Francesco Torella

Autologous versus allogeneic transfusion in aortic surgery: a multicenter randomized clinical trial.

ObjectiveTo evaluate the efficacy of acute normovolemic hemodilution (ANH) and intraoperative cell salvage (ICS) in blood-conservation strategies for infrarenal aortic surgery. Summary Background DataRecent concerns over the risks of transfusion-related infection have resulted in sharp rises in the cost of blood preparations. Autologous transfusion may be a safe alternative to allogeneic transfusion, which has been associated with immune modulation and postoperative infection. MethodsThis multicenter prospective randomized trial compared standard transfusion practice with autologous transfusion combining ANH with ICS in 145 patients undergoing elective aortic surgery. The primary outcome measures were the proportion of patients requiring allogeneic blood and the volume of allogeneic transfusion. The secondary outcome measures were the frequency of complications, including postoperative infection, and postoperative hospital stay. ResultsThe combination of ANH and ICS reduced the volume of allogeneic blood transfused from a median of two units to zero units. The proportion of patients transfused was 56% in allogeneic and 43% in autologous. There were no significant differences in complications or length of hospital stay. ConclusionsBoth ANH and ICS were safe and reduced the allogeneic blood requirement in patients undergoing elective infrarenal aortic surgery.

Acute normovolemic hemodilution in moderate blood loss surgery: a randomized controlled trial

BACKGROUND:  The risks associated with allogeneic blood transfusion are increasingly recognized. More blood is cross‐matched for moderate blood loss surgery than any other indication. The role of acute normovolemic hemodilution (ANH) as a blood transfusion strategy was evaluated in a prospective randomized controlled trial.

Late Rupture of Abdominal Aortic Aneurysm After Previous Endovascular Repair: A Systematic Review and Meta-analysis.

Purpose: To report a systematic literature review of late rupture of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) and the results of a pooled analysis of causes, treatment, and outcomes. Methods: Electronic information sources and bibliographic reference lists were interrogated using a combination of free text and controlled vocabulary searches; 11 articles were ultimately identified that fulfilled the inclusion criteria. The articles reported a total of 190 patients who were included in the qualitative and quantitative synthesis. Mortality within 30 days or during the admission with aneurysm rupture was a primary endpoint; major perioperative morbidity was a secondary endpoint. A meta-analysis was performed for 30-day/in-hospital mortality using the random effects model. Results: A total of 152 ruptures occurred after 16,974 EVAR procedures reported by 8 of the case series, giving an incidence of 0.9% [95% confidence interval (CI) 0.77 to 1.05]. The mean time to rupture was 37 months. Twenty-nine percent (95% CI 20 to 39) of the patients had at least one previous secondary endovascular intervention following the initial EVAR, and 37% (95% CI 30 to 45) were not compliant with surveillance. Type I and III endoleaks were the predominant causes of rupture. Open surgical treatment was undertaken in 61% (95% CI 53 to 68) of the patients who underwent treatment. The pooled estimate for perioperative mortality was 32% (95% CI 24 to 41). A significantly lower mortality was found with endovascular treatment than open surgical management (p=0.027). Conclusion: Graft-related endoleaks appear to be the predominant causes of late aneurysm rupture. Quality of and compliance with post-EVAR surveillance are important factors in late rupture; a large proportion of late ruptures are amenable to endovascular treatment.

Regional tissue oxygenation during hemorrhage: can near infrared spectroscopy be used to monitor blood loss?

We investigated whether near infrared spectroscopy could be used to monitor regional tissue oxygenation during uncompensated hemorrhage in man. A Somanetics INVOS 4100 oximeter was used to measure regional hemoglobin oxygen saturation in the cerebral cortex (CsO2, left frontal area) and from the left calf muscle (PsO2) in 40 volunteers donating 470 mL of the whole blood. A Critikon 2001 Cerebral Redox Instrument was used to monitor total (tHb), oxygenated (O2Hb), and deoxygenated (HHb) hemoglobin in the right calf muscle. The oxygenation index, [HbD] = [O2Hb] − [HHb] was derived. CsO2 decreased by a mean (95% CI) of 2 (1–3.3%) (P < 0.001), PsO2 decreased by a mean (95% CI) of 3.2 (1.7–4.6%) (P < 0.001), and HbD decreased by a median (95% CI) of 6.4 (2.65–10.16) &Dgr;&mgr;M/cm (P < 0.001) during blood collection. There was an inverse correlation between blood loss and CsO2 (R = −0.59, P < 0.001), PsO2 (R = −0.61, P < 0.001), and HbD (R = −0.5, P < 0.001). Regional tissue oxygenation decreases in proportion to uncompensated blood loss. Near infrared spectroscopy may potentially be developed into a transfusion trigger.

Meta-analysis of the effects of statins on perioperative outcomes in vascular and endovascular surgery.

BACKGROUND Compelling evidence from large randomized trials demonstrates the salutary effects of statins on primary and secondary protection from adverse cardiovascular events in high-risk populations. Our objective was to investigate the role of perioperative statin therapy in noncardiac vascular and endovascular surgery. METHODS Electronic information sources were systematically searched to identify studies comparing outcomes after noncardiac surgical or endovascular arterial reconstruction in patients who were and were not taking statin in the perioperative or peri-interventional period. The Cochrane Collaborations tool and the Newcastle-Ottawa scale were used to assess the methodologic quality and risk of bias of the selected studies. Random-effects models were applied to calculate pooled outcome data. RESULTS Four randomized controlled trials and 20 observational cohort or case-control studies were selected for analysis. The randomized studies enrolled 675 patients, and the observational studies enrolled 22,861 patients. Statin therapy was associated with a significantly lower risk of all-cause mortality (odds ratio [OR], 0.54; 95% CI, [CI], 0.38-0.78), myocardial infarction (OR, 0.62; 95% CI, 0.45-0.87), stroke (OR, 0.51; 95% CI, 0.39-0.67), and the composite of myocardial infarction, stroke, and death (OR, 0.45; 95% CI, 0.29-0.70). No significant differences in cardiovascular mortality (OR, 0.82; 95% CI, 0.41-1.63) and the incidence of kidney injury (OR, 0.90; 95% CI, 0.58-1.39) between the groups were identified. CONCLUSIONS Our analysis demonstrated that statin therapy is beneficial in improving operative and interventional outcomes and should be considered as part of the optimization strategy for prevention of adverse cardiovascular and cerebrovascular events and death.

