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Liang JW, Zhou M, Jin YQ, Li TT, Wen JP. High-sensitivity troponin T levels before and after cardiac surgery and the 30-day mortality: a retrospective cohort study. Front Cardiovasc Med 2023; 10:1276035. [PMID: 38099226 PMCID: PMC10720580 DOI: 10.3389/fcvm.2023.1276035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
Background The suggested threshold level of cardiac troponin T elevation after cardiac surgery is not very clear, and the values recommended by various guidelines and literature reports are quite different. Methods In this retrospective cohort study, we collected clinical data of patients who underwent heart surgery at Tsinghua University First Hospital between January 2015 and December 2022. Using the high-sensitivity cardiac troponin T levels (reference upper limit: 14 ng/L) measured at 1-3 days postoperation, the relationship between the cardiac troponin T level and the 30-day mortality risk was evaluated using Cox regression analysis. Results Among the 3,128 patients included in this study, the types of operations mainly consisted of coronary artery bypass graft (CABG, 1,164, 37.2%), aortic valve replacement (AVR, 735, 23.5%), and other cardiac operations (1,229, 39.3%). Within 30 days postoperation, 57 patients (1.8%) died and 72 patients (2.3%) developed major vascular complications. In patients undergoing CABG or AVR, the cardiac troponin T threshold level measured within one day postoperation related to an increased 30-day mortality was determined to be 3,012 ng/L (95% CI: 1,435-3,578 ng/L), which is 218 times higher than the reference upper limit. In patients undergoing other cardiac operations, this threshold was 5,876 ng/L (95% CI: 2,458-8,119 ng/L), which is 420 times higher than the reference upper limit. Conclusion The high-sensitivity cardiac troponin T level associated with an increased 30-day mortality risk after cardiac surgery is significantly higher than the current recommendations for defining clinically important perioperative myocardial injury.
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Affiliation(s)
- Jian-Wei Liang
- Laboratory Medicine Department, Tsinghua University First Hospital, Beijing, China
| | - Min Zhou
- Obstetrics and Gynecology Department, Tsinghua University First Hospital, Beijing, China
| | - Yong-Qiang Jin
- Department of Medical Laboratory, Tianjin Medical University, Tianjin, China
| | - Ting-Ting Li
- Laboratory Medicine Department, Tsinghua University First Hospital, Beijing, China
| | - Jiang-Ping Wen
- Laboratory Medicine Department, Tsinghua University First Hospital, Beijing, China
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2
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Montero-Baker M, Sommerset J, Miranda JA. Hybrid superficial venous arterialization and endovascular deep venous arterialization. J Vasc Surg Cases Innov Tech 2023; 9:101160. [PMID: 37404577 PMCID: PMC10315921 DOI: 10.1016/j.jvscit.2023.101160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/24/2023] [Indexed: 07/06/2023] Open
Abstract
We report on two venous arterialization (VA) techniques for treatment of CLTI in patients traditionally considered as having no treatment options for standard arterial endovascular or surgical bypass procedures. Screening and the preprocedural workup findings are outlined as deciding factors in determining a patient's fitness for the two techniques, with a focus on careful preprocedure arterial duplex ultrasound and assessment for vein suitability. Cardiac and infection screening are also factors in determining patient suitability for VA. In addition, radiographic assessment for the presence of medial artery calcification, which is used as a marker of technical difficulty and is a predictor of poor outcomes, is required. Ultimately, anatomic factors are used to determine the decision between hybrid superficial VA and or endovascular deep VA. Those with an occluded anterior tibial artery and suitable great saphenous vein are prioritized to hybrid superficial VA, and those with an occluded posterior tibial artery to endovascular deep VA. Both procedures are described in detail in this report of vascular and surgical techniques.
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Affiliation(s)
| | - Jill Sommerset
- Hope Vascular & Podiatry Clinical Innovation Center, Houston, TX
- Advanced Vascular Centers, Portland, OR
| | - Jorge A. Miranda
- Division of Vascular and Endovascular Surgery, Department of Surgery, Baylor College of Medicine, Houston, TX
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3
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Farazdaghi A, Manunga JM, Bhatti UH, Nuttall GA, Bower TC, Heins C, Harmsen WS, Kalra M. Asymptomatic myocardial injury identified on postoperative troponin testing after open or endovascular surgical procedures is a predictor of mortality. J Vasc Surg 2023; 77:1216-1223. [PMID: 36565776 DOI: 10.1016/j.jvs.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/25/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Elevated troponin (TnT) levels after open or endovascular surgical procedures have been previously shown to correlate with significantly higher postoperative and short-term mortality. The incidence of asymptomatic myocardial injury after vascular surgical procedures has also been shown to be high. The aim of the present study was to evaluate the utility of routine postoperative TnT screening and long-term outcomes for patients with postoperative TnT elevation. METHODS Data from consecutive patients who had undergone open or endovascular surgery on an emergent or elective basis with routine postoperative TnT testing from January 2010 to December 2012 were retrospectively analyzed. Elevated postoperative TnT was considered >0.01 ng/mL. Patients with no documented postoperative TnT levels, those who had denied research authorization, and those with elevated TnT levels secondary to renal insufficiency alone were excluded. Patients were also excluded if they had required a dialysis access procedure, varicose vein procedure, or any procedure performed on an outpatient basis, because these were considered nonmajor surgeries. The end points were all-cause mortality at 30 days and 1, 2, 4, and 8 years postoperatively. Mortality data were retrieved from the electronic medical records and the Social Security Death Index and Accurint Death database. RESULTS During the 3-year study period, 1632 patients with postoperative TnT levels available had met the inclusion criteria (70% men; 30% women; mean age, 69.7 years). Postoperatively, 410 patients (25.1%) had had elevated TnT levels (TnT+) and 1222 (74.9%) had had nonelevated TnT levels (TnT-). Of the 410 TnT+ patients, 261 had undergone open, 143 had undergone endovascular, and 6 had undergone hybrid procedures. These included 180 aortic, 128 infrainguinal, 22 cerebrovascular, and 80 upper extremity or miscellaneous procedures. Of the 410 TnT+ patients, 168 had experienced asymptomatic myocardial injury. The 30-day mortality was significantly higher for the TnT+ patients than for the TnT- patients (3.9% vs 0.8%; P < .001). The cumulative probability of death for the TnT+ patients remained significantly higher than that for the TnT- patients at 1 (13% vs 3.2%), 2 (17.8% vs 4.8%), 4 (43% vs 18.5%), and 8 (81.4% vs 48.6%) years (P < .0001). The difference held true even for the 168 asymptomatic TnT+ patients compared with the TnT- patients at 30 days (2.4% vs 0.8%) and 1 (7.6% vs 3.2%), 2 (13.3% vs 4.8%), 4 (43.6 vs 18.5%) and 8 (80.8 vs 48.6%) years (P < .0001). CONCLUSIONS In the present study, patients with elevated TnT levels after vascular surgery had had significantly higher early and late all-cause mortality compared with those with normal postoperative TnT levels. This was true even for patients with asymptomatic TnT elevation, suggesting a role might exist for routine postoperative TnT screening to allow for long-term risk stratification and targeted medical management.
