Category Archives: Vascular

Preoperative evaluation & perioperative management of coronary artery disease in patients undergoing vascular surgery

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Bauer SM, Cayne NS, Veith FJ. New developments in the preoperative evaluation and perioperative management of coronary artery disease in patients undergoing vascular surgery. J Vasc Surg. 2010 Jan;51(1):242-51.

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Conclusions: Routine stress testing should not be performed before VS. The Lee index should be used to stratify risk in patients undergoing VS. Patients with >or=3 risk factors or active cardiac conditions should undergo stress testing, if VS can be delayed. All VS patients, except those with 0 risk factors, should be considered for a beta-blocker (bisoprolol, 2.5-5 mg/d started 1 month before VS, titrated to a pulse <70 beats/min and a systolic blood pressure >or=120 mm Hg). Intermediate risk factors may not require aggressive heart rate control but simply maintenance on a low-dose beta-blocker. Statins should be started (ideally 30 days) before all VS using long-acting formulations such as fluvastatin (80 mg/d) for patients unable to take oral medication.

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Prognostic factors in splanchnic vein thromboses

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Ageno W, et al. Long-term Clinical Outcomes of Splanchnic Vein Thrombosis: Results of an International Registry. JAMA Intern Med. 2015 Sep;175(9):1474-80. doi: 10.1001/jamainternmed.2015.3184.

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RESULTS: Of the 604 patients (median age, 54 years; 62.6% males), 21 (3.5%) did not complete follow-up. The most common risk factors for SVT were liver cirrhosis (167 of 600 patients [27.8%]) and solid cancer (136 of 600 [22.7%]); the most common sites of thrombosis were the portal vein (465 of 604 [77.0%]) and the mesenteric veins (266 of 604 [44.0%]). Anticoagulation was administered to 465 patients in the entire cohort (77.0%) with a mean duration of 13.9 months; 175 of the anticoagulant group (37.6%) received parenteral treatment only, and 290 patients (62.4%) were receiving vitamin K antagonists. The incidence rates (reported with 95% CIs) were 3.8 per 100 patient-years (2.7-5.2) for major bleeding, 7.3 per 100 patient-years (5.8-9.3) for thrombotic events, and 10.3 per 100 patient-years (8.5-12.5) for all-cause mortality. During anticoagulant treatment, these rates were 3.9 per 100 patient-years (2.6-6.0) for major bleeding and 5.6 per 100 patient-years (3.9-8.0) for thrombotic events. After treatment discontinuation, rates were 1.0 per 100 patient-years (0.3-4.2) and 10.5 per 100 patient-years (6.8-16.3), respectively. The highest rates of major bleeding and thrombotic events during the whole study period were observed in patients with cirrhosis (10.0 per 100 patient-years [6.6-15.1] and 11.3 per 100 patient-years [7.7-16.8], respectively); the lowest rates were in patients with SVT secondary to transient risk factors (0.5 per 100 patient-years [0.1-3.7] and 3.2 per 100 patient-years [1.4-7.0], respectively).

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The surgical management of mycotic (infected) aneurysms

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Razavi MK, Razavi MD. Stent-graft treatment of mycotic aneurysms: a review of the current literature. J Vasc Interv Radiol. 2008;19(6 Suppl):S51–S56.

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“Mycotic aneurysms are rare but are associated with a high risk of rupture if not treated promptly. The early mortality rate associated with traditional surgery depends on patients’ condition and can be as high as 43%. The use of stent-grafts is less invasive but the outcome is unproven in the setting of infected aneurysms. In an attempt to better elucidate the role of stent-grafts in this setting, a literature search was performed to examine 52 articles describing 91 patients with mycotic aneurysms who were treated with stent-grafts. The early mortality rate was 5.6%. Incidences of late aneurysm-related mortality and complications were 12.2% and 7.8%, respectively. The most consistent predictor of poor outcome was development of aortoenteric fistula. Although the 30-day mortality rate associated with the use of stent-grafts appears to be lower than that associated with surgery, late aneurysm-related events are frequent and warrant a more vigilant follow-up regimen than used with noninfected aneurysms.”

