Sequential Surgical Procedures in Vascular Surgery Patients Are Associated With Perioperative Adverse Cardiac Events

Patients at elevated cardiovascular risk are prone to perioperative cardiovascular complications, like myocardial injury after non-cardiac surgery (MINS). We have demonstrated in a mouse model of atherosclerosis that perioperative stress leads to an increase in plaque volume and higher plaque vulnerability. Regulatory T cells (Tregs) play a pivotal role in development and destabilization of atherosclerotic plaques. For this exploratory post-hoc analysis we identified 40 patients recruited into a prospective perioperative biomarker study, who within the inclusion period underwent sequential open vascular surgery. On the basis of protein markers measured in the biomarker study, we evaluated the perioperative inflammatory response in patients' plasma before and after index surgery as well as before and after a second surgical procedure. We also analyzed available immunohistochemistry samples to describe plaque vulnerability in patients who underwent bilateral carotid endarterectomy (CEA) in two subsequent surgical procedures. Finally, we assessed if MINS was associated with sequential surgery. The inflammatory response of both surgeries was characterized by postoperative increases of interleukin-6,−10, Pentraxin 3 and C-reactive protein with no clear-cut difference between the two time points of surgery. Plaques from CEA extracted during the second surgery contained less Tregs, as measured by Foxp3 staining, than plaques from the first intervention. The 2nd surgical procedure was associated with MINS. In conclusion, we provide descriptive evidence that sequential surgical procedures involve repeat inflammation, and we hypothesize that elevated rates of cardiovascular complications after the second procedure could be related to reduced levels of intraplaque Tregs, a finding that deserves confirmatory testing and mechanistic exploration in future populations

Conventional culture diagnostics vs. multiplex PCR for the detection of causative agents of vascular graft infections - results of a single centre observational pilot study

Background: Timely diagnosis of vascular graft infections is of major importance in vascular surgery. The detection of causative microorganisms is needed for specific medical treatment, but conventional culture is often slow, insensitive and inconclusive due to antibiotic pre-treatment. Detection of bacterial DNA by polymerase chain reaction (PCR) might bypass these problems. We hypothesised that multiplex PCR (mPCR) is feasible, fast and sensitive to detect causative microorganisms in vascular graft infections. Patients and methods: We performed a pilot observational prospective study comparing conventional culture and a commercial mPCR. Inclusion criteria were: confirmed graft infection, suspicious imaging, clinical suspicion, anastomotic aneurysm and repeated graft occlusion. Diagnostic methods were performed using identical samples. Time to result, microorganisms and antibiotic resistance in both groups were compared using Student's t-test or nonparametric tests. Results: 22 samples from 13 patients were assessed and 11 samples were negative for bacteria. Some showed multiple germs. In total, we found 15 different organisms. 13 samples matched, 9 had non-concordant results. Out of the mismatches 3 microorganisms identified in PCR were not detected by culture. Time to result with PCR was shorter (median 5 h vs. 72 h, p < 0.001) than with culture. No resistance genes were detected by mPCR, but conventional culture allowed susceptibility testing and revealed resistance in 5 samples. Conclusions: mPCR seems to be a feasible and quick tool to detect causes of vascular graft infections within 24 h and might be helpful in antibiotic pre-treated patients. The detection of antibiotic resistance with mPCR needs improvement for clinical practice

Is There an Upper Limit to Cardiopulmonary Bypass Times?

