Muhammad Anees Sharif

Role of the Hardman Index in Predicting Mortality for Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysm

Purpose: To correlate the Hardman prognostic index with perioperative mortality in patients undergoing open and endovascular repair of ruptured abdominal aortic aneurysm (rAAA). Methods: Over a 5-year period, 126 patients (109 men; mean age 74 years, range 51–91) underwent open (n=74) or endovascular (n=52) repair of rAAA in a single unit. Five Hardman factors (age >76 years, history of loss of consciousness, ECG evidence of ischemia, hemoglobin <9.0 g/dL, and serum creatinine >0.19 mmol/L) were assessed, and their association with in-hospital or 30-day mortality was evaluated retrospectively by chi-square or logistic regression analysis. Results: The mortality for open repair was 51.4% (38/74) in comparison to 32.7% (17/52) for the endovascular group (p=0.05). On multivariate analysis, loss of consciousness (p=0.03, OR 2.9, 95% CI 1.1 to 7.5) was the only significant predictor of mortality in both groups. The mortality rates for open repair patients with Hardman scores <2 were 43.5% (20/46) in comparison to 22.9% (8/35) for the endovascular group (p=0.06), whereas mortality rates for patients with scores ≥2 were 64.3% (18/28) and 52.9% (9/17) for the respective groups (p=0.54). Conclusion: The Hardman index correlates well with mortality in both the open and endovascular groups. Those with a score <2 have a trend toward better survival following endovascular repair compared to open repair, while this benefit is not obvious in patients with a score ≥2.

The Vascular and Biochemical Effects of Cilostazol in Diabetic Patients With Peripheral Arterial Disease

Objectives: Cilostazol improves walking in patients with peripheral arterial disease (PAD). We hypothesized that cilostazol reduces diabetic complications in PAD patients. Methods: Diabetic PAD patients were prospectively recruited to a randomized double-blinded, placebo-controlled trial, using cilostazol 100mg twice a day. Clinical assessment included ankle-brachial index, arterial compliance, peripheral transcutaneous oxygenation, treadmill walking distance and validated quality of life (QoL) questionnaires. Biochemical analyses included glucose and lipid profiles. All tests were at baseline, 6, and 24 weeks. Results: 26 diabetic PAD patients (20 men) were recruited. Cilostazol improved absolute walking distance at 6 and 24 weeks (86.4% vs. 14.1%, P = .049; 143% vs. 23.2%, P = .086). Arterial compliance and lipid profiles improved as did some QoL indices for cilostazol at 6 and 24 weeks. Blood indices were similar at baseline and at follow-up points for both treatment groups. Conclusions: Cilostazol is a well-tolerated and efficacious treatment, which improves claudication distances in diabetic PAD patients with further benefits in arterial compliance, lipid profiles, and QoL.

Retroperitoneal Repair of Abdominal Aortic Aneurysm Reduces Bowel Dysfunction

Objective: To assess the effect of intestinal manipulation and mesenteric traction on gastro-intestinal function and postoperative recovery in patients undergoing abdominal aortic aneurysm (AAA) repair. Methods: Thirty-five patients undergoing AAA repair were randomised into 3 groups. Group I (n = 11) had repair via retroperitoneal approach while Group II (n = 12) and Group III (n = 12) were repaired via transperitoneal approach with bowel packed within the peritoneal cavity or exteriorised in a bowel bag respectively. Gastric emptying was measured pre-operatively (day 0), day 1 and day 3 using paracetamol absorption test (PAT) and area under curve (PAUC) was calculated. Intestinal permeability was measured using the Lactulose-Mannitol test. Results: Aneurysm size, operation time and PAT (on day 0 and day 3) were similar in the three groups. On day 1, the PAUC was significantly higher in Group I, when compared with Group II and Group III (P = .02). Resumption of diet was also significantly earlier in Group I as compared to Group II and Group III. The intestinal permeability was significantly increased in Group II and Group III at day 1 when compared with day 0, with no significant increase in Group I. Retroperitoneal repair was also associated with significantly shorter intensive care unit (P = .04) and hospital stay (P = .047), when compared with the combined transperitoneal repair group (Group II and III). Conclusion: Retroperitoneal AAA repair minimises intestinal dysfunction and may lead to quicker patient recovery when compared to transperitoneal repair.

