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Richard P. Cambria - One of the best experts on this subject based on the ideXlab platform.
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postoperative renal dysfunction independently predicts late mortality in patients undergoing Aortic Reconstruction
Journal of Vascular Surgery, 2013Co-Authors: Virendra I Patel, Robert T Lancaster, Emel Ergul, Mark F Conrad, Daniel J Bertges, Marc L Schermerhorn, Phillip Goodney, Richard P. CambriaAbstract:Objective Preoperative chronic kidney disease (CKD) has been shown to predict postoperative renal complications and mortality after open Aortic surgery; the impact of postoperative renal complications less severe than permanent dialysis are unknown. We evaluated the impact of postoperative renal dysfunction severity on survival using a regional quality improvement registry. Methods Patients undergoing intact open Aortic Reconstruction in the Vascular Study Group of New England registry (2003-2012) were stratified by severity of postoperative renal complications; none, creatinine increase of greater than 0.5 mg/dL (incCr), or any hemodialysis (HD). Predictors of renal dysfunction and impact of renal complications on survival were analyzed using multivariable methods. Results We included 2695 patients, of which 65% (n = 1733) underwent open abdominal Aortic aneurysm repair, and 35% (n = 962) open aortoiliac Reconstruction. At baseline, 15% of patients had preoperative moderate CKD and 1.2% had severe CKD. Postoperative renal complications of incCr occurred in 8.5% of patients, and 1.5% required HD. Multivariable cumlogit regression identified severe baseline CKD (odds ratio [OR], 15; 95% confidence interval [CI], 6.4-34; P P P P P P P = .01), baseline chronic obstructive pulmonary disease (OR, 1.6; 95% CI, 1.2-2.2; P P = .009), and HD (OR, 4.8; 95% CI, 1.8-12.7); P = .009) independently increased 30-day mortality. Risk-adjusted multivariable Cox regression showed that incCr (hazard ratio, 1.8; 95% CI, 1.3-2.6; P P P Conclusions Increasing severity of postoperative renal dysfunction independently predicts increased risk of late mortality after open Aortic surgery. Perioperative measures to decrease renal complications may potentially prolong the survival of patients after open Aortic surgery.
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Transperitoneal versus retroperitoneal approach for Aortic Reconstruction: A randomized prospective study
Journal of Vascular Surgery, 1990Co-Authors: Richard P. Cambria, David C. Brewster, William M. Abbott, Marion Freehan, Joseph Megerman, Glenn M. Lamuraglia, Roger S. Wilson, Donna J. Wilson, Richard Teplick, J.kenneth DavisonAbstract:A prospective, randomized study was conducted to compare the retroperitoneal versus transperitoneal approach for elective Aortic Reconstruction. One hundred thirteen patients (transperitoneal = 59, retroperitoneal = 54) were randomized between March 1987 and October 1988. In addition, to assess the changing course of patients undergoing Aortic Reconstruction similar data were gathered retrospectively on a group of 56 patients undergoing Aortic Reconstruction by the same surgeons performed via a transperitoneal approach in 1984 to 1985. Randomized patients were identical in age, male to female ratio, smoking history, incidence and severity of cardiopulmonary disease, indication for operation, and use of epidural anesthetics. Details of operation including operative and Aortic cross-clamp times, crystalloid and transfusion requirements, degree of hypothermia on arrival at the intensive care unit, and perioperative fluid and blood requirements did not differ significantly for patients undergoing transperitoneal versus retroperitoneal Reconstruction. Respiratory morbidity, as assessed by percent of patients requiring postoperative ventilation, deterioration in pulmonary function tests, and the incidence of respiratory complications, was identical in randomized patients. Other aspects of postoperative recovery including recovery of gastrointestinal function, the requirement for narcotics, metabolic parameters of operative stress, the incidence of major and minor complications, and the duration of hospital stay were similar for randomized patients undergoing transperitoneal and retroperitoneal Reconstruction. When compared to retrospectively reviewed patients having Aortic Reconstruction, randomized patients undergoing transperitoneal and retroperitoneal operations had highly significant (p less than 0.001) reductions in postoperative ventilation, transfusion requirements, and length of hospital stay. Such trends were all independent of transperitoneal versus retroperitoneal approach.(ABSTRACT TRUNCATED AT 250 WORDS)
F U Weiguo - One of the best experts on this subject based on the ideXlab platform.
