Coexistence and management of abdominal aortic aneurysm and coronary artery disease

Background: Abdominal aortic aneurysm (AAA) and coronary atherosclerosis share common risk factors. In this study, a single-center management experience of patients with a coexistence of AAA and coronary artery disease (CAD) is presented.Methods: 271 consecutive patients who underwent elective AAA repair were reviewed. Coronary imaging in 118 patients was considered suitable for exploration of AAA coexistence with CAD.Results: Significant coronary stenosis (> 70%) were found in 65.3% of patients. History of cardiac revascularization was present in 26.3% of patients, myocardial infarction (MI) in 31.4%, and 39.8% had both. In a subgroup analysis, prior history of percutaneous coronary intervention (PCI) (OR = 6.9, 95% CI 2.6–18.2, p < 0.001) and patients’ age (OR = 1.1, 95% CI 1.0–1.2, p = 0.007) were independent predictors of significant coronary stenosis. Only 52.0% (40/77) of patients with significant coronary stenosis underwent immediate coronary revascularization prior to aneurysm repair: PCI in 32 cases (4 drug-eluting stents and 27 bare metal stents), coronary artery bypass graft in 8 cases. Patients undergoing revascularization prior to surgery had longer mean time from coronary imaging to AAA repair (123.6 vs. 58.1 days, p < 0.001). Patients undergoing coronary artery evaluation prior to AAA repair had shorter median hospitalization (7 [2–70] vs. 7 [3–181] days, p = 0.007) and intensive care unit stay (1 [0–9] vs. 1 [0–70] days, p = 0.014) and also had a lower rate of major adverse cardiovascular events or multiple organ failure (0% vs. 3.9%, p = 0.035). A total of 11.0% of patients had coronary artery aneurysms.Conclusions: Patients with AAA might benefit from an early coronary artery evaluation strategy

Stress in adults with congenital heart disease : preliminary results on anxiety, life events, coping and socioeconomic factors (RCD code: IV)

We performed pilot analysis of the anxiety level, frequency of life events and their interactions among adults with congenital heart disease (CHD), and evaluated their coping strategies and socioeconomic functioning. In a cross-sectional questionnaire study on 30 consecutive ambulatory patients with CHD we addressed these issues by a custom-designed tool incorporating state-anxiety scale of the State-Trait Anxiety Inventory, the brief-COPE questionnaire (Polish versions) and 10 selected life events. We found that state-anxiety level adjusted for sex, age and life events di ered by CHD defect category (R2 = 0,51; p<0,001). Other factors are characterized and brie y discussed. JRCD 2014; 1 (6): 10-1

Impact of arterial procedures on coagulation and fibrinolysis : a pilot study

Abstract Objective: The main goal of our study was to assess the impact of vascular procedures on the activity of hemostatic and fibrinolytic pathways. Methods: We enrolled 38 patients with ≥ 45 years old undergoing surgery for abdominal aortic aneurysm or peripheral artery disease under general or regional anesthesia and who were hospitalized at least one night after the procedure. Patients undergoing carotid artery surgery and those who had acute bypass graft thrombosis, cancer, renal failure defined as estimated glomerular filtration rate < 30 ml/min/1.73m2, venous thromboembolism three months prior to surgery, or acute infection were excluded from the study. We measured levels of markers of hemostasis (factor VIII, von Willebrand factor:ristocetin cofactor [vWF:CoR], antithrombin), fibrinolysis (D-dimer, tissue plasminogen activator [tPA], plasmin-antiplasmin complexes), and soluble cluster of differentiation 40 ligand (sCD40L) before and 6-12h after vascular procedure. Results: Significant differences between preoperative and postoperative levels of factor VIII (158.0 vs. 103.3, P<0.001), antithrombin (92.1 vs. 74.8, P<0.001), D-dimer (938.0 vs. 2406.0, P=0.005), tPA (10.1 vs. 12.8, P=0.002), and sCD40L (9092.9 vs. 1249.6, P<0.001) were observed. There were no significant differences between pre- and postoperative levels of vWF:CoR (140.6 vs. 162.8, P=0.17) and plasmin-antiplasmin complexes (749.6 vs. 863.7, P=0.21). Conclusion: Vascular surgery leads to significant alterations in hemostatic and fibrinolytic systems. However, the direction of these changes in both pathways remains unclear and seems to be different depending on the type of surgery. A study utilizing dynamic methods of coagulation and fibrinolysis assessment performed on a larger population is warranted

Temporal changes in the pattern of invasive angiography use and its outcome in suspected coronary artery disease : implications for patient management and healthcare resource utilization

