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- The impact of infrainguinal endovascular interventions on the results of subsequent femoro-tibial bypass procedures: a retrospective cohort study. [JOURNAL ARTICLE]
- Int J Surg 2014 Dec 17.
Endovascular recanalization has become the accepted first-line treatment strategy for most lower extremity arterial occlusions, especially in patients with critical limb ischemia (Rutherford 4-6). Prior endovascular interventions have been described as risk factors for the outcome of subsequent lower extremity bypass surgery. The effect on subsequent tibial and peroneal bypasses is controversial. We analyzed the impact of prior endovascular lower extremity revascularization procedures on the short- and mid-term results of femoro-tibial and femoro-peroneal bypasses.A retrospective analysis was conducted of all patients who had undergone tibial or peroneal bypass surgery after prior endovascular interventions (PEI-Group, n = 40) of the same extremity in our department from October 2007 to October 2012. We compared this group with a group of patients who had received a tibial or peroneal bypass as primary revascularization procedure (BF-Group, n = 93) during the same period of time because primary endovascular therapy had been deemed unfeasible in those cases. Indication in all cases was critical limb ischemia; the median age was 78 years (range 50 - 90 years), 45.1% were diabetics, and 42.9% were female. The graft material was autologous vein in 80 cases and HePTFE in 53 cases. Endpoints of the analysis were primary and secondary patency rates, limb salvage and survival at 2 years postoperatively.At 2 years overall primary patency was 68.4%, secondary patency was 69.5%, limb salvage was 83.6% and survival was 62.6%. Primary patency for the BF-Group was 74.3% vs. 55.1% for the PEI-Group (P = .310) at 2 years; secondary patency was 74.6% vs. 59.1% (P = .268). Prior endovascular intervention did not have any significant effects on limb salvage (83.7% vs. 83.6%; P = .470) or survival rates (61.0% vs. 65.0%; P = .258) at the 2-year mark, either. There were no significant differences in graft occlusion, death and major amputation rates within the first 30 postoperative days. Except for male gender, there were no significant differences in risk factors and indications between the two groups.Prior endovascular intervention of femoro-tibial vessels does not have a negative impact on the outcome of subsequent tibial or peroneal bypass surgery in patients with critical limb ischemia.
- Psychological Distress and Intensive Care Unit Stay After Cardiac Surgery: The Role of Illness Concern. [JOURNAL ARTICLE]
- Health Psychol 2014 Dec 22.
Objective: To examine the association between psychological factors and length of intensive care unit (ICU) stay in patients undergoing elective coronary artery bypass graft (CABG) surgery. Method: We studied 212 adults undergoing CABG surgery preoperatively to assess depression symptoms, anxiety symptoms, and illness perceptions and then followed them up during the in-hospital stay to measure length of ICU stay. Results: Greater preoperative concern about the illness (B = .200, 95% CI [.094, .305], p = < .001), but not depression or anxiety symptoms, was significantly related to longer ICU stays after controlling for demographic, clinical, and behavioral covariates. Conclusions: Illness concern may be particularly relevant for CABG recovery, though more work is needed to delineate the exact mechanisms of this effect. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
- Repeated hepatic resection combined with inferior vena cava replacement: Case report and review of literature. [JOURNAL ARTICLE]
- Int J Surg Case Rep 2014 Dec 2.:114-117.
Advanced tumors of the liver involving the inferior vena cava (IVC) have always been considered a contraindication to surgery.We report a case of a patient, who previously underwent right hepatectomy, with recurrence of colorectal liver metastasis invading the IVC. The patient had a liver resection together with replacement of the vena cava using a ringed polytetrafluoroethylene (PTFE) graft tube. The operation was carried out in hepatic vascular exclusion (HVE) without the use of veno-venous bypass. The patient was healthy and tumor-free at 6 months post-surgery.In patients with hepatic malignancy involving the IVC, extended hepatic resection and reconstruction of the IVC is often the prerequisite to obtaining a resection margin.Extended hepatic resection with IVC reconstruction for hepatic malignancy may offer a chance of cure to selected patients who otherwise have poor survival rates.
- Augmented Reality-Assisted Bypass Surgery: Embracing Minimal Invasiveness. [REVIEW]
- World Neurosurg 2014 Dec 17.
