Theodore Rapanos

Rectal indomethacin reduces postoperative pain and morphine use after cardiac surgery.

PurposeTo evaluate the combination of rectal indomethacin with patient controlled intravenous morphine analgesia (PCA) on postoperative pain relief and opioid use after cardiac surgery.MethodsWith institutional ethics approval, 57 consenting adults undergoing elective aortocoronary bypass surgery were randomly assigned preoperatively in a double-blind fashion to receive either placebo (n = 26) or indomethadn 100 mg suppositories (n = 31), 2–3 hr postoperatively, and 12 hr later. Both groups utilized PCA morphine. Pain scores in the two treatment groups were assessed on a 10-cm visual analogue scale (VAS) (at rest and with cough) at 4, 6, 12, 18 and 24 hr after initial dosing, and were analyzed through a 2 × 5 repeated measures of variance. The 24 hr analgesic consumption, 12 and 24 hr chest tube blood loss, and time to tracheal extubation were also recorded, and compared for the two treatment arms through Student’s t test on independent samples.ResultsPostoperative morphine consumption in the first 24 hr was 38% less in the indomethadn group (22.40 ± 12.55 mg) than the placebo group (35.99 ± 25.84 mg), P= 0.019. Pain scores, measured with a VAS, were 26% to 66% lower in the indomethacinvs placebo group at rest (P=0.006), but not with cough, for all times assessed. There was no difference in blood loss (at 12 hr) or time to tracheal extubation for both groups.ConclusionThe combination of indomethacin with morphine after cardiac surgery results in reduced postoperative pain scores and opioid use without an increase in side effects.RésuméObjectifÉvaluer l’action combinée d’indométhacine rectale et d’analgésie contrôlée par le patient (ACP) avec de la morphine intraveineuse sur la douleur postopératoire et l’usage d’opioïde en cardiochirurgie.MéthodeAyant obtenu l’approbation du comité d’éthique de l’hôpital, 57 adultes consentants qui devaient subir un pontage aortocoronarien électif ont été répartis au hasard avant l’opération afin de recevoir en double insu, soit un placebo (n = 26), soit de l’indométhacine (n = 31) en suppositoires de 100 mg, 2–3 h après l’opération et 12 h plus tard. Tous ont utilisé de la morphine pour l’ACP. Les scores de douleur ont été évalués à l’aide d’une échelle visuelle analogue (EVA) de 10 cm (au repos et lors de la toux) à 4, 6, 12, 18 et 24 h après le dosage initial et analysés selon un plan 2 × 5 de mesures répétées de la variance. La consommation d’analgésique à 24 h, la perte sanguine au drain thoracique à 12 et 24 h et le moment de l’extubation endotrachéale ont été notés et comparés d’un groupe à l’autre par le test t de Student sur des échantillons indépendants.RésultatsLa demande postopératoire de morphine des 24 premières h a été de 38% moindre avec l’indométhacine (22,40 ± 12,55 mg) qu’avec le placebo (35,99 ± 25,84 mg),P = 0,019. Les scores de douleur de l’EVA ont été de 26% à 66% plus faibles pour l’indométhacine vs le placebo, au repos (P = 0,006), non lors de la toux, et ce, pour tous les temps de mesures. La perte sanguine a été semblable dans les deux groupes (à 12 h) ainsi que le temps total d’intubation.ConclusionAdministrée après une intervention cardiaque, la combinaison d’indométhacine et de morphine a réduit les douleurs et l’usage d’opioïdes sans augmenter les effets secondaires.

Mortality and reintervention following elective abdominal aortic aneurysm repair.

BACKGROUND The objective of this study is to provide an up-to-date meta-analysis on the short- and long-term mortality rates of elective repair of abdominal aortic aneurysms (AAAs) via the open and endovascular approaches. METHODS MEDLINE, EMBASE, and Cochrane Central Register of Controlled trials, conference proceeding from major vascular meetings were searched for randomized trials comparing open vs elective endovascular aneurysm repair (EVAR) of AAAs. A random-effects model was used for analysis. Risk ratio (RR) and 95% confidence intervals (CIs) of open vs EVAR were calculated for short- and long-term mortality and reintervention rates. RESULTS The analysis encompassed four randomized controlled trials with a total of 2783 patients. The open repair group resulted in significantly increased 30-day postoperative all-cause mortality compared with EVAR repair group (3.2% vs 1.2%; RR, 2.81; 95% CI, 1.60-4.94); however, there is no statistical difference in the long-term all-cause mortality between both groups (RR, 0.97; 95% CI, 0.86-1.10). Interestingly, fewer patients underwent reintervention procedures in the open repair group compared with those who had EVAR repair (9.3% vs 18.9%; RR, 0.49; 95% CI, 0.40-0.60), but this finding is doubtful due to the large heterogeneity. Lastly, no statistical difference in long-term mortality rates attributable to cardiovascular disease (CVD), aneurysm related, or stroke were found between the two types of repair. CONCLUSIONS Results of this meta-analysis demonstrate that the 30-day all-cause mortality rate is higher with open than with EVAR repair; however, there is no statistical difference in the long-term all-cause and cause-specific mortality between both groups. The reintervention rate attributable to procedural complication was higher in the EVAR group. Because of the equivalency of long-term outcomes and the short-term benefits of EVAR, an endovascular-first approach to AAAs can be supported by the meta-analysis.

