Intensive care of the patient following open abdominal aortic surgery

Prognostic value of extended cardiac risk assessment before elective open abdominal aortic surgery

BACKGROUND

Major vascular surgery is associated with a high perioperative risk and significant mortality. Despite advances in risk stratification, monitoring, and management of perioperative complications, cardiac complications are still common. Stress echocardiography is well established in coronary artery disease diagnostics; however, its prognostic value before high-risk aortic surgery is unknown. This prospective, single-center study compared the outcome of patients undergoing extended cardiac risk assessment before open abdominal aortic surgery with the outcome of patients who had received standard preoperative assessment.

METHODS

The study included patients undergoing elective open abdominal aortic surgery. Patients who underwent standard preoperative assessment before the start of a dedicated protocol were compared with patients who had extended cardiac risk assessment, including dobutamine stress echocardiography, as part of a stepwise interdisciplinary cardiovascular team approach. The combined primary endpoint was cardiovascular death, myocardial infarction, emergency coronary revascularization, and life-threatening arrhythmia within 30 days. The secondary endpoint was acute renal failure and severe bleeding.

RESULTS

In total, 77 patients (mean age 68.1 ± 8.1 years, 70% male) were included: 39 underwent standard and 38 underwent cardiac risk assessment. The combined primary endpoint was reached significantly more often in patients before than after implementation of the extended cardiac stratification procedure (15% vs. 0%, p = 0.025). The combined secondary endpoint did not differ between the groups.

CONCLUSIONS

Patients with extended cardiac risk assessment undergoing elective open abdominal aortic surgery had better 30-day outcomes than did those who had standard preoperative assessment.

Editor's Choice - Trend-break in Abdominal Aortic Aneurysm Repair With Decreasing Surgical Workload

BACKGROUND

The epidemiology and management of abdominal aortic aneurysms (AAAs) has changed drastically in the past decades, with implementation of nationwide screening programs, introduction of endovascular repair (EVAR), and reduced prevalence of the disease. This report aims to assess recent trends in AAA repair epidemiology in Sweden in this context.

METHODS

Primary AAA repairs registered in the nationwide Swedish Vascular Registry (Swedvasc) 1994-2014 were analyzed regarding patient characteristics, repair incidence, technique, and outcome. Four time periods were compared: 1994-1999, 2000-2004, 2005-2009, and 2010-2014.

RESULT

The incidence of intact AAA repair increased (18.4/100,000 1994-1999, 27.3/100,000 2010-2014, p < .001) predominantly among octogenarians (12.7/100,000 1994-1999, 36.0/100,000 2010-2014, p < .001). The utilization of EVAR increased (58% of all intact AAA repairs 2010-2014), especially among octogenarians (80% 2010-2014). During the last time period, however, the incidence of intact AAA repair stabilized, despite an increasing number of screening-detected AAAs operated on (19% in 2010-2014). Short- and long-term outcome after intact AAA repair continued to improve, most pronounced among octogenarians (30-day mortality 9% 1994-1999, 2% 2010-2014, p < .001). The incidence of ruptured AAA repair steadily decreased (9.2/100,000 1994-1999, 6.9/100,000 2010-2014, p < .001) and the use of EVAR for ruptures increased (30% in 2010-2014). The previously observed improvement of short- and long-term outcome after ruptured AAA repair (30-day mortality 38% 1994-1999, 28% 2010-2014, p < .001) stalled during the last time period. The overall 30-day mortality after ruptured AAA repair was 22% after EVAR versus 31% after open repair in 2010-2014. The corresponding mortality for octogenarians was 28% versus 42%.

CONCLUSIONS

For the first time, a halt in intact AAA repair workload could be identified. This trend-break occurred despite continued increase in treatment of octogenarians and screening-detected aneurysms. Additionally, the ruptured AAA repair incidence continued to decrease. These findings, together with the sustained improvement in survival after AAA repair, may have important impact on planning of vascular surgical services.

Editor's Choice - Abdominal Compartment Syndrome After Surgery for Abdominal Aortic Aneurysm: A Nationwide Population Based Study

OBJECTIVE/BACKGROUND

The understanding of abdominal compartment syndrome (ACS), and its importance for outcome, has increased over time. The aim was to investigate the incidence and clinical consequences of ACS after open (OR) and endovascular repair (EVAR) for ruptured and intact infrarenal abdominal aortic aneurysm (rAAA and iAAA, respectively).