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Affiliation(s)
- Armin Farazdaghi
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Jesse M Manunga
- Division of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Umer H Bhatti
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Gregory A Nuttall
- Division of Cardiac Anesthesia, Department of Anesthesia, Mayo Clinic, Rochester, MN
| | - Thomas C Bower
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | | | | | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
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4
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Lee C, Columbo JA, Stone DH, Creager MA, Henkin S. Preoperative evaluation and perioperative management of patients undergoing major vascular surgery. Vasc Med 2022; 27:496-512. [PMID: 36214163 PMCID: PMC9551317 DOI: 10.1177/1358863x221122552] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
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Affiliation(s)
| | | | | | | | - Stanislav Henkin
- Stanislav Henkin, Heart and Vascular
Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at
Dartmouth, Lebanon, NH 03756, USA.
Twitter: @stanhenkin
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5
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Matsumoto S, Omiya H, Fujinaka W, Morimatsu H. Association between intraoperative hyperglycemia and postoperative end-organ dysfunctions after cardiac surgery: a retrospective observational study. J Anesth 2021; 36:174-184. [PMID: 34807289 DOI: 10.1007/s00540-021-03024-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Hyperglycemia has been associated with postoperative morbidity in patients who undergo cardiac surgery. However, it remains unclear whether the duration of hyperglycemia is as important as its magnitude in the development of postoperative end-organ dysfunction (PEOD). This retrospective study investigated the hypothesis that the intraoperative blood glucose (BG) exposure index (GE index), calculated by the product of the magnitude and duration of BG concentration ≥ 180 mg/dL, which is an integration of the severity and duration of hyperglycemia, is associated with the incidence of PEOD in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS The primary outcome in this study was PEOD within 72 h of surgery, which was defined as a composite of postoperative acute kidney injury, delirium, myocardial injury, and prolonged mechanical ventilation. The GE index (the magnitude of BG concentration deviation ≥ 180 mg/dL [Formula: see text] duration of BG concentration ≥ 180 mg/dL) of each patient was calculated based on the intraoperative BG concentration. The relationship between the GE index and the primary outcome was examined via logistic regression model with adjustment for potential confounders. RESULTS Within 72 h of surgery, 301 patients (54.5%) developed PEOD. PEOD was more common in patients with greater GE index quartiles (first versus third quartile; adjusted odds ratio, 5.65, 95% confidence interval (95% CI), 2.94-10.90; P < 0.001; first versus forth quartile, adjusted odds ratio, 20.80; 95% CI, 8.01-54.00; P < 0.001). CONCLUSION In patients undergoing cardiac surgery with cardiopulmonary bypass, the GE index was an independent predictor of PEOD.
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Affiliation(s)
- Shinsaku Matsumoto
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan.
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Hiroki Omiya
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Waso Fujinaka
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Patra V, Jha R, Anand V, Dhillan R, Mehra R, Reddy TS. Role of Cardio-biomarkers (NT-Pro BNP and Troponin I) in cardiac risk stratification of patients undergoing major vascular surgeries. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_144_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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7
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Magoon R, Makhija N, Das D. Perioperative myocardial injury and infarction following non-cardiac surgery: A review of the eclipsed epidemic. Saudi J Anaesth 2020; 14:91-99. [PMID: 31998026 PMCID: PMC6970380 DOI: 10.4103/sja.sja_499_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 09/02/2019] [Indexed: 12/23/2022] Open
Abstract
The perioperative period induces unpredictable and significant alterations in coronary plaque characteristics which may culminate as adverse cardiovascular events in background of a compromised myocardial oxygen supply and demand balance. This “ischemic-imbalance” provides a substrate for perioperative cardiac adversities which incur a considerable morbidity and mortality. The propensity of myocardial injury is dictated by the conglomeration of various factors like pre-existing medical condition, high-risk surgical interventions, intraoperative hemodynamic management, and the postoperative care. Perioperative myocardial infarction (PMI) differs from myocardial infarction (MI) in a non-operative setting. PMI can often be notoriously “silent” demonstrating a conspicuous absence of the classic clinical symptoms. Moreover, myocardial injury following non-cardiac surgery (MINS) characterized by an elevation of the cardiac insult biomarkers has demonstrated an independent prognostic significance in the perioperative scenario despite the lack of a formal categorization as PMI. This has evoked interest in the meticulous characterization of MINS as a discrete clinical entity. Multifactorial etiology, varying symptomatology, close differential diagnosis, and a debatable management regime makes perioperative myocardial injury-infarction, a subject of detailed discussion.
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Affiliation(s)
- Rohan Magoon
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Neeti Makhija
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Devishree Das
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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8
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Kepler T, Kuusik K, Lepner U, Starkopf J, Zilmer M, Eha J, Vähi M, Kals J. Remote Ischaemic Preconditioning Attenuates Cardiac Biomarkers During Vascular Surgery: A Randomised Clinical Trial. Eur J Vasc Endovasc Surg 2019; 59:301-308. [PMID: 31870692 DOI: 10.1016/j.ejvs.2019.09.502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 09/06/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on preventing the leakage of cardiac damage biomarkers in patients undergoing vascular surgery. METHODS This is a randomised, sham-controlled, double-blinded, single-centre study. Patients undergoing open abdominal aortic aneurysm repair, surgical lower limb revascularisation surgery or carotid endarterectomy were recruited non-consecutively. The RIPC protocol consisting of 4 cycles of 5 minutes of ischaemia, followed by 5 minutes of reperfusion, was applied. A RIPC or a sham procedure was performed noninvasively along with preparation for anaesthesia. High sensitivity troponin T level was measured preoperatively and 2, 8 and 24 hours after surgery and pro b-type natriuretic peptide was measured preoperatively and 24 hours after surgery. RESULTS There was significantly higher leakage of high sensitivity troponin T (peak change median 2 ng/L, IQR 0.9-6.2 ng/L vs 0.6 ng/L, IQR 0.7-2.1 ng/L, p = .0002) and pro b-type natriuretic peptide (change median 144 pg/mL, IQR 17-318 pg/mL vs 51 pg/mL, IQR 12-196 pg/mL, p = .02) in the sham group compared to the RIPC group. CONCLUSION RIPC reduces the leakage of high sensitivity troponin T and pro b-type natriuretic peptide. Therefore, it may offer cardioprotection in patients undergoing non-cardiac vascular surgery. The clinical significance of RIPC has to be evaluated in larger studies excluding the factors known to influence its effect.
