Survival, Short And Long-Term Outcomes Of Open And Endovascular Surgical Repair Of Unruptured Infrarenal Abdominal Aortic Aneurysms

INTRODUCTION

Endovascular Aortic Repair (EVAR) has become the standard management of Unruptured Infrarenal Abdominal Aortic Aneurysm (UIAAA); however, current evidence is limited and uncertain in our environment compared to Open repair. Our study aimed to determine the survival, short and long-term outcomes of EVAR vs. Open in a Peruvian cohort of UIAAA.

METHODS

A single-center observational, analytical, longitudinal study using a retrospective registry of 251 patients treated (EVAR=205 vs Open=46) for UIAAA from 2000 to 2017. Variables considered were baseline, comorbidities, type of treatment, short-term (<30 days) and long-term (<5 years) outcomes, postoperative mortality according to the Vascular Quality Initiative (VQI) Risk Score, survival curves including reoperation-free rate and according to size (<65 mm vs. >65 mm) of long-term UIAAA. All variables were grouped according to the treatment performed (EVAR vs. Open) and we used the descriptive, multivariate, Cox regression, and Kaplan-Meier survival statistical analyses.

RESULTS

251 UIAAA were evaluated and the mean age was 74.5 years [±13.32], smoking, family members with UIAAA, and previous abdominal surgery were the main antecedents. Diabetes mellitus 2 was the main comorbidity; more than 50% of patients with UIAAA had diameters greater than 65 mm (p=0.021). The calculated mortality (VQI) was Open=2.21% vs. EVAR=1.65%. The outcomes in short-term were mortality (Open=2.92% vs. EVAR=0%; p=0.039), blood transfusion >4 Units (Open=72.68% vs. EVAR=17.39%; p=0.021) and overall hospital stay (Open=14 vs. EVAR=5 days; p=0.049. A reduction in mortality (HR 0.76, 95% CI, 0.62-0.96, p=0.045) and readmission for aneurysmal rupture was identified for EVAR (HR 0.81, 95% CI, 0.79-0.85, p=0.031). In long-term outcomes, mortality (Open=3.41% vs. EVAR=19.56%; p=0.047), aneurysmal rupture (Open=0% vs. EVAR 13.04%; p=0.032) and reinterventions (Open=2.43% vs. EVAR=10.86%; p=0.002). An 86% risk of mortality (HR 1.86, 95% CI, 1.32-2.38, p=0.039) and elevated risk of readmission for aneurysmal rupture was identified for EVAR (HR 2.21, 95% CI, 1.98-2.45, p=0.028). At 5 years, survival for Open=93.67% vs. EVAR=80.44% (p=0.043), reintervention-free survival for Open=89.26% vs. EVAR=47.82% (p=0.021), survival for treated IUAAA <65 mm for Open=95.77% vs. EVAR=63.63% (p=0.019) and >65 mm for Open=92.53% vs. EVAR=85.71% (p=0.059).

CONCLUSION

EVAR has shown better short-term benefits and survival than Open management; however, the latter still prevails in the long term in our Peruvian UIAAA cohort. Further follow-up studies are required to demonstrate the long-term benefit of EVAR in our population.

Analysis of congenital heart disease research: Mapping impact, production and global collaboration

Background

Congenital heart disease (CHD) is a severe childhood health problem worldwide. This study analyzes the scientific production on CHD published in Scopus during the last decade.

Methods

This study assessed the research on CHD conducted during the 2011-2020 period. Indexed publications were identified using a list of keywords consisting of MeSH (Medical Subject Heading) and Emtree (EMBASE) terms for the category "Congenital Heart Defects." The studies obtained were analyzed using the SciVal platform, and the production, impact, and collaboration indicators were considered. Additionally, an analysis of co-occurrence between countries and keywords was carried out with the VOSviewer software.

Results

The study found 8934 articles on CHD. A growing trend was observed during the last decade. The distribution of the scientific production at the international level shows that most publications are from the United States, China, and the United Kingdom, whereas Latin American countries have the lowest production. The articles analyzed contain a total of 89,835 citations. Most studies are published in high-impact journals (Q1), with 3273 studies corresponding to 39.3% of the total production analyzed. In the keyword analysis, we found five areas investigated.