Endovascular repair of popliteal artery aneurysms with anaconda limbs: Technique and early results†

Objectives: The objective is to report the feasibility and technique of treating popliteal artery aneurysms (PAA) with a stent made of nitinol rings externally supported by thin polyester (Anaconda limbs). Background: PAA are the most common peripheral aneurysms. The main limitations of stents used in these settings are: short lengths, longitudinal and horizontal compliance mismatch; graft failure from angulation and movement at the joint level; and dislodgment. Methods: This is a prospective multicenter cohort study of consecutive symptomatic and asymptomatic PAA treated in tertiary vascular centers. Outcomes included patency of the stent and postoperative time‐to‐independent‐ambulation and to‐climb‐a‐flight‐of‐stairs. Results: Fourteen PAA were treated in 12 men, age 72 ± 3 years. The median ASA classification was 2.5. The length of artery covered was 147 ± 41 mm. The PAA diameter was 31 ± 5 mm, 6 were symptomatic. One stent was used in 6 aneurysms, two in 7, and three in 1. The average stent diameter was 10 ± 1 mm. The length of the proximal neck was 24 ± 6 mm with a diameter of 9.8 ± 1.9, and length of the distal neck 23 ± 3 mm with a diameter of 8.7 ± 1.2 mm. In 6 aneurysms, the stent crossed the knee joint. There was no mortality, and one stent occluded (primary patency 93% at 6 ± 3 months). The median hospital stay was 1.7 days, time to independent ambulation was 3 hr and the time to climbing a flight of stairs was 1 day. Conclusions: The use of Anaconda limbs for endovascular repair of PAA is feasible and safe.

Anaconda Endovascular Limbs for the Treatment of Isolated Iliac Artery Aneurysms

The purpose of this article is to report the feasibility and preliminary results of the treatment of isolated iliac artery aneurysms (IAAs) with Anaconda limbs (Vascutek Ltd., Inchinnan, Renfrewshire, Scotland). A prospective cohort is reported of consecutive IAAs treated by two senior surgeons from May to December 2006. One or more Anaconda limbs were used, and internal iliac arteries were embolized if necessary. Twelve IAAs in 11 patients were treated. The average IAA diameter was 4.3 ± 1.1 cm, and the average diameter of stent used was 14 ± 2.5 mm, with an average total length of 97 ± 25 mm. At a mean follow-up of 12 ± 4 months, there were no graft-related complications, graft occlusions, or requirements for reintervention. Endovascular treatment for isolated IAAs under local anesthesia using Anaconda limbs is feasible, safe, and effective. However, as with all new technology, longer follow-up data are necessary.

Myocardial Injury After Noncardiac Surgery (MINS) in Vascular Surgical Patients: A Prospective Observational Cohort Study.

Objective: To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients. Background: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described. Methods: This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring. Results: The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%–22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%–20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%–3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46–25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1–29.1) and without an ischemic feature (12.2%; 95% CI, 5.3–25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6–82.4). Conclusions: Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.

User-Centered Requirements Analysis and Design Solutions for Chronic Disease Self-management

An aging population and the attendant growth in the need to care for people with serious chronic illnesses has created a demand for online support systems that can assist older adults to self-manage their illnesses. This could play a role in relieving some of the load on the healthcare system. Determining user-centered requirements of older adults for such systems is different from usual requirements analysis because older adults have particular needs, depending upon their chronic illnesses, their ability to manage technology, their access to appropriate technologies, and their cognitive abilities. This paper discusses in detail the use of the persona-scenario approach to elicit these needs from outpatients, informal care givers, and physicians. It proposes several suitable interface designs, depending on outpatient ability to deal with the proposed systems.