Introduction: Invasive coronary angiography (CAG), the ‘gold standard’ in coronary artery disease (CAD) diagnosis, requires hospitalization, is not risk-free, and engages considerable healthcare resources. Aim: To assess recent (throught out 10 years) evolution of ‘significant’ (≥ 50% stenosis(es)) CAD prevalence in subjects undergoing CAG for CAD diagnosis in a high-volume tertiary referral center. Material and methods: Anonymized medical records were compared from the last vs. the first 2-years of the decade (June 2007 to May 2018). Referrals for suspected CAD were 2067 of 4522 hospitalizations (45.7%) and 1755 of 5196 (33.8%) respectively (p < 0.001). Results: The median patient age (64 vs. 68 years) and the prevalence of heart failure (24.1% vs. 42.2%) increased significantly (p < 0.001). The CAG atherosclerotic lesions, for all stenosis categories (< 50%; ≥ 50%; ≥ 70%; occlusion(s)), were significantly more prevalent in men. The proportion of subjects with any atherosclerosis on CAG increased (80.7% vs. 77.6%, p = 0.015). However, in the absence of any gross change in, for instance, the fraction of women (40.4% vs. 41.8%), the proportion of CAGs with significant CAD (lesion(s) ≥ 50%) decreased from 55.2% in 2007/2008 to below 1 in every 2 angiograms (48.9%) in 2017/2018 (p < 0.001). This unexpected finding occurred consistently across nearly all CAG referral categories. Conclusions: Despite more advanced age and a higher proportion of subjects with ‘any’ coronary atherosclerosis on CAG, the likelihood of a ‘negative’ angiogram (lesion(s) < 50%; no further evaluation/intervention) has increased significantly over the last decade. The exact nature of this phenomenon requires further investigation, particularly as a reverse trend would be expected with the growing role (and current high penetration) of contemporary non-invasive diagnostic tools to rule out significant CAD

The role of preoperative stress, measured with anxiety questionnaires (STAI, APAIS) and physiological markers (CORTISOL, IL-6), on vascular surgery course and complications.

WprowadzenieStres to faktyczne lub przewidywane zaburzenie homeostazy lub dobrostanu, które implikuje zmiany neurohormonalne w organizmie. Reakcja stresowa jest koordynowana przez CSN, który integruje dane emocjonalne i fizjologiczne, celem modulacji dwóch głównych systemów efektorowych: osi HPA i AUN. Kortyzol jest zasadniczym hormonem osi HPA. IL-6 jest cytokiną prozapalną, w ostatnim czasie powiązaną swoiście ze stresem psychologicznym. Najpopularniejszym podejściem badawczym w kwantyfikacji stresu emocjonalnego jest pomiar poziomu lęku. Każdego roku na świecie przeprowadzanych jest przeszło 200 mln zabiegów operacyjnych, obarczonych istotnym odsetkiem powikłań – ponad 1 mln dorosłych umiera w ciągu 30 dni od operacji, a MACE zdarzają się u więcej niż 5% chorych operowanych w wieku 45 lat lub wyższym. Kortyzol powoduje supresję odporności komórkowej, co prowadzi do zwiększonego ryzyka infekcji i przedłużonego gojenia ran. Sercowo-naczyniowe komplikacje stresu obejmują zatorowość płucną, zaburzenia rytmu i zawał mięśnia serca oraz nagły zgon sercowy, jednak jego rola w okresie okołooperacyjnym pozostaje niezbadana. CelOcena wpływu przedoperacyjnego lęku, aktywacji osi HPA oraz poziomu IL-6 na przebieg operacji i jej powikłania. MetodaGrupa badawcza obejmowała 72 pacjentów (57 mężczyzn, 15 kobiet) operowanych w Oddziale Chirurgii Naczyń Szpitala im. Św. Jana w Krakowie, którzy wypełnili kwestionariusze psychologiczne: STAI i APAIS. Oznaczenia laboratoryjne obejmowały kortyzol oraz IL-6 i zostały przeprowadzone na rozmrożonych próbkach surowicy krwi, pobranej przed operacją w dniu zabiegu pomiędzy godziną 6:30 a 7:30 rano. Pacjenci byli obserwowani pod kątem powikłań do wypisu ze szpitala a po 30 dniach od przeprowadzono telefoniczny follow-up.WynikiNie było różnicy w średnim poziomie lęku pomiędzy kwestionariuszami wypełnionymi w godzinach rannych lub wieczornych, ale kobiety osiągnęły istotnie wyższe wyniki w STAI-stan (p=0.006), STAI-cecha i APAIS-lęk całkowity (p80. percentylowi dla populacji w podobnym wieku, N=37) był związany z większymi śródoperacyjnymi fluktuacjami rytmu serca, wyższym przedoperacyjnym ciśnieniem rozkurczowym krwi, niższym śródoperacyjnym skurczowym ciśnieniem krwi oraz dłuższą hospitalizacją (p13 ug/dL (zakres normy: 5-25) był związany z występowaniem infekcji w follow-up po 30 dniach (AUC=0.71), częstość infekcji w tej grupie to 25% w porównaniu do 0 % wśród pacjentów z poziomem 13 ug/dL wydaje się związany z powikłaniami infekcyjnymi, co jest w zgodności z doniesieniami, że stres i kortyzol mogą upośledzać odporność. Te wyniki wymagają potwierdzenia.IntroductionStress is an actual or anticipated disruption in homeostasis or well-being, which triggers neurohormonal changes in the organism. Stress response is coordinated by the central nervous system that integrates emotional and physiological data to modulate the two major effector systems: hypothalamo-pituitary-adrenal (HPA) axis and autonomic nervous system. Cortisol is the most abundant and potent hormone of the HPA axis. IL-6 is an inflammatory cytokine recently associated specifically with psychological stress. The most popular approach to quantify emotional stress is to measure the anxiety level. Annually, over 200 mln surgeries are performed worldwide with significant fraction of complications – over 1 mln adults die within 30 days following surgery and major adverse cardiovascular events (MACE) occur in more than 5% of surgical patients aged 45 or more. Cortisol is known to suppress cellular immunity, which leads to an increased risk of infection and protracted wound healing. The cardiovascular complications of stress include pulmonary embolism, cardiac dysrhythmias, infarction and sudden death, but little is known about its role in the perioperative period.AimTo evaluate the effect of preoperative perceived anxiety, HPA axis activation and IL-6 level on surgery course and complications.MethodStudy group comprised 72 patients (57 male, 15 female) operated on in the Department of Vascular Surgery at St. John’s Hospital in Cracow, who participated in the VISION study, and completed the psychological questionnaires: STAI and APAIS. Laboratory testing included Cortisol and IL-6 and was performed on thawed serum samples that were drawn in the morning on the day of surgical procedure between 6:30 and 7:30 a.m. The patients were observed for complications until discharge and after 30 days a follow-up by phone was performed. ResultsNo difference was noted in the anxiety score between the questionnaires completed in the evening or in the morning, but women scored significantly higher in STAI-state (p=.006), STAI-trait and APAIS-overall anxiety (p80th percentile for population in this age, N=37) was associated with more intraoperative HR fluctuations, higher preoperative diastolic BP, lower intraoperative systolic BP and longer hospitalization (p<.05).Cortisol correlated with scores of perceived anxiety only in men: STAI-state r=.42, STAI-trait r=.31, APAIS-overall anxiety r=.40 (p<.05), and its level was independent of sex, age, BMI or renal function. ROC curve analysis revealed that cortisol level of more than 13 ug/dL (normal range: 5-25) was related to the occurrence of infection at 30days follow-up (AUC=.71), the occurrence of which was 25% compared to 0% in the <13 ug/dL group (p<.05). No associations were noted with MACE. ConclusionsSurgery is a potent stressor, and STAI-state seems to reliably reflect the perceived anxiety in surgical setting. Women scored significantly higher in STAI-state than men, although the scores for this tests are no different between sexes according to the Polish normalization. Further, the dissociation of cortisol and anxiety levels among women may indicate that females tend to declare higher preoperative anxiety, and that questionnaires alone may not be sufficient to reliably reflect preoperative stress in this group. The preoperative STAI-state score of 48 or more points appear to be heightened and associated with greater risk of hemodynamic instability and longer hospitalization. Preoperative morning serum cortisol level above 13ug/dL seems related to infectious complications, which is in concordance with reports that stress and cortisol can compromise immunity. These findings require confirmatio