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Splenic artery aneurysms: Comparing open and endovascular surgical modalities

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Barrionuevo P, Malas MB, Nejim B, et al. A systematic review and meta-analysis of the management of visceral artery aneurysms. J Vasc Surg. 2019;70(5):1694–1699.

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“We included 33 case series of 523 splenic artery aneurysms treated with an endovascular approach and 22 series of 252 splenic artery aneurysms treated with open surgery. Short-term and long-term mortality rates were very low and not significantly different between the two interventions. Mortality was high for ruptured aneurysms treated with an open approach, with an event rate of 0.29 (95% CI, 0.04-0.71). End-organ infarction and gastrointestinal complications rates were not significantly different between the two approaches. The need for reintervention was lower for open surgery 0.00 (95% CI, 0.00-0.11) than for the endovascular approach 0.07 (95% CI, 0.01-0.17). The risk of access site complications for the endovascular approach was low at 0.02 (95% CI, 0.00-0.09). Rates of PES and coil migration were 0.38 (95% CI, 0.04-0.79) and 0.08 (95% CI, 0.00-0.24), respectively. Data were insufficient to identify a difference in mortality based on aneurysm size.”

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The utility of Trendelenburg position on subclavian port placement

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Kwon MY, Lee EK, Kang HJ, et al. The effects of the Trendelenburg position and intrathoracic pressure on the subclavian cross-sectional area and distance from the subclavian vein to pleura in anesthetized patients. Anesth Analg. 2013;117(1):114–118.

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“We evaluated the effects of increased intrathoracic pressure (20 cm H2O) or Trendelenburg position on the CSA and DSCV-pleura during SCV catheterization and general anesthesia, and determined whether their changes were clinically relevant (defined as [DELTA]CSA and [DELTA]DSCV-pleura >=15% vs S-0). Applying positive intrathoracic pressure alone or Trendelenburg position alone provided a statistically increased CSA of the SCV, but this increase did not meet our defined threshold for a relevant degree ([DELTA]CSA of >=15%). Only the combined application of these 2 maneuvers yielded a relevant increase in the CSA ([DELTA]CSA 23.2% vs S-0). No maneuvers provided a relevant change of DSCV-pleura ([DELTA]DSCV-pleura >=15%) despite their statistically significant changes in some conditions.” (Kwon, 2013, p. 116)

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AAA repair: retroperitoneal vs transperitoneal approach

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One discussion this week included transperitoneal vs retroperitoneal  approach following AAA repair.

Reference: Buck DB, et al. Transperitoneal vs retroperitoneal approach for open abdominal aortic aneurysm repair in the targeted vascular NSQIP. Journal of Vascular Surgery. 2016 Sept;64(3):585-591. doi:10/1016/j.jvs.2016.01.055.

Summary: This study aims to identify the demographic and anatomical differences between patients currently selected for elective transperitoneal versus retroperitoneal AAA repair and to assess differences in intra-operative details, and perioperative mortality and complications.

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The PAUSE study: Safety of perioperative DOAC management in patients with atrial fibrillation

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A discussion during a previous conference included the perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant (DOAC).

Reference: Douketis JD, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Internal Medicine. 2019 Aug 5; doi:10/1001/jamainternmed.2019.2431

Summary: Each year, 1 in 6 patients with AF, or an estimated 6 million patients worldwide, will require perioperative anticoagulant management. When DOAC regimens became available for clinical use in AF, starting in 2010, no studies had been conducted to inform the timing of perioperative DOAC therapy interruption and resumption, whether heparin bridging should be given, and whether preoperative coagulation function testing was needed. Uncertainty about the perioperative management of DOACs may be associated with unsubstantiated practices and increased harm to patients.

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