Open thoracic or thoracoabdominal aortic aneurysm repair after previous abdominal aortic aneurysm surgery

ObjectiveThe purpose of this study was to provide insight into the incidence of thoracic and thoracoabdominal aortic aneurysm repair following previous infrarenal abdominal aortic aneurysm (AAA) surgery and to determine whether thoracic or thoracoabdominal aortic aneurysm repair after prior infrarenal AAA surgery is associated with higher mortality and morbidity rates.MethodsMEDLINE, Cochrane Library CENTRAL, and EMBASE databases were searched for relevant articles. Selected articles were critically appraised and meta-analyses were performed.ResultsA total of 12.4% of patients with thoracic aortic aneurysms and 18.7% of patients with thoracoabdominal aortic aneurysms have had prior AAA surgery. The chance of developing a thoracic aortic aneurysm in patients with AAA is 2.2% and 2.5% for developing a thoracoabdominal aortic aneurysm. The mean time interval between prior AAA surgery and subsequent thoracoabdominal aortic aneurysm surgery or detection is 8.0 years with a wide variation between individuals. Surgery in these patients is technically feasible. The 30-day mortality of patients undergoing open thoracoabdominal aortic aneurysm repair does not significantly differ from patients without prior AAA surgery and the 30-day mortality is 11.8%. No data were available about mortality of patients with prior AAA repair undergoing thoracic aortic aneurysm surgery. Morbidity risks are higher in patients with thoracic or thoracoabdominal aortic aneurysms. Prior AAA repair was a significant risk factor for neurological deficit after thoracic or thoracoabdominal aortic aneurysms surgery with relative risks (RRs) of 11.1 (95% confidence interval [CI] 3.8-32.3, P value < .0001) and 2.90 (95% CI 1.26-6.65, P value = .008), respectively. Prior AAA repair was a significant risk factor for developing renal failure in patients undergoing thoracoabdominal aortic aneurysm repair (RR 3.47, 95% CI 1.74-6.91, P value = .0001). Determinants of the prognosis in these patients include distal aortic perfusion, distal extent of the landing zone of the graft, drainage of cerebrospinal fluid for thoracic aortic aneurysm repair and age, history of cardiac diseases, extent of the aneurysm, rupture, amount of estimated blood loss, aortic clamp time, and visceral ischemic times for thoracoabdominal aortic aneurysm repair.ConclusionsA considerable group of patients with thoracic or thoracoabdominal aortic aneurysms have had prior AAA repair. The risk of postoperative morbidity is increased in these patients. Mortality appears to be similar for patients with thoracoabdominal aortic aneurysms. Patients with prior AAA repair undergoing thoracic or thoracoabdominal aortic aneurysm repair should be provided maximum care to protect their spinal cord and renal function

Association between hypotension and serious illness in the emergency department: an observational study

Background The value of routine blood pressure measurement in the emergency department (ED) is unclear. Objective To determine the association between hypotension in addition to tachycardia and the Shock Index for serious illness. Design Observational study. Setting University ED (2009–2016). Participants, methods and main outcomes Routine data collected from consecutive children <16 years. Using logistic regression, we assessed the association between hypotension (adjusted for tachycardia) and Shock Index (ratio heart rate/blood pressure [BP]) for serious illness. The predictive accuracy (sensitivity, specificity) for hypotension and Shock Index was determined for serious illness, defined as intensive care unit (ICU) and hospital admissions. Results We included 10 698 children with measured BP. According to three age-adjusted clinical cut-offs (Advanced Paediatric Life Support, Paediatric Advanced Life Support and Paediatric Early Warning Score), hypotension was significantly associated with ICU admission when adjusted for tachycardia (range OR 2.6–5.3). Hypotension showed low sensitivity (rang

Inflammation and endothelial dysfunction are associated with retinopathy: the Hoorn study