Conclusions

Scientific production has shown sustained growth in the past years. Increased scientific production in specific research areas may have helped decrease morbimortality due to CHD.

[Atypical presentation of ruptured aneurysmal right sinus of Valsalva with severe aortic insufficiency]

Aneurysm of the Sinus of Valsalva (ASV) is a rare abnormality and affects less than 0.1% of the general population. We describe the case of a 37-year-old woman with a clinical picture characterized by dyspnea, palpitations, and syncope of 6 years of evolution. The echocardiographic study revealed a right ASV with a sub pulmonary interventricular perforation of 8mm and producing a regurgitant jet into the right ventricle, causing dilatation of the right ventricular outflow tract, pulmonary artery, and severe aortic insufficiency Carpentier DI. The patient underwent successful repair of the defect and interventricular perforation, and valve replacement was not necessary. Timely echocardiographic diagnosis and early surgery are the main predictors that make the difference between an excellent outcome and certain death.

Congenital Gerbode defect in an adult patient: report of an extremely rare case

Gerbode Defect (GD) is a rare congenital heart disease that mainly affects the upper portion of the membranous septum, generating a shunt between the left ventricle and the right atrium. Even though most cases are congenital, it has also been reported acquired cases due to cardiac surgery, infective endocarditis, acute ischemic heart disease, and invasive percutaneous procedures. The diagnostic workup includes the clinical evaluation and the echocardiographic study. Here, we present the case of a 43-year-old adult patient with an incidental finding of a congenital GD in the context of acute appendicitis. Imaging plays a role in the diagnostic workup of congenital diseases; in this case, it allowed us to identify more details and the decision-making for our patient.

Bentall surgery and total arch repair with debranching of supra-aortic vessels: a case report

Background

The surgical approach to pathologies of the Ascending Thoracic Aorta (ATA) that compromise aortic root and the aortic arch is currently one of the most complex interventions in the spectrum of cardiac surgery, where circulatory arrest with cerebral perfusion plays an important role for Success postoperative and patient survival.

Case presentation

We present the case of a 57-year-old patient with the only history of arterial hypertension and an ATA Aneurysm that compromised segment of the aortic root up to segment 2 of the aortic arch. A successful Bentall surgery was performed, debranching supra-aortic vessels with Total Circulatory Arrest with Deep Hypothermic Cerebral Perfusion-Antegrade Bilateral.

Conclusions

With the advent of new anesthetic and neuroprotection techniques, perioperative imaging protocols, advanced hemodynamic monitoring, and invaluable advances in perfusion and Extracorporeal Circulation with circulatory arrest, they have made this surgical challenge a valuable tool for today’s cardiovascular surgeon.

Ankle-brachial index: more than a diagnostic test?

The ankle-brachial index (ABI) is the relationship between the systolic blood pressure taken at the ankle level and the brachial artery. A pathological ABI (<0.90 or >1.40) indicates the presence of peripheral artery disease (PAD). Many studies indicate the great utility of this test in the diagnosis of PAD due to its ease of use, reproducibility, low cost, and high cost-effectiveness. This evaluation can be directly correlated with cardiovascular morbidity and mortality; however, it has recently been confirmed that a low ABI can be a predictor of major cardiovascular events, as it is related to diabetes mellitus, chronic coronary disease, stroke, and more. The objective of this work was to review the current evidence on the importance of ABI in the diagnosis of PAD and its main role as a predictor of cardiovascular morbidity and mortality.

Acute Limb Ischemia in a Peruvian Cohort Infected by COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) infection can cause alterations in the coagulation mechanism conditioning thrombotic phenomena such as acute limb ischemia (ALI) as the only manifestation of the infection. The aim of the study was to describe clinical and surgical characteristics of a group of patients infected with severe acute respiratory syndrome coronavirus 2 who presented ALI in the context of the COVID-19 pandemic at Lima, Peru.

METHODS

A multicenter, observational, and retrospective study was performed in six general hospitals, from March to July 2020. The variables considered were the pathological history and associated habits, laboratory tests, the severity of COVID-19 infection and ALI, the anatomic location of the lesion, treatment, evolution, and discharge conditions.

