Shahin Hajibandeh

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.

Percutaneous access for endovascular aortic aneurysm repair: A systematic review and meta-analysis

Purpose Our objective was to undertake a comprehensive review of the literature and conduct an analysis of the outcomes of percutaneous endovascular aneurysm repair. Methods MEDLINE; EMBASE; CINAHL; CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists were searched to identify all studies providing comparative outcomes of the percutaneous technique for endovascular aneurysm repair. Success rate and access-related complications were defined as the primary outcome parameters. Combined overall effect sizes were calculated using fixed effect or random effects models. We conducted a network meta-analysis of different techniques for femoral access applying multivariate meta-analysis assuming consistency. Findings Three randomised controlled trials and 18 observational studies were identified. Percutaneous access was associated with a lower frequency of groin infection (p < 0.0001) and lymphocele (p = 0.007), and a shorter procedure time (p < 0.0001) and hospital length of stay (p = 0.03) compared with open surgical access. Moreover, percutaneous endovascular aneurysm repair did not increase the risk of haematoma, pseudoaneurysm, and arterial thrombosis or dissection. Conclusion Percutaneous access demonstrates advantages over conventional surgical exposure for endovascular aneurysm repair, as indicated by access-related complications and hospital length of stay. Further research is required to define its impact on resource utilization, cost-effectiveness and quality of life.

Is intervention better than surveillance in patients with type 2 endoleak post-endovascular abdominal aortic aneurysm repair?

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether, in patients with persistent type 2 endoleak (T2EL) post-endovascular abdominal aortic aneurysm repair (EVAR), intervention is associated with better outcomes than observation. Four hundred and eighty-three papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In a recently published systematic review including 21 744 patients who underwent EVAR, 35.4% of T2ELs resolved spontaneously, 28.5% of secondary interventions were unsuccessful and rupture occurred in only 0.9% of patients with isolated T2EL. Spontaneous sealing in 62-75% of T2ELs were reported by two included studies. A failure rate of 80% associated with transarterial embolization in aggressive treatment of any T2EL was reported by one study. Conversely, another study reported a clinical success rate of 80% associated with the transarterial approach. One study reported that of patients who underwent embolization of a persistent T2EL, 37.9% continued to experience sac growth and 20% had recurrent endoleak at 5 years. One study demonstrated that the transealing procedure for T2EL had a technical success rate of 94.1%. We conclude that the available evidence with regard to management of persistent T2EL is mainly based on retrospective case series. Conflicting results from heterogeneous studies, however, failed to support an optimal threshold for intervention. Considering the reported relatively benign natural course of most T2ELs and the fact that most T2ELs seal spontaneously, conservative management of persistent T2EL in the absence of sac expansion might be appropriate. Where intervention is indicated, imaging should exclude occult type I and III leaks as ∼25% are not simple T2EL. Translumbar embolization of T2EL is associated with higher success rates than transarterial. Following a successful intervention, continued long-term surveillance is necessary due to the high risk (25-80%) of recurrence. The current evidence indicates that aneurysmal rupture due to an isolated T2EL is rare. Long-term prospective studies may provide better evidence to define the optimal threshold for intervention.

Meta-analysis of Left Subclavian Artery Coverage With and Without Revascularization in Thoracic Endovascular Aortic Repair.

Purpose: To examine the role of left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) with LSA coverage. Methods: A systematic search was conducted to identify all studies providing comparative outcomes with or without LSA revascularization for LSA occlusion during TEVAR. The search included MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov , ISRCTN Register, and bibliographic reference lists. The primary outcome parameters were perioperative stroke, spinal cord ischemia (SCI), and mortality. Combined overall effect sizes were calculated using fixed effect or random effects models; results are reported as the odds ratio (OR) and 95% confidence interval (CI). Results: Five observational studies reporting a total of 1161 patients were identified; 444 patients underwent LSA revascularization and the remaining 717 patients did not. LSA revascularization was associated with a similar risk of stroke (OR 0.70, 95% CI 0.43 to 1.14, p=0.15), SCI (OR 0.56, 95% CI 0.28 to 1.10, p=0.09), and mortality (OR 0.87, 95% CI 0.55 to 1.39, p=0.56) compared with no LSA revascularization. Conclusion: LSA revascularization was not found to significantly reduce neurologic complications or mortality in patients undergoing TEVAR with coverage of the LSA origin. Randomized clinical trials are required to elucidate the role of routine or selective LSA revascularization in these cases.

