MANAGEMENTUL PROTEZELOR VASCULARE INFECTATE

Introduction: Despite routine antibiotic prophylaxis and refinements in implantation technique, microbial infection of the vascular prostehesis can occur. Infection involving a vascular graft is difficult to eradicate. If not recognized or treated promptly, implant failure will occur by producing sepsis, hemorrhage or thrombosis. Management involves graft excision alone, graft preservation within the implant wound, in/situ graft replacement, or graft  excision in conjunction with extra-anatomic bypass grafting. Matherial and method: We retrospectively analysed the operative registers of our clinic as well as the regular archives, from 2000 until 2008, searching for reported graft infections which needed excisions and extraanatomical bypasses or for conservative therapy. There were  50 patients in this interval admitted and treated in Surgical Clinic No.1, out of a total of  950 vascular interventions. 10 of them were early graft infections(4 months).Using Szilagyi’s classification, 10 were grade I, 17 were grade II and 23 grade III.We followed antibiotic prophylaxis protocols in all of the cases, prior to first vascular intervention. Staphylococcus aureus was the most prevalent pathogen ( 95% ) found affecting our grafts. Results: We performed 20 graft excisions for infrainguinal graft infections, with the removal of the entire graft, radical debridement of infected perigraft tissues, closure of the arteriotomies with monofilament suture and the administration of systemic and topical antibiotics. We attempted graft preservation in 5 cases of infrainguinal prosthetic bypass graft infection( with serial surgical wound debridement, coupled with antibiotic therapy, early muscle flap coverage and repeated wound cultures to identify any development of bacterial resistance or change in the microbial flora). We used the staged approach in 20 cases, beginning with drainage of the perigraft abscess, followed in 2 or 3 days by graft excision and autogenous vein grafting. We performed none in-situ replacements with Rifampin-bonded prosthesis, partly because they were not  available until a few years. For the patients with  infection localized to only a portion of an aortofemoral graft, we preferred, for the decreased morbidity, the excision of the infected portion of the graft(partial graft excision) and after solving the inguinal infection, a staged extra-anatomical bypass- in     cases.As for the gold standard regarding the aortic graft- total graft excision and ex-situ bypass, we only performed 5 of them. 3 patients died and 2 required major amputation. Conclusions: Dissatisfaction with the morbidity and the mortality of treating vascular graft infections, regardless of location, by total graft excision and remote bypass has been the impulse for the expanded application of lately performed in-situ bypasses or even for the prophylactic use of antibiotic-bonded grafts, in carefully selected cases.Introducere: In ciuda antibioprofilaxiei de rutina si a rafinarii tehnicilor de implantare, infectiile protezelor vasculare pot totusi surveni si constitui o patologie extrem de complexa si periculoasa, fiind greu de eradicat si producand esecul grafturilor prin sepsis, hemoragie sau tromboza. Tratamentul necesita justa evaluare a unor criterii specifice si individualizarea asocierii mijloacelor din arsenalul terapeutic, reprezentate de: simpla excizie a graftului, excizia in conjunctie cu revascularizatie extra-anatomica, prezervarea graftului sau excizie cu revascularizatie in-situ. Material si metoda: S-a analizat retrospectiv registrele operatorii si celelalte registre ale Clinicii Chirurgie I din cadrul Spitalului Clinic Judetean de urgenta Titgu Mures, din 2000 pana in 2008. Am inclus un numar de 50 de pacienti cu infectii depistate de graft arterial, din totalul de 950 de interventii vasculare. Conform clasificarii Syilagyi, 10  au fost infectii de grad I,17 de grad II si 23 de grad III. Alte 10 au fost infectii precoce si 40 tardive. La revascularizatia primara am folosit la toate cazurile protocoale de antibioprofilaxie. Majoritatea infectiilor (95%) au fost cu Stafilococ auriu, dar a crescut in ultimul timp proportia cazurilor infectate cu germeni gram-negativi si multirezistentí (MRSA). Rezultate: Au fost efectuate 20 de excizii de graft pentru infectii infrainghinale, cu indepartarea intregului graft, debridari radicale ale tesuturilor perigraft, inchiderea arteriotomiilor si asocierea de antibioterapie sistemica si topica. A fost realizata prezervarea graftului la 5 cazuri (cuplata cu antibioterapie si acoperire cu pedicul muscular). A fost  folosita tactica seriata la 20 de cazuri, cu drenarea initiala a abcesului perigraft, urmata dupa 2-3 zile de excizie si graftare autologa. Nu a fost facuta nici o inlocuire in-situ cu proteza impregnata cu Rifampicina. Pentru pacientii cu infectie a unui by-pass aorto-femural localizata doar la nivelul triunghiului Scarpa, s-a preferat excizia partiala, iar dupa vindecarea procesului la acest nivel, o revascularizatie extra-anatomica. A fost  extrasa total proteza aortica doar la 5 pacienti, dintre care 3 au murit, iar ceilalti 2 au necesitat o amputatie majora. Concluzii: Insatisfactia morbiditatii si mortalitatii mari prin aplicarea  metodelor de excizie totala a fost impulsul necesar pentru cautarea unor noi solutii terapeutice pentru problema infectiei protezelor vasculare. Viitorul este reprezentat de materialele revolutionare impregnate cu antibiotice, folosite chiar profilactic, la prima revascularizatie, in cazuri selectate

