Hashem M. Barakat

Preoperative Supervised Exercise Improves Outcomes After Elective Abdominal Aortic Aneurysm Repair: A Randomized Controlled Trial.

Objective: The aim of the study was to assess the impact of a preoperative medically supervised exercise program on outcomes after elective abdominal aortic aneurysm (AAA) repair. Background: Functional capacity is an important predictor of postoperative outcomes after elective AAA repair. Improving patients’ preoperative fitness with exercise has the potential to positively influence recovery. Methods: A randomized controlled trial was performed at a tertiary vascular unit. Patients scheduled for open or endovascular AAA repair were randomized to either 6 weeks of preoperative supervised exercise or standard treatment using sealed envelopes. The primary outcome measure was a composite endpoint of cardiac, pulmonary, and renal complications. Secondary outcome measures were 30-day mortality, lengths of hospital and critical care stay, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, reoperation, and postoperative bleeding. Results: One hundred twenty-four patients were randomized (111 men, mean [SD] age 73 [7] y). Fourteen patients sustained postoperative complications in the exercise group (22.6%), compared with 26 in the nonexercise group (41.9%; P = 0.021). Four patients (2 in each group) died within the first 30 postoperative days. Duration of hospital stay was significantly shorter in the exercise group (median 7 [interquartile range 5–9] vs 8 [interquartile range 6–12.3] d; P = 0.025). There were no significant differences between the groups in the length of critical care stay (P = 0.845), APACHE II scores (P = 0.256), incidence of reoperations (P = 1.000), or postoperative bleeding (P = 0.343). Conclusions: A period of preoperative supervised exercise training reduces postoperative cardiac, respiratory, renal complications, and length of hospital stay in patients undergoing elective AAA repair.

Meta-analysis of angiotensin converting enzyme inhibitors effect on walking ability and ankle brachial pressure index in patients with intermittent claudication

OBJECTIVE The aim of this meta-analysis was to investigate the effect of angiotensin converting enzyme (ACE) inhibitors on maximum walking distance (MWD), pain-free walking distance (PFWD) and ankle brachial pressure index (ABPI) in patients with intermittent claudication (IC). METHODS MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to July 2013 on randomised controlled trials (RCTs) that assessed the effect of ACE inhibitors on MWD, PFWD and ABPI in patients with IC. RESULTS Of 348 publications found, a meta-analysis was conducted of 6 RCTs comprising 821 patients. Treatment with ACE inhibitors improved MWD by mean difference (95 per cent confidence interval) of 120.8 (2.95-238.68) m (P = 0.040), improved PFWD by 74.87 (25.24-124.50) m (P = 0.003) and insignificantly improved ABPI by 0.07 (-0.02-0.17) (P = 0.110) compared to placebo. Heterogeneity across studies was significant. Maximum treatment benefit was achieved after a 6-months treatment period with ramipril as the ACE inhibitor. CONCLUSION Treatment with ACE inhibitors improved walking ability in patients with IC. However, this was not associated with significant improvement in ABPI. Patients with IC might benefit from treatment with a high tissue affinity ACE inhibitor for a period of 6 months.

Prediction of organ‐specific complications following abdominal aortic aneurysm repair using cardiopulmonary exercise testing

This study aimed at assessing whether measures of aerobic fitness can predict postoperative cardiac and pulmonary complications, 30‐day mortality and length of hospital stay following elective abdominal aortic aneurysm repair. We prospectively collected cardiopulmonary exercise testing data over two years for 130 patients. Upon multivariate analysis, a decreased anaerobic threshold (OR (95% CI) 0.55 (0.37–0.84); p = 0.005) and open repair (OR (95% CI) 6.99 (1.56–31.48); p = 0.011) were associated with cardiac complications. Similarly, an increased ventilatory equivalent for carbon dioxide (OR (95% CI) 1.18 (1.05–1.33); p = 0.005) and open repair (OR (95% CI) 14.29 (3.24–62.90); p < 0.001) were associated with pulmonary complications. Patients who had an endovascular repair had shorter hospital and critical care lengths of stay (p < 0.001). Measures of fitness were not associated with 30‐day mortality or length of hospital stay. Cardiopulmonary exercise testing variables, therefore, seem to predict different postoperative complications following abdominal aortic aneurysm repair, which adds value to their routine use in risk stratification and optimisation of peri‐operative care.