Effect of preoperative renal dysfunction on mortality and postoperative renal failure following endovascular abdominal aortic aneurysm repair.

This study was aimed to assess the effect of preoperative renal dysfunction on mortality and postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm. A total of 155 patients with a mean age of 74.9 years (±6.4) were included. In all, 31 patients (20%) had a preoperative creatinine level of >1.5 mg/dL, whereas 66 patients (42.6%) had an estimated glomerular filtration rate of <60 mL/min. Perioperative mortality was 2.6% with no significant difference between those with and without abnormal renal indices. Long-term survival at 4 years was 30% in patients with creatinine >1.5 mg/dL compared to over 60% in those with normal creatinine (P < .02). The difference in long-term survival was not as significant in patients with normal or reduced glomerular filtration rate (P = .13). However, neither creatinine nor glomerular filtration rate were found to accurately predict survival even though both demonstrated strong predictivity for postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm.

N-Acetylcysteine Does Not Improve the Endothelial and Smooth Muscle Function in the Human Saphenous Vein

Oxidative stress can lead to vein graft dysfunction in the saphenous vein. This ex vivo study is aimed to compare the effects of increasing concentrations of the antioxidant N-acetylcysteine (NAC) with heparinized saline (HS) on endothelial and smooth muscle function in the human saphenous vein. Long saphenous vein segment obtained during infrainguinal bypass surgery was divided into 7 rings; 1 immersed in HS and the remaining 6 in increasing NAC concentrations (0.0025%, 0.005%, 0.01%, 0.02%, 0.03%, and 0.04%). Rings were mounted in an organ bath, and relaxant responses to acetylcholine and sodium nitroprusside were assessed through isometric tension studies. Endothelium-dependent relaxations were observed in 77 vein segments from 11 patients. No significant difference was seen in veins treated with either lower NAC concentrations (0.0025%, 0.005%, 0.01%, 0.02%, and 0.03%) or HS. However, HS-treated veins showed significantly better relaxation compared to those treated with maximum (0.04%) NAC (P < .05). Endothelium-independent relaxations were observed in 91 segments from 13 patients. No difference in relaxation was observed between veins treated with HS or any of the NAC concentrations. In conclusion, lower NAC concentrations do not offer better endothelial protection than HS, whereas the highest NAC concentration has a detrimental effect on endothelium-dependent relaxation. Moreover, NAC did not show beneficial effect on direct smooth muscle relaxation.

Retroperitoneal Approach to Abdominal Aortic Aneurysm Repair Preserves Splanchnic Perfusion as Measured by Gastric Tonometry

BACKGROUND We investigated if minimizing bowel manipulation and mesenteric traction using the retroperitoneal approach in open abdominal aortic aneurysm (AAA) repair preserves splanchnic perfusion, as measured by gastric tonometry, and reduces the systemic inflammatory response and dysfunction of the various organs. METHODS Patients undergoing elective AAA repair were randomized into three groups. Group I had repair via the retroperitoneal approach, while groups II and III were repaired via the transperitoneal approach with the bowel packed within the peritoneal cavity or exteriorized in a bowel bag, respectively. A tonometer was used to measure gastric intramucosal pH (pHi), as an indicator of splanchnic perfusion, just prior to aortic clamping, during clamping, and at 0.5, 1, 2, 4, 6, and 12 hr after clamp release. Multiorgan dysfunction syndrome (MODS) and systemic inflammatory response syndrome (SIRS) scores were calculated and systemic interleukins (IL-6 and IL-10) measured at predetermined intervals. RESULTS Thirty-four patients were successfully randomized. The gastric pHi was significantly lower in group II (n=12) and group III (n=11) compared to group I (n=11) during aortic clamping and immediately after clamp release (p<0.05). The aortic clamp time, blood loss, MODS and SIRS scores, and systemic cytokine response were similar in all three groups. When the three groups were combined, there were significant positive correlations between the operation time, aortic clamp time, and amount of blood lost and transfused with plasma IL-6 levels and MODS score on the first postoperative day. CONCLUSION The retroperitoneal approach for open AAA repair is associated with gastric tonometric evidence of better splanchnic perfusion compared to the transperitoneal approach.

