Αποκατάσταση αορτοβρογχικής επικοινωνίας – Συστηματική ανασκόπηση βιβλιογραφίας

Σκοπός της μελέτης: Η ανασκόπηση της βιβλιογραφίας για την ανοικτή, ενδαγγειακή, σταδιακή αντιμετώπιση της αορτοβρογχικής επικοινωνίας. Υλικό και μέθοδος: Η μελέτη αυτή αποτελεί συστηματική ανασκόπηση όπου χρησιμοποιήθηκαν οι κάτωθι μηχανές αναζήτησης: Pubmed, Scopus, Cochrane Library. (Περίοδος: Ιανουάριος 1999- Δεκέμβριος 2019). Κατάλληλες κρίθηκαν οι εργασίες που αφορούσαν ασθενείς με αορτοβρογχική επικοινωνία στους οποίους διενεργήθηκε κάποια από τις διαθέσιμες θεραπείες (πλην της συντηρητικής) και οι οποίες ανέφεραν μετεγχειρητικά αποτελέσματα (θάνατος ή διαθέσιμος επανέλεγχος). Επικοινωνήσαμε με τους υπεύθυνους για την αλληλογραφία συγγραφείς για ενημέρωση σχετικά με την έκβαση των ασθενών τους. Αποτελέσματα: Συνολικά συμπεριελήφθησαν 90 εργασίες (214 ασθενείς). Οι επεμβάσεις υπολογίστηκαν 271 αθροιζομένων των επεμβάσεων για σταδιακή αποκατάσταση και των επανεπεμβάσεων (λόγω υποτροπής ή λοίμωξης). Η πλειοψηφία (75,12%) αντιμετωπίστηκε ενδαγγειακά, ανοικτά αντιμετωπίστηκε το 17,48% των περιπτώσεων και σταδιακά μόλις το 5,85%. Η εντόπιση της επικοινωνίας αφορούσε κατά κύριο λόγο την κατιούσα θωρακική αορτή (64,6%) (ζώνη 3/4) με δεύτερη σε συχνότητα τη ζώνη 2 (23,8%). 12,6% των συνολικών επικοινωνιών προέκυψαν μετά από ενδαγγειακή αποκατάσταση βλάβης στη θωρακική αορτή. Υποτροπή ή λοίμωξη προέκυψε στο 20% των ασθενών (43 ασθενείς). Στα περιστατικά με υποτροπή, η ενδοδιαφυγή ήταν σχεδόν πάντα παρούσα. Η χορήγηση μακροχρόνιας αντιβιοτικής αγωγής (>1 μήνα) ήταν συνηθισμένη πρακτική από τους θεράποντες ιατρούς, ακόμη και εάν αυτή ήταν εμπειρική. Η ενδαγγειακή θεραπεία παρουσιάζει περισσότερους θανάτους σχετιζόμενους με την νόσο αλλά φαίνεται ότι οι ασθενείς είναι μεγαλύτεροι σε ηλικία. Τέλος, ο μέσος όρος των επανελέγχων ήταν 25,1 μήνες (0-188 μήνες) και η μέθοδος που επιλέχθηκε (ανοικτή/ενδαγγειακή/σταδιακή) δε σχετίζεται με το διαθέσιμο χρόνο επανελέγχου. Συμπεράσματα: Η αορτοβρογχική επικοινωνία είναι σύνθετη νόσος και ενδεχομένως η συχνότητα της να έχει υποεκτιμηθεί. Φαίνεται ότι οι ενδοδιαφυγές συμμετέχουν στη δημιουργία και υποτροπή της νόσου οπότε θα πρέπει να υπάρχει επαγρύπνηση και έγκαιρη αντιμετώπιση για να αποτρέψουμε την πιθανή αύξηση των αορτοβρογχικών επικοινωνιών τα επόμενα χρόνια. Οι διαθέσιμες θεραπευτικές μέθοδοι για την αντιμετώπιση των αορτοβρογχικών επικοινωνιών είναι εφάμιλλες όσο αφορά τα αποτελέσματα τους (διάρκεια επανελέγχου) και οι θεράποντες μπορούν να επιλέξουν όποια μέθοδο θεωρούν κατάλληλη, λαμβάνοντας πάντα υπόψη την εμπειρία τους, την ηλικία και τη γενική κατάσταση του ασθενούς.Objectives: The aim of the study was to summarize and compare outcomes of open, staged, and endovascular repair of aortobronchial fistula. Material and Methods: A systematic literature review was conducted to identify eligible studies published between January of 1999 and December of 2019. The Cochrane Library, PubMed and Scopus databases were used as search engines. Eligible studies were those including postoperative outcomes (death or follow-up information). The corresponding authors were contacted to provide additional information/update about outcome (recurrence/reoperation/infection/death). Results: Overall, there were 214 patients (90 studies), undergoing 271 procedures (including re-do procedures and staged procedures). Most of the patients were treated by endovascular means (75,12%). Open surgical repair was performed in 17,48% and staged procedures in 5,85%. Aortobronchial fistulae most commonly located in descending thoracic aorta (zone 3,4) (64,6%) and in zone 2 (23,8%). Twelve percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43 patients). In the case of recurrence, endoleak was almost every time visible. Long-term antibiotic administration (>1 months) was a usual therapeutic approach. Considering outcomes, mean follow-up was 25.1 months (0-188 months) and it is not associated significantly with the treatment provided. Conclusion: Aortobronchial fistula is a complex disease and its prevalence may be underestimated. Endoleaks seems to be involved in the development and in recurrence process and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal and thus, surgeons should feel confident to apply the treatment of their choice, taking in mind their experience, patient’s age, and clinical condition