The impact of iatrogenic embolisation and endovascular removal of a fractured central vein catheter on the Health Related Quality of Life (HRQoL)

Iatrogenic embolisation of the right ventricle of the heart by a fragment of one of the most basic ICU devices, which has fractured and detached the central vein catheter, is rarely described in subject literature. Removing such an element from the heart is highly risky and requires the use of very modern techniques and equipment. The Atrieve Vascular Snare™ was employed in the described patient. Therefore, it is necessary to present this process and its effectiveness through an evaluation of the health related quality of life (HRQoL) associated with the perception of health status by those patients. This is a requirement in modern medicine. The main aim of this paper was to evaluate the HRQoL after this embolisation. A 67-year-old patient was referred to the Vascular Surgery Department with Endovascular Interventions Ward, John Paul II Hospital in Kraków, after the defragmenting of the central vein catheter and replacement to the right ventricle of the heart. An endovascular approach through the right common femoral vein (RCFV) under local anesthesia of the groin was chosen as the preferred method for removing the broken catheter fragment. The right ventricle of the heart was reached using a 18-30mm Atrieve Vascular Snare™. A structure consisting of three loops facilitated the quick grasp and removal of the catheter fragment at the first attempt through the RCFV. Despite the short time needed for the procedure, the patient experienced periprocedural ventricular fibrillation (VF) with the necessity of defibrillation. After one successful defibrillation attempt, sinus rhythm was restored. The post-operative course showed no complications whatsoever, and the patient was sent to the General Surgery Ward in order for a new Hickman catheter to be implemented and further parenteral nutrition treatment to be carried out. The endovascular technique with the use of Atrieve Vascular Snare™ is an effective method which was used in the case of our patient under local anesthesia. It provides for the fast, safe and convenient removal of a disrupted and dislocated catheter fragment. It allows one to improve the patient’s HRQoL not only in the short term, but also in the longitudinal (6 months after surgery) follow up