METHODS

In 2008, ACS and decompression laparotomy (DL) were introduced as variables in the Swedish vascular registry (Swedvasc), offering an opportunity to study this complication in a prospective, population based design. Operations carried out in the period 2008-13 were analysed. Of 6,612 operations, 1,341 (20.3%) were for rAAA (72.0% OR) and 5,271 (79.7%) for iAAA (41.9% OR). In all, 3,171 (48.0%) were operated on by OR and 3,441 by EVAR. Prophylactic open abdomen (OA) treatment was validated through case records. Cross-matching with the national population registry secured valid mortality data.

RESULTS

After rAAA repair, ACS developed in 6.8% after OR versus 6.9% after EVAR (p = 1.0). All major complications were more common after ACS (p < .001). Prophylactic OA was performed in 10.7% of patients after OR. For ACS, DL was performed in 77.3% after OR and 84.6% after EVAR (p = .433). The 30 day mortality rate was 42.4% with ACS and 23.5% without ACS (p < .001); at 1 year it was 50.7% versus 31.8% (p < .001). After iAAA repair, ACS developed in 1.6% of patients after OR versus 0.5% after EVAR (p < .001). Among those with ACS, DL was performed in 68.6% after OR and in 25.0% after EVAR (p = .006). Thirty day mortality was 11.5% with ACS versus 1.8% without it (p < .001); at 1 year it was 27.5% versus 6.3% (p < .001). When ACS developed, renal failure, multiple organ failure, intestinal ischaemia, and prolonged intensive care were much more frequent (p < .001). Morbidity and mortality were similar, regardless of primary surgical technique (OR/EVAR/iAAA/rAAA).

CONCLUSION

ACS and OA were common after treatment for rAAA. ACS is a devastating complication after surgery for rAAA and iAAA, irrespective of operative technique, emphasizing the importance of prevention.

Hypoxia-induced inflammation and purinergic signaling in cross clamping the human aorta

Open aortic surgery evokes a systemic inflammatory response and is associated with high morbidity and mortality. Purinergic signaling has been shown to be crucial for maintaining vascular integrity and attenuating inflammation related to hypoxia. The involvement of purinergic signaling in cross clamping of major human arteries is unknown. Our aim was to compare systemic inflammatory responses and hypoxia-induced purinergic signaling in patients undergoing either open infra-renal abdominal aortic repair or infra-inguinal revascularization. Pre- and 24 h post-operative blood samples were gathered from 6 patients undergoing aortic clamping and 6 similar patients undergoing common femoral artery cross-clamping. Using Biorad Multipex™ 21- and 27-panels 48 different cytokines, chemokines and growth factors were analyzed, in addition to circulating levels of ATP, ADP, CD39, CD73 and HIF-1α, and compared between the groups. Several inflammatory cytokines were elevated from baseline levels after aortic clamping, but not after femoral cross clamping. Most pronoun rises were seen in IL-6 (667 %, P = 0.016) and HGF (760 %, P = 0.016). HIF-1α values showed a steady increase after clamping of either artery unless the subject underwent blood transfusion. Despite an adequate increase in HIF-1α CD39 and CD73 activity decreased significantly after aortic clamping (P = 0.047 and P = 0.016, respectively). Aortic clamping is associated with a clear and strong systemic inflammatory response and impaired repair mechanisms in terms of purinergic signaling. Patients undergoing open aorta repair could benefit from pre-operative medical therapy, which enhances CD73 expression.

Clinical outcome of early relaparotomy after elective open repair of abdominal aortic aneurysms

Purpose

The aim of this study was to retrospectively evaluate the association of need for early relaparotomy with clinical outcomes after elective open repair of abdominal aortic aneurysms (AAAs).

Methods

A total of 292 consecutive patients who underwent elective open AAA repair at Asan Medical Center from January 2001 to December 2010 were included in this study, and we compared the demographics, clinical characteristics, related risk factors, and clinical outcomes of early relaparotomy versus nonrelaparotomy patients.

Results

The incidence of early relaparotomy during a single hospital stay was 4.1% (n = 12), and the most common causes were bowel ischemia (n = 5, 41.7%) and postoperative bleeding (n = 3, 25.0%). Among the demographics and clinical characteristics significantly associated with relaparotomy were: age (P = 0.025), chronic obstructive pulmonary disease (COPD) (P = 0.010), number of RBC units transfused during the AAA repair (P = 0.022) and in the following week (P = 0.005), and length of intensive care (P < 0.001) and overall hospital stay (P < 0.001). On multivariate analysis, presence of COPD (P = 0.009) and number of RBC units transfused during the AAA repair (P = 0.006) were statistically significantly associated with relaparotomy. Furthermore, early relaparotomy was associated with perioperative (within 30 days) (P = 0.048) and overall in-hospital mortality (P = 0.001).