RESULTS

Thirty patients with ALI infected with COVID-19 were evaluated. Their mean age was 60 ± 15 years, the condition being more frequent in men (76.6%). The main comorbidities were arterial hypertension (33.3%), obesity (33.3%), and diabetes mellitus 2 (26.6%). There were 23.3% asymptomatic patients, and their only manifestation was ALI. Rutherford IIA and IIB stage included 93.2% of patients. The most frequent location of the thrombosis was the lower limbs (73.3% vs. 26.6%). Thrombectomy was performed in 76.6% of the patients, and amputation (primary and secondary) was performed in 30% of the patients. The mortality rate was 23.3%, all of it because of acute respiratory distress syndrome.

CONCLUSIONS

ALI is a vascular pathology associated with embolic and thrombotic processes. COVID-19 infection can cause severe alterations in coagulation mechanisms, leading some patients to present severe acute arterial complications such as thrombosis, as the only associated manifestation. We report a younger cohort than those described in other studies and with a high frequency of amputations despite adequate surgical treatment.

Survival and adequate preoperative staging in patients undergoing gastric cancer surgery at a Peruvian Police Hospital

INTRODUCTION

Gastric cancer is the fifth most common malignant neoplasm and the third leading cause of cancer-related death worldwide. In Peru, its incidence is 15.8 per 100,000 population, and it is associated with high mortality rates, especially in areas with low socioeconomic status. The aim of this study was to compare preoperative, postoperative, and anatomopathological staging results and their relation to disease recurrence and survival.

METHODS

We conducted a retrospective cohort study of patients undergoing surgery for gastric cancer with a definitive postoperative anatomopathological diagnosis from 2005 to 2014 at the Hospital Nacional Luis N. Sáenz. Statistical analyses included descriptive and correlation statistics using the κ index, determination of associations between preoperative and postoperative staging and surgical reintervention and recurrence using the χ²  test, as well as Kaplan Meier survival analysis.

RESULTS

There was little correlation between preoperative staging and final anatomopathological diagnosis, while there was a good correlation with postoperative staging. A significant association was found between preoperative staging and cancer recurrence. In the survival analysis, survival was lower among patients with underestimated staging.

CONCLUSIONS

The survival of patients with gastric cancer can be affected by an overestimation of preoperative staging, therefore improvements in preoperative staging could lengthen the survival of patients undergoing gastric cancer surgery.

[Clinical and epidemiological review of tegumentary leishmaniasis in a central region of Peru]

BACKGROUND

Leishmaniasis is an infectious disease with a high prevalence and worldwide incidence, causing around 70,000 deaths per year.

AIM

To determine the clinical and epidemiological profile of cases of tegumentary leishmaniasis in the Province of Ambo, Department of Huánuco, Peru, during the period from 2000 to 2017.

METHODS

A descriptive, observational, retrospective and cross-sectional study was conducted population base.

RESULTS

We identified 1,312 confirmed cases of tegumentary leishmaniasis, the cutaneous clinical form had a higher prevalence compared to mucocutaneous (83.2 vs 16.7%). The infection in the masculine gender had greater predominance in front of the feminine one (53.3 vs 46.6%). The highest reported annual incidence rate was 412.67/ 100,000 inhabitants during the year 2000 while the lowest registered was in 2015 with 24.45/ 100,000 inhabitants. The Ambo district was the most affected in the clinical cutaneous form (43.1%) as mucocutaneous (38.2%) of the disease. The main diagnostic method for both clinical forms was microscopy (82.0 vs 81.0%) and the most used therapy was sodium stibogluconate (85.6 vs 78.6%). Failure to treatment was reported in 25% for both presentations clinics.

CONCLUSIONS

The eco-environmental conditions of this area of Peru have allowed the establishment of tegumentary leishmaniasis; showing trends similar to world literature. However, more research is needed to explain the epidemiological behavior of this disease that allows the creation of epidemiological prediction models for timely and adequate control.

[Skin lesions of a disseminated histoplasmosis in Peru]

The dermatological manifestations of disseminated histoplasmosis present in about 17% of the cases, is a challenge for its diagnosis. We report the case of a patient from the northern coast of Peru, who presented diffuse dermal lesions, erythema-violaceous nodules, and ulcers histopathologically compatible with the infection of the genus Histoplasma var. capsulatum.