Course details here

Christopher A. Troianos, Gregg S. Hartman, Kathryn E. Glas, Nikolaos J. Skubas, Robert T. Eberhardt, Jennifer D. Walker, Scott T. Reeves,  Guidelines for Performing Ultrasound Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists Anesth Analg January 2012 114:46-72
http://www.anesthesia-analgesia.org/content/114/1/46.full.pdf+html

Five strong predictors for PRF emerged from evaluation of the data:

• surgery type,
• The riskiest surgeries were those of the brain, aorta, and foregut/hepatopancreatobiliary region.
• emergency case,
• dependent functional status,
• preoperative sepsis,
• higher American Society of Anesthesiologists class.

“PRF develops in approximately 3% of patients, and more than 25% of them die within 30 days. Up to 40% of postoperative complications after abdominal and vascular surgeries are pulmonary in nature.

The study, from Himani Gupta, MD and colleagues from the University of Pittsburgh in Pennsylvania and Creighton University in Omaha, Nebraska, considers all surgeries and distinguishes PRF from other pulmonary complications. Data are from the American College of Surgeons’ National Surgical Quality Improvement Program, which represents more than 180 hospitals.”

I’ve always been concerned about the generalizability of Poldermans’ work.  A PubMed search of his name and “vascular surgery” returns over 150 references.  His work has continued to support perioperative beta blockade while other studies, such as POISE, have found adverse outcomes.  He is lead author of the European Society of Cardiologists Perioperative Guidelines for Noncardiac Surgery.

Now, Prof Poldermans has been fired by Erasmus University, among allegations:

The professor is accused of faking academic data and compromising patient trust, the paper says. In particular, he failed to obtain patient consent for carrying out research and recorded results ‘which cannot be resolved to patient information,’ the university said.

Don Poldermans has spent years researching the risk of complications during cardio-vascular surgery and has some 500 publications to his name.

A spokesman for Poldermans told the paper he admitted not keeping to research protocols but denied faking data.

The ESC has therefore stated:

In its statement, the ESC said that the society is reviewing this document “in order to decide if these need to be re-examined in the light of recent events. A new statement will be issued by the ESC once a decision has been reached.”

Now Danyi et al have written a review article highlighting the potential for medical therapy to replace some surgery for thoracic aneurysms.

Specifically, they describe molecular mechanisms that may lead to aneurysm formation, and how:

• Angiotensin receptor blockers (ARBs) are thought to inhibit the above pathways via inhibition of the AT1 receptors.
• Angiotensin-converting enzyme inhibitors (ACEIs) block angiotensin II.
• Statins block the NADH/NADPH system;
• tetracyclines and macrolides reduce MMP activity. β-Blockers reduce shear stress on the vessel.

Given the high M&M of thoracic aortic surgery, even with endovascular and hybrid approaches, these are hopeful advances.

Fig. 2. MRI parasagittal gated image showing a saccular aneurysm of the aortic isthmus just distal to the left subclavian artery (white arrow). The cine-gradient echo image signal intensity in the aneurysm is inhomogeneous because of the intraluminal turbulence.

www.thelancet.com Published online October 6, 2011 DOI:10.1016/S0140-6736(11)61381-0

“Methods We analysed data for patients undergoing major non-cardiac surgery in 2008 from The American College of Surgeons’ National Surgical Quality Improvement Program database (a prospective validated outcomes registry from 211 hospitals worldwide in 2008). We obtained anonymised data for 30-day mortality and morbidity (cardiac, respiratory, CNS, urinary tract, wound, sepsis, and venous thromboembolism outcomes), demographics, and preoperative and perioperative risk factors. We used multivariate logistic regression to assess the adjusted and modified (nine predefined risk factor subgroups) eff ect of anaemia, which was defi ned as mild (haematocrit concentration >29–<39% in men and >29–<36% in women) or moderate-to-severe (≤29% in men and women) on postoperative outcomes.

Interpretation Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery.”

Vascular patients were more anemic than others (no surprise there).  Any anemia in vascular surgery patients had OR for mortality = 1·44 (1·24–1·68) for morbidity 1·24 (1·14–1·35).

In all patient groups (by level of anemia or not), transfused patients did NOT have increase mortality or morbidity. Go figure.

A few quotes from a review by — Allan S. Brett, MD:

Because medical therapy has improved since these trials were conducted, researchers have examined whether stroke rates in patients with ACS have declined during the past decade. In fact, rates have fallen to around 1% annually in medically treated patients.^4,5

Thus, we must ask whether CEA has any role in patients with ACS. Recently, researchers have proposed several imaging findings that might identify high-risk subgroups — plaque echolucency, plaque ulceration, and embolic signals on transcranial Doppler ultrasound of the ipsilateral middle cerebral artery…

Thus, many asymptomatic patients who now undergo CEA (or carotid stenting, which is not safer than CEA) are likely risking harm without commensurate benefit. Use of embolic signals and plaque characteristics to identify candidates for CEA is promising but requires larger studies and assurance that the techniques are reliable in community settings.

4. Marquardt L et al. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: A prospective, population-based study. Stroke 2010 Jan; 41:e11. (http://dx.doi.org/10.1161/STROKEAHA.109.561837)

• Original article (Subscription may be required)
• Medline abstract (Free)

5. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: Results of a systematic review and analysis.Stroke 2009 Oct; 40:e573. (http://dx.doi.org/10.1161/STROKEAHA.109.556068)

• Original article (Subscription may be required)
• Medline abstract (Free)

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