The overlay of virtual images on the surgical field, defined as augmented reality, has been used for image-guidance during various neurosurgical procedures. Although this technology could conceivably address certain inherent problems of extracranial-to-intracranial bypass procedures, this potential has not been explored to date. We evaluate the usefulness of an augmented reality-based setup, which could help in harvesting donor vessels through their precise localization in real-time, in performing tailored craniotomies, and in identifying preoperatively selected recipient vessels for the purpose of anastomosis.Our method was applied to three patients suffering from Moya-Moya disease who underwent superficial temporal artery-to-middle cerebral artery anastomoses, and to one patient who underwent an occipital artery-to-posteroinferior cerebellar artery bypass due to a dissecting aneurysm of the vertebral artery. Patients' heads, skulls and extracranial and intracranial vessels were preoperatively segmented from 3-dimensional image data sets (3-dimensional digital subtraction angiography, angio-magnetic resonance imaging, angio-computed tomography), and injected intraoperatively into the operating microscope's eyepiece for image guidance.In each case, the described setup helped in precisely localizing donor and recipient vessels, and in tailoring craniotomies to the injected images.The presented system based on augmented reality can optimize the workflow of extracranial-to-intracranial bypass procedures, by providing essential anatomical information, entirely integrated to the surgical field, and can help to perform minimally invasive procedures.
- Cardiac purinergic signalling in health and disease. [JOURNAL ARTICLE]
- Purinergic Signal 2014 Dec 20.
This review is a historical account about purinergic signalling in the heart, for readers to see how ideas and understanding have changed as new experimental results were published. Initially, the focus is on the nervous control of the heart by ATP as a cotransmitter in sympathetic, parasympathetic, and sensory nerves, as well as in intracardiac neurons. Control of the heart by centers in the brain and vagal cardiovascular reflexes involving purines are also discussed. The actions of adenine nucleotides and nucleosides on cardiomyocytes, atrioventricular and sinoatrial nodes, cardiac fibroblasts, and coronary blood vessels are described. Cardiac release and degradation of ATP are also described. Finally, the involvement of purinergic signalling and its therapeutic potential in cardiac pathophysiology is reviewed, including acute and chronic heart failure, ischemia, infarction, arrhythmias, cardiomyopathy, syncope, hypertrophy, coronary artery disease, angina, diabetic cardiomyopathy, as well as heart transplantation and coronary bypass grafts.
- Spinal cord injury after endovascular treatment for thoracoabdominal aneurysm or dissection† [JOURNAL ARTICLE]
- Eur J Cardiothorac Surg 2014 Dec 18.
Postoperative spinal cord injury (SCI) is a devastating complication of surgical repair for thoracoabdominal aortic aneurysm or dissection (TAAD), despite the complex reconstruction of inter-costal or lumbar arteries involved in the surgery. As an alternative technique, endovascular thoracoabdominal aneurysm repair (EVTAR) with visceral artery reconstruction has been accepted as a treatment option for severe comorbid patients of TAAD, because there is a permissible frequency of SCI after EVTAR in spite of no reconstruction of inter-costal or lumbar arteries. We report the results of EVTAR at our hospital with a focus on spinal cord injury.We analyzed data from 54 consecutive patients with TAAD (mean age, 74 ± 9.6 years; 42 men) who underwent EVTAR at our hospital between February 2007 and February 2014. Three types of EVTAR technique were used: fenestrated and/or branched stent graft implantation in 39 patients, a hybrid technique (bypass grafts to visceral arteries and straight stent graft implantation) in 10 patients, and intentional coverage of the coeliac artery and straight stent graft implantation in 5 patients. In all patients, mean systemic blood pressure was maintained at ≥80 mmHg. Opioid use was avoided in the perioperative period.According to the Crawford classification, the graft coverage extent was 9% (5/54) in type I, 11% (6/54) in type II, 39% (21/54) in type III, 22%(12/54) in type IV and 19% (10/54) in type V. In most patients (74%, 40/54), cerebrospinal fluid drainage was done intraoperatively and 1 day postoperatively. Hospital mortality was 5.6% (3/54). No patient developed SCI in the perioperative period. However, in the follow-up period 2 patients developed paraplegia as a consequence of shock caused by an aortic event.With close attention to spinal cord protection, EVTAR may be associated with only a low incidence of SCI in the perioperative period. Therefore, EVTAR is expected to become a promising treatment option for appropriately selected patients with TAAD.
- Cefazolin and linezolid penetration into sternal cancellous bone during coronary artery bypass grafting. [JOURNAL ARTICLE]
- Eur J Cardiothorac Surg 2014 Dec 18.