Aorto-mesenteric Bypass for the Treatment of Chronic Mesenteric Ischemia

Chronic mesenteric artery disease has a much lower incidence than the acute one, but it raises the same problems in terms of patient survival. The long-term outcomes for open surgery are crucial for the right choice of a particular technique. We present the case of a 39-year-old female patient with a history of total nephrectomy, chronic kidney failure, and hypertension, who presented in the Emergency Department with abdominal pain with high intensity, for which she was admitted to the General Surgery Department. Abdominal computed tomography angiography was performed, which indicated the diagnosis of partial upper mesenteric artery stenosis. The patient underwent surgery, during which a retrograde aorto-mesenteric bypass with a Gore-Tex 5 mm diameter prosthesis was performed. In situations where the endovascular approach fails or has no indication (multiple incidence lesions from the origin of the superior mesenteric artery), open surgery is the indication in chronic mesenteric ischemia

Negative Impact of the COVID-19 Pandemic on Kidney Disease Management—A Single-Center Experience in Romania

Background: The evolution of the COVID-19 pandemic affected healthcare systems worldwide. The patients with chronic kidney disease (CKD), diabetes, and cardiovascular disease were most affected and had an unfavorable outcome. Methods: We examined the activity of the Nephrology Department from Târgu-Mureș County Emergency Hospital retrospectively, comparing two periods: June 2020–November 2021 (COVID-19 period) and June 2018–November 2019 (non-COVID-19 period). Results: In the COVID-19 period, there were fewer one-day hospitalizations registered, 77.27% more dialysis catheters were installed, and 43.75% more arteriovenous fistulas were performed. An overall increase in the number of patients requiring dialysis during the pandemic was recorded, as of the number of dialysis sessions performed. Moreover, we observed a statistically significant increase in the number of dialysis sessions per patient and a statistically significant increase in the number of hospitalization days in the pandemic interval. Acute kidney injury (AKI) and urosepsis were the diagnoses that increased the most among in-patients during the pandemic, while all other nephrology diagnoses decreased. Conclusions: The COVID-19 pandemic accelerated kidney pathology and worsened the outcomes of nephrology patients in our center. The number of chronic and patient’s access to one-day hospitalization decreased in order to minimalize the exposure and the risk of infection. In contrast, the need for emergency dialysis increased significantly

The Predictive Value of NLR, MLR, and PLR in the Outcome of End-Stage Kidney Disease Patients

Background: Chronic kidney disease (CKD) is a global public health problem with a high mortality rate and a rapid progression to end-stage kidney disease (ESKD). Recently, the role of inflammation and the correlation between inflammatory markers and CKD progression have been studied. This study aimed to analyze the predictive value of the neutrophil–lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) in assessing the outcome of ESKD patients. Methods: A retrospective study which included all patients admitted in the Department of Nephrology of the County Emergency Clinical Hospital, Târgu-Mureș, Romania, between January 2016 and December 2019, diagnosed with ESKD. Results: Mortality at 30 days was clearly higher in the case of the patients in the high-NLR groups (40.12% vs. 1.97%; p < 0.0001), high-MLR (32.35% vs. 4.81%; p < 0.0001), and respectively high-PLR (25.54% vs. 7.94%; p < 0.0001). There was also a significant increase in the number of hospital days and the average number of dialysis sessions in patients with high-NLR (p < 0.0001), high-MLR (p < 0.0001), and high-PLR (p < 0.0001). The multivariate analysis showed that a high baseline value for NLR (p < 0.0001), MLR (p < 0.0001), and PLR (p < 0.0001) was an independent predictor of 30-day mortality for all recruited patients. Conclusions: Our findings established that NLR, MLR, and PLR determined at hospital admission had a strong predictive capacity of all-cause 30-day mortality in ESKD patients who required RRT for at least 6 months. Elevated values of the ratios were also associated with longer hospital stays and more dialysis sessions per patient

