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The Cochrane Database of Systematic... Apr 2023Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic... (Review)
Review
BACKGROUND
Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic aneurysms include directly exposing the aorta and replacing the diseased segment via open repair, or endovascular repair. Endovascular repair uses fluoroscopic-guidance to access the aorta and deliver a device to exclude the aneurysmal aortic segment without requiring a large surgical incision. Endovascular repair can be performed under a general anesthetic, during which the unconscious patient is paralyzed and reliant on an anesthetic machine to maintain the airway and provide oxygen to the lungs, or a loco-regional anesethetic, for which medications are administered to provide the person with sufficient sedation and pain control without requiring a general anesthetic. While people undergoing general anesthesia are more likely to remain still during surgery and have a well-controlled airway in the event of unanticipated complications, loco-regional anesthesia is associated with fewer postoperative complications in some studies. It remains unclear which anesthetic technique is associated with better outcomes following the endovascular repair of aortic aneurysms.
OBJECTIVES
To evaluate the benefits and harms of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repair.
SEARCH METHODS
We used standard, extensive Cochrane search methods. The latest search was 11 March 2022.
SELECTION CRITERIA
We searched for all randomized controlled trials that assessed the effects of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repairs.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methods. Our primary outcomes were: all-cause mortality, length of hospital stay, length of intensive care unit stay. Our secondary outcomes were: incidence of endoleaks, requirement for re-intervention, incidence of myocardial infarction, quality of life, incidence of respiratory complications, incidence of pulmonary embolism, incidence of deep vein thrombosis, and length of procedure. We planned to use GRADE methodology to assess the certainty of evidence for each outcome.
MAIN RESULTS
We found no studies, published or ongoing, that met our inclusion criteria.
AUTHORS' CONCLUSIONS
We did not identify any randomized controlled trials that compared general versus loco-regional anesthesia for endovascular aortic aneurysm repair. There is currently insufficient high-quality evidence to determine the benefits or harms of either anesthetic approach during endovascular aortic aneurysm repair. Well-designed prospective randomized trials with relevant clinical outcomes are needed to adequately address this.
Topics: Humans; Anesthesia, Conduction; Anesthesia, General; Anesthetics, General; Aortic Aneurysm, Abdominal; Endovascular Procedures; Prospective Studies; Quality of Life
PubMed: 37052421
DOI: 10.1002/14651858.CD013182.pub2 -
European Journal of Orthopaedic Surgery... Oct 2023Patients undergoing total hip (THA) or knee (TKA) arthroplasty are at high risk of venous thromboembolism (VTE). As the number performed annually increases, the... (Review)
Review
The use of pre-operative Inferior Vena Cava filters for thromboprophylaxis in ultra-high-risk patients undergoing total hip and knee arthroplasty: a systematic review and narrative analysis.
PURPOSE
Patients undergoing total hip (THA) or knee (TKA) arthroplasty are at high risk of venous thromboembolism (VTE). As the number performed annually increases, the population at risk of fatal pulmonary embolism (PE) also grows. Ultra-high-risk arthroplasty patients (UHRAPs) include those with additional comorbidities, or a history of VTE, for many of whom routine prophylaxis will previously have failed. Pre-operative insertion of Inferior Vena Cava filters (IVCFs) has been recommended for thromboprophylaxis in UHRAPs, and this review was performed to establish their results.
METHODS
A systematic search of MEDLINE and Embase databases was performed for studies reporting the use of Inferior Vena Cava filters in hip and knee arthroplasty patients.
RESULTS
Ten studies met the inclusion criteria, containing 718 IVCFs in Orthopaedic patients, 343 of which were permanent (47.8%), 369 potentially retrievable (51.4%), 5 absorbable (0.6%) and one of unknown design (0.1%). Patient age averaged 64.7yrs (17-95) and 56% were female. Pre-operatively, 415 prophylactic IVCFs were inserted in 409 UHRAPs, undergoing a total of 438 total joint arthroplasties (TJA). There were 11 cases of PE in the entire series (1.5%) only one of which was fatal (0.01%), with four non-fatal PE in the UHRAP group (0.96%). Removal was attempted for 283 of the retrievable filters (76.7%) and was successful in 280 (98.9%).