Deep sternal wound infection is a severe complication after cardiac surgery. Insufficient antibiotic target site concentrations may account for variable success of perioperative prophylaxis. Therefore, we measured perioperative penetration of cefazolin and of linezolid into sternal cancellous bone after sternotomy in coronary artery bypass grafting (CABG) patients by in vivo microdialysis.Nine patients underwent CABG using a skeletonized left internal mammary artery. Standard antibiotic prophylaxis consisted of 4 g cefazolin prior to skin incision and additional 2 g during skin closure. In addition, 600 mg of linezolid were administered prior to skin incision and after 12 h for study purposes. Two microdialysis probes were inserted into the sternal cancellous bone (left and right side) after sternotomy.First mean peak cefazolin and linezolid plasma concentrations were 273 ± 92 µg/ml and 22.1 ± 8.9 µg/ml, respectively. Mean peak concentrations of antibiotics in sternal cancellous bone on the left and right sternal side were 112 ± 59 µg/ml and 159 ± 118 µg/ml for cefazolin and 10.9 ± 4.0 µg/ml and 12.6 ± 6.1 µg/ml for linezolid, respectively. Cefazolin exceeded the required tissue concentrations for relevant pathogens by far, but linezolid did not gain effective tissue concentrations in all patients for some relevant pathogens. Mammary artery harvesting had no significant effect on antibiotic tissue penetration.Direct measurement of antibiotic concentration in sternal cancellous bone with in vivo microdialysis is technically demanding but safe and feasible. We could demonstrate sufficient antibiotic coverage with our standard cefazolin-dosing regimen in the sternal cancellous bone during cardiac surgery. Mammary artery harvesting had no clinically relevant effect on tissue penetration. Linezolid concentrations were not sufficient for some relevant pathogens.
- Use of antiplatelet drugs after cardiac operations. [Journal Article]
- Semin Thorac Cardiovasc Surg 2014; 26(3):223-30.
Unfortunately, venous bypass grafts still have a prominent role in operative coronary revascularization (coronary artery bypass graft [CABG]). Venous grafts develop pathologically occlusive disease that limits the effectiveness of CABG, and antiplatelet drugs following operation may limit this problem. The types and indications of antiplatelet drugs following CABG generate some controversy in the recent literature. This review surveys relevant evidence about the use of antiplatelet drugs following CABG to identify the controversial issues, define appropriate questions, and attempt to provide evidence-based interventions that may be helpful in limiting graft occlusion after CABG. Evidence suggests that, in most CABG patients, dual antiplatelet drugs (aspirin and clopidogrel), given after operation, minimizes early (within 1 year) graft failure and improves intermediate-term outcomes, better than single antiplatelet therapy with aspirin alone. There are gaps in the knowledge base that supports this contention, and future clinical trials will likely augment or alter this recommendation.
- Role of percutaneous coronary intervention in the treatment of left main coronary artery disease. [Journal Article]
- Semin Thorac Cardiovasc Surg 2014; 26(3):187-91.
Revascularization with coronary artery bypass graft surgery is the choice of therapy in patients with left main (LM) coronary artery stenosis. During the last decade, the introduction of drug-eluting stents, together with antiplatelet and antithrombotic treatments, has improved the outcome of percutaneous coronary interventions (PCIs) by reducing the number of repeat revascularizations and the risk of stent thrombosis. Many institutions inside and outside the United States have adopted stent treatment of unprotected LM coronary artery disease as a more routine strategy. However, coronary bypass surgery has improved as well by using more arterial grafts, better perioperative care, and optimizing medical treatment postoperatively. The advances in stent technique may reduce the gap between coronary surgery and PCIs further, but the results of the Evaluation of Xience Prime versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization study, randomizing patients with LM coronary artery disease between coronary bypass grafting and PCIs, will be needed to test whether PCIs is noninferior to coronary bypass surgery.
- Outcomes of arterial revascularization. [Journal Article]
- Semin Thorac Cardiovasc Surg 2014; 26(3):174-5.
Editors Note: This invited editorial is in response to articles recently published in The Journal of Thoracic and Cardiovascular Surgery. For more in depth information on this subject, please refer to the manuscript: The long-term impact of diabetes on graft patency after coronary artery bypass grafting surgery: a substudy of the mulicenter Raidal Artery Patency Study. J Thorac Cardiovasc Surg 2014; 148:1246-1253.