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Affiliation(s)
- Teele Kepler
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Department of Biochemistry, Institute of Biomedicine and Translational Medicine, Centre of Excellence for Genomics and Translational Medicine, University of Tartu, Tartu, Estonia.
| | - Karl Kuusik
- Department of Biochemistry, Institute of Biomedicine and Translational Medicine, Centre of Excellence for Genomics and Translational Medicine, University of Tartu, Tartu, Estonia; Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Urmas Lepner
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Tartu University Hospital, Tartu, Estonia
| | - Joel Starkopf
- Tartu University Hospital, Tartu, Estonia; Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Mihkel Zilmer
- Department of Biochemistry, Institute of Biomedicine and Translational Medicine, Centre of Excellence for Genomics and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Jaan Eha
- Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Tartu University Hospital, Tartu, Estonia
| | - Mare Vähi
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
| | - Jaak Kals
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Department of Biochemistry, Institute of Biomedicine and Translational Medicine, Centre of Excellence for Genomics and Translational Medicine, University of Tartu, Tartu, Estonia; Tartu University Hospital, Tartu, Estonia
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9
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Prognostic effect of troponin elevation in patients undergoing carotid endarterectomy with regional anesthesia – A prospective study. Int J Surg 2019; 71:66-71. [DOI: 10.1016/j.ijsu.2019.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 09/07/2019] [Accepted: 09/16/2019] [Indexed: 01/21/2023]
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Kanchi M. Approach to Noncardiac Surgery in a Cardiac Patient: Do We Need to Modify? J Cardiothorac Vasc Anesth 2019; 33:3531-3534. [PMID: 31416677 DOI: 10.1053/j.jvca.2019.07.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/02/2019] [Accepted: 07/22/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Muralidhar Kanchi
- Narayana Institute of Cardiac Sciences, Narayana Hrudayalaya Health City, Bangalore, Karnataka, India
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11
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Prediction of postoperative myocardial infarction after suprainguinal bypass using the Vascular Quality Initiative Cardiac Risk Index. J Vasc Surg 2019; 69:1831-1839. [DOI: 10.1016/j.jvs.2018.08.195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/15/2018] [Indexed: 11/21/2022]
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12
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Barker EJ, Valentijn TM, Van De Luijtgaarden KM, Hoeks SE, Voute MT, Goncalves FB, Verhagen HJ, Stolker RJ. Type 2 Diabetes Mellitus, Independent of Insulin Use, is Associated with an Increased Risk of Cardiac Complications after Vascular Surgery. Anaesth Intensive Care 2019; 41:584-90. [DOI: 10.1177/0310057x1304100515] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- E. J. Barker
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Departments of Anesthesiology and Vascular Surgery
| | - T. M. Valentijn
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anaesthesiology
| | - K. M. Van De Luijtgaarden
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anaesthesiology
| | - S. E. Hoeks
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anaesthesiology
| | - M. T. Voute
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Vascular Surgery
| | - F. B. Goncalves
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Vascular Surgery
| | - H. J. Verhagen
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Vascular Surgery
| | - R. J. Stolker
- Departments of Anaesthesiology and Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anaesthesiology
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Chou J, Ma M, Gylys M, Seong J, Salvatierra N, Kim R, Jiang L, Barseghian A, Rinehart J. Preexisting Right Ventricular Dysfunction Is Associated With Higher Postoperative Cardiac Complications and Longer Hospital Stay in High-Risk Patients Undergoing Nonemergent Major Vascular Surgery. J Cardiothorac Vasc Anesth 2018; 33:1279-1286. [PMID: 30429063 DOI: 10.1053/j.jvca.2018.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate whether the presence of preexisting right ventricular (RV) dysfunction in high-risk patients undergoing nonemergent major vascular surgery is associated independently with higher incidents of postoperative cardiac complications and a longer length of hospital stay. DESIGN Retrospective chart review. SETTING Single-center university hospital setting. PARTICIPANTS The patient population consisted of those identified as American Society of Anesthesiologists classification III and above who had a preoperative echocardiogram within 1 year of undergoing nonemergent major vascular surgery between January 2010 and May 2017. MEASUREMENTS AND MAIN RESULTS After multivariate analyses, RV dysfunction (RVD) is associated independently with a higher incidence of postoperative major cardiac complications with an odds ratio = 6.3 (95% confidence interval [CI], 1.0-38.5; p = 0.046). In addition, patients with RVD had a 50% longer length of stay than those without RVD (incident rate ratio [95% CI], 1.5 [1.2-1.8]; p < 0.001). CONCLUSION In this retrospective study of high-risk patients undergoing major vascular surgery, RV dysfunction was associated independently with a higher incidence of postoperative major cardiovascular events and longer length of hospital stays. Based on current findings, the prognostic value of RVD extends beyond the cardiac surgical cohort. Knowledge in management of patients with RVD in the perioperative setting should be understood by all anesthesiologists. Of note, a future study with a larger sample size is needed to validate the current findings given the small sample size of this study.