Prognostic significance of ankle brachial pressure index: A systematic review and meta-analysis:

Purpose To synthesize and quantify the excess risk of morbidity and mortality in individuals with low ankle-brachial pressure index. Methods Electronic databases were searched to identify studies investigating morbidity and mortality outcomes in individuals undergoing ankle-brachial pressure index measurement. Meta-analysis of the outcomes was performed using fixed- or random-effects models. Uncertainties related to varying follow-up periods among the studies were resolved by meta-analysis of time-to-event outcomes. Results Forty-three observational cohort studies, enrolling 94,254 participants, were selected. A low ankle-brachial pressure index (<0.9) was associated with a significant risk of all-cause mortality (risk ratio: 2.52, 95% CI 2.26–2.82, P < 0.00001); cardiovascular mortality (risk ratio: 2.94, 95% CI 2.72–3.18, P < 0.00001); cerebrovascular event (risk ratio: 2.17, 95% CI 1.90–2.47, P < 0.00001); myocardial infarction (risk ratio: 2.28, 95% CI 2.07–2.51, P < 0.00001); fatal myocardial infarction (risk ratio: 2.81, 95% CI 2.33–3.40, P < 0.00001); fatal stroke (risk ratio: 2.28, 95% CI 1.80–2.89, P < 0.00001); and the composite of myocardial infarction, stroke, and death (risk ratio: 2.29, 95% CI 1.87–2.81, P < 0.00001). Similar findings resulted from analyses of individuals with asymptomatic PAD, individuals with cardiovascular or cerebrovascular co-morbidity, and patients with diabetes. Conclusions A low ankle-brachial pressure index is associated with an increased risk of subsequent cardiovascular and cerebrovascular morbidity and mortality. Randomised controlled trials are required to investigate the effectiveness of screening for PAD in asymptomatic and undiagnosed individuals and to evaluate benefits of early treatment of screen-detected PAD.

Covered vs Uncovered Stents for Aortoiliac and Femoropopliteal Arterial Disease: A Systematic Review and Meta-analysis.

Purpose: To evaluate outcomes of covered vs bare metal stents for the treatment of lower limb peripheral artery disease. Methods: A search of electronic databases was performed to identify all studies comparing outcomes of covered vs bare metal stents for treatment of aortoiliac and femoropopliteal arterial disease. The Cochrane tool and the Newcastle-Ottawa scale were used to assess the risk of bias in randomized controlled trials (RCTs) and observational studies, respectively. Fixed or random effects models were applied to analyze pooled outcome data. The results for dichotomous outcome variables are presented as the odds ratio (OR) and 95% confidence interval (CI); intergroup comparisons of continuous clinical variables are reported as the mean difference (MD) and 95% CI. Results: Two RCTs and 4 retrospective cohort studies, enrolling 744 patients (mean age 67 years; 477 men) and 918 diseased arteries, were identified. For aortoiliac disease, treatment with a covered stent showed no significant improvement in primary patency (OR 2.10, 95% CI 0.48 to 9.11, p=0.32), but it was associated with higher ankle-brachial index (ABI) (MD 0.08, 95% CI 0.07 to 0.09, p<0.001) and a lower reintervention rate (OR 0.19, 95% CI 0.09 to 0.42, p<0.001). For femoropopliteal disease, use of covered stents was associated with increased primary patency (OR 1.84, 95% CI 1.11 to 3.06, p=0.02), higher ABI (MD 0.08, 95% CI 0.00 to 0.16, p=0.04), and a lower reintervention rate (OR 0.51, 95% CI 0.30 to 0.87, p=0.01). No significant differences in technical success, complications, limb salvage, or survival were identified between the groups in either segment. Conclusion: Theoretically, the use of covered stents may increase the patency rate due to decreased restenosis after stent placement. This analysis found that the primary patency was improved with the use of a covered stent in femoropopliteal lesions but not in aortoiliac disease. Improved outcomes were seen with covered stents compared with bare metal stents as indicated by a lower need for reintervention and an improved ABI. It remains to be investigated whether such beneficial effects can be translated into improved clinical outcomes, such as limb salvage and amputation-free survival. Long-term results of the comparative efficacy of covered stents over bare metal stents are not currently available.