CONCLUSION
The use of IVCFs eliminated fatal PE in UHRAPs, but larger, high-quality studies, with standardised reporting, are still required to determine their absolute indications for use, complication profile, efficacy and optimum design.
Topics: Humans; Female; Child; Adolescent; Young Adult; Adult; Middle Aged; Aged; Aged, 80 and over; Male; Vena Cava Filters; Venous Thromboembolism; Arthroplasty, Replacement, Knee; Anticoagulants; Pulmonary Embolism; Risk Factors; Retrospective Studies
PubMed: 37000238
DOI: 10.1007/s00590-023-03531-z -
Immunity, Inflammation and Disease Mar 2023Since publishing successful clinical trial results of mRNA coronavirus disease 2019 (COVID-19) vaccines in December 2020, multiple reports have arisen about... (Review)
Review
BACKGROUND AND OBJECTIVES
Since publishing successful clinical trial results of mRNA coronavirus disease 2019 (COVID-19) vaccines in December 2020, multiple reports have arisen about cardiovascular complications following the mRNA vaccination. This study provides an in-depth account of various cardiovascular adverse events reported after the mRNA vaccines' first or second dose including pericarditis/myopericarditis, myocarditis, hypotension, hypertension, arrhythmia, cardiogenic shock, stroke, myocardial infarction/STEMI, intracranial hemorrhage, thrombosis (deep vein thrombosis, cerebral venous thrombosis, arterial or venous thrombotic events, portal vein thrombosis, coronary thrombosis, microvascular small bowel thrombosis), and pulmonary embolism.
METHODS
A systematic review of original studies reporting confirmed cardiovascular manifestations post-mRNA COVID-19 vaccination was performed. Following the PRISMA guidelines, electronic databases (PubMed, PMC NCBI, and Cochrane Library) were searched until January 2022. Baseline characteristics of patients and disease outcomes were extracted from relevant studies.
RESULTS
A total of 81 articles analyzed confirmed cardiovascular complications post-COVID-19 mRNA vaccines in 17,636 individuals and reported 284 deaths with any mRNA vaccine. Of 17,636 cardiovascular events with any mRNA vaccine, 17,192 were observed with the BNT162b2 (Pfizer-BioNTech) vaccine, 444 events with mRNA-1273 (Moderna). Thrombosis was frequently reported with any mRNA vaccine (n = 13,936), followed by stroke (n = 758), myocarditis (n = 511), myocardial infarction (n = 377), pulmonary embolism (n = 301), and arrhythmia (n = 254). Stratifying the results by vaccine type showed that thrombosis (80.8%) was common in the BNT162b2 cohort, while stroke (39.9%) was common with mRNA-1273 for any dose. The time between the vaccination dosage and the first symptom onset averaged 5.6 and 4.8 days with the mRNA-1273 vaccine and BNT162b2, respectively. The mRNA-1273 cohort reported 56 deaths compared to the 228 with BNT162b2, while the rest were discharged or transferred to the ICU.
CONCLUSION
Available literature includes more studies with the BNT162b2 vaccine than mRNA-1273. Future studies must report mortality and adverse cardiovascular events by vaccine types.
Topics: Humans; 2019-nCoV Vaccine mRNA-1273; BNT162 Vaccine; COVID-19; COVID-19 Vaccines; Myocardial Infarction; Myocarditis; Pulmonary Embolism; Stroke; Thrombocytopenia; Thrombosis
PubMed: 36988252
DOI: 10.1002/iid3.807 -
Journal of Clinical Medicine Mar 2023Critically ill COVID-19 patients have a high incidence of thromboembolic events, which significantly influence the risk of mortality. Anticoagulant therapy is generally... (Review)
Review
Critically ill COVID-19 patients have a high incidence of thromboembolic events, which significantly influence the risk of mortality. Anticoagulant therapy is generally recommended to these patients but the optimal dosing regimens require further investigations. The objective of this systematic review and meta-analysis was to assess the efficacy and safety of prophylactic, intermediate and therapeutic dose anticoagulation in COVID-19 patients admitted to the ICU. A systematic search for original prospective observational studies and clinical trials was performed in online databases from 2020 to 2022. A total of 13 studies (3239 patients) were included. The type of anticoagulant dosing showed no significant influence on short-term mortality ( = 0.84), deep vein thrombosis ( = 0.66), arterial thrombosis ( = 0.44), major bleeding ( = 0.35) and minor bleeding incidence ( = 0.46). An anticoagulation regimen significantly influenced pulmonary embolism occurrence (16% for prophylactic dose vs. 4% for therapeutic dose, = 0.02), but the number of studies in the analysis was relatively low. In conclusion, the results of this meta-analysis suggest that critically ill COVID-19 patients admitted in the ICU have no benefit from therapeutic doses of anticoagulants and that all three thromboprophylaxis regimes have a comparable effect on short term mortality and venous thromboembolism incidence but for pulmonary embolism, for which the results were inconclusive.