Free Esophageal Perforation Following Hybrid Visceral Debranching and Distal Endograft Extension to Repair a Ruptured Thoracoabdominal Aortic Aneurysm

Free esophageal perforation following a hybrid visceral debranching and distal endograft extension to repair a ruptured thoracoabdominal aortic aneurysm (TAAA) is a rare complication. The authors report a 56-year-old male who underwent elective thoracic endovascular aortic repair of a thoracic aneurysm. Four and a half years later, he presented with a new aneurysm extending from the distal end of the thoracic stent graft to the aortic bifurcation involving all the visceral arterial branches. The TAAA ruptured while he was awaiting an elective repair, and as a result, he underwent an emergency hybrid procedure. This involved debranching the visceral arterial branches including autotransplantation of the left kidney and distal endograft extension. Postoperatively, he developed free esophageal perforation secondary to ischemic necrosis requiring esophageal resection and gastric pull-up. The patient was well 6 months after the gastrointestinal restorative procedure. Thus, esophageal perforation following an emergency hybrid repair of ruptured TAAA is a rare complication, and a successful outcome depends on early recognition and surgical exclusion of the ruptured viscus.

Advantages and Pitfalls of Abdominal Aortic Aneurysm Screening in High-Risk Patients

Screening for abdominal aortic aneurysm (AAA) has been suggested for older men. Our aim was to determine the effect of participant selection on prevalence and treatment suitability. Men aged 65 to 75 years attending cardiology clinics composed the high-risk group; the control group was from the community. AAA screening was performed, with follow-up or surgery arranged. Four hundred eight of 651 (62.7%) high-risk men and 109 of 908 (45.0%; p < .0001) men attended from the community. In the high-risk patients, 40 AAAs were diagnosed, with a mean diameter of 41.4 mm (± 10.4 mm). In the control group, 22 new AAAs were found, with an average size of 40.9 mm (± 10.4 mm). Higher polypharmacy existed in the high-risk group (4.6 ± 2.2 vs 2.3 ± 2.0; p < .0001). More aneurysm patients were on dual-antiplatelet therapy (32.5% vs 15.4%; p = .048) compared with the overall high-risk group. In this group, three underwent surgery; one was anatomically unsuitable for endovascular repair and medically unfit for open repair. Two in the control group had surgery. A higher prevalence of AAA is encountered in high-risk men. Most aneurysms are small; however, a significant proportion of the aneurysms detected were of a size that would warrant repair. The decision to perform surgical repair is likely to be influenced by the comorbid medical conditions, which placed the patients in the high-risk category.

Repair of Thoracoabdominal Aortic Aneurysm with Thrombosed Infrarenal Component: A Modified Hybrid Technique without Aortic Cross Clamping

The authors report the successful repair of a Crawford type III thoracoabdominal aortic aneurysm (TAAA) with a thrombosed infrarenal component using a modified hybrid technique without aortic clamping in a high-risk patient. A 64-year-old male with a history of hypertension, diabetes, and severe chronic obstructive pulmonary disease presented with acute on chronic backache and bilateral short distance claudication. A computerized tomography scan demonstrated a large, nonleaking Crawford type III TAAA with thrombosed infrarenal component of the aneurysm. In addition, both common iliac arteries were occluded with the chronic thrombus. A single-stage, modified hybrid procedure involving an aortobifemoral bypass without aortic clamping, debranching of right renal, superior mesenteric, and celiac arteries as well as an endovascular repair of the thoracic aneurysm was performed. Unfortunately, despite a technically sound repair, the patient died postoperatively from a massive pulmonary embolism. TAAA with a thrombosed infrarenal aorta and bilateral common iliac arteries can be repaired using a single-stage modified hybrid procedure without aortic clamping in high-risk patients who cannot tolerate thoracotomy and aortic cross clamping.