Background: There are no safe operations in cardiac surgery. Every operation can possibly go wrong. We therefore retrospectively evaluated all cardiac operations lasting more than 300 minutes of bypass time at our institution to evaluate outcome and factors relevant for perioperative mortality and morbidity. Methods: We retrospectively included patients receiving cardiac operations or operations at the great&nbsp; vessels with cardiopulmonary bypass times above 300 minutes operated from 1/1/1996 until 12/1/2012 in our study. Patients receiving lung or heart or combined heart and lung transplantations were excluded from our study. 240 patients were included in our study. CPB times, clamp times and operation times were 356.53 ± 55.06 min, 166.18± 65.95 min, 500.47± 96.56 min respectively. Euro score of patients was 4.92 ± 15.35 (range 0.64-79.48). Results: Intraoperative and in-hospital mortality was 11.7% (n=28) and 32.9% (n=79), respectively. Overall mortality was 50.4%. Complication rates were high. Stroke, postoperative dialysis, re-thoracotomy rates were 11.1% (n=24), 35.9% (n=78) and 30.4% (n=66), respectively. Sex, age, infectious endocarditis, need for re-thoracotomy, CABG, aortic clamp times and postoperative dialysis predicted overall mortality in the multivariate analysis. CPB times and operation times were no independent predictors for overall mortality in this collective. In the patients collective excluding the intraoperative deaths, multivariate analysis revealed postoperative lactate levels, amylase levels, and intraoperative need for thrombcyte concentrates and ECMO support to be predictors of mortality. The introduction of reliable ECMO support (general availability starting in 2009) resulted in a signifi cant reduction of intraoperative mortality and overall mortality (p&lt;0.001). Conclusion: Very long CPB times due to intraoperative encountered complications can occur at any given Euroscore. They are associated with a high mortality and morbidity, however even bypass times of over 500 minutes can be survived. The introduction of the ECMO reduced intraoperative mortality however, had no impact on in-hospital mortality.</p

Vascular procedures in patients with left ventricular assist devices: single-center experience

Objective!#!A growing number of patients suffering from heart failure is living with a left ventricular assist device (LVAD) and is in the need for non-cardiac surgery. Vascular procedures due to ischemia, bleeding, or other device-related complications may be required and pose a challenge to the caregivers in terms of monitoring and management of these patients. Therefore, we reviewed our experience with LVAD patients undergoing vascular surgery.!##!Methods!#!From January 2010 until March 2017, a total of 54 vascular procedures were performed on 41 LVAD patients at our institution. Patient records were reviewed retrospectively in terms of incidence of LVAD-related complications, including thrombosis, stroke, bleeding, wound healing, and survival associated with vascular surgery. The type of surgery was recorded, as well as various clinical demographic variables.!##!Results!#!Vascular procedures were performed in 35 men (85.4%) and 6 women (14.6%) with LVADs. There were no perioperative strokes, device thromboses, or device malfunctions. Thirty-day mortality overall was 26.8% (eleven patients), with most patients dying within 30 days after LVAD implantation due to multi-organ failure. In 25 procedures (46.3%), a blood transfusion was necessary.!##!Conclusion!#!Patients on LVAD support are a complex cohort with a high risk for perioperative complications. In a setting where device function and anticoagulation are monitored closely, vascular surgery in these patients is feasible with an acceptable perioperative risk

Prospective evaluation of preoperative lung ultrasound for prediction of perioperative outcome and myocardial injury in adult patients undergoing vascular surgery (LUPPO study)

BACKGROUND Myocardial injury after non-cardiac surgery (MINS) is a frequent perioperative event in vascular surgery, associated both with worse outcome and subsequent cardiovascular events. Current guidelines advocate troponin (hs-cTnT) and NT-proBNP measurements in selected patients before surgery, but accurate preoperative identification of patients at risk for MINS is an unmet clinical need. Focused lung ultrasound (LUS) might help to select patients at increased risk for MINS, because it can visualize B-line artifacts correlating to cardiopulmonary disease. Therefore, we investigated whether quantification of B-line artifacts improves perioperative risk predictive accuracy for MINS. METHODS In this prospective single-center observational study, 136 consecutive open vascular surgery patients underwent conventional preoperative assessment expanded by lung ultrasound. Lung ultrasound B-lines were counted in each of 28 bilateral scan fields of the anterior and lateral chest. Improvement of risk predictive accuracy was quantified with area under receiver operating characteristic (ROC) curve analysis and net reclassification improvement (NRI). RESULTS We included 118 patients into the final analysis. Twenty-three (19%) patients fulfilled the criteria for the primary endpoint MINS. Three or more bilateral positive B-line fields were calculated as the best ROC-derived cutoff associated with an increased incidence of MINS (odds ratio: 4.4; 95% confidence interval [CI]: 1.5 to 12.7; P=0.007). Adding LUS to hs-cTnT measurements improved risk predictive accuracy for MINS (NRI: 0.36, P=0.043). CONCLUSIONS Lung ultrasound in combination with hs-cTnT showed a better test accuracy than hs-cTnT alone and might guide clinicians to identify vascular patients at increased risk for MINS

Renal function interferes with copeptin in prediction of major adverse cardiac events in patients undergoing vascular surgery.