PubMed: 36983222
DOI: 10.3390/jcm12062222 -
World Journal of Cardiology Feb 2023Pulmonary vein stenosis (PVS) is an uncommon but known cause of morbidity and mortality in adults and children and can be managed with percutaneous re-vascularization...
BACKGROUND
Pulmonary vein stenosis (PVS) is an uncommon but known cause of morbidity and mortality in adults and children and can be managed with percutaneous re-vascularization strategies of pulmonary vein balloon angioplasty (PBA) or pulmonary vein stent implantation (PSI).
AIM
To study the safety and efficacy outcomes of PBA PSI in all patient categories with PVS.
METHODS
We performed a literature search of all studies comparing outcomes of patients evaluated by PBA PSI for PVS. We selected all published studies comparing PBA PSI for PVS with reported outcomes of restenosis and procedure-related complications in all patient categories. In adults, PVS following atrial fibrillation ablation and in children PVS related to congenital etiology or post-procedural PVS following total or partial anomalous pulmonary venous return repair were included. The patient-centered outcomes were risk of restenosis requiring re-intervention and procedural-related complications. The meta-analysis was performed by computing odds ratios (ORs) using the random effects model based on underlying statistical heterogeneity.
RESULTS
Eight observational studies treating 768 severe PVS in 487 patients met our inclusion criteria. The age range of patients was 6 months to 70 years and 67% were males. The primary outcome of the re-stenosis requiring re-intervention occurred in 196 of 325 veins in the PBA group and 111 of 443 veins in the PSI group. Compared to PSI, PBA was associated with a significantly increased risk of re-stenosis (OR 2.91, 95%CI: 1.15-7.37, = 0.025, = 79.2%). Secondary outcomes of the procedure-related complications occurred in 7 of 122 patients in the PBA group and 6 of 69 in the PSI group. There were no statistically significant differences in the safety outcomes between the two groups (OR: 0.94, 95%CI: 0.23-3.76, = 0.929), = 0.0%).
CONCLUSION
Across all patient categories with PVS, PSI is associated with reduced risk of re-intervention and is as safe as PBA and should be considered first-line therapy for PVS.
PubMed: 36911751
DOI: 10.4330/wjc.v15.i2.64 -
Orthopaedic Surgery Apr 2023The optimal dose and efficacy of tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) in total knee arthroplasty (TKA) were under controversial, and we aimed to... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The optimal dose and efficacy of tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) in total knee arthroplasty (TKA) were under controversial, and we aimed to make comparisons between different doses of TXA and EACA in intravenous (IV) or intra-articular (IA) applications in patients undergoing TKA.
METHODS
This network meta-analysis was guided by the Priority Reporting Initiative for Systematic Assessment and Meta-Analysis (PRISMA). According to the administrations of antifibrinolytic agents, patients in eligible studies were divided into three subgroups: (i) IA applications of TXA and EACA; (ii) IV applications (g) of TXA and EACA; (iii) IV applications (mg/kg) of TXA and EACA. Total blood loss (TBL), hemoglobin (HB) drops and transfusion rates were the primary outcomes, while drainage volume, pulmonary embolism (PE) or deep vein thrombosis (DVT) risk were the secondary outcomes. A multivariate Bayesian random-effects model was adopted in the network analysis.
RESULTS
A total of 38 eligible trials with different regimens were assessed. Overall inconsistency and heterogeneity were acceptable. Taking all primary outcomes into account, 1.0-3.0 g TXA were most effective in IA applications, 1-6 g TXA and 10-14 g EACA were most effective in IV applications (g), while 30 mg/kg TXA and 150 mg/kg EACA were most effective in IV applications (mg/kg). None of the regimens showed increasing risk for pulmonary embolism (PE) or deep vein thrombosis (DVT) compared with placebo.