Conclusion

Early relaparotomy has an adverse effect on clinical outcomes: increased mortality and hospital length of stay. Presence of COPD and need for RBC transfusion are associated with early relaparotomy.

Postoperative ICU management of vascular surgery patients

Critical care management of vascular surgical patients poses significant challenges owing to patients' comorbidities and the magnitude of the surgical procedures. The primary goals of the anesthesiologist and intensivist are reestablishing preoperative homeostasis, optimizing hemodynamics until return of normal organ function, and managing postoperative complications promptly and effectively. Postoperative critical care management demands a detailed knowledge of the various vascular surgical procedures and the potential postoperative complications. In this review, the authors describe the postoperative complications related to the major specific vascular surgical procedures and their perioperative management.

Changes in the management of infrarenal abdominal aortic aneurysm disease in Sweden

Background

Treatment of abdominal aortic aneurysm (AAA) has changed over time, with endovascular repair (EVAR) being the main technical revolution. This study assessed the effect of this change on outcome on a national basis over a 17-year interval.

Methods

Primary infrarenal AAA repairs in Swedish residents aged 50 years and older, in the Swedish Vascular Registry (Swedvasc) 1994–2010, were analysed. The rate per 100 000 population, patient characteristics, operative technique and outcome were assessed for the intervals 1994–1999, 2000–2005 and 2006–2010.

Results

Some 11 336 intact aneurysm repairs were performed. The overall rate per 100 000 increased (18·4 in 1994–1999, 19·4 in 2000–2005 and 24·0 in 2006–2010; P &lt; 0·001), most noticeably among older people (18 per cent increase among those aged 50–64 years, P = 0·004; 27 per cent in 65–79-year-olds, P &lt; 0·001; 128 per cent in those aged at least 80 years, P &lt; 0·001). The use of EVAR increased rapidly after 2005 (rate: 0·6 in 1994–1999, 4·4 in 2000–2005 and 11·8 in 2006–2010; P &lt; 0·001). The 30-day mortality rate decreased after open repair (4·7, 3·4 and 2·7 per cent respectively; P &lt; 0·001), but was stable after EVAR (2·6, 2·2 and 1·6 per cent; P = 0·227). Some 4972 ruptured aneurysm (rAAA) repairs were performed. The rate decreased after 2005 (9·3 in 1993–1999, 9·3 in 2000–2005 and 8·4 in 2006–2010; P = 0·006). The use of EVAR for rAAA increased over time (rate: 0, 0·5 and 1·6 respectively; P &lt; 0·001), whereas open repair decreased (9·3, 8·8 and 6·8; P &lt; 0·001). Thirty-day mortality decreased over time (38·3, 32·8 and 28·4 per cent; P &lt; 0·001).

Conclusion

The introduction of EVAR has been associated with an increased number of intact AAA repairs, which has accelerated recently, whereas the rate of rAAA repair has started to decline. Simultaneously, outcomes have improved.

Patients' experience of open repair of abdominal aortic aneurysm--preoperative information, hospital care and recovery

AIMS AND OBJECTIVES

The aim was to elucidate patients' lived experience of the care pathway of going through open surgery for abdominal aortic aneurysm.

BACKGROUND

Open surgical treatment has a great impact on patients' health-related quality of life both before and after treatment. The transition from being independent and asymptomatic to dependent on nursing care can be difficult. To facilitate this process and provide high-quality care, patients' needs must be better understood.

DESIGN

An exploratory descriptive design was chosen to describe and understand patients' lived experience.

METHOD

Audio-taped interviews were performed three months postoperatively, covering the care pathway before and after surgery. Interviews were analysed with qualitative content analysis.

RESULTS

The informants made a transition from becoming aware of the deadly risk associated with abdominal aortic aneurysm to gradually understanding the physical and emotional impact of the surgical procedure during the recovery process. The experience of not understanding fully the risks of undergoing surgery or its consequences on daily life made the informants unprepared for complications and limitations during the recovery period. Many concerns emerged, with a need for more dialogue and opportunities to understand their own care than those provided by the health care staff.

CONCLUSIONS

To facilitate the transition process, health care staff should consider patients' unpreparedness for the physical and emotional impact that can follow diagnosis and treatment for abdominal aortic aneurysm and recognise the need for dialogue to enhance participation during recovery.