Cerebral and peripheral oxygen saturation during red cell transfusion

BACKGROUND Changes in regional hemoglobin oxygen saturation occur in response to blood transfusion and can be measured by near infrared spectroscopy. PATIENTS AND METHODS Cerebral (CsO2) and peripheral (PsO2) oxygen saturation were monitored with an INVOS 4100 near infrared spectroscopy oximeter in 29 patients undergoing 84 intraoperative blood transfusions during aortic or spinal surgery. Hemoglobin concentration was measured before and after transfusion. Mean arterial pressure, end tidal carbon dioxide tension, and arterial oxygen saturation were also monitored. RESULTS Mean arterial pressure, arterial oxygen saturation and end tidal carbon dioxide tension remained stable during transfusion, while CsO2 rose by a mean (95% CI) of 4.2 (3.2-5.2%; P = 0.001) and PsO2 rose by a mean (95% CI) of 1.6 (0.3-2.8%; P = 0.016). The rise in CsO2 correlated well with the rise in hemoglobin (r = 0.59, P < 0.001) and with the volume transfused (r = 0.58, P < 0.001). PsO2 correlated with the volume transfused (r = 0.35, P = 0.019) but not with hemoglobin concentration (r = 0.08, P = 0.47). CONCLUSIONS Near infrared spectroscopy detected significant rises in tissue oxygenation in response to blood transfusion, particularly in the cerebral cortex. CsO2 may be developed into a blood loss monitor if further research confirms our findings.

Cerebral and peripheral near-infrared spectroscopy: an alternative transfusion trigger?

Background and Objectives To develop a transfusion trigger based on tissue oxygenation, near‐infrared spectroscopy (NIRS) was evaluated in a model of compensated haemorrhage.

Unchanging attitudes to autologous transfusion in the UK

. Our aim was to assess changes in attitudes to autologous transfusion amongst surgeons over a 10‐year period in response to scientific evidence, public awareness, published guidelines, management and the increasing cost of blood products.

Monitoring blood loss with near infrared spectroscopy

Experimental research has shown correlation between near infrared spectroscopy (NIRS) and blood loss, but these findings have not been validated in man. Ten blood donors were monitored before, during and for 10 min after blood collection (470 ml) with NIRS. A Somanetics INVOS 4100 oximeter monitored regional haemoglobin saturation in the cerebral cortex (cSO(2)-left frontal area) and from the left calf (pSO(2)). A Critikon 2001 Cerebral Redox Model monitored total (tHb), oxygenated (O(2)Hb) and deoxygenated (HHb) haemoglobin from the right calf. The oxygenation index [HbD]=[O(2)Hb]-[HHb] was derived from the data. cSO(2) (P<0.001), pSO(2) (P<0.001) and HbD (P=0.001) decreased during blood collection. Maximum changes occurred 10 minutes after collection for cSO(2), with a mean fall (95% C.I.) of 2.5 (-0.06-4.86)%, at the end of blood collection for pSO(2), with a mean fall (95% C.I.) of 3 (0.74-5.26)% and after 8% of blood volume loss for HbD, with a mean fall (95% C.I.) of 7.2 (2.25-12.16). Cerebral and peripheral oxygenation did not recover after blood collection. There was good correlation between NIRS parameters and blood loss. NIRS is a potentially useful technique for monitoring blood loss in humans. Further research is needed to define its role in clinical practice.

Prediction of Major Adverse Cardiac Events in Vascular Surgery: Are Cardiac Risk Scores of Any Practical Value?

Background: Disease-specific preoperative scoring systems are often used to predict postoperative cardiac complications. We retrospectively evaluated the accuracy of 2 cardiac risk scores in the prediction of major adverse cardiac events (MACE) after vascular surgery. Methods: Consecutive procedures were ‘‘scored’’ according to the Revised Cardiac Risk Index (RCRI) and the Eagle criteria. Two ‘‘generic’’ risk scoring systems, ASA (American Society of Anesthesiology) grade and the physiology Portsmouth POSSUM (P-POSSUM) score, were also documented for comparison. Results: After 344 surgical procedures, 18 patients suffered a MACE (5.2%; 95% CI = 2.8-7.58-4 fatal). The RCRI (AUC 95% CI = 0.68 [0.57-0.83], P = .009) and the Eagle criteria (AUC 95% CI = 0.73 [0.57-0.8], P = .001) were no better than P-POSSUM (AUC 95% CI = 0.82 [0.73-0.91], P < .001) and ASA grade (AUC 95% CI = 0.67 (0.56-0.78), P = 0.016) in predicting MACE. Of the variables included in the 2 cardiac scoring systems, only age and history of ischemic heart disease were associated with MACE in our patients. Conclusion: Cardiac risk scores were no better than generic risk scoring systems in predicting MACE. Poor performance may be due to differences between our patient population and those in which the scores were developed and to improved perioperative management of cardiac risk.