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femorofemoral cardiopulmonary bypass in descending thoracic Aortic Reconstruction
Chinese Journal of Thoracic and Cardiovaescular Surgery, 2002Co-Authors: F U WeiguoAbstract:Objective: To study the role of femorofemoral cardiopulmonary bypass in descending thoracic Aortic Reconstruction. Methods: Twelve patients underwent descending thoracic Aortic Reconstruction under femorofemoral cardiopulmonary bypass between December, 1999 and June, 2001. Fifteen cases of descending thoracic Aortic Reconstruction between June, 1994 and August, 1999 were selected as non-bypass group. Comparison was made in the two groups in terms of paraplegia, visceral ischemia, blood transfusion and coagulopathy. Results: Femorofemoral cardiopulmonary bypass minimized the likelihood of paraplegia when Aortic cross-clamping time exceeded 60 minutes (P0.05). Abnormal hepatic function occurred less in the bypass group than in the non-bypass group (P0.05), but no statistical difference was found in abnormal renal function between the two groups (P0.05). There was significantly less blood transfusion in the bypass group (P0.01), and more coagulopathies in the non-bypass group (P0.05). Conclusions: Femorofemoral cardiopulmonary bypass, an easy and safe approach, has significant advantages over simple Aortic cross-clamping, in preventing paraplegia and visceral ischemia and reducing blood transfusion and coagulopathy, in descending thoracic Aortic Reconstruction.
Calvin B. Ernst - One of the best experts on this subject based on the ideXlab platform.
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Supraceliac Aortic cross-clamping: Determinants of outcome in elective abdominal Aortic Reconstruction
Journal of Vascular Surgery, 1993Co-Authors: Timothy J. Nypaver, Alexander D. Shepard, Daniel J. Reddy, Joseph P. Elliott, Calvin B. ErnstAbstract:Abstract Purpose: A 7-year experience in which 43 patients underwent supraceliac Aortic cross-clamping (SC-AXC) during elective abdominal Aortic Reconstruction was reviewed. Methods: Operation was performed for abdominal Aortic aneurysm (AAA) in 29 (68%) patients, aortoiliac occlusive disease in seven (16%), proximal anastomotic AAA in three (7%), "shaggy" aorta syndrome in three (7%), and in situ grafting of a previously ligated aorta in one (2%) patient. The indications for supraceliac control included pararenal AAA origin (25), pararenal Aortic atherosclerosis (18), inflammatory AAA (2), and a short infrarenal Aortic stump (1). Vital organ ischemic complications (VOICs) were defined as any major ischemic complication involving the liver, kidneys, bowel, or spinal cord. Results: The incidence of VOICs was significantly increased when concomitant renal or visceral revascularization (CRVR) was required ( p = 0.002) and correlated with an increasing SC-AXC time ( p = 0.015). In patients undergoing CRVR ( n = 16) the perioperative mortality rate was 25%; VOICs developed in six patients and included renal failure (3), mesenteric/colonic ischemia (3), hepatic ischemia with coagulopathy (2), and spinal cord ischemia (1). In contrast, in those not requiring CRVR ( n = 27), SC-AXC was well tolerated. There were no VOICs and no deaths; morbidity rate was 33%. Conclusions: The incidence of VOICs associated with the use of SC-AXC is primarily related to the level of preoperative renal or mesenteric insufficiency, the severity of pararenal Aortic atherosclerosis, the extent of the operative procedure, and the duration of proximal Aortic cross-clamping. In complex abdominal Aortic Reconstruction in which infrarenal Aortic control is either not possible or deemed hazardous, SC-AXC is a safe and valuable technique for achieving proximal control. (J VASC SURG 1993;17:868-76.)
