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Annals of Cardiac Anaesthesia Apr 2024Postoperative visual loss (POVL) is an infrequent yet consequential complication that can follow cardiac surgical interventions. This systematic review aims to provide a...
Postoperative visual loss (POVL) is an infrequent yet consequential complication that can follow cardiac surgical interventions. This systematic review aims to provide a comprehensive analysis of the incidence of POVL after cardiac surgery and to delineate the associated risk factors. A comprehensive search was conducted in major medical databases for relevant studies published up to September 2022. Eligible studies reporting on the incidence of POVL and identifying risk factors in patients undergoing cardiac surgery were included. Data extraction was performed independently by two reviewers. The pooled incidence rates and the identified risk factors were synthesized qualitatively. POVL after cardiac surgery has an overall incidence of 0.015%, that is, 15 cases per 100,000 cardiac surgical procedures. Risk factors for POVL include patient characteristics (advanced age, diabetes, hypertension, and preexisting ocular conditions), procedural factors (prolonged surgery duration, cardiopulmonary bypass time, and aortic cross-clamping), anesthetic considerations (hypotension, blood pressure fluctuations, and specific techniques), and postoperative complications (stroke, hypotension, and systemic hypoperfusion). Ischemic optic neuropathy (ION) is an uncommon complication, associated with factors like prolonged cardiopulmonary bypass, low hematocrit levels, excessive body weight gain, specific medications, hypothermia, anemia, raised intraocular pressure, and micro-embolization. Diabetic patients with severe postoperative anemia are at increased risk for anterior ischemic optic neuropathy (AION). Posterior ischemic optic neuropathy (PION) can occur with factors like hypertension, postoperative edema, prolonged mechanical ventilation, micro-embolization, inflammation, hemodilution, and hypothermia.While the overall incidence of POVL postcardiac surgery remains modest, its potential impact is substantial, necessitating meticulous consideration of modifiable risk factors. Notably, prolonged surgical duration, intraoperative hypotension, anemia, and reduced hematocrit levels remain salient contributors. Vigilance is indispensable to promptly detect this infrequent yet visually debilitating phenomenon in the context of postcardiac surgical care.
Topics: Humans; Incidence; Hypothermia; Risk Factors; Hypertension; Hypotension; Anemia
PubMed: 38607873
DOI: 10.4103/aca.aca_85_23 -
European Journal of Vascular and... Mar 2021To investigate whether a percutaneous approach has better clinical outcomes than surgical access for standard endovascular repair of abdominal aortic aneurysms. (Meta-Analysis)
Meta-Analysis
Editor's Choice - Percutaneous Access Does Not Confer Superior Clinical Outcomes Over Cutdown Access for Endovascular Aneurysm Repair: Meta-Analysis and Trial Sequential Analysis of Randomised Controlled Trials.
OBJECTIVE
To investigate whether a percutaneous approach has better clinical outcomes than surgical access for standard endovascular repair of abdominal aortic aneurysms.
DATA SOURCES
MEDLINE and Embase were searched using the Healthcare Databases Advanced Search interface developed by the National Institute for Health and Care Excellence.
REVIEW METHODS
Randomised controlled trials (RCTs) that compared percutaneous and cutdown endovascular aneurysm repair (EVAR) were considered. Pooled effect estimates were calculated using the odds ratio (OR), risk difference, or mean difference (MD) and 95% confidence interval (CI). The Mantel-Haenszel or inverse variance statistical method was used as appropriate. Trial sequential analysis was performed to quantify the available evidence and control for the risk of type 1 and type 2 error. Risk of bias was assessed with the revised tool developed by Cochrane and the quality of evidence was graded using the GRADE system (Grades of Recommendation, Assessment, Development and Evaluation).
RESULTS
Four RCTs were identified, reporting a total of 368 patients and 530 access sites. Meta-analysis showed no difference in access site complications or infection, post-operative bleeding/haematoma, access related arterial injury, femoral artery occlusion, pseudo-aneurysm, or peri-operative mortality between percutaneous and cutdown EVAR. Seroma/lymphorrhoea was significantly less frequent after percutaneous EVAR (0%) compared with cutdown EVAR (3%; OR 0.18 [95% CI 0.04-0.83]) and the procedure time was significantly shorter (MD -11.53 minutes; 95% CI -15.71-7.34), but hospital length of stay was not different between treatments. Neither the O'Brien-Fleming boundaries nor the futility boundaries were crossed by the cumulative Z curve, and the required information size was not reached for any of the outcomes. All trials were judged to be high risk of bias or have some concerns, and the level of the body of evidence was low or very low for all outcomes.
CONCLUSION
The evidence is very uncertain about the effect of percutaneous EVAR on clinically important outcomes.
Topics: Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Postoperative Complications
PubMed: 33309488
DOI: 10.1016/j.ejvs.2020.11.008 -
The Journal of Thoracic and... Oct 2018Retrograde cerebral perfusion is becoming less frequently used as a method of neuroprotection during aortic surgery. The present meta-analysis aims to compare outcomes... (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
Retrograde cerebral perfusion is becoming less frequently used as a method of neuroprotection during aortic surgery. The present meta-analysis aims to compare outcomes after arch surgery with hypothermic circulatory arrest versus hypothermic circulatory arrest + retrograde cerebral perfusion.