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Affiliation(s)
- Jody Chou
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA.
| | - Michael Ma
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Maryte Gylys
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Jenny Seong
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Nicolas Salvatierra
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Robert Kim
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
| | - Luohua Jiang
- Department of Epidemiology, School of Medicine - University of California Irvine, Irvine, CA
| | - Ailin Barseghian
- Department of Interventional Cardiology, Internal Medicine - University of California Irvine Medical Center, Irvine, CA
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, CA
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14
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Juo YY, Mantha A, Ebrahimi R, Ziaeian B, Benharash P. Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults. JAMA Surg 2017; 152:e173360. [PMID: 28877308 DOI: 10.1001/jamasurg.2017.3360] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Advances in perioperative cardiac management and an increase in the number of endovascular procedures have made significant contributions to patients and postoperative myocardial infarction (POMI) risk following high-risk vascular procedures. Whether these changes have translated into real-world improvements in POMI incidence remain unknown. Objective To examine the temporal trends of myocardial infarction (MI) following high-risk vascular procedures. Design, Setting, and Participants A retrospective cohort study was performed using data collected from January 1, 2005, to December 31, 2013, in the American College of Surgeons National Surgery Quality Improvement Program database, to which participating hospitals across the United States report their preoperative, operative, and 30-day outcome data. A total of 90 303 adults who underwent a high-risk vascular procedure-open aortic surgery or infrainguinal bypass-during the study period were identified. Patients were divided into cohorts based on their year of operation, and their baseline cardiac risk factors and incidence of POMI were compared. Cases from 2005 to 2014 in the database were eligible for inclusion if one of their Current Procedural Terminology codes matched any of the operations identified as a high-risk vascular procedure. Data analysis took place from August 1, 2016, to November 15, 2016. Exposures The main exposure was the year of the operation. Other variables of interest included demographics, comorbidities, and other risk factors for MI. Main Outcomes and Measures Primary outcome of interest was the incidence of POMI. Results Of the 90 303 patients included in the study, 22 836 (25.3%) had undergone open aortic surgery and 67 467 (74.7%) had had infrainguinal bypass. The open aortic cohort comprised 16 391 men (71.9%), had a mean (SD) age of 69.1 (11.5) years, and was predominantly white (18 440 patients [80.8%] self-identified as white race/ethnicity). The infrainguinal bypass cohort included 41 845 men (62.1%), had a mean (SD) age of 66.7 (11.7) years, and had 51 043 patients (75.7%) who self-identified as white race/ethnicity. During the study period, patients who underwent open aortic procedures were more likely to be classified as American Society of Anesthesiologists class IV (7426 patients [32.6%] vs 15 683 [23.3%] for the infrainguinal bypass cohort) or class V (1131 [5.0%] vs 206 [0.3%]; P < .001) and to undergo emergency procedures (4852 [21.3%] vs 4954 [7.3%]; P < .001). The open aortic procedure cohort also experienced significantly higher actual incidence of POMI (464 [3.0%] vs 1270 [1.9%]; P < .001). From 2009 to 2014, the incidence of POMI demonstrated no substantial temporal change (2.7% in 2009 to 3.1% in 2014; P = .64 for trend). Postoperative MI was consistently associated with poor prognosis, with a 3.62-fold (95% CI, 2.25-5.82) to 11.77-fold (95% CI, 6.10-22.72) increased odds of cardiac arrest and a 3.01-fold (95% CI, 2.08-4.36) to 6.66-fold (95% CI, 4.66-9.52) increased odds of mortality. Conclusions and Relevance The incidence of MI did not significantly decrease in the past decade and has been consistently associated with worse clinical outcomes. Further inquiry into why advanced perioperative care did not reduce cardiac complications is important to quality improvement efforts.
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Affiliation(s)
- Yen-Yi Juo
- Center for Advanced Surgical and Interventional Technology, UCLA (University of California, Los Angeles).,Department of Surgery, George Washington University, Washington, DC
| | - Aditya Mantha
- School of Medicine, University of California, Irvine
| | - Ramin Ebrahimi
- Department of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Peyman Benharash
- Center for Advanced Surgical and Interventional Technology, UCLA (University of California, Los Angeles).,Department of Surgery, UCLA
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15
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Beta-blockers in vascular surgery patients: is the debate still going on? J Anesth 2016; 30:1031-1036. [DOI: 10.1007/s00540-016-2232-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 08/05/2016] [Indexed: 12/27/2022]
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16
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Thomas KN, Cotter JD, Williams MJA, van Rij AM. Diagnosis, Incidence, and Clinical Implications of Perioperative Myocardial Injury in Vascular Surgery. Vasc Endovascular Surg 2016; 50:247-55. [DOI: 10.1177/1538574416637441] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Introduction: Routine measurement of cardiac biomarkers such as troponin T (TnT) is recommended perioperatively, especially in high-risk vascular surgery. Long-term prognosis is worse even in those with nonspecific perioperative myocardial injury. However, a clear understanding of these biomarker profiles and how they should affect patient management is lacking. Methods: We examined the perioperative profile of high-sensitivity TnT (hsTnT) release in 85 patients undergoing elective major vascular surgery. Plasma hsTnT was measured preoperatively, at 6, 12, and 24 hours postoperatively, and then every 24 hours for a maximum of 5 days. Significant elevations in hsTnT with/without clinical indicators of ischemia were used to diagnose myocardial infarction or injury. Results: A high incidence of myocardial injury was evident (46% had elevated hsTnT); only 5% were associated with myocardial infarction, and 41% were due to myocardial injury. Conclusions: This study emphasizes the high incidence of perioperative myocardial injury and stress in vascular surgery as revealed by the use of the robust and very sensitive biomarker of myocardial damage, hsTnT. The high availability and swift development of increasingly sensitive assays allow detection of abnormal elevated hsTnT levels in a higher proportion of the population. Consequent challenges are the reduced specificity to separate acute events as well as to deduce the prognostic value of elevations due to confusing criteria; this is especially the case in a patient group with multiple comorbidities that affect hsTnT levels chronically.
