J. Jenkins

Important observations made managing carotid body tumors during a 25-year experience

OBJECTIVES Our objective was to assess the short- and long-term outcome for patients after carotid body tumor (CBT) resection and discuss the potential pitfalls of the treatment. METHODS An analysis was undertaken of all patients who underwent CBT resection at Royal Brisbane and Womens Hospital and Greenslopes Private Hospital between 1982 and 2007. Primary tumor characteristics, surgical technique, and outcomes were recorded and analyzed. RESULTS A total of 49 consecutive CBT resections (2 recurrent tumors) were carried out in 39 patients (26 women [56%]) who were a mean age of 49 years (range, 17-75 years). A nontender neck mass was the presenting complaint in 85%, followed by screening in familial or contralateral tumors in 26%. Familial cases occurred in 11 patients (28%). There were no operative deaths. Complications occurred in 13 of the 49 operations (27%), predominantly temporary nerve palsies and were more likely to occur in tumors of large volume or in cases of removal of coexisting vagal tumors. Malignant disease was present in seven cases (15%). All patients have been followed-up postoperatively for a mean of 11 years (range, 2-26 years). Metachronous paragangliomas have been discovered in six patients, all with familial disease. CONCLUSIONS Early resection of carotid body tumors should be undertaken while still small to minimize the risk of neural injury, which increases with tumor size. In cases of bilateral CBT, we recommend that the smaller tumor be resected first, before the staged resection of the larger contralateral tumor. In familial or bilateral tumor cases, other synchronous and metachronous paragangliomas should be excluded. Mandatory lifelong follow-up is essential.

Using postoperative cardiac Troponin-I (cTi) levels to detect myocardial ischaemia in patients undergoing vascular surgery

BACKGROUND Cardiac complications occur commonly in vascular surgery patients. Diagnosis of cardiac complications is difficult because of the inaccuracies associated with traditional cardiac enzyme measurements. CTi, a highly sensitive and specific marker of myocardial injury, may be able to detect cardiac complications with greater ease and accuracy. METHODS The study prospectively examined 100 consecutive patients who underwent major vascular surgery between 6/7/98 and 31/12/98 at the Royal Brisbane Hospital. Daily measurements of cTi, creatine kinase (CK), creatine kinase MB (CKMB), CKMB index, renal function and haemoglobin were taken for three postoperative days. One postoperative electrocardiograph (ECG) was taken. An extensive cardiac history was taken. Intraoperative and postoperative events were recorded. FINDINGS There were 100 patients. 18 patients (18%) had a cTi elevation. On the basis of classical diagnostic criteria, 15 patients (15%) suffered one or more cardiac complication (either myocardial infarction, congestive cardiac failure, unstable angina or atrial fibrillation). One patient (1%) who had a cTi elevation died. CTi elevation occurred in five patients (5%) who were not diagnosed with cardiac complications based on traditional criteria. Despite not meeting specific diagnostic criteria for cardiac complications, all patients showed signs and symptoms that could be attributed to myocardial ischaemia. Every patient who developed congestive cardiac failure or atrial fibrillation had a cTi elevation. A Chi-square analysis revealed a significant association between cTi elevation and postoperative cardiac complications. Four variables contributed small but significant amounts of unique variance to the prediction of peak cTi on linear regression analysis. These were peak CKMB index, postoperative congestive cardiac failure, postoperative chest pain and postoperative cardiac complications. CONCLUSIONS Routine cTi monitoring of postoperative vascular patients would be an effective and inexpensive way to detect patients with cardiac complications. The relationship between postoperative cTi elevation and significant coronary artery disease remains to be shown.