OBJECTIVE:Precise perioperative risk stratification is important in vascular surgery patients who are at high risk for major adverse cardiovascular events (MACE) peri- and postoperatively. In clinical practice, the patient's perioperative risk is predicted by various indicators, e.g. revised cardiac index (RCRI) or modifications thereof. Patients suffering from chronic kidney disease (CKD) are stratified into a higher risk category. We hypothesized that Copeptin as a novel biomarker for hemodynamic stress could help to improve the prediction of perioperative cardiovascular events in patients undergoing vascular surgery including patients with chronic kidney disease. METHODS:477 consecutive patients undergoing abdominal aortic, peripheral arterial or carotid surgery from June 2007 to October 2012 were prospectively enrolled. Primary endpoint was 30-day postoperative major adverse cardiovascular events (MACE). RESULTS:41 patients reached the primary endpoint, including 63.4% aortic, 26.8% carotid, and 9.8% peripheral surgeries. Linear regression analysis showed that RCRI (P< .001), pre- (P< .001), postoperative Copeptin (P< .001) and Copeptin level change (P= .001) were associated with perioperative MACE, but CKD remained independently associated with MACE and Copeptin levels. Multivariate regression showed that increased Copeptin levels added risk predictive information to the RCRI (P= .003). Especially in the intermediate RCRI categories was Copeptin significantly associated with the occurrence of MACE. (P< .05 Kruskal Wallis test). Subdivision of the study cohort into CKD stages revealed that preoperative Copeptin was significantly associated with CKD stages (P< .0001) and preoperative Copeptin measurements could not predict MACE in patients with more severe CKD stages. CONCLUSION:Preoperative Copeptin loses its risk predictive potential for perioperative MACE in patients with chronic kidney disease undergoing vascular surgery

ROC analysis comparing the RCRI alone or combined with Copeptin-derived parameters.

<p>Only preoperative Copeptin (blue dotted line) improved risk predictive accuracy of the RCRI (P = .0371, AUC .752). The RCRI-ROC Curve (black line) (AUC .714) indicates prediction of the occurrence of major adverse cardiovascular events (MACE). The combination of RCRI and postoperative Copeptin (red dashed line) (P = .0620, AUC .751) and RCRI and Copeptin changes (P = .1525, AUC .710) during the perioperative course (green dashed and dotted line) do not reach significantly larger AUCs. * marks significant values.</p

Copeptin is elevated in patients sustaining Major Adverse Cardiovascular Events (MACE) throughout the perioperative phase.

<p>Boxplots of pre- (A) and postoperative (B) Copeptin levels as well as perioperative Copeptin change (C) (pmol/L). Groups were analyzed by Mann-Whitney U test (A) P = .0001, (B) P = .0002, (C) P = .014.</p

Demographical data of study population subdivided into surgical procedures.

<p>P depicts P value of univariate linear regression calculated for each variable and type of surgery. The number of patients (n) for each group as well as percentage (%) is depicted. Other variables are shown as median with 25–75 percentile. Abbreviations are used as follows: coronary artery disease (CAD), revised cardiac risk index (RCRI), glomerular filtration rate (GFR), preoperative values for Copeptin (preop Copeptin), postoperative values for Copeptin (postop Copeptin), change of Copeptin levels between pre- and postoperative sample (Copeptin delta absolute), Major adverse cardiovascular events (MACE).</p><p>Demographical data of study population subdivided into surgical procedures.</p

Copeptin interferes with kidney injury in prediction of MACE.

<p>Preoperative Copeptin levels (pmol/L) are significantly (P<.0001) elevated in patients with chronic kidney disease increasing with severity of kidney injury (A). Preoperative Copeptin is not associated with MACE in patients with CKD 1&2 (B) (P = .3787) or CKD 4&5 (D) (P = .2264) but shows significant association with MACE in CKD 3 (C) (P = .0163). Data were analyzed using Mann Whitney U test for comparing two groups and Kruskal Wallis test followed by Dunns test for multiple comparisons. Blots are depicted as 5–95 percentile.</p