Hypothermic renal protection using cold histidine-tryptophan-ketoglutarate solution perfusion in suprarenal aortic surgery.
ABSTRACT We examined data of 21 patients who were treated with selective perfusion of both renal arteries with 500 mL of 8 degrees C histidine-tryptophan-ketoglutarate (HTK) solution each for renal protection during aortic surgery. Only the data from aortic surgeries with unavoidable suprarenal aortic cross-clamping for juxtarenal or suprarenal abdominal aortic aneurysms (AAAs) or high Leriche syndrome accompanied with stenosis of renal arteries are presented. Five patients underwent immediate surgery because of perforation of an AAA; the other 16 patients went through elective surgeries. In three cases (14%) stenosis of the renal arteries was diagnosed; nevertheless, implantation of an aortorenal bypass was necessary in seven patients. In total, 14 aortorenal bypasses were implanted (five venous grafts and nine prosthesis grafts). Four (19%) patients needed catecholaminergic support to establish stable circulatory conditions; in two (9%) of these cases additional ischemia of the colon was observed and sigmoidectomy was performed. All of these four patients underwent immediate surgery, and one died after surgery because of severe sepsis. In four cases postsurgical renal insufficiency was observed. Three of these patients were admitted for emergency surgery because of their hemodynamic situation due to perforation of the AAA. None of the patients needed chronic dialysis after surgery. Whereas in all patients who underwent elective surgery the renal function remained stable as judged by postoperative serum creatinine values, in five out of seven patients with aortorenal bypass surgery the renal function improved. Perfusion with cold HTK solution offers an additional procedure to protect renal function in patients undergoing elective surgery with suprarenal cross-clamping of the aorta.
- SourceAvailable from: Luca Bertoglio[Show abstract] [Hide abstract]
ABSTRACT: Open surgical repair of thoracoabdominal aortic aneurysms has evolved significantly over the last decades thanks to technical improvements, especially in the area of organ protection. However, despite adjunctive strategies, morbidity and mortality rates are still not negligible. Repair of the thoracoabdominal aorta represents a formidable challenge for surgeons, anesthesiologists and patients alike. While operative repair is generally carried out in specialized institutions, knowledge of the state-of-the-art diagnostic, anesthesiologic, surgical and endovascular aspects will certainly be of great value to all physicians involved in the care of these patients at any level. This "How to" video will explain all of these diagnostic, anesthesiologic and surgical aspects in our daily practice.Annals of cardiothoracic surgery. 09/2012; 1(3):398-403.
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ABSTRACT: To determine whether renal perfusion with cold crystalloid solution enriched with histidine-tryptophan-ketoglutarate (Custodiol; Dr Franz-Kohler Chemie GmbH, Bensheim, Germany) provides better protection against renal ischemic injury than cold lactated Ringer's solution in patients undergoing thoracoabdominal aortic aneurysm open repair. We analyzed a prospectively compiled database containing all 111 consecutive patients who underwent thoracoabdominal aortic aneurysm open repair at our center from 2008 to 2011. A cohort of 104 consecutive patients was identified of which 50 (48%) had renal perfusion with Custodiol and 54 (52%) with lactated Ringer's solution. Propensity score matching based on baseline clinical variables, which were expected to influence renal outcomes, was performed to correct for any bias that may have been associated with the use of Custodiol. Acute kidney injury (AKI) as defined by Kidney Disease Improving Global Outcomes guidelines and perioperative estimated glomerular filtration rate were compared in the two groups. Independent predictors of AKI were also identified by multivariate analysis. After propensity score matching, we were able to match 42 Custodiol cases one-to-one with those receiving perfusion with lactated Ringer's solution. Overall 30-day mortality was 5.9%; temporary hemodialysis or continuous veno-venous hemofiltration was needed in 4.8% of the patients without any case of dialysis at discharge. Freedom from AKI was significantly increased in the Custodiol group (38.1% vs 9.5%; P = .002) despite longer total renal ischemic time (51.5 ± 16.4 minutes vs 43.6 ± 16.0 minutes; P = .05). By analysis of variance for repeated measures, a significant upward trend of perioperative estimated glomerular filtration rate was observed in the Custodiol group (group × time interaction = F3,66; P < .001), and by multivariate analysis, Custodiol perfusion was the only independent predictor of non-AKI (P = .04). The use of Custodiol was safe and provided improved perioperative renal function compared with lactated Ringer's solution. Randomized trials are needed to confirm these data and to assess their clinical consequences.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2013; · 3.52 Impact Factor
Article: Juxtarenal aortic aneurysm repair.[Show abstract] [Hide abstract]
ABSTRACT: Juxtarenal aortic aneurysms (JAA) account for approximately 15% of abdominal aortic aneurysms. Despite advances in endovascular aneurysm repair, open repair requiring suprarenal aortic cross-clamping is still the treatment of choice for JAA. We performed a systematic review of the literature to determine perioperative mortality and postoperative renal dysfunction after open repair for non-ruptured JAA. The Medline, Embase, and Cochrane databases were searched to identify all studies reporting non-ruptured JAA repair published between January 1966 and December 2008. Two independent observers selected studies for inclusion, assessed the methodologic quality of the included studies, and performed the data extraction. Study heterogeneity was assessed using forest plots and by calculating the between-study variance. Outcomes were perioperative mortality, postoperative renal dysfunction, and new onset of dialysis. Summary estimates with 95% confidence interval (95% CI) were calculated using a random effects model based on the binomial distribution. Twenty-one non-randomized cohort studies from 1986 to 2008, reporting on 1256 patients, were included. Heterogeneity between the studies was low. The mean perioperative mortality was 2.9% (95% CI, 1.8 to 4.6). The mean incidence of new onset of dialysis was 3.3% (95% CI, 2.4 to 4.5). Incidence of postoperative renal dysfunction could be derived from 13 studies and ranged from 0% to 39% (median, 18%). In seven studies, cold renal perfusion during suprarenal clamping was performed in order to preserve renal function; however, based upon the included data, definitive conclusions regarding its efficacy could not be drawn. Open repair of non-ruptured JAA using suprarenal cross-clamping can be performed with acceptable perioperative mortality; however, postoperative deterioration of renal function is a common complication. Preservation of renal function after JAA repair requires further investigation.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 04/2010; 52(3):760-7. · 3.52 Impact Factor