The Vicorder device compared with SphygmoCor in the assessment of carotid-femoral pulse wave velocity in patients with peripheral arterial disease.

To assess the reliability and reproducibility of the Vicorder’s carotid–femoral pulse wave velocity (cfPWV) measurements in patients with peripheral arterial disease (PAD) and to compare between cfPWV measurements obtained using the Vicorder with those obtained using the SphygmoCor device as a reference. Some 30 patients with PAD (23 men, mean age 64.9±7.5) underwent cfPWV measurement twice by a single investigator during one visit using the Vicorder and the SphygmoCor according to the manufacturer’s instructions. Intra-rater reproducibility for each device was assessed using intraclass correlation coefficients (ICC) and Bland–Altman method. The latter was also used to compare between the two devices. The mean difference (s.d.) between repeated measurements was 0.03±0.92 m s−1, P=0.85 and 0.01±0.54 m s−1, P=0.91 for the SphygmoCor and Vicorder, respectively. Measurements of cfPWV were highly reproducible using both devices (ICC=0.94 and 0.92, for the Vicorder and SphygmoCor, respectively). Limits of Agreement using the Bland–Altman method were −1.07 to 1.09 m s−1 and −1.79 to 1.85 m s−1 for the Vicorder and the SphygmoCor, respectively. Bland–Altman plots indicated that 90% of the cfPWV measurements using the Vicorder and 93% of the measurements using the SphygmoCor fell within two s.d.s of the mean difference. Transit time (TT) differed significantly between the two devices (mean difference 30±9.2 m s, P<0.001), with the Vicorder recording higher values. Nevertheless, the two devices recorded nearly similar cfPWV measurements (mean difference −0.69±1.6 m s−1, P=0.02) with 97% of cfPWV values falling within two s.d. values of the mean difference on Bland–Altman plot. Both devices generated highly reproducible cfPWV measurements in patients with PAD and were in good agreement when compared with each other. However, the discrepancy in TT between the two devices lead to the Vicorder producing lower values of cfPWV at high values produced by the SphygmoCor.

Outcomes after Open Repair of Ruptured Abdominal Aortic Aneurysms in Octogenarians: A 20-Year, Single-Center Experience

BACKGROUND The purpose of this study was to evaluate morbidity, mortality, and survival in octogenarians undergoing open repair of ruptured abdominal aortic aneurysms (RAAAs) in comparison to younger patients. METHODS This investigation was a retrospective analysis of a prospectively maintained database from a tertiary referral center. We included all consecutive RAAA patients who underwent open repair from 1990 to 2011. Univariate and multivariate analyses were used to identify predictors of inferior short- and long-term outcomes. RESULTS Overall, 463 patients were identified, of whom 138 (30%) were octogenarians (group 2), with a mean age of 84 ± 0.47 years. There were 96 (69%) men and 42 women (31%). There were more women in group 2 (31%) compared with the <80-year-old patients of group 1 (14%) (P < 0.001). The 30-day mortality for group 2 was 43.5% compared with 28.0% for group 1 (P < 0.001). Preoperatively, 63% of group 1 patients presented with shock compared with 65% of those in group 2 (P = 0.751). There was no difference between the two groups in terms of preoperative systolic blood pressure (SBP), duration of operation, and intraoperative blood loss (P > 0.05). Median preoperative hemoglobin (P < 0.001) and creatinine (P = 0.031) levels were significantly different between the groups. There was no significant difference between the two groups in terms of postoperative complications and length of hospital stay. Median long-term survival for octogenarians (group 2) was 5.4 years compared with 12.4 years for the younger patient group (group 1) (P < 0.001). Multivariate analysis identified age as an independent predictor of 30-day mortality (odds ratio [OR] = 1.154, 95% confidence interval [CI] 1.037-1.285) and inferior long-term survival (OR = 1.074, 95% CI 1.011-1.141). History of cigarette smoking also predicted worse long-term outcomes (OR = 3.044, 95% CI 1.318-7.032) as did multiorgan failure in the postoperative course (OR = 1.363, 95% CI 1.080-14.130). CONCLUSIONS Advanced age is associated with high surgical mortality; however, for octogenarians surviving surgical repair, long-term outcome is acceptable. Therefore, with responsible decision-making, surgical intervention is justifiable in the elderly. Smoking and multiorgan failure were both predictive of worse survival.