METHODS
Electronic searches were performed using 7 databases from their inception to September 2016. Relevant comparative studies that included patient groups who underwent aortic arch surgery using hypothermic circulatory arrest with continuous retrograde cerebral perfusion or hypothermic circulatory arrest alone were identified, and data were extracted by 2 independent researchers. Data were aggregated using a random-effects model per predefined clinical end points.
RESULTS
Twenty-eight comparative studies were identified, with 2705 hypothermic circulatory arrest cases and 2817 hypothermic circulatory arrest + retrograde cerebral perfusion cases. No significant differences were seen between both groups in terms of age, gender, proportion of dissections and aneurysms, and hemiarch/total arch repair. The hypothermic circulatory arrest + retrograde cerebral perfusion group had slightly longer cardiopulmonary bypass time and lower body arrest time. Mortality was significantly increased for the hypothermic circulatory arrest cohort compared with the hypothermic circulatory arrest + retrograde cerebral perfusion cohort (odds ratio, 1.75; 95% confidence interval, 1.16-2.63; P = .007; I = 54%), but not on pooling of adjusted estimates. Stroke was also increased for the hypothermic circulatory arrest cohort (odds ratio, 1.50; 95% confidence interval, 1.07-2.10; P = .02; I = 29%). No difference in temporary neurologic deficit was identified (P = .66). Meta-regression found the treatment effect for mortality and stroke to be less pronounced in more contemporary series.
CONCLUSIONS
These results suggest that the addition of retrograde cerebral perfusion during aortic arch surgery may provide better outcomes than using hypothermic circulatory arrest alone, although significant confounders exist. Further robust studies are required to confirm the utility of retrograde cerebral perfusion in arch surgery.
Topics: Aorta, Thoracic; Brain; Cardiovascular Surgical Procedures; Circulatory Arrest, Deep Hypothermia Induced; Humans; Perfusion; Treatment Outcome
PubMed: 29789153
DOI: 10.1016/j.jtcvs.2018.04.063 -
European Journal of Vascular and... Aug 2019Low psoas muscle mass is associated with increased mortality and morbidity after surgery. Recent evidence has linked low psoas muscle mass with survival after abdominal... (Meta-Analysis)
Meta-Analysis
Effect of Low Skeletal Muscle Mass on Post-operative Survival of Patients With Abdominal Aortic Aneurysm: A Prognostic Factor Review and Meta-Analysis of Time-to-Event Data.
OBJECTIVE/BACKGROUND
Low psoas muscle mass is associated with increased mortality and morbidity after surgery. Recent evidence has linked low psoas muscle mass with survival after abdominal aortic aneurysm (AAA) repair. The aim of this study was to investigate the prognostic role of low skeletal muscle mass in survival of patients with AAA undergoing open or endovascular aneurysm repair (EVAR).
METHODS
A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration number: CRD42018107793). The prognostic factor of interest was degenerative loss of skeletal muscle. A time-to-event data meta-analysis was performed for all cause mortality using the inverse variance method and the results were reported as summary hazard ratio (HR) and 95% confidence interval (CI). Pooled estimates of peri-operative outcome data were calculated using the odds ratio (OR) or risk difference (RD) and 95% CI. Random-effects models of meta-analysis were applied.
RESULTS
Seven observational cohort studies reporting a total of 1,440 patients were eligible for quantitative synthesis. Patients with low skeletal muscle mass had a significantly higher hazard of mortality than those without low skeletal muscle mass (HR 1.66, 95% CI 1.15-2.40; p = .007). Subgroup analysis including only patients who underwent EVAR showed a marginal survival benefit for patients without low skeletal muscle mass (HR 1.86, 95% CI 1.00-3.43; p = .05). Meta-analysis of two studies found no significant difference in peri-operative mortality (RD 0.04, 95% CI -0.13 to 0.21) and morbidity (OR 1.58, 95% CI 0.90-2.76; p = .11) between patients with and without low skeletal muscle mass.
CONCLUSION
There is a significant link between low skeletal muscle mass and mortality in patients undergoing AAA repair. Prospective studies validating the use of body composition for risk prediction after aortic surgery are required before this tool can be used to support decision making and patient selection.
Topics: Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Body Composition; Endovascular Procedures; Frailty; Health Status; Humans; Muscle, Skeletal; Risk Assessment; Risk Factors; Sarcopenia; Treatment Outcome
PubMed: 31204184
DOI: 10.1016/j.ejvs.2019.03.020 -
Ontario Health Technology Assessment... 2020Surgical aortic valve replacement (SAVR) is the conventional treatment for patients with severe aortic valve stenosis at low surgical risk. Transcatheter aortic valve... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Surgical aortic valve replacement (SAVR) is the conventional treatment for patients with severe aortic valve stenosis at low surgical risk. Transcatheter aortic valve implantation