CONCLUSION
0 g IA TXA, 1.0 g IV TXA or 10.0 g IV EACA, as well as 30 mg/kg IV TXA or 150 mg/kg IV EACA were most effective and enough to control bleeding for patients after TKA. TXA was at least 5 times more potent than EACA.
Topics: Humans; Administration, Intravenous; Aminocaproic Acid; Antifibrinolytic Agents; Arthroplasty, Replacement, Knee; Bayes Theorem; Blood Loss, Surgical; Network Meta-Analysis; Pulmonary Embolism; Tranexamic Acid; Venous Thrombosis
PubMed: 36878889
DOI: 10.1111/os.13678 -
Cureus Feb 2023Colchicine is a potent anti-inflammatory agent whose benefits have been explored for various conditions, including atrial fibrillation (AF). In this article, we tried... (Review)
Review
Colchicine is a potent anti-inflammatory agent whose benefits have been explored for various conditions, including atrial fibrillation (AF). In this article, we tried to understand why colchicine might be beneficial in AF and reviewed various studies that looked at the effect of colchicine against AF. We followed the PRISMA algorithm and undertook a literature search to identify studies with control groups that looked at the effect of colchicine against AF and conducted a meta-analysis. We identified six studies on post-cardiac surgical patients, three on post-pulmonary vein isolation (PVI)/ablation patients, and two on coronary artery disease. In patients who underwent cardiac surgery, we found that colchicine is beneficial against postoperative atrial fibrillation (POAF) with a relative risk (RR) of 0.70 (95% CI of 0.58 to 0.84) and a p-value of 0.0001. We also found that in patients who underwent PVI/ablation, colchicine is beneficial in decreasing AF recurrence over three months with an RR of 0.57 (95% CI of 0.39 to 0.83) and a p-value of 0.0032 and over 12 months follow-up with an RR of 0.58 (95% CI of 0.42 - 0.80) and a p-value of 0.0008. Our meta-analysis showed that in patients with coronary artery disease, colchicine had no significant benefit in decreasing the incidence of AF with a hazard ratio (HR) of 0.86 (95% CI of 0.69 - 1.06) and a p-value of 0.16. From this study, we conclude that colchicine may be beneficial for decreasing the incidence of AF in post-cardiac surgery patients and post-PVI/ablation patients. It may not decrease the incidence of AF in patients with coronary artery disease.
PubMed: 36819949
DOI: 10.7759/cureus.35120 -
Journal of Orthopaedic Surgery and... Feb 2023To summarize the incidence, risk factors, diagnosis methods, prophylaxis methods, and treatment of venous thromboembolism (VTE) following arthroscopic shoulder surgery. (Review)
Review
PURPOSE
To summarize the incidence, risk factors, diagnosis methods, prophylaxis methods, and treatment of venous thromboembolism (VTE) following arthroscopic shoulder surgery.
METHODS
Literature on VTE after arthroscopic shoulder surgeries was summarized, and all primary full-text articles reporting at least 1 case of deep vein thrombosis (DVT) or pulmonary embolism (PE) after arthroscopic shoulder surgeries were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, diagnosis, prophylaxis, and management of VTE following arthroscopic shoulder surgeries.
RESULTS
This study included 42 articles in which the incidence of VTE ranges from 0 to 5.71% and the overall incidence was 0.26%. Most VTE events took place between the operation day and the 14th day after the operation (35/51). Possible risk factors included advanced age (> 70 years), obesity (BMI ≥ 30 kg/m), diabetes mellitus, thrombophilia, history of VTE, prolonged operation time, hormone use, and immobilization after surgery. The most common prophylaxis method was mechanical prophylaxis (13/15). No statistical difference was detected when chemoprophylaxis was applied. The management included heparinization followed by oral warfarin, warfarin alone and rivaroxaban, a direct oral anticoagulant.
CONCLUSION
Based on the included studies, the incidence rate of VTE after arthroscopic shoulder surgeries is relatively low. The risk factors for VTE are still unclear. CT/CTA and ultrasound were the mainstream diagnosis methods for PE and DVT, respectively. Current evidence shows that chemical prophylaxis did not deliver significant benefits, since none of the existing studies reported statistically different results. High-quality studies focusing on the prophylaxis and management of VTE population undergoing arthroscopic shoulder surgeries should be done in the future.
