigated the other 28 cases with BW >30 kg.

Results

There was no difference from unaffected subjects except for cold ischemic time (CIT), which was significantly longer: 86.2 ± 10.4 minutes vs 46.0 ± 4.8 minutes (P = .001). Balloon angioplasty, which was selected as the initial treatment for all stricture patients, improved 2 patients after 1 and 5 treatments, respectively, but 3 subjects underwent repeated HVOO, finally being treated with self-expandable metallic stents at 9, 6, and 10 years after LDLT, respectively. All patients finally resolved their strictures.

Conclusion

HVOO reflects intimal hyperplasia and fibrosis at the anastomotic sites or compression and twisting of the anastomosis caused by graft regeneration. In addition, progression of chronic rejection and fibrosis are possibly responsible for late-onset HVOO. Longer CIT possibly reflects difficulties in the venoplasty before anastomosis. No bleeding or thrombosis complications were observed during dilatation among our cases. The selection of the stent size for each case and careful stent deployment are important to prevent complications. Stent placement should be considered in patients with chronic rejection who are refractory to several balloon angioplasties with early-onset or late-onset HVOO.     

Does conversion of intended remote iliac artery endarterectomy alter the early and long-term outcome?

The purpose of this study was to compare the perioperative and long-term results of initial successful remote iliac artery endarterectomies (RIAEs) with converted procedures. From April 1994 to September 2003, 63 remote endarterectomies of the external and/or common iliac artery were planned in 62 patients (41 males, 42 procedures). The median age was 65 years (range 39-83 years), and the indication for operation was severe claudication in 37 (59%), rest pain in 16 (25%), and gangrene in 10 (16%) procedures. Initial technical success was achieved in 56 (89%) procedures (group 1); seven conversions (group 2) were necessary. In group 1, the 5-year primary patency rate improved from 64 +/- 15% to a primary assisted patency of 88 +/- 9.3% after percutaneous transluminal angioplasty in 11 patients, with 7 requiring stent placement. The 5-year secondary patency rate was 94 +/- 7.4%. The primary and secondary patency rates in group 2 were 86 +/- 19% and 100%, respectively. RIAE can be offered to patients with long occlusions of the iliac arteries as a first treatment option. The inherent risk of a possible conversion of an intended RIAE to a more invasive surgical procedure has no significant adverse clinical effect on the early and 5-year clinical outcomes.     

Does preoperative coronary angioplasty improve perioperative cardiac outcome?

BACKGROUND: Percutaneous coronary intervention (PCI) is performed in patients with coronary artery disease who are undergoing major noncardiac procedures to reduce perioperative cardiac morbidity and mortality. However, the impact of this approach on postoperative outcome remains controversial. METHODS: The authors analyzed a cohort of 1,152 patients after abdominal aortic surgery in which 78 patients underwent PCI. A propensity score analysis was performed. Also, using a logistic regression model, the authors determined variables associated with a severe postoperative coronary event or a death in patients without PCI. Then, in patients with PCI, they compared the expected and observed outcome. RESULTS: Five variables (age > 75 yr, blood transfusion > 3 units, repeated surgery, preoperative hemodialysis, and previous cardiac failure) independently predicted (with 94% correctly classified) a severe postoperative coronary event, and five variables (age > 75 yr, repeated surgery, previously abnormal ST segment/T waves, previous hypertension, and previous cardiac failure) independently predicted (with 97% correctly classified) postoperative death. In the PCI group, the observed percentages of patients with a severe postoperative coronary event (9.0% [95% confidence interval, 4.4-17.4]) or death (5.1% [95% confidence interval, 2.0-12.5]) were not significantly different from the expected percentages (8.2 and 6.9%, respectively). When all patients were pooled together, the odds ratios of PCI were not significant. The propensity score analysis provided a similar conclusion. CONCLUSION: PCI did not seem to limit significantly cardiac risk or death after aortic surgery.     

Does coronary artery bypass surgery improve survival?