The Predictive Role of NLR and PLR in Outcome and Patency of Lower Limb Revascularization in Patients with Femoropopliteal Disease

Background: Peripheral arterial disease (PAD) changes the arterial structure and function, and is the most common manifestation of the atherosclerotic process, except for the coronary and cerebral arterial systems. Inflammation is well known to have a role in the progression of atherosclerosis and, by extension, in PAD. Among the recently studied markers in the literature, we list the neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR). This study aims to analyze the preoperative role of NLR and PLR in the medium-term outcome of patients surgically revascularized for femoropopliteal disease. Methods: A retrospective study included patients admitted to the Vascular Surgery Clinic of the County Emergency Clinical Hospital of Târgu-Mureș, Romania, between January 2017 and December 2019, diagnosed with femoropopliteal disease and having presented an indication for surgical revascularization. The patients included in the study were classified according to the 12 months primary patency in two groups: “patency” and “nonpatency”. Results: Depending on the Rutherford classification (RC), there was a higher incidence of stages II and III in the patency group and a higher incidence of stage V in the nonpatency group. Depending on the optimal cut-off value according to ROC for the 12 months primary patency, obtained from Youden’s index (3.95 for NLR (82.6% sensitivity and 89.9% specificity), and 142.13 for PLR (79.1% sensitivity and 82.6% specificity)), in all high-NLR and high-PLR groups, there was a higher incidence of all adverse outcomes. Moreover, a multivariate analysis showed that a high baseline value for NLR and PLR was an independent predictor of all outcomes for all recruited patients. Furthermore, for all hospitalized patients, RC 5 was an independent predictor of poor prognosis. Conclusions: Our findings establish that a high value of preoperative NLR and PLR determined at hospital admission is strongly predictive of primary patency failure (12 months after revascularization). Additionally, elevated ratio values are an independent predictor for a higher amputation rate and death for all patients enrolled in the study, except for mortality in RC 2, and both amputation and mortality in RC 5

The Predictive Value of Systemic Inflammatory Markers, the Prognostic Nutritional Index, and Measured Vessels’ Diameters in Arteriovenous Fistula Maturation Failure

Background: An arteriovenous fistula (AVF) is the first-line vascular access pathway for patients diagnosed with end-stage renal disease (ESRD). In planning vascular access, it is necessary to check the diameters of the venous and arterial components for satisfactory long-term results. Furthermore, the mechanism underlying the maturation failure and short-term patency in cases of AVFs is not fully known. This study aims to verify the predictive role of inflammatory biomarkers (the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), systemic inflammatory index (SII), and C-reactive protein (CRP)), Ca-P product, the prognostic nutritional index (PNI), and the diameters of the venous and arterial components in the failure of AVF maturation. Methods: The present study was designed as an observational, analytical, and retrospective cohort study with a longitudinal follow-up, and included all patients with a diagnosis of ESRD that were admitted to the Vascular Surgery Clinic of the Targu Mures Emergency County Hospital, Romania, between January 2019 and December 2021. Results: The maturation of AVF at 6 weeks was clearly lower in cases of patients in the high-NLR (31.88% vs. 91.36%; p < 0.0001), high-PLR (46.94% vs. 85.55%; p < 0.0001), high-SII (44.28% vs. 88.89%; p < 0.0001), high-CRP (46.30% vs. 88.73%; p < 0.0001), high-Ca-P product (40.43% vs. 88.46%; p < 0.0001), and low-PNI (34.78% vs. 91.14%; p < 0.0001) groups, as well as in patients with a lower radial artery (RA) diameter (40% vs. 94.87%; p = 0.0009), cephalic vein (CV) diameter (44.82% vs. 97.14%; p = 0.0001) for a radio-cephalic AVF (RC-AVF), and brachial artery (BA) diameter (30.43% vs. 89.47%; p < 0.0001) in addition to CV diameter (40% vs. 94.59%; p < 0.0001) for a brachio-cephalic AVF (BC-AVF), respectively. There was also a significant increase in early thrombosis and short-time mortality in the same patients. A multivariate analysis showed that a baseline value for the NLR, PLR, SII, CRP, Ca-P product, and PNI was an independent predictor of adverse outcomes for all of the recruited patients. Furthermore, for all patients, a high baseline value for vessel diameter was a protective factor against any negative events during the study period, except for RA diameter in mortality (p = 0.16). Conclusion: Our findings concluded that higher NLR, PLR, SII, CRP, Ca-P product, and PNI values determined preoperatively were strongly predictive of AVF maturation failure, early thrombosis, and short-time mortality. Moreover, a lower baseline value for vessel diameter was strongly predictive of AVF maturation failure and early thrombosis