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Affiliation(s)
- Kate N. Thomas
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - James D. Cotter
- School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - Michael J. A. Williams
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - André M. van Rij
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Thomas KN, Cotter JD, Williams MJA, van Rij AM. Repeated Episodes of Remote Ischemic Preconditioning for the Prevention of Myocardial Injury in Vascular Surgery. Vasc Endovascular Surg 2016; 50:140-6. [PMID: 27075990 DOI: 10.1177/1538574416639150] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Remote ischemic preconditioning (RIPC) involves the phenomenon whereby transient episodes of limb ischemia induced by cuff inflation provide cardioprotection. The effectiveness of RIPC in vascular surgery is uncertain. This randomized, controlled trial was designed to investigate the potential of two episodes of RIPC to provide myocardial protection in patients undergoing vascular surgery. DESIGN AND METHODS Patients undergoing an elective major vascular procedure (open abdominal aortic aneurysm (AAA) repair, endovascular aneurysm repair, and lower-limb bypass grafting) were randomized into RIPC group (n = 42) or control group (n = 43). Remote ischemic preconditioning consisted of three 5-minute cycles of upper limb cuff occlusion with 5-minutes of reperfusion between cycles, both 24 hours and immediately before surgery. Control patients received a similarly timed sham treatment. Cardiac high-sensitivity troponin T (hsTnT) concentration was measured in plasma at 6, 12, 24, and 48 hours post-surgery, and at 72, 96, and 120 hours in patients still in hospital. Perioperative clinical adverse events and readmissions within ∼12 months were recorded. RESULTS Myocardial injury was demonstrated perioperatively in 43% of RIPC patients and 49% of controls, as defined by a significant hsTnT elevation. These incidences were statistically equivalent (odds ratio 0.79, 95% confidence interval 0.33-1.85, P = .58). The 48-hour area under the curve for hsTnT change from baseline also revealed no difference (RIPC vs control median: 5.3 vs 7.5 ng/L.h, P = .22). Each group had one type I and one type II myocardial infarction and no difference in complications or readmissions. CONCLUSIONS This trial could not confirm that two episodes of RIPC reduce myocardial injury following vascular surgery. Along with other equivocal studies, it appears that RIPC does not induce a clear benefit in vascular surgery.
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Affiliation(s)
- Kate N Thomas
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - James D Cotter
- School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
| | - Michael J A Williams
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - André M van Rij
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Benetis R, Kavaliauskiene Z, Antusevas A, Kaupas RS, Inciura D, Kinduris S. Comparison of results of endovascular stenting and bypass grafting for TransAtlantic Inter-Society (TASC II) type B, C and D iliac occlusive disease. Arch Med Sci 2016; 12:353-9. [PMID: 27186180 PMCID: PMC4848365 DOI: 10.5114/aoms.2016.59261] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 07/19/2014] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION The priority use of endovascular techniques in the management of aortoiliac occlusive disease has increased in the last decade. The aim of the present article is to report 1- and 2-year results of iliac artery stenting (IAS) and aortoiliac grafting in the management of patients with TASC II type B, C and D iliac lesions and chronic limb ischaemia. MATERIAL AND METHODS In this prospective, non-randomised, one-centre clinical study, iliac artery stents and vascular grafts used for the treatment of patients with symptomatic lesions in the iliac artery were evaluated. This study enrolled 2 groups: 54 patients in the stent group and 47 patient in the surgery group. RESULTS The primary patency rates at 1 and 2 years were 83% and 79.9% after IAS and 97.1% and 97.1% after surgical reconstruction, respectively (p = 0.015). The assisted primary stent patency at 1 and 2 years was 87.9% and 78.2%, respectively. The complication rate was 7.4% in the stent group and 6.3% in the surgery group. There was no perioperative mortality in either group. CONCLUSIONS Our results reveal that patients with severe aortoiliac occlusive disease (TASC II types B, C and D) can be treated with IAS or surgically with satisfactory results. Iliac artery stenting is associated with decreased primary patency compared with the surgery group. Iliac artery stenting should be considered with priority in elderly patients or in patients with severe comorbidities.
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Affiliation(s)
- Rimantas Benetis
- Clinic of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, Lithuania; Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Zana Kavaliauskiene
- Clinic of Cardiothoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Aleksandras Antusevas
- Clinic of Cardiothoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rytis Stasys Kaupas
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Donatas Inciura
- Clinic of Cardiothoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Sarunas Kinduris
- Clinic of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, Lithuania; Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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19
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Yang B, Fung A, Pac-Soo C, Ma D. Vascular surgery-related organ injury and protective strategies: update and future prospects. Br J Anaesth 2016; 117:ii32-ii43. [DOI: 10.1093/bja/aew211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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20
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Boulanger M, Camelière L, Felgueiras R, Berger L, Rerkasem K, Rothwell PM, Touzé E. Periprocedural Myocardial Infarction After Carotid Endarterectomy and Stenting. Stroke 2015; 46:2843-8. [DOI: 10.1161/strokeaha.115.010052] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/21/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Marion Boulanger
- From the Service de Neurologie (M.B., E.T.), and Service de Chirurgie Vasculaire (L.C., L.B.), CHU Côte de Nacre, Université de Caen Basse Normandie, Caen, France; Neurology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal (R.F.); Department of Surgery, Faculty of Medicine and Research Institute for Health Science, Chiang Mai University, Chiang Mai, Thailand (K.R.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford,
| | - Lucie Camelière
- From the Service de Neurologie (M.B., E.T.), and Service de Chirurgie Vasculaire (L.C., L.B.), CHU Côte de Nacre, Université de Caen Basse Normandie, Caen, France; Neurology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal (R.F.); Department of Surgery, Faculty of Medicine and Research Institute for Health Science, Chiang Mai University, Chiang Mai, Thailand (K.R.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford,
| | - Rui Felgueiras
- From the Service de Neurologie (M.B., E.T.), and Service de Chirurgie Vasculaire (L.C., L.B.), CHU Côte de Nacre, Université de Caen Basse Normandie, Caen, France; Neurology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal (R.F.); Department of Surgery, Faculty of Medicine and Research Institute for Health Science, Chiang Mai University, Chiang Mai, Thailand (K.R.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford,
