Smoking and plasma fibrinogen, lipoprotein (a) and serotinin are markers for postoperative infrainguinal graft stenosis

Objectives:A number of systemic variables are associated with infrainguinal graft failure and also with experimental smooth muscle hyperplasia. Stenosis is the most common cause of infrainguinal graft thrombosis but it is not known if systemic variables are associated with stenosis.Design, materials and methods:In this study, clinical and serological factors were measured and correlated with stenosis development in 81 infrainguinal bypass grafts (52 vein, 29 PTFE; 28 with stenosis) in prospective (n = 46) and retrospective (n = 35) groups. Pre-existing stenosis was ecluded by perioperative graft assessment.Results:There was a significantly greater proportion of smokers in the patients who developed stenosis (11/18; 61%) compared with those who did not (6/28; 21%, p = 0.006; x2). Patients who developed stenosis also had significantly (Mann Whitney U-tests), higher circulating levels of [median (interquartile range)] fibrinogen (412.5 (356–484.5) vs. 339 (300–397.7) mg/100ml, p = 0.003), Lipoprotein (a) (0.20 (0.05–0.45) vs. 0.085 (0.05–0.23), g/l, p = 0.03) and 5-hydroxytryptamine (14.1 (6.6–45) vs. 4.41 (3–8.39) nmol/l, p = 0.005), than those without stenosis.By logistic regression, these associations were independent of graft material and whether grafts were studied prospectively or retrospectively.Conclusions:Smoking and plasma fibrinogen, Lp(a) and 5-hydroxytryptamine are markers for postoperative infrainguinal graft stenosis

11-Year Experience with Anatomical and Extra-anatomical Repair of Mycotic Aortic Aneurysms

AbstractBackground. We have reviewed our management, of both ruptured and non-ruptured, abdominal and thoraco-abdominal mycotic aneurysms in order to determine the safety and efficacy of in situ and extra-anatomical prosthetic repairs.Methods. Data regarding presenting symptoms, investigations, operative techniques and outcome, were collected on patients treated at a singe centre over 11 years.Results. There were 11 men and four women, with a median age of 70 years (range, 24–79). All but one patient were symptomatic and six had a contained leak on admission. In six patients no organisms were identified in either blood or tissue cultures. Pre-operative CT identified; four infra-renal, four juxta-renal, three (Crawford thoraco-abdominal) type IV, three type III and one type II, aortic aneurysms. Thirteen were repaired with in situ prostheses and two required axillo-femoral prosthetic grafts. There were four early deaths. All surviving patients have been followed-up for a median duration of 38 months (range 1/2–112 months). There were two late deaths at 3 months (juxta-renal) and at 2 years (type III), the latter relating to graft infection.Conclusions. In the absence of uncontrolled sepsis, repair of mycotic aortic aneurysms using prosthetic grafts can achieve durable results

Myocardial injury in major aortic surgery

AbstractPurpose: The purpose of this study was to examine the effects of major aortic surgery and its associated oxidative stress and injury on the myocardium. Methods: Plasma from 27 patients who underwent thoracoabdominal aortic aneurysm (TAAA) repair and 17 patients who underwent infrarenal aortic aneurysm (AAA) repair was collected at incision, aortic crossclamping, and reperfusion and 1, 8, and 24 hours thereafter. Samples were assayed for the myocardial specific protein troponin-T, total antioxidant status, and lipid hydroperoxides. Results: Ten patients experienced cardiac dysfunction in the first 24 hours after surgery (eight patients in the TAAA group and two patients in the AAA group). Immediately after reperfusion, total antioxidant status levels dropped in all patients with TAAA and with AAA; this was more marked in patients with TAAA, leading to a significant difference between the two groups at this time point and for up to 1 hour thereafter (P <.01). Patients with TAAA showed a sharp rise in lipid hydroperoxide levels immediately after reperfusion, and levels were significantly higher than in patients with AAA (P =.0007). In patients with AAA, no significant change in troponin-T was observed throughout the study period; whereas in patients with TAAA, levels were significantly elevated at 8 and 24 hours after reperfusion (P <.01). Troponin-T levels significantly correlated with total antioxidant status (r = –0.5) and lipid hydroperoxides (r = 0.78) but not with systolic blood pressure. Conclusion: Supracoeliac aortic crossclamping is associated with a significant release of the myocardial injury marker troponin-T. This seems to correlate with the severity of oxidative rather than hemodynamic stresses. Ameliorating oxidative injury during TAAA surgery may therefore have a cardioprotective effect. (J Vasc Surg 2000;31:742-50.

Prevention of Paraplegia during Thoracoabdominal Aortic Aneurysm Repair

AbstractParaplegia affects up to 22% of patients undergoing thoarcoabdominal aneurysm surgery, producing long-term morbidity and a significant burden to healthcare. This article discusses the mechanisms that may lead to paraplegia during open and endovascular repair from an anatomical and physiological perspective. There are many adjuncts that must be considered to reduce the risk of spinal cord injury, such as revascularisation of intercostal arteries, maintenance of high mean blood pressure, spinal cord drainage and cooling. These adjuncts are discussed, highlighting the evidence available for each method and the practical ways in which they may be used