Asif Mahmood

Randomized clinical trial comparing the effects on renal function of hydroxyethyl starch or gelatine during aortic aneurysm surgery

The optimal colloid for renal protection during abdominal aortic aneurysm (AAA) surgery is not known. This study compared the effects of two hydroxyethyl starch (HES) solutions and gelatine on perioperative renal function.

Randomized Trial Comparing Quixil Surgical Sealant with Kaltostat Hemostatic Dressing to Control Suture Line Bleeding after Carotid Endarterectomy with ePTFE Patch Reconstruction

Following carotid endarterectomy (CEA), patch angioplasty provides a significant reduction in the risk of perioperative complications. The expanded polytetrafluoroethylene (ePTFE) patch is strong, is resistant to infection, and has low thrombogenicity; but it remains unpopular because of its tendency of prolonged bleeding at the suture line. We aimed to investigate whether the application of Quixil sealant to the suture line could improve the time to achieve hemostasis and reduce local blood loss when compared to a standard topical hemostat Kaltostat. A prospective, randomized trial of 20 patients undergoing CEA was undertaken. Patients were randomized to receive either Quixil sealant (treatment group) or topical Kaltostat (controls) as a hemostatic agent to the patch suture line. Hemostasis was defined as no bleeding at the suture line for 1 minute. Statistical analysis was performed using the Mann-Whitney test. The two groups had a similar age and sex distribution. The mean age was 71 years, and there were seven men and three women in each group. The time to achieve hemostasis was significantly lower in the Quixil group (median 2.5 minutes, range 1–4 minutes) compared to the controls (median 17 minutes, range 7–59 minutes) (p < 0.001). Blood loss after clamp release was also significantly reduced in the Quixil group; median 24.5 ml (range 5.5–105.0 ml) versus 203 ml (range 54.5–817.0 ml) (p < 0.001). This study has demonstrated that Quixil human surgical sealant is an effective sealant of ePTFE patch suture holes and does not compromise the patch repair. It could be used during other vascular procedures involving ePTFE.

Splanchnic Microcirculation Protection by Hydroxyethyl Starches During Abdominal Aortic Aneurysm Surgery

OBJECTIVE To specifically compare the effect of two hydroxyethyl starches (HES) on the splanchnic microcirculation and systemic inflammation during abdominal aortic aneurysm (AAA) surgery. MATERIALS AND METHODS A prospective randomised study was carried out on 62 patients who received HES of molecular-weight 200 kDa (HES200/0.62), 130 kDa (HES130/0.4) or gelatine for 24h peri-operatively. Gastric-mucosal pHi (GpHi) and anti-endotoxin antibody were used as markers of splanchnic perfusion and endotoxaemia respectively. C-reactive protein (CRP) and lung-injury score (LIS) were used as markers of systemic inflammation and end-organ dysfunction respectively. Data was collected prospectively. RESULTS The drop in GpHi was least with HES200/0.62 compared to HES130/0.4 and gelatine at reperfusion (7.32 vs 7.28 and 7.28, p=0.017 and 0.009 respectively) and compared to gelatine at 2h as well (7.43 vs 7.28, p=0.001). GpHi dropped less with HES130/0.4 compared to gelatine at 2h (7.39 vs 7.28, p=0.002). Endotoxaemia increased only with gelatine. CRP was lower with HES200/0.62 (178 mg/mL) than gelatine (221 mg/mL) and HES130/0.4 (223 mg/mL) at 48 h (p=0.049 and p=0.009 respectively). There was no difference in LIS but ventilation duration was less with HES200/0.62 compared with gelatine (4 vs 11h, p=0.012). CONCLUSION During AAA surgery, HES200/0.62 provides the best splanchnic microcirculation protection, also reducing inflammation and duration of ventilation.

Ruptured inflammatory aortic aneurysm with aortoenteric fistula and infected with Streptococcus pneumoniae: a review of the literature

We present a case report of a 65-year-old gentleman who presented with an aortoenteric fistula along with a review of the literature. He was found, in addition, to have an inflammatory infrarenal aortic aneurysm with a posterior rupture. Cultures of the aneurysm sac confirmed a Streptococcus pneumoniae infection. The patient had previously presented with pneumonia. Antibody testing revealed an isolated pneumococcal IgG deficiency. The case demonstrates the diverse pathologies associated with aortic aneurysms and a need to be vigilant and occasionally expect the unusual.

Temporal artery biopsy: impact on the clinical management of patients

ObjectivesTemporal artery biopsy (TAB) is requested in an attempt to confirm the diagnosis of temporal arteritis (TA). Patients symptoms and signs are highly variable and TA is often focal and potentially missed in a small biopsy. The study aimed to determine if TAB helps in the management of patients with suspected TA.MethodsThe case records of sixty-six consecutive patients who had undergone temporal artery biopsy were recalled and examined for presenting symptoms, management, therapy, results and outcome.ResultsThere were 23 men and 43 women with a mean age of 70.2 and 71.1 years respectively. Presenting symptoms varied with unilateral headache in 53, scalp tenderness in 16, muscle weakness in 10, visual disturbance in 16, jaw claudication in 5 and peri-orbital pain in 1 patient. The temporal artery was tender in 21 patients and thickened in 4 patients. Thirty-eight patients were commenced on steroids prior to biopsy and 6 more before the histology became available. Only 8% of biopsies were positive for TA. Of the patients started on steroids with a negative biopsy, the steroids were continued in 26 and stopped in 9. In the patients not put on steroids [22], biopsy was positive in 2; they were commenced on steroids. Therefore, the histological diagnosis resulted in a change in patient management in only 18% of patients.ConclusionThe results of TAB do not appear to affect the clinical management of most patients with suspected temporal arteritis. We must therefore question the routine use of this invasive investigation.