| | - Ludovic Berger
- From the Service de Neurologie (M.B., E.T.), and Service de Chirurgie Vasculaire (L.C., L.B.), CHU Côte de Nacre, Université de Caen Basse Normandie, Caen, France; Neurology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal (R.F.); Department of Surgery, Faculty of Medicine and Research Institute for Health Science, Chiang Mai University, Chiang Mai, Thailand (K.R.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford,
| | - Kittipan Rerkasem
- From the Service de Neurologie (M.B., E.T.), and Service de Chirurgie Vasculaire (L.C., L.B.), CHU Côte de Nacre, Université de Caen Basse Normandie, Caen, France; Neurology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal (R.F.); Department of Surgery, Faculty of Medicine and Research Institute for Health Science, Chiang Mai University, Chiang Mai, Thailand (K.R.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford,
| | - Peter M. Rothwell
- From the Service de Neurologie (M.B., E.T.), and Service de Chirurgie Vasculaire (L.C., L.B.), CHU Côte de Nacre, Université de Caen Basse Normandie, Caen, France; Neurology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal (R.F.); Department of Surgery, Faculty of Medicine and Research Institute for Health Science, Chiang Mai University, Chiang Mai, Thailand (K.R.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford,
| | - Emmanuel Touzé
- From the Service de Neurologie (M.B., E.T.), and Service de Chirurgie Vasculaire (L.C., L.B.), CHU Côte de Nacre, Université de Caen Basse Normandie, Caen, France; Neurology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal (R.F.); Department of Surgery, Faculty of Medicine and Research Institute for Health Science, Chiang Mai University, Chiang Mai, Thailand (K.R.); Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford,
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21
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Kufner S, Cassese S, Groha P, Byrne RA, Schunkert H, Kastrati A, Ott I, Fusaro M. Covered stents for endovascular repair of iatrogenic injuries of iliac and femoral arteries. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:156-62. [PMID: 25770666 DOI: 10.1016/j.carrev.2015.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 02/23/2015] [Accepted: 02/26/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND The growing number of complex endovascular procedures is expected to increase the risk of iatrogenic injuries of peripheral arteries. A strategy of percutaneous transluminal angioplasty (PTA) with covered stent (CS) may represent a valuable alternative to open surgery. However, systematic evaluations of CS in this setting represent a scientific gap. In the present study, we investigate the procedural and clinical outcomes associated with PTA and CS implantation to repair iatrogenic injuries of peripheral arteries. METHODS All patients undergoing PTA with CS for endovascular repair of iatrogenic injuries of peripheral arteries between August 2010 and July 2013 at our Institution were retrospectively analyzed. The primary endpoint was the technical success. Secondary endpoints were in-hospital mortality and cumulative death, target lesion revascularization (TLR), amputation and major stroke at 12-month follow-up. RESULTS During the period of observation, a total of 30 patients underwent PTA with either self-expandable (43.3%) or balloon-expandable CS (56.7%) for iatrogenic injuries of peripheral arteries. Injuries consisted of perforation/rupture (76.7%), arteriovenous fistula (16.7%) and pseudoaneurysm (6.7%) of iliac-femoral arteries. Technical success was achieved in all cases. Median follow-up was 409days [210-907]. The incidence of in-hospital mortality was 10.0%. At 12-month follow-up, the incidence of death, TLR, amputation and major stroke was 20.0%, 17.0%, 3.3% and 6.7%, respectively. CONCLUSION The use of covered stents for endovascular repair of iatrogenic injuries of peripheral arteries shows a high technical success and may be alternative to surgery. Further studies with larger populations are needed to confirm these preliminary findings.
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Affiliation(s)
- Sebastian Kufner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Philipp Groha
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Ilka Ott
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Massimiliano Fusaro
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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22
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Galyfos G, Tsioufis C, Theodorou D, Katsaragakis S, Zografos G, Filis K. Predictive Role of Stress Echocardiography before Carotid Endarterectomy in Patients with Coronary Artery Disease. Echocardiography 2014; 32:1087-93. [DOI: 10.1111/echo.12826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- George Galyfos
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Constantinos Tsioufis
- First Department of Cardiology; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Dimitris Theodorou
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Stilianos Katsaragakis
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Georgios Zografos
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
| | - Konstantinos Filis
- First Department of Propaedeutic Surgery; University of Athens Medical School; Hippocration Hospital; Athens Greece
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Falkensammer J, Frech A, Duschek N, Gasteiger S, Stojakovic T, Scharnagl H, Huber K, Fraedrich G, Greiner A. Prognostic relevance of ischemia-modified albumin and NT-proBNP in patients with peripheral arterial occlusive disease. Clin Chim Acta 2014; 438:255-60. [PMID: 25195005 DOI: 10.1016/j.cca.2014.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 08/25/2014] [Accepted: 08/25/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular morbidity is high among patients with peripheral arterial occlusive disease (PAOD). The aim of this study was to evaluate the ability of ischemia-modified albumin (IMA), N-terminal proBNP (NT-proBNP), and high-sensitive cardiac Troponin T (hs-cTnT) to predict cardiovascular complications in male patients with Fontaine stage II PAOD. METHODS 68 men with stage II PAOD underwent treadmill testing. NT-proBNP, IMA and hs-cTnT were measured before and after exercise. Patients were followed up prospectively and complete follow-up data were available for 66 individuals. RESULTS Median follow-up time was 43.0months. 12 (18.2%) patients had suffered from a major adverse cardiac event (MACE). IMA and NT-proBNP baseline concentrations were significantly higher in patients who developed MACE during follow-up: IMA: 110.6±2.4kU/L vs. 102.5±0.9kU/L (p<0.001); NT-proBNP: 270.5±295.9ng/L vs. 84.6±15.4ng/L (p=0.007). In multivariable regression models only IMA was significantly associated with the primary endpoint (HR=1.07, CI 1.01-1.13; p=0.029). CONCLUSION In the present study, a serum concentration of >103.9kU/L of IMA was a better independent predictor of MACE than NT-proBNP or hs-cTnT. IMA might be a valuable tool for risk stratification in PAOD patients.
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Affiliation(s)
- Jürgen Falkensammer
- Department of Vascular and Endovascular Surgery, Wilhelminen hospital, Vienna, Austria; Department of Vascular Surgery, Medical University Innsbruck, Austria.