A systematic review of therapies for aortobronchial fistulae

Objective: The aim of the study was to summarize epidemiologic data about aortobronchial fistulae and compare outcomes (mortality, recurrence, reoperation) of open, staged, and endovascular repair of aortobronchial fistula. Methods: A systematic literature review was conducted to identify eligible studies published between January 1999 and December 2019. The Cochrane Library, PubMed, and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series, and thus, only descriptive data with data heterogeneity were available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death). Results: Overall, 214 patients (90 studies) underwent 271 procedures (including redo procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae were located most often in the descending thoracic aorta (zone 3 or 4) (64.6%) and in zone 2 (23.8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43) patients. Recurrences were, to some extent, associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whereas 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61 patients, 3 received lifelong antibiotics and for 58 patients data were not available. Considering outcomes, the mean follow-up was 25.1 months (0188 months) and not significantly different among treatments. Limitations: Literature review has revealed only case reports and small case series, and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease, which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies that have not been conducted till today. Conclusions: Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and the recurrence process, and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal, and thus, surgeons should feel confident to apply the treatment of their choice, keeping in mind their experience, patient’s age, and clinical condition

Fenestrated Endovascular Repair for Pararenal or Juxtarenal Abdominal Aortic Aneurysms: a Systematic Review

Background: This review aims to collect all available data on early and late outcomes in patients undergoing fenestrated endovascular aortic aneurysm repair (F-EVAR) for pararenal or juxtarenal abdominal aortic aneurysms (AAAs). Methods: The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Studies reporting at least early mortality after F-EVAR in patients with pararenal or juxtarenal AAA were included. Thirty-day outcomes were defined as early, and outcomes reported after 30 days postoperatively were defined as late. Basic characteristics of all studies and demographics of patients were reported. Results: Overall, 30 studies (17 retrospective and 13 prospective) including 23,385 patients in total were included. Out of 23,385 patients, a total of 2,271 patients were treated with F-EVAR for pararenal/juxtarenal AAA. Overall, 4,216 target vessels were to be treated (data from 24 studies). Pooled early mortality reached 2.55% (ranging from 0% to 6.74%), with a pooled technical success of 96.8% (ranging from 82.8% to 100%). Regarding late outcomes, pooled allcause mortality reached 17% (ranging from 0% to 50%), 1-year primary patency was 94.6% (ranging from 91.8% to 97.1%) and reintervention rate was 10.4% (ranging from 0% to 57.4%). Mean/median follow-up ranged from 3 to 60 months. Conclusions: Early outcomes indicate that F-EVAR is a safe and efficient treatment for patients with pararenal/juxtarenal AAAs. Although long-term outcomes are acceptable, late-intervention rate remains high

Managing central venous access during a health care crisis

10.1016/j.jvs.2020.06.112JOURNAL OF VASCULAR SURGERY7241184-

Managing central venous access during a health care crisis.

ObjectiveDuring the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic.MethodsWe conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19.ResultsParticipants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group).ConclusionsImplementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises