Distinct factors correlating with adverse cardiac events after major vascular surgery
ABSTRACT Cardiovascular complications remain the principal cause of both morbidity and mortality after major vascular surgery. The well-known coincidence between vascular disease and coronary artery disease provided the rationale for a detailed analysis of major perioperative cardiovascular complications in their relation to preoperative and intraoperative parameter
90 patients scheduled to undergo either femoral-popliteal bypass (n = 74) or repair of an infrarenal aortic aneurysm (n = 16) were prospectively included in the study. All patients had no signs of unstable cardiac disease and required no cardiac testing. Both preoperative and intraoperative parameter were correlated to adverse cardiac events (cardiac death and myocardial infarction -MI).
Univariate analysis identified the following parameter to be significantly related to cardiac complications: prior MI and intraoperative hypertension (systolic blood pressure above 200 mmHg). In contrast perioperative betablocker therapy was revealed to be protective. In multivariate analysis the history of MI and intraoperative hypertension correlated with poor cardiac outcome.
Our results underline the importance of the individual history in predicting perioperative risk and corroborate the beneficial effects of long-standing beta-blocker therapy. Additionally the significance of stable intraoperative hemodynamic parameter is demonstrated.
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ABSTRACT: A variety of clinical and anatomic factors influence the choice between infrainguinal bypass surgery (BPG) and percutaneous endovascular procedures (PTA) to treat lower extremity vascular disease. The decision, in part, is dependant on periprocedural morbidity. The goal of this study was to document the contemporary morbidity and mortality of infrainguinal BPG, utilizing the previously validated National Surgical Quality Improvement Program (NSQIP) database. Data from the private sector NSQIP, a prospectively validated systematic-sample database, using Current Procedural Terminology (CPT) codes for all infrainguinal BPG performed between January 1, 2005, and December 31, 2006, were analyzed. Study endpoints included 30-day death and NSQIP-defined major complications, including graft failure, differentiated between systemic vs operative-site related complications. Potentially associated clinical variables were assessed by univariate methods to create the multivariate models of factors associated with study endpoints. There were 2404 infrainguinal BPG (infrapopliteal distal anastomosis 42%, prosthetic 29%) performed in the study interval with patient variables: age 67 +/- 12, male 66%, diabetes 44%, limb salvage indications 48%. The 30-day composite mortality/major morbidity was 19.5%. The overall mortality was 2.7% and correlated with (P value, odds ratio [OR]): patient age (<.001, 1.056), low body weight (.007, 0.988), significant preoperative dyspnea (.03, 1.97), dialysis (.003, 5.26), history transient ischemic attack (.03, 2.43), and bleeding disorder (.02, 2.01). Major complications occurred in 18.7% patients, including 7.4% graft thromboses, and 9.4% wound infections. Major systemic complications occurred in 5.9% and correlated with: age (.001, 1.03), history myocardial infarction (.02, 2.37), dialysis (<.001, 2.52), impaired sensorium (.005, 2.93), and general (vs regional) anesthesia (.04, 1.9). Major operative site-related complications occurred in 15.1% and correlated with: history chronic obstructive pulmonary disease (.04, 1.40), limb salvage indication (<.001, 1.71), impaired sensorium (.01, 2.26), non-independent preoperative functional status (.03, 1.37), and operative time (<.001, 1.002). The combination of dialysis and age >80 was identified as the most powerful high-risk composite for death (13.3-fold) and major complications (2.2-fold). Infrainguinal BPG is accompanied by significant major morbidity and mortality in contemporary practice. These results reinforce the precept that stringent indications for BPG should be maintained, when considering the method of lower extremity revascularization.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 08/2009; 50(2):299-304, 304.e1-4. DOI:10.1016/j.jvs.2009.01.043 · 2.98 Impact Factor
Journal of cardiothoracic and vascular anesthesia 06/2011; 25(3):509-25. DOI:10.1053/j.jvca.2011.01.018 · 1.48 Impact Factor
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ABSTRACT: Even extremely high-doses of the potent opioid, sufentanil, cannot reliably suppress stress responses to intense surgical stimuli such as sternotomy. The chemically related opioid remifentanil with its different pharmacokinetics and binding affinities for delta- and kappa-opioid receptors might be more effective in attenuating these responses. ASA I-III patients scheduled for a surgical procedure with sternotomy under balanced anesthesia (sevoflurane and sufentanil 3 μg.kg(-1) bolus, 0.017 μg.kg(-1).min(-1) infusion) were randomized into two groups. Patients in the study group were supplemented with remifentanil (2 μg.kg(-1) bolus, 2-7 μg.kg(-1).min(-1) infusion) starting ten minutes before sternotomy. Heart rate, arterial blood pressures, cardiac index, ejection fraction, systemic vascular resistance index (SVRI), total body oxygen uptake (VO2) and electric dermal response were measured and compared between the groups. 62 patients were studied (study group 32, control group 30). Systolic and mean arterial blood pressures, SVRI, VO2 and skin conductance increased during sternotomy and sternal spread in the control group but not in the study group. Systolic blood pressure increase: 7.5 ± 19 mmHg vs. -3.4 ± 8.9 (p = 0.005); VO2 increase: 31 ± 46% vs. -0.4 ± 32%; incidence of systolic blood pressure increase greater than 15 percent: 20% vs. 3% (p = 0.035) (control vs. study group). High-dose remifentanil added to sevoflurane-sufentanil anesthesia suppresses the sympathoadrenergic response to sternotomy and sternal spread better than high-dose sufentanil alone. DRKS00004327, August 31, 2012.BMC Anesthesiology 01/2015; 15(1):3. DOI:10.1186/1471-2253-15-3 · 1.33 Impact Factor