RELEVANCE TO CLINICAL PRACTICE

Throughout the care pathway, patients' need for information and for opportunities to reflect on bodily and emotional reactions to the diagnosis and treatment of abdominal aortic aneurysm should be recognised by nurses and physicians to support patients getting realistic expectations of the consequences of treatment and facilitate participation in decisions concerning care and medical treatment.

Improved Long-Term Survival After Abdominal Aortic Aneurysm Repair

Background— Treatment of abdominal aortic aneurysm (AAA) has changed significantly over the past 2 decades. In this perspective, time trends in long-term survival were studied.

Methods and Results— We identified 8663 primary intact and 4171 ruptured AAA repairs in the Swedish Vascular Registry from 1987 to 2005. Mortality was obtained from the national population registry. Crude survival was analyzed, including all mortality. To analyze the long-term outcome among those surviving the AAA repair, relative survival, which denotes the survival rate of patients compared with that of the general population adjusted for age, sex, and calendar year, was calculated, excluding 90-day mortality. In a comparison of AAA repairs from 1987 to 1999 and 2000 to 2005, age (71.4 versus 72.5 years; P <0.001), patients with comorbidities (65.0% versus 68.5%; P <0.001), and endovascular repair (1.6% versus 17.0%; P <0.001) increased. After intact AAA repair, crude 5-year survival was 69.0% (99% confidence interval [CI], 67.7 to 70.4), and relative 5-year survival excluding 90-day mortality was 90.3% (99% CI, 88.6 to 92.0). Relative 5-year survival was better for those operated on from 2000 to 2005 compared with 1987 to 1999 (difference, 4.7%; 99% CI, 1.3 to 8.1), for men versus women (4.6%; 99% CI, 0.4 to 8.8), and for octogenarians versus patients <80 years of age (10.2%; 99% CI, 1.5 to 18.8); no difference was observed between open and endovascular repair (6.0%; 99% CI, −1.5 to 13.4). After ruptured AAA repair, crude 5-year survival was 41.7% (99% CI, 39.6 to 43.7) and relative 5-year survival was 87.1% (99% CI, 83.9 to 90.3). No significant differences in relative 5-year survival were observed between time periods, sex, or age groups.

Conclusions— Long-term survival improved over time after intact AAA repair despite a change in case mix toward older patients with more comorbidities. Long-term survival was stable after ruptured AAA repair.

The Value of a Nationwide Vascular Registry in Understanding Contemporary Time Trends of Abdominal Aortic Aneurysm Repair

Nationwide vascular registries offer rapid feed-back in an environment of fast new technical development, as is the case with the treatment of abdominal aortic aneurysm (AAA). Furthermore, they offer an opportunity to study non-selected, population-based data. The aim of this review was to analyze time-trends in published papers from nationwide registries on AAA-repair. In contrast to several US reports, an increased rate of intact AAA repair, associated with the introduction of endovascular repair, was reported in a recent publication based on the Swedish Vascular Registry (Swedvasc). The rate of ruptured abdominal aortic aneurysm (rAAA) repair is stable in most reports, while some report a decreasing incidence. Most nationwide studies report a reducing mortality over time after intact AAA repair, while time trends on the mortality after ruptured AAA repair are more heterogenic.

Outcome after abdominal aortic aneurysm repair in Sweden 1994–2005

Background

The aim was to study the epidemiology of abdominal aortic aneurysm (AAA) repair in Sweden.

Methods

Primary AAA repairs registered in the Swedish Vascular Registry between 1994 and 2005 were studied. Mortality data were obtained from the national population registry, and age- and sex-specific populations for each calendar year from Statistics Sweden.

Results

Some 10 691 primary AAA repairs were identified. In the population aged 60 years or over the incidence of intact AAA repair increased from 27·0 per 100 000 in 1994–1999 to 28·8 per 100 000 in 2000–2005 (P = 0·006), while the incidence of surgery for ruptured AAA (rAAA) remained stable (13·8 versus 14·1 per 100 000; P = 0·595). Open repair with a bifurcated graft decreased, whereas endovascular repair (EVAR) increased to 35·0 per cent of intact AAA and 10·3 per cent of rAAA procedures in 2005. Patients who had EVAR were older than those undergoing open repair (74·1 versus 71·9 years; P &lt; 0·001). The 30-day mortality rate decreased over time for intact and ruptured aneurysm operations (P = 0·001). Age, female sex and open repair (compared with EVAR) were independently associated with a higher 30-day mortality rate in a logistic regression model.

Conclusion

The introduction of EVAR was associated with an increasing incidence of intact AAA repair, whereas the rate of rAAA was stable. Perioperative mortality rates decreased over time.