Neuromuscular electrical stimulation for thromboprophylaxis: A systematic review

Objective To evaluate the effect of neuromuscular electrical stimulation on lower limb venous blood flow and its role in thromboprophylaxis. Method Systematic review of randomised and non-randomised studies evaluating neuromuscular electrical stimulation, and reporting one or more of the following outcomes: incidence of venous thromboembolism, venous blood flow and discomfort profile. Results Twenty-one articles were identified. Review of these articles showed that neuromuscular electrical stimulation increases venous blood flow and is generally associated with an acceptable tolerability, potentially leading to good patient compliance. Ten comparative studies reported DVT incidence, ranging from 2% to 50% with neuromuscular electrical stimulation and 6% to 47.1% in controls. There were significant differences, among included studies, in terms of patient population, neuromuscular electrical stimulation delivery, diagnosis of venous thromboembolism and blood flow measurements. Conclusion Neuromuscular electrical stimulation increases venous blood flow and is well tolerated, but current evidence does not support a role for neuromuscular electrical stimulation in thromboprophylaxis. Randomised controlled trials are required to investigate the clinical utility of neuromuscular electrical stimulation in this setting.

The Time Is Now to Use Clinical Outcomes as Quality Indicators for Effective Leadership in Trauma

Author(s): Hajibandeh, Shahab; Hajibandeh, Shahin; Burner, Elizabeth; Arora, Sanjay; Menchine, Michael | Abstract: Not applicable (Letter to the Editor)

Meta-analysis of epidural analgesia versus peripheral nerve blockade after total knee joint replacement

Background: Postoperative pain after major knee surgery can be severe. Our aim was to compare the outcomes of epidural analgesia and peripheral nerve blockade (PNB) in patients undergoing total knee joint replacement (TKR). Moreover, we aimed to compare outcomes of adductor canal block (ACB) with those of femoral nerve block (FNB) after TKR. Methods: We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; and the Cochrane Central Register of Controlled Trials (CENTRAL). We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above databases. Pain intensity assessed on visual analogue scale (VAS), nausea and vomiting, systolic hypotension, and urinary retention was the reported outcome parameters. Results: We identified 12 randomised controlled trials (RCTs) comparing outcomes of epidural analgesia and PNB reporting a total of 670 patients. There was no significant difference between two groups in VAS scores at 0–12 h (MD -0.48; 95% CI -1.07–0.11, P = 0.11), 12–24 h (MD 0.04; 95% CI -0.81–0.88, P = 0.93), and 24–48 h (MD 0.16; 95% CI -0.08–0.40, P = 0.19). However, epidural analgesia was associated with significantly higher risk of postoperative nausea and vomiting (RR 1.65; 95% CI, 1.20–2.28, P = 0.002), hypotension (RR 1.76; 95% CI, 1.26–2.45, P = 0.0009), and urinary retention (RR 4.51; 95% CI, 2.27–8.96, P<0.0001) compared to PNB. Moreover, pooled analysis of data from 6 RCTs demonstrated no significant difference in VAS score between ACB and FNB at 24 h (MD -0.00; 95% CI, -0.56–0.56, P = 0.99) and 48 h (MD -0.06; 95% CI, -0.14–0.03, P = 0.23). Conclusions: PNB is as effective as epidural analgesia for postoperative pain management in patients undergoing TKR. Moreover, it is associated with significantly lower postoperative complications. ACB appears to be an effective PNB with similar analgesic effect to FNB after TKR. Future RCTs may provide better evidence regarding knee range of motion, length of hospital stay, and neurological complications.

Systematic Review: Adjuvant Chemotherapy for Locally Advanced Rectal Cancer with respect to Stage of Disease

Background. Recent meta-analysis of 21 randomised controlled trials (RCTs) supports the use of adjuvant chemotherapy for nonmetastatic rectal carcinoma. In order to define a subgroup of patients who can potentially benefit from postoperative adjuvant chemotherapy, this study aims to review trials investigating adjuvant chemotherapy with respect to stage of disease in patients with locally advanced rectal cancer who had undergone surgery for cure (stage II and stage III). Methods. We searched electronic information sources to identify randomised trials evaluating adjuvant chemotherapy in patients with stages II and III rectal cancer with overall survival or disease-free survival as outcomes. Scottish Intercollegiate Guidelines Network notes on methodology were used to assess the methodological quality of the selected studies. Random-effects models were applied to calculate pooled outcome data. Results. Eight studies reporting total of 5527 patients were selected for analysis. Adjuvant chemotherapy was associated with statistically significant improvement in disease-free survival and overall survival compared to surgery alone in both stage II and stage III cancer. Conclusions. This study indicates that both stage II and stage III rectal cancer patients may benefit from postoperative adjuvant chemotherapy. However, the benefits of adjuvant chemotherapy for patients who already had neoadjuvant chemoradiation still remain unknown.