AIMS/HYPOTHESIS: The exact pathogenesis of retinopathy in diabetic and non-diabetic individuals is incompletely understood, but may involve chronic low-grade inflammation and dysfunction of the vascular endothelium. The aim of this study was to investigate the association of inflammation and endothelial dysfunction with prevalent retinopathy in individuals with and without type 2 diabetes. METHODS: As part of a population-based cohort study, 625 individuals aged 50-74 years, stratified according to age, sex and glucose tolerance status, underwent an extensive physical examination. Retinopathy was assessed by an ophthalmological examination, including funduscopy and two-field 45 degrees fundus photography with mydriasis in both eyes. Levels of C-reactive protein (CRP), soluble intercellular adhesion molecule-1 (sICAM-1), von Willebrand factor, and soluble vascular adhesion molecule-1 (sVCAM-1) were assessed, together with the urinary albumin : creatinine ratio, and the results were combined to obtain summarising z scores for inflammation and endothelial dysfunction. RESULTS: The prevalence of retinopathy was positively associated with tertiles of CRP and sICAM-1. When compared with the lowest tertile, the highest tertile of the inflammatory z score was associated with retinopathy in all subjects (odds ratio [OR]=2.2, 95% CI 1.2-4.1, adjusted for age, sex and glucose tolerance status). The highest tertile of the endothelial dysfunction z score was associated with retinopathy among diabetic individuals (OR=4.4, 95% CI 1.2-15.9, adjusted for age and sex) but not in non-diabetic individuals. Additional adjustment for other risk factors, such as systolic and diastolic blood pressure, BMI, total cholesterol and triglycerides, or mutual adjustment of the inflammatory and endothelial dysfunction z scores did not change the results. CONCLUSIONS/INTERPRETATION: In this study, inflammatory activity and endothelial dysfunction were associated with retinopathy, which suggests their involvement in the pathogenesis of retinopath

Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm

IntroductionRuptured descending thoracic aortic aneurysm (rDTAA) is associated with high mortality rates. Data supporting endovascular thoracic aortic aneurysm repair (TEVAR) to reduce mortality compared with open repair are limited to small series. We investigated published reports for contemporary outcomes of open and endovascular repair of rDTAA.MethodsWe systematically reviewed all studies describing the outcomes of rDTAA treated with open repair or TEVAR since 1995 using MEDLINE, Cochrane Library CENTRAL, and Excerpta Medica Database (EMBASE) databases. Case reports or studies published before 1995 were excluded. All articles were critically appraised for relevance, validity, and availability of data regarding treatment outcomes. All data were systematically pooled, and meta-analyses were performed to investigate 30-day mortality, myocardial infarction, stroke, and paraplegia rates after both types of repair.ResultsOriginal data of 224 patients (70% male) with rDTAA were identified: 143 (64%) were treated with TEVAR and 81 (36%) with open repair. Mean age was 70 ± 5.6 years. The 30-day mortality was 19% for patients treated with TEVAR for rDTAA compared 33% for patients treated with open repair, which was significant (odds ratio [OR], 2.15, P = .016). The 30-day occurrence rates of myocardial infarction (11.1% vs 3.5%; OR, 3.70, P < .05), stroke (10.2% vs 4.1%; OR, 2.67; P = .117), and paraplegia (5.5% vs 3.1%; OR, 1.83; P = .405) were increased after open repair vs TEVAR, but this failed to reach statistical significance for stroke and paraplegia. Five additional patients in the TEVAR group died of aneurysm-related causes after 30 days, during a median follow-up of 17 ± 10 months. Follow-up data after open repair were insufficient. The estimated aneurysm-related survival at 3 years after TEVAR was 70.6%.ConclusionEndovascular repair of rDTAA is associated with a significantly lower 30-day mortality rate compared with open surgical repair. TEVAR was associated with a considerable number of aneurysm-related deaths during follow-up

A comparison of clinical paediatric guidelines for hypotension with population-based lower centiles: A systematic review

Background: Different definitions exist for hypotension in children. In this study, we aim to identify evidence-based reference values for low blood pressure and to compare these with existing definitions for systolic hypotension. Me