Increased Epicardial Adipose Tissue (EAT), Left Coronary Artery Plaque Morphology, and Valvular Atherosclerosis as Risks Factors for Sudden Cardiac Death from a Forensic Perspective

Background: In sudden cardiac deaths (SCD), visceral adipose tissue has begun to manifest interest as a standalone cardiovascular risk factor. Studies have shown that epicardial adipose tissue can be seen as a viable marker of coronary atherosclerosis. This study aimed to evaluate, from a forensic perspective, the correlation between body mass index (BMI), heart weight, coronary and valvular atherosclerosis, left ventricular morphology, and the thickness of the epicardial adipose tissue (EAT) in sudden cardiac deaths, establishing an increased thickness of EAT as a novel risk factor. Methods: This is a retrospective case–control descriptive study that included 80 deaths that were autopsied, 40 sudden cardiac deaths, and 40 control cases who hanged themselves and had unknown pathologies prior to their death. In all the autopsies performed, the thickness of the epicardial adipose tissue was measured in two regions of the left coronary artery, and the left ventricular morphology, macro/microscopically quantified coronary and valvular atherosclerosis, and weight of the heart were evaluated. Results: This study revealed a higher age in the SCD group (58.82 ± 9.67 vs. 53.4 ± 13.00; p = 0.03), as well as a higher incidence in females (p = 0.03). In terms of heart and coronary artery characteristics, there were higher values of BMI (p = 0.0009), heart weight (p p p p = 0.004), heart weight (OR: 5.47; p p p p = 0.045), type Vb plaque (OR: 17.19; p p = 0.002), and moderate left ventricle dilatation (OR: 16.71; p = 0.008) all act as predictors of SCD. Conclusions: The data of this research revealed that higher baseline values of BMI, heart weight, EAT LCx, and EAT LAD highly predict SCD. Furthermore, age above 55 years, type Vb plaque, mild valvular atherosclerosis, and left ventricle dilatation were all risk factors for SCD

Polytetrafluorethylene (PTFE) vs. Polyester (Dacron^®) Grafts in Critical Limb Ischemia Salvage

Background: Critical ischemia of the lower limbs refers to the last stages of peripheral arterial disease. It is characterized by resting discomfort or trophic disorders such as ulceration, skin necrosis, or gangrene in the lower limbs. Critical ischemia corresponds to Leriche–Fontaine (LF) stages III-IV and Rutherford stages 4–6. The purpose of this study was to observe the patency and postoperative complications of patients who have had infra-inguinal surgical revascularization and compare the results based on the kind of graft utilized. Methods: The present study was designed as an observational retrospective cohort study, including all patients from 2018 to 2019 diagnosed with severe ischemia of the lower limbs who were hospitalized at the Vascular Surgery Clinic of the County Emergency Clinical Hospital of Targu Mures. Results: Patients with a polytetrafluoroethylene (PTFE) graft had a higher incidence of chronic obstructive pulmonary disease (p = 0.01), stage III LF (70.41% vs. 55.29%), p = 0.03), and a lower incidence of stage IV LF (29.95% vs. 44.71%, p = 0.03). As for complications, the PTFE group showed a lower incidence of bypass thrombosis (29.59% vs. 44.71%; p = 0.03) and graft infection (9.18% vs. 21.18%; p = 0.02), but no statistical significance in the event of bleeding (p = 0.40). Regarding the outcomes, no statistical significance was seen for below-the-knee amputations or death. However, the PTFE group had a lower incidence of above-the-knee amputations (11.22% vs. 24.71%; p = 0.01). At multivariate analysis, the PTFE graft is an independent predictor of primary patency at 6, 12, and 24 months (OR: 2.15, p = 0.02; OR: 1.84, p = 0.04; and OR: 1.89, p = 0.03), as well as a protective factor against bypass thrombosis (OR: 0.52; p = 0.03), graft infection (OR: 0.37; p = 0.02), and above-the-knee amputation (OR: 0.38; p = 0.01).; Conclusions: According to this study’s findings, there were minor differences regarding the long-term patency, bypass thrombosis, graft infections, and above-the-knee amputations. In addition, the PTFE graft group had a higher incidence of primary patency at 6, 12, and 24 months, as well as a lower incidence of bypass thrombosis, graft infection, and above-the-knee amputations