| | - Andreas Frech
- Department of Vascular Surgery, Medical University Innsbruck, Austria
| | - Nikolaus Duschek
- Department of Vascular and Endovascular Surgery, Wilhelminen hospital, Vienna, Austria
| | - Simon Gasteiger
- Department of Vascular Surgery, Medical University Innsbruck, Austria
| | - Tatjana Stojakovic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria
| | - Hubert Scharnagl
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria
| | - Kurt Huber
- 3rd Medical Department, Cardiology, Wilhelminen hospital, Vienna, Austria
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University Innsbruck, Austria
| | - Andreas Greiner
- Department of Vascular Surgery, Medical University Innsbruck, Austria; Department of Vascular Surgery, University Hospital Aachen, Germany
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Combined Use of High-sensitivity C-Reactive Protein and N-Terminal Pro-B-type Natriuretic Peptide for Risk Stratification of Vascular Surgery Patients. Ann Vasc Surg 2014; 28:1522-9. [DOI: 10.1016/j.avsg.2014.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/05/2013] [Accepted: 01/09/2014] [Indexed: 12/31/2022]
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25
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Cardiac damage after carotid intervention: a meta-analysis after a decade of randomized trials. J Anesth 2014; 28:866-72. [DOI: 10.1007/s00540-014-1843-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
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26
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Lins EM, Barros JW, Appolonio F, Anacleto E, Lima EC. Acute myocardial infarctation in patients with critical ischemia underwent lower limb revascularization. J Vasc Bras 2013. [DOI: 10.1590/jvb.2013.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND: Atherosclerosis is the main cause of peripheral artery occlusive disease (PAOD) of the lower limbs. Patients with PAOD often also have obstructive atherosclerosis in other arterial sites, mainly the coronary arteries. This means that patients who undergo infrainguinal bypass to treat critical ischemia have a higher risk of AMI. There are, however, few reports in the literature that have assessed this risk properly. OBJECTIVE: The aim of this study was to determine the incidence of acute myocardial infarction in patients who underwent infrainguinal bypass to treat critical ischemia of the lower limbs caused by PAOD. MATERIAL AND METHODS: A total of 64 patients who underwent 82 infrainguinal bypass operations, from February 2011 to July 2012 were studied. All patients had electrocardiograms and troponin I blood assays during the postoperative period (within 72 hours). RESULTS: There were abnormal ECG findings and elevated blood troponin I levels suggestive of AMI in five (6%) of the 82 operations performed. All five had conventional surgery. The incidence of AMI as a proportion of the 52 conventional surgery cases was 9.6%. Two patients died. CONCLUSION: There was a 6% AMI incidence among patients who underwent infrainguinal bypass due to PAOD. Considering only cases operated using conventional surgery, the incidence of AMI was 9.6%.
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Clerico A, Passino C, Emdin M. Surgery casualties: do not leave hearts behind enemy lines. J Am Coll Cardiol 2013; 63:181-3. [PMID: 24076286 DOI: 10.1016/j.jacc.2013.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 09/05/2013] [Indexed: 01/27/2023]
Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy.
| | - Claudio Passino
- Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
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Galyfos G, Sigala F, Tsioufis K, Bakoyiannis C, Lagoudiannakis E, Manouras A, Zografos G, Filis K. Postoperative Cardiac Damage After Standardized Carotid Endarterectomy Procedures in Low- and High-Risk Patients. Ann Vasc Surg 2013; 27:433-40. [DOI: 10.1016/j.avsg.2012.06.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 06/03/2012] [Accepted: 06/14/2012] [Indexed: 10/26/2022]
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Kouvelos GN, Arnaoutoglou EM, Matsagkas MI, Kostara C, Gartzonika C, Bairaktari ET, Milionis HJ. Effects of Rosuvastatin With or Without Ezetimibe on Clinical Outcomes in Patients Undergoing Elective Vascular Surgery. J Cardiovasc Pharmacol Ther 2012; 18:5-12. [DOI: 10.1177/1074248412445506] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Cardiovascular complications represent a major cause of morbidity and mortality in patients undergoing vascular surgery. This was a prospective randomized, open-label study to investigate the effect of lipid-lowering treatment by statin monotherapy or intensified by combining statin with ezetimibe on a 12-month prognosis after vascular surgery. Methods: Patients were randomly assigned to receive rosuvastatin (RSV) 10 mg/d or rosuvastatin 10 mg/d plus ezetemibe (RSV/EZT) 10 mg/d, starting prior to scheduled surgical procedure. The primary end point was the first major cardiovascular event, including death from cardiac causes, nonfatal myocardial infarction, ischemic stroke, and unstable angina. Results: A total of 136 patients assigned to RSV and 126 to RSV/EZT completed the study protocol. As many as 6.6% of patients in the RSV group experience a major cardiovascular event within 30 days after surgery versus 5.6% in the RSV/EZT group ( P = .72). From month 1 to 12 of the follow-up period, primary end point was observed (9 taking RSV vs 2 in the RSV/EZT group [ P = .04]). Intensified lipid-lowering therapy with RSV/EZT was associated with a greater decrease in low-density lipoprotein cholesterol levels compared with RSV (75.87 ± 31.64 vs 87.19 ± 31.7, P = .004), while no differential effect on triglyceride, high-density lipoprotein cholesterol or high-sensitivity C-reactive protein levels was noted between groups. Conclusion: Our findings indicate that statin therapy intensified by ezetimibe may reduce the incidence of cardiovascular events within the first 12 months after vascular surgery. Nonetheless, whether the use of ezetimibe as an add-on therapy to reduce cardiovascular risk in these patients needs to be tested in larger future studies.
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Affiliation(s)
- George N. Kouvelos
- Department of Surgery–Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Eleni M. Arnaoutoglou
- Department of Anesthesiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Miltiadis I. Matsagkas
- Department of Surgery–Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Christina Kostara
- Department of Laboratory of Clinical Chemistry, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Constantina Gartzonika
- Department of Microbiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Eleni T. Bairaktari
- Department of Laboratory of Clinical Chemistry, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Haralampos J. Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Bassuoni AS, Amr YM. Cardioprotective effect of sevoflurane in patients with coronary artery disease undergoing vascular surgery. Saudi J Anaesth 2012; 6:125-30. [PMID: 22754437 PMCID: PMC3385253 DOI: 10.4103/1658-354x.97024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The present study was conducted to evaluate the cardioprotective effect of sevoflurane compared with propofol in patients with coronary artery disease (CAD) undergoing peripheral vascular surgery; and to address the question whether a volatile anesthetic might improve cardiac outcome in these patients. METHODS One hundred twenty-six patients scheduled for elective peripheral vascular surgery were prospectively randomized to receive either sevoflurane inhalation anesthesia or total intravenous anesthesia. ST-segment monitoring was performed continuously during intra- and post-operative 48 h periods. The number of ischemic events and the cumulative duration of ischemia in each patient were recorded. Blood was sampled in all patients for the determination of cTnI. Samples were obtained before the induction of anesthesia, on admission to the ICU, and at 6, 12, 24, and 48 h after admission to the intensive care unit (ICU). Patients were followed-up during their hospital stay for any adverse cardiac events. RESULTS The incidence of ischemia were comparable among the groups [16 (25%) patients in sevoflurane group vs 24 (39%) patients in propofol group; P=0.126]. Duration, cumulative duration, and magnitude of ST-segment depression of ischemic events in each patient were significantly less in sevoflurane group (P=0.008, 0.048, 0.038, respectively). cTnI levels of the overall population were significantly less in sevoflurane group vs propofol group (P values <0.0001) from 6 h postoperative and onward. Meanwhile, cTnI levels at 6, 12, 24, and 48 h after admission to the ICU in patients who presented with ischemic electrocardiographic (ECG) changes were significantly lower in sevoflurane group than in the propofol group (P<0.0001, <0.0001, <0.0001, 0.0003). None of the patients presented with unstable angina, myocardial infarction, congestive heart failure, or serious arrhythmia either during ICU or hospital stay. CONCLUSION Patients with CAD receiving sevoflurane for peripheral vascular surgery had significantly lower release of cardiac troponin I at 6 h postoperatively and lasting for 48 h than patients receiving propofol for the same procedure with significant decrease in duration, cumulative duration of ischemic events, and degree of ST depression in each patient.