Abstract Objectives. According to guide-lines, coronary bypass surgery improves survival in high risk patients. The evidence for this is more than 20 years old and may be questioned. Long waiting lists for coronary bypass surgery are detrimental but offer the possibility to compare the risk of death before and after surgery. We hypothesized that the risk of death is lower after bypass surgery than before the operation in high risk patients in a more recent cohort. Design and results. Death hazard functions were calculated by the use of Poisson regression scheduled for bypass surgery between 1 Jan 1995 and 31 July 2005. The analyses were performed in two states: 1) in the period after triage until admission for surgery during which optimal medication was intended and 2) after surgery and up to 11 years (corresponding to 57,548 patient years). The probability of death was calculated by entering individual risk profile data into the two multivariable functions. There were several significant differences between the hazard functions in the two states. All variables reflecting angiographic severity of coronary lesions indicated lower risk of death after bypass surgery. The risk associated with left ventricular impairment was lower after surgery (beta coefficients - 0.0546 vs. - 0.0234, p <0.001). Only one variable, age, indicated higher risk after surgery (which is also seen in a general population over time). The reduction of risk was dependent on preoperative risk with a large reduction when preoperative risk was high and vice versa. When preoperative risk was low, however, the risk increased due to surgical mortality. Conclusions. The risk of death is lower after bypass surgery than before the operation in high risk patients. This is most likely explained by a prognostic gain from bypass surgery. The gain is largest in high-risk patients but small or absent in low risk patients.     

Emergency endovascular repair of iliac artery rupture caused by post-stenting angioplasty with an endograft

I liac artery rupture is a rare complication of post-stenting angioplasty and can lead to massive life-threatening haemorrhage. Conventional surgery can not repair the damaged vessel easily and may cause substantial blood loss and high operative morbidity and mortality. We report our experience with a self-expanding covered endoprosthesis for endovascular repair of the rupture of an iliac artery caused by stenting angioplasty.     

Does three-dimensional computer simulation improve results of scaphoid nonunion surgery?

The purpose of this study was to clarify the effectiveness of the three-dimensional computer simulations in scaphoid nonunion surgery. Seven consecutive clinical patients with scaphoid nonunion at the middle third comprised the study group. Surface models of the scaphoid were constructed on the computer using computed tomography data of the bilateral wrists in neutral position. The distal and proximal fragments of the nonunion model were matched to the mirror image of the contralateral scaphoid model. The rotation of the distal fragment relative to the proximal fragment was calculated, and reduction of the displaced fragment of the scaphoid nonunion was simulated. Similarly, the estimated bone defect and the appropriate site and direction of the screw insertion were simulated. Full-sized hard models of the bone, including a model with simulated reduction and screw insertion, then were made using stereolithography based on the computer data. In the actual surgery, reduction, bone grafting, and screw insertion were achieved using the hard models as guides. All the patients obtained solid bone fusion and substantial clinical improvement with normalized scapholunate and radiolunate angles after surgery. Three-dimensional computer simulations were found as useful for accurate correction of scaphoid nonunions and proper screw placement, which consequently leads to good clinical results.     

Does the right internal thoracic artery or saphenous vein graft offer superior revascularization of the right coronary artery?

A best evidence topic was written according to a structured protocol. The question addressed was whether the right internal thoracic artery (RITA) provides a superior outcome for revascularization of the right coronary artery (RCA) compared with the saphenous vein graft (SVG). Using a designated search strategy, 226 articles were found, of which five represented the best available evidence. The authors, journal, date, country of publication, study type, patient group studied, relevant outcomes and results were tabulated. Of these five studies, one offered level I evidence (data from a randomized trial) and four were level II studies (reports of observational data). The outcome measures varied considerably, but most included graft patency at varying levels of the follow-up. The randomized data showed strong evidence favouring the SVG, mainly in terms of mid-term patency. With the exception of a large cohort study that demonstrated the superior patency of the RITA compared with the SVG in the right coronary territory, the observational studies showed better results for SVG in graft patency, reintervention and cardiovascular complication rate. Overall, and in view of the methodological limitations and the different weight of evidence among studies, it appears that the SVG may offer a superior outcome for revascularization of the RCA when compared with the RITA.     

Does laparoscopy-aided gastrostomy placement improve or worsen gastroesophageal reflux in patients with neurological impairment?