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Retroperitoneal Aortic Reconstruction: Indications and Pitfalls
Modern Vascular Surgery, 1992Co-Authors: David F.j. Tollefson, Calvin B. ErnstAbstract:The first reported use of the retroperitoneal approach for abdominal vessel Reconstruction was ligation of an external iliac artery aneurysm by Sir Astley Cooper in 1808.1 The first successful repair of an abdominal Aortic aneurysm was performed via the retroperitoneal approach and was reported by Dubost in 1951.2 Since then, numerous authors have reported on the advantages of the retroperitoneal approach.3,4,5 However, retroperitoneal Aortic Reconstruction still remains a novel and little used approach by most surgeons.
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Colon Ischemia Following Aortic Reconstruction
Annals of Vascular Surgery, 1991Co-Authors: David F.j. Tollefson, Calvin B. ErnstAbstract:Ischemic colitis following Aortic Reconstruction, although uncommon, has potentially devastating consequences. While clinically apparent after only about 2% of Aortic Reconstructions, subclinical episodes undoubtedly occur much more frequently. The mortality associated with transmural colonic infarction can exceed 50%. Colon ischemia is usually due to a watershed phenomenon, wherein the collateral blood flow to the sigmoid colon from the superior mesenteric artery (SMA) or hypogastric arteries (HGA) is inadequate after inferior mesenteric artery (IMA) occlusion occurring incident to Aortic Reconstruction. This collateral blood flow is through either the meandering mesenteric artery (for SMA to IMA flow) or the marginal artery of Drummond. Certain criteria are useful in predicting individuals at risk for postoperative colon ischemia. Early postoperative diagnosis is crucial to minimize morbidity and mortality associated with ischemic colitis. While diarrhea, fever, severe postoperative abdominal pain, or signs of sepsis and peritonitis all suggest colonic ischemia, flexible sigmoidoscopy is essential to establish the diagnosis and can be performed at the bedside. Nonoperative management, including broad spectrum antibiotics and careful attention to fluid and electrolyte administration, is the preferred treatment for mild cases of colon ischemia involving only the mucosa. However, at the first signs of advanced ischemia, whether noted endoscopically or clinically, resection of all necrotic bowel with
Richard K Chessler - One of the best experts on this subject based on the ideXlab platform.
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pelvic radiation therapy as a risk factor for ischemic colitis complicating abdominal Aortic Reconstruction
Journal of Vascular Surgery, 1996Co-Authors: Doron Israeli, Herbert Dardik, Fred Wolodiger, Fred Silvestri, Burton Scherl, Richard K ChesslerAbstract:Ischemic colitis is an infrequent but potentially devastating complication of abdominal Aortic Reconstruction. Identification of patients with predisposing risk factors for the development of ischemic colitis can guide intraoperative measures to preserve or restore colonic blood flow during Aortic surgery. Previous radiation therapy for pelvic malignancy may be one such predisposing risk factor. Two cases are presented in which ischemic colitis complicated, abdominal Aortic Reconstruction in the setting of previous pelvic irradiation. In the months after radiation therapy for prostate cancer, one patient underwent infrarenal abdominal Aortic aneurysm repair. Ischemic infarction of the sigmoid colon developed acutely after surgery and required emergent sigmoid colectomy. The second patient underwent Reconstruction of an infrarenal abdominal Aortic aneurysm after having had radiation therapy for a bladder tumor. Despite an initial satisfactory result, the patient's abdominal pain and diarrhea progressively worsened and he eventually required sigmoid colectomy for severe ischemic colitis. In both of these patients, the inferior mesenteric arteries were patent and had not been reimplanted. The association of pelvic radiation therapy with ischemic colitis after Aortic Reconstruction should focus attention to the operative, details for maintaining the colonic ciruculation in these patients. Reimplantation of the inferior mesenteric artery in particular may prevent both the acute and the insidious variants of this complication in patients who undergo Aortic surgery and decrease the incidence of this complication in patients with a history of radiation therapy to the pelvis.
Kenneth J. Cherry - One of the best experts on this subject based on the ideXlab platform.