Thrombus volume is similar in patients with ruptured and intact abdominal aortic aneurysms

OBJECTIVE Most abdominal aortic aneurysms (AAAs) contain intraluminal thrombus (ILT), which has been demonstrated to contain proteolytic enzymes and proinflammatory cytokines implicated in AAA progression and rupture. In animal models, anticoagulants have been shown to limit AAA progression. Whether ILT plays a role in AAA rupture is unknown. The aim of this study was to compare the volume of ILT in patients with ruptured and intact AAAs. METHODS We matched by maximum axial diameter alone, on a 1:2 basis, 28 patients with ruptured AAAs and 56 patients with intact AAAs. Total infrarenal aortic volume and ILT volume were measured from computed tomography angiograms using a previously validated and reproducible semiautomated workstation protocol. Clinical risk factors were also recorded. The Mann-Whitney U test was used to compare ILT volumes between patients with ruptured and intact AAAs. RESULTS Median (interquartile range [IQR]) maximum AAA diameter (84.0 [77.5-93.9] mm vs 82.6 [77.1-93.3] mm; P = .769) and median (IQR) total AAA volume (372.8 [277.4-486.1] cm(3) vs 358.4 [289.1-563.4] cm(3); P = .977) were similar in patients with ruptured and intact AAAs. Median (IQR) AAA ILT volume was similar in patients with ruptured (152.7 [84.8-252.4] cm(3)) and intact (180.1 [89.9-254.8] cm(3); P = .414) AAAs. CONCLUSIONS This study suggests that ILT volume is not different in ruptured and intact AAAs.

Association between metformin prescription and growth rates of abdominal aortic aneurysms

It has been suggested that diabetes medications, such as metformin, may have effects that inhibit abdominal aortic aneurysm (AAA) growth. The aim of this study was to examine the association of diabetes treatments with AAA growth in three patient cohorts.

Long-term outcomes and factors influencing late survival following elective abdominal aortic aneurysm repair: a 24-year experience

Background Abdominal aortic aneurysms can be either treated by an open abdominal aortic aneurysm repair or an endovascular repair. Comparing clinical predictors of outcomes and those which influence survival rates in the long term is important in determining the choice of treatment offered and the decision-making process with patients. Aims To determine the influence of pre-existing clinical predictors and perioperative determinants on late survival of elective open abdominal aortic aneurysm repair and endovascular repair at a tertiary hospital. Methods Consecutive patients undergoing elective abdominal aortic aneurysm repair from 1990 to 2013 were included. Data were collected from a prospectively acquired database and death data were gathered from the Queensland state death registry. Pre-existing risks and perioperative factors were assessed independently. Kaplan–Meier and Cox regression modeling were performed. Results During the study period, 1340 abdominal aortic aneurysms were repaired electively, of which 982 were open abdominal aortic aneurysm repair. The average age was 72.4 years old and 81.7% were males. The cumulative percentage survival rates for open abdominal aortic aneurysms repair at 5, 10, 15 and 20 years were 79, 49, 31 and 22, respectively. The corresponding 5-, 10- and 15-year survival rates for endovascular repair were not significantly different at 75, 49 and 33%, respectively (P = 0.75). Predictors of reduced survival were advanced age, American Society of Anaesthesiology scores, chronic obstructive pulmonary disease, renal impairment, bifurcated grafts, peripheral vascular disease and congestive heart failure. Conclusions Open repair offers a good long-term treatment option for patients with an abdominal aortic aneurysm and in our experience there is no significant difference in late survival between open abdominal aortic aneurysms repair and endovascular repair. Consideration of the factors identified in this study that predict reduced long-term survival for open abdominal aortic aneurysms repair and endovascular repair should be considered when deciding repair of abdominal aortic aneurysm.

Metformin prescription is associated with reduced abdominal aortic aneurysm growth in three cohorts

It has been suggested that diabetes medications, such as metformin, may have effects that inhibit abdominal aortic aneurysm (AAA) growth. The aim of this study was to examine the association of diabetes treatments with AAA growth in three patient cohorts.

Risk of major amputation in patients with intermittent claudication undergoing early revascularization

Revascularization is being used increasingly for the treatment of intermittent claudication and yet few studies have reported the long‐term outcomes of this strategy. The aim of this study was to compare the long‐term outcome of patients with intermittent claudication who underwent revascularization compared with a group initially treated without revascularization.

Association Between Metformin Prescription and Growth Rates of Abdominal Aortic Aneurysms

Michael C. Dalsing, MD, SECTION EDITOR Aortic Wall Inflammation Predicts Abdominal Aortic Aneurysm Expansion, Rupture and Need