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Affiliation(s)
- Ahmed S. Bassuoni
- Department of Anesthesia and Intensive Care, Tanta University, Egypt
| | - Yasser M. Amr
- Department of Anesthesia and Intensive Care, Tanta University, Egypt
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Bakker E, Ravensbergen N, Voute M, Hoeks S, Chonchol M, Klimek M, Poldermans D. A Randomised Study of Perioperative Esmolol Infusion for Haemodynamic Stability during Major Vascular Surgery; Rationale and Design of DECREASE-XIII. Eur J Vasc Endovasc Surg 2011; 42:317-23. [DOI: 10.1016/j.ejvs.2011.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 05/03/2011] [Indexed: 10/18/2022]
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Scrutinio D, Passantino A, Di Serio F, Angiletta D, Santoro D, Regina G. High-sensitivity C-reactive protein predicts cardiovascular events and myocardial damage after vascular surgery. J Vasc Surg 2011; 54:474-9. [PMID: 21458205 DOI: 10.1016/j.jvs.2011.01.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/12/2011] [Accepted: 01/15/2011] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the association of high-sensitivity C-reactive protein (hsCRP) to adverse cardiovascular events and perioperative myocardial damage in patients after elective vascular surgery. METHODS This was a prospective observational study in a tertiary-care teaching hospital, with 239 patients undergoing elective vascular surgery. The receiver-operating characteristic (ROC) curve was calculated to assess the optimal cut-off value of hsCRP. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Multiple logistic regression analysis was used to identify the predictors of the primary outcome. The primary outcome was a composite of periprocedural myocardial damage, defined as cardiac troponin I (cTn-I) elevation above the decision limit of 0.15 μg/L, death, acute coronary syndrome, stroke, acute heart failure, or intrastent thrombosis within 30 days of surgery. RESULTS On ROC analysis, the optimal cut-off value of hsCRP was 3.2 mg/L. The primary outcome occurred in 48 patients (20.1%). On univariate analysis, smoking (P = .009), known hypercholesterolemia (P = .01), previous ischemic heart disease (P = .0003), open surgery (P = .03), and hsCRP levels (P < .0001) were associated with the primary outcome. On multiple logistic regression analysis, only hsCRP was independently associated with the primary outcome. The unadjusted and adjusted ORs for the primary outcome among patients with hsCRP levels >3.2 mg/L were 7.5 (CI, 3.7-15.2; P < .0001) and 4.6 (CI, 2.1-9.9; P = .0001), respectively. CONCLUSION Our data suggest that higher levels of hsCRP are independently associated with an increased risk of perioperative myocardial damage and early adverse cardiovascular events in patients undergoing elective vascular surgery. This may have implications for risk stratification and therapeutic approach.
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Affiliation(s)
- Domenico Scrutinio
- Division of Cardiology and Cardiac Rehabilitation, S. Maugeri Foundation, Institute of Cassano Murge, Bari, Italy.
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van Kuijk JP, Voute MT, Flu WJ, Schouten O, Chonchol M, Hoeks SE, Boersma EE, Verhagen HJ, Bax JJ, Poldermans D. The efficacy and safety of clopidogrel in vascular surgery patients with immediate postoperative asymptomatic troponin T release for the prevention of late cardiac events: Rationale and design of the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo-VII (DECREASE-VII) trial. Am Heart J 2010; 160:387-93. [PMID: 20826244 DOI: 10.1016/j.ahj.2010.06.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 06/24/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Major vascular surgery patients are at high risk for developing asymptomatic perioperative myocardial ischemia reflected by a postoperative troponin release without the presence of chest pain or electrocardiographic abnormalities. Long-term prognosis is severely compromised and characterized by an increased risk of long-term mortality and cardiovascular events. Current guidelines on perioperative care recommend single antiplatelet therapy with aspirin as prophylaxis for cardiovascular events. However, as perioperative surgical stress results in a prolonged hypercoagulable state, the postoperative addition of clopidogrel to aspirin within 7 days after perioperative asymptomatic cardiac ischemia could provide improved effective prevention for cardiovascular events. STUDY DESIGN DECREASE-VII is a phase III, randomized, double-blind, placebo-controlled, multicenter clinical trial designed to evaluate the efficacy and safety of early postoperative dual antiplatelet therapy (aspirin and clopidogrel) for the prevention of cardiovascular events after major vascular surgery. Eligible patients undergoing a major vascular surgery (abdominal aorta or lower extremity vascular surgery) who developed perioperative asymptomatic troponin release are randomized 1:1 to clopidogrel or placebo (300-mg loading dose, followed by 75 mg daily) in addition to standard medical treatment with aspirin. The primary efficacy end point is the composite of cardiovascular death, stroke, or severe ischemia of the coronary or peripheral arterial circulation leading to an intervention. The evaluation of long-term safety includes bleeding defined by TIMI criteria. Recruitment began early 2010. The trial will continue until 750 patients are included and followed for at least 12 months. SUMMARY DECREASE-VII is evaluating whether early postoperative dual antiplatelet therapy for patients developing asymptomatic cardiac ischemia after vascular surgery reduces cardiovascular events with a favorable safety profile.
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