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Abdominal Aortic Reconstruction in infected fields: Early results of the United States cryopreserved Aortic allograft registry
Journal of Vascular Surgery, 2002Co-Authors: Audra A. Noel, Peter Gloviczki, Kenneth J. Cherry, Mark D. Morasch, Hazim J. Safi, Jerry Goldstone, Kaj JohansenAbstract:Abstract Objective: Aortic Reconstructions for primary graft infection (PGI), mycotic aneurysm (MA), and Aortic graft-enteric erosion (AEE) bear high morbidity and mortality rates, and current treatment options are not ideal. Cryopreserved grafts have been implanted successfully in infected fields and may be suitable for abdominal Aortic Reconstructions. Registry data from several institutions were compiled to examine results of cryopreserved Aortic allograft (CAA) placement. Methods: The experience of 31 institutions was reviewed for CAAs inserted from March 4, 1999, to August 23, 2001. Indications for CAA, organisms, mortality, and complications were identified. Results: Fifty-six patients, 43 men and 13 women, with a mean age of 66 years (range, 44 to 90 years) had in situ Aortic replacement with CAA. Indications for CAA placement were PGI in 43 patients (77%), MA in seven (14%), AEE in four (7%), and Aortic Reconstruction with concomitant bowel resection in two (4%). Infectious organisms were identified in 33 patients (59%); the most frequent organism was Staphylococcus aureus in 17 (52%). Thirty-one patients (55%) needed an additional cryopreserved segment for Reconstruction. The mean follow-up period was 5.3 months (range, 1 to 22 months). One patient died in the operating room, and the 30-day surgical mortality rate was 13% (7/56). Seven additional patients died during the follow-up period, yielding an overall mortality rate of 25% (14 patients). Two patients (4%) had graft-related mortality as the result of hemorrhage from the CAA and persistent infection. Graft-related complications included persistent infection with perianastomotic hemorrhage in five patients (9%), graft limb occlusion in five (9%), and pseudoaneurysm in one (2%). Three patients (5%) needed amputation. Conclusion: In situ Aortic Reconstruction with CAA in infected fields carries a high mortality rate, but most deaths are not the result of allograft failure. However, CAA infection and lethal hemorrhage caused by graft rupture occurs and is concerning. Early reinfection was not reported. Late graft-related complications, such as reinfection, thrombosis, or aneurysmal changes, are unknown. Preliminary data from this registry fail to justify the preferential use of CAA for PGI, MA, or AEE. A multicenter, randomized study is needed to compare results with established techniques. (J Vasc Surg 2002;35:847-52.)
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Aortic Reconstruction in kidney transplant recipients
Annals of Vascular Surgery, 1996Co-Authors: Jean M. Panneton, Peter Gloviczki, Linda G. Canton, Thomas C. Bower, Matthew S. T. Chow, Peter C. Pairolero, Hartzell V. Schaff, John W. Hallett, Kenneth J. CherryAbstract:Renal transplantation has increased the longevity of patients with uremia. An increasing number undergo Aortic Reconstruction, which exposes the transplanted kidney to ischemic injury. To evaluate the risk for renal failure, loss of the transplant, and methods of renal protection, we reviewed our experience. Clinical data were reviewed for 10 consecutive patients (7 men, 3 women; mean age 52.7 years [range 32 to 75 years]) with a transplanted kidney who underwent Aortic Reconstruction between 1977 and 1994 at our institution. Mean interval between renal transplantation and Aortic Reconstruction was 5.9 years (range 1 month to 12.7 years). Seven patients required emergency repair because of dissection (2 patients), aneurysm rupture (4 patients), or symptomatic aneurysm (1 patient); three underwent elective repair. Reasons for Reconstruction included Aortic dissection (2 patients), aneurysm of the descending thoracic (2 patients), thoracoabdominal (1 patient), or abdominal aorta (3 patients), and aortoiliac occlusive disease (2 patients). Patients with thoracic or thoracoabdominal Reconstructions underwent repair with atriofemoral, aortofemoral, or femorofemoral shunt placement or bypass. Of the five abdominal Aortic Reconstructions, the kidney was protected with aortofemoral shunt placement in one patient and cold renal perfusion in three. In two of them, topical cooling of the kidney also was used. One patient with acute Aortic dissection died at 39 days as a result of respiratory failure. Loss of the recently transplanted kidney was caused by acute rejection. One patient had a transient increase in serum creatinine concentration. Eight had no worsening of renal function, and none of the nine survivors lost the transplanted kidney. We conclude that Aortic Reconstruction can be safely performed in kidney transplant recipients. Patients in whom thoracic or thoracoabdominal Aortic Reconstruction was required were protected with an atriofemoral or aortofemoral bypass or shunt. Patients undergoing abdominal Aortic Reconstruction did well when cold renal perfusion with or without local cooling of the transplant was used for renal protection. Transplanted kidneys appeared to tolerate ischemic injury similarly to native kidneys.