Topics: Humans; Aged; Venous Thromboembolism; Warfarin; Shoulder; Pulmonary Embolism; Rivaroxaban; Risk Factors; Anticoagulants; Incidence
PubMed: 36788620
DOI: 10.1186/s13018-023-03592-0 -
Open Forum Infectious Diseases Feb 2023Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse...
BACKGROUND
Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse effects of these catheters. We aimed to evaluate the relative risk of complications from midlines and PICCs.
METHODS
We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. The primary outcomes were catheter-related bloodstream infection (CRBSI) and thrombosis. Secondary outcomes evaluated included mortality, failure to complete therapy, catheter occlusion, phlebitis, and catheter fracture. The certainty of evidence was assessed using the GRADE approach.
RESULTS
Of 8368 citations identified, 20 studies met the eligibility criteria, including 1 RCT and 19 observational studies. Midline use was associated with fewer patients with CRBSI compared with PICCs (odds ratio [OR], 0.24; 95% CI, 0.15-0.38). This association was not observed when we evaluated risk per catheter. No significant association was found between catheters when evaluating risk of localized thrombosis and pulmonary embolism. A subgroup analysis based on location of thrombosis showed higher rates of superficial venous thrombosis in patients using midlines (OR, 2.30; 95% CI, 1.48-3.57). We did not identify any significant difference between midlines and PICCs for the secondary outcomes.
CONCLUSIONS
Our findings suggest that patients who use midlines might experience fewer CRBSIs than those who use PICCs. However, the use of midline catheters was associated with greater risk of superficial vein thrombosis. These findings can help guide future cost-benefit analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs vs midline catheters.
PubMed: 36751645
DOI: 10.1093/ofid/ofad024 -
Annals of the Academy of Medicine,... Jan 2023Despite promising trials, catheter ablation is still regarded as an adjunct to antiarrhythmic drugs (AADs) in the treatment of paroxysmal atrial fibrillation (PAF). This... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Despite promising trials, catheter ablation is still regarded as an adjunct to antiarrhythmic drugs (AADs) in the treatment of paroxysmal atrial fibrillation (PAF). This study aimed to compare the effectiveness of various ablation therapies and AADs.
METHOD
Randomised controlled trials or propensity score-matched studies comparing atrial tachyarrhythmia recurrence among any combination of ablation modalities or AAD were retrieved. Kaplan-Meier curves and risk tables for this outcome were graphically reconstructed to extract patient-level data. Frequentist network meta-analysis (NMA) using derived hazard ratios (HRs), as well as 2 restricted mean survival time (RMST) NMAs, were conducted. Treatment strategies were ranked using P-scores.
RESULTS
Across 24 studies comparing 6 ablation therapies (5,132 patients), Frequentist NMA-derived HRs of atrial fibrillation recurrence compared to AAD were 0.35 (95% confidence interval [CI]=0.25-0.48) for cryoballoon ablation (CBA), 0.34 (95% CI=0.25-0.47) for radiofrequency ablation (RFA), 0.14 (95% CI=0.07-0.30) for combined CBA and RFA, 0.20 (95% CI=0.10-0.41) for hot-balloon ablation, 0.43 (95% CI=0.15-1.26) for laser-balloon ablation (LBA), and 0.33 (95% CI=0.18-0.62) for pulmonary vein ablation catheter. RMST-based NMAs similarly showed significant benefit of all ablation therapies over AAD. The combination of CBA + RFA showed promising long-term superiority over CBA and RFA, while LBA showed favourable short-term efficacy.
CONCLUSION
The advantage of ablation therapies over AAD in preventing atrial tachyarrhythmia recurrence suggests that ablation should be considered as the first-line treatment for PAF in patients fit for the procedure. The promising nature of several specific therapies warrants further trials to elicit their long-term efficacy and perform a cost-benefit analysis.
Topics: Humans; Anti-Arrhythmia Agents; Atrial Fibrillation; Catheter Ablation; Heart Atria; Network Meta-Analysis; Recurrence; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 36730803
DOI: 10.47102/annals-acadmedsg.2022326