Background/purposeThe purpose of this study was to retrospectively investigate whether laparoscopy-aided gastrostomy placement (LGP) improved or worsened gastroesophageal reflux (GER) in neurological impairment (NI) patients.MethodsSubjects included 26 NI patients nourished via nasogastric tubes (age, 1–17 years; median, 6 years). They were divided into groups based on the percentage of time with an esophageal pH < 4.0 (reflux index: RI) before LGP: Group 1 (GI, n = 13), RI < 5.0%; Group II (GH, n = 13), RI ≥ 5.0%. Acid/nonacid reflux episodes (RE) were evaluated using combined pH-multichannel intraluminal impedance (pH-MII) monitoring, and gastric emptying was measured with the C breath test before and after LGP.ResultsRI and number of RE evaluated with pH analyses and number of total/acid distal and proximal bolus RE with pH-MH increased significantly in GI. RI and acid clearance time with pH analyses and number of total bolus RE with pH-MII decreased significantly in GH. Gastric emptying parameters did not change significantly in GI, whereas the half-gastric emptying time and gastric emptying coefficient improved significantly in GH.ConclusionLGP reduces GER in NI patients with pathological GER by improving gastric emptying, although it has a paradoxical influence on those without pathological GER.     

Does routine use of the radial artery increase complexity or morbidity of coronary bypass surgery?

BACKGROUND: Despite increasing data supporting its use, the uptake of radial artery coronary bypass grafting by most surgeons remains low. This may partly be from perceptions that it increases risk or complexity of coronary surgery. METHODS: Data on 151 patients who had radial grafts are compared with 179 concurrent nonrandomized controls that underwent conventional surgery using saphenous vein. Additionally, telephone interviews were conducted on 127 radial recipients to assess subjective outcome. RESULTS: Cardiopulmonary bypass and cross-clamp times were similar in both groups (72 versus 74 minutes and 20 versus 22 minutes). Morbidity was comparable (mortality 1% versus 2%; cerebral vascular accident 1% versus 2%; sternal infection 1% versus 2%; resternotomy 4% versus 6%). Of 127 patients contacted, 41 (32%) reported that they had experienced parasthesia, and 65 (51%) reported numbness related to radial harvest; of these, 75% reported their symptoms as resolved or resolving. Early angiography performed in 36 patients revealed a radial patency rate of 92%. CONCLUSIONS: Concerns about increased morbidity and mortality should not hinder adoption of radial artery grafting.     

Long-term results of stent graft treatment of subclavian artery injuries: Management of choice for stable patients?

BACKGROUND: The management of penetrating subclavian artery injuries poses a formidable surgical challenge. The feasibility of stent graft repair is already established. General use of this modality is not widely accepted due to concerns regarding the long-term outcome in a generally young patient population. We review our stent graft experience to examine long-term outcomes. METHODS: All patients with penetrating subclavian artery injuries were evaluated for stent graft repair. Patients were excluded when hemodynamically unstable or unsuitable on other clinical and angiographic grounds. Patients were followed prospectively for early (<30 days) and late (>30 days) complications. Clinical and telephone evaluation, Doppler pressures, duplex Doppler, and angiography (when indicated), were used to asses patients at follow-up. Outcomes were recorded as technical success of procedure, graft patency, arm claudication, limb loss, the need for open surgical repair, the presence or absence of other complications, and death. RESULTS: Fifty-seven patients underwent stent graft treatment during the 10-year period. Mean age was 34, and 91% were men. There were 53 stab wounds and four gunshot injuries. Pathology included false aneurysms (n = 42), arteriovenous fistula (n = 12), and three arterial occlusions. Early complications: One patient (2%) had a femoral puncture site injury which was managed with open surgical repair. One patient died early due to multiple organ failure related to concomitant injuries. Three patients (5%) presented with graft occlusion and nonlimb threatening ischemia in the first week after treatment. All three patients were managed successfully with a second endovascular intervention. Late complications: Twenty-five (44%) of the 57 patients with subclavian artery injuries were followed-up with a mean duration of 48 months. Two patients died as a result of fatal stab wounds months after their first injuries. Five patients (20%) and three patients (12%) presented with angiographically significant stenosis and occlusions, respectively. The stenotic lesions were successfully managed with endovascular intervention, and the occluded lesions were managed conservatively. No patient experienced life or limb loss or any incapacitating symptoms at the end of the study period. There was no need for conversion to open surgery. CONCLUSIONS: This study has reaffirmed the feasibility and safety of stent graft repair in treating stable patients with selected penetrating subclavian artery injuries. The results of this study also confirmed acceptable long-term follow-up without any limb or life threatening complications. We conclude that endovascular repair should be considered the first choice of treatment in stable patients with subclavian artery injuries.