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Advanced carotid disease in patients requiring Aortic Reconstruction
The American Journal of Surgery, 1993Co-Authors: Thomas C. Bower, Peter Gloviczki, John W. Hallett, Kenneth J. Cherry, Steven W. Merrell, Barbara J. Toomey, James M. Naessens, Peter C. PairoleroAbstract:Perioperative stroke is a devastating complication of abdominal Aortic operations. Patients requiring Aortic Reconstruction with advanced carotid occlusive disease pose a particularly challenging management problem regarding timing of operations. All patients (n=121) undergoing both carotid artery endarterectomy (CEA) and abdominal Aortic Reconstruction (AAR) within 1 year of each other between 1979 and 1989 were reviewed. The sequence of operation was analyzed to determine its effect on early and late outcome. CEA was the first operation in 99 patients (group I); AAR was performed first in 22 patients (group II). Age, gender, number, types of risk factors, and associated medical problems were similar in both groups. Indications for CEA were: transient ischemic attacks (TIAs), recent ipsilateral stroke, or high-grade asymptomatic carotid artery stenosis exceeding 80%. Indications for Aortic operation included: abdominal Aortic aneurysm, aortoiliac occlusive disease, and combined Aortic and renovascular disease. There were five perioperative strokes, two in group I (2%) and three in group II (14%) (p
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The role of intravenous fluorescein in the detection of colon ischemia during Aortic Reconstruction.
Annals of Vascular Surgery, 1992Co-Authors: R. Thomas Bergman, Peter Gloviczki, Thomas C. Bower, Peter C. Pairolero, John W. Hallett, James M. Naessens, Timothy J. Welch, Kenneth J. CherryAbstract:Intravenous fluorescein is an accurate predictor of small bowel viability, but its effectiveness in assessing colon perfusion during Aortic surgery has not been evaluated. Over a 10 year period 186 of 3,306 patients undergoing Aortic Reconstruction received 500 to 1000 mg of intravenous fluorescein intraoperatively to evaluate colon viability. Prior history of colectomy, hypogastric or mesenteric arterial occlusive disease, or ruptured aneurysm placed these patients at risk to develop ischemic colitis. Patients were operated on for aneurysmal disease (n = 94), occlusive disease (n = 66), or a combination of both (n = 26): 171 exhibited uniform normal perfusion patterns under Wood's lamp illumination, while in 11 it was "patchy." None of these patients developed full-thickness ischemic colitis (observed specificity: 100%). Fluorescence of the rectosigmoid was absent in four patients. One of these patients with a ruptured aneurysm underwent immediate sigmoid resection, while three underwent inferior mesenteric artery reimplantation. The fluorescein pattern subsequently normalized in two patients, but one underwent sigmoid resection for an expanding mesenteric hematoma. The second patient recovered without complications. The final patient continued to show a segmental sigmoid defect and postoperatively developed full-thickness injury requiring sigmoidectomy. During the same period 18 other patients developed transmural colon ischemia from 3,120 Aortic Reconstructions (0.6%), with a mortality rate of 56%. None had received intraoperative fluorescein. Selective use of intravenous fluorescein may reduce the mortality of ischemic colitis following Aortic Reconstruction.