Attitudes towards the surgical safety checklist and factors associated with its use: A global survey of frontline medical professionals

Background The Surgical Safety Checklist (SSC) has been shown to reduce perioperative errors and complications and its implementation is recommended by the World Health Organisation (WHO). However, it is unknown how widely this intervention is used. We investigated attitudes and factors associated with use of WHO SSC in frontline medical professionals across the globe using a survey distributed through social networks. Methods A survey of usage and opinions regarding the SSC was posted on the Facebook and Twitter pages of a not-for-profit surgical news website for one month (March 2013). Respondents were grouped into four groups based on their countrys Gross National Income: high, upper middle, lower middle and low income. Univariate and multivariate analyses were performed to investigate how different factors were associated with the use of the SSC. Results 6269 medical professionals from 69 countries responded to the survey: most respondents were from lower middle (47.4%) countries, followed by: high (35.0%), upper middle (14.6%), and low (3.0%) income countries. In total, 57.5% reported that they used the WHO SSC perioperatively. Fewer respondents used the WHO SSC in upper middle, lower middle and low income countries (LMICs) compared to high income countries (43.5% vs. 83.5%, p < 0.001). Female (61.3% vs. 56.4% males, p = 0.001), consultant surgeons (59.6% vs. 53.2% interns, p < 0.001) and working in university hospitals (61.4% vs. 53.7% non-university hospitals, p < 0.001) were more likely to use the SSC. Believing the SSC was useful, did not work or caused delays was independently associated with the respondents reported use of the SSC (OR 1.22 95% CI 1.07–1.39; OR 0.47 95% CI 0.36–0.60; OR 0.64 95% CI 0.53–0.77, respectively). Conclusion This study suggests the use of the WHO SSC is variable across countries, especially in LMICs where it has the most potential to improve patient safety. Critical appraisal of the documented benefits of the WHO SSC may improve its adoption by those not currently using it.

Chylous Ascites Complicating Elective Abdominal Aortic Aneurysm Repair: Case Report and Review of Treatment Options

Introduction: Chylous ascitis is a rare complication of abdominal aortic aneurysm (AAA) surgery with only 38 cases reported since the early 70s. Due to their anatomical relation with the abdominal aorta, cisterna chyli injury is more common following open AAA repairs when compared to other surgeries; 81% of all postsurgical chylous ascites reported. Case presentation: We present a case of severe chylous ascitis following elective AAA repair in a 76-year-old caucasian male who gradually developed abdominal distension following discharge. A conservative approach was followed by a peritoneovenous shunt insertion, but this had no clinical benefit. The site of chyle leak was identified and ligated at relaparatomy to eventually resolve his ascitis. Conclusion: Many reports in literature demonstrate successful conservative measures and highlight the importance of nutritional status in the course of persistent postoperative chylous ascitis. In our experience, complete resolution only came after relaparatomy and repair of leaking lymphatics.

Endovascular versus Open Repair of Asymptomatic Popliteal Artery Aneurysms: A Systematic Review and Meta-Analysis

This systematic review compared outcomes between endovascular and open repair of asymptomatic popliteal artery aneurysms (PAAs). Endovascular repair was associated with increased 30-day graft occlusion (odds ratio [OR] = 3.14; 95% confidence interval [CI], 1.43-6.92) and increased 30-day reintervention (OR = 4.09; 95% CI, 2.79-6.00). The 12-month primary patency rate was significantly higher in the open repair group (hazard ratio = 1.95; 95% CI, 1.14-3.33). Endovascular repair was associated with shorter length of hospital stay (mean difference = -3 d; 95% CI, -4.09 to -1.91; P < .001). Endovascular repair is associated with inferior perioperative and postoperative outcomes compared with open repair.