Blunt innominate artery trauma requiring repair and carotid ligation

Traumatic dissection of the innominate artery is a rare clinical entity. Management of a patient with motorsensory compromise and dissection extending to the subclavian and right common carotid arteries is quite rare and can be quite involved. Here we present such a case and discuss the unique peri-operative decision-making in the context of what is reported in the literature. Restoration of motorsensory function is critical and in this case, requiring a multi-disciplinary team.

IP077. Novel Approach to Acute Limb Occlusion After EVAR With Pharmacomechanical Thrombectomy: Preliminary Analysis

Objectives: This preliminary study examined the technical efficacy and safety of treating acute limb occlusion after EVAR with pharmacomechanical thrombectomy (PMT) using the AngioJet rheolytic system. Methods: The technical aspects, success, and complications of the first seven consecutive patients presenting with acute limb occlusion after EVAR treated with PMT were analyzed. All patients underwent surgical femoral exposure to facilitate distal arterial control and limit distal embolization. Completion thrombectomy angiograms were reviewed to identify anatomical or structural causes for limb occlusion and subsequently treated accordingly. Technical success, distal embolization, major hemorrhagic complications, acute kidney injury, compartment syndrome, 30-day patency, and amputation-free survival were evaluated. Results: Six of seven patients (86%) presented with acute limb occlusion within 30 days of the original EVAR procedure. All patients were on antiplatelet therapy at time of presentation. Narrowing or kinking of the endograft limb was apparent on computed tomography scan in three patients (43%). An embolic etiology of limb occlusion was suspected in two patients (29%). The technical success rate with PMT treatment was 100%. All patients subsequently underwent EVAR limb stenting in the same procedure. There were no reported cases of distal embolization after PMT or major hemorrhagic complications. Two patients (29%) developed compartment syndrome after revascularization requiring lower leg fasciotomies. Furthermore, two patients (29%) developed acute kidney injury during their hospital admission. The 30-day patency and amputation-free survival rate for PMT was 100%. The overall mean length of stay in hospital for PMT treatment was 9.8 6 4.2 days. Conclusions: Early results of PMT with the AngioJet system represent a novel strategy for treating acute limb occlusion after EVAR that is safe and effective.

PC224 Thrombin-Mediated Human Aortic Endothelial Barrier Dysfunction Alters MicroRNA Pathways Involved in Cell Survival, Injury, and Cancer

Objectives: Endothelial cells (ECs) must maintain an effective physiologic barrier in a highly dynamic environment. Capable of regulating other cells within the vasculature (eg, smooth muscle cells), ECs govern response to injury and inflammation. MicroRNAs (miR) are emerging as critical regulators of vascular disease, implicating EC miRs in homeostasis maintenance. Increased EC permeability has been documented in atherosusceptible regions of the aorta, suggesting it plays a role in disease development, but whether this is a cause or consequence is unknown. We hypothesized EC barrier dysfunction is a critical event that perpetuates chronic vascular disease via altered miR profiles. Methods: Human aortic endothelial cells (HAEC) cultured in transwells were exposed to thrombin (0.5, 1, 2 U/mL), and permeability was measured by fluorescence flux across monolayers at 90 minutes. Total HAEC RNA was isolated at various time points, with individual miR transcripts counted using nanoString nCounter (n 1⁄4 6 samples). miRs that were altered more than twofold compared to controls were analyzed using nSolver software and Ingenuity Pathway Analysis. Results: Thrombin exposure increased EC permeability to 130% 6 8.4% of untreated controls (2 U/mL thrombin; n 1⁄4 16 transwells; P < .05). Heatmaps from miR counts showed extensive miR profile changes in response to thrombin (n 1⁄4 6 samples; control, 90 minutes, 4 hours, 24 hours). Ingenuity Pathway Analysis showed miRs were clustered based on seed regions and matched with experimentally confirmed mRNA targets. At all time points, mRNA targets were shown to be most involved in cancer and injury disease pathways, with top cellular functions identified as cell movement, proliferation, growth, and survival. Conclusions: In response to a permeability insult, HAEC miR levels are significantly altered. Although our preliminary data need to be further substantiated, they highlight a possible mechanism whereby EC barrier dysfunction is a critical event that perpetuates chronic vascular disease. In this way, we might envision a scenario not unlike cancer (which has been compared to atherosclerosis), where an initial appropriate endothelial repair response becomes dysregulated in the context of ongoing injury (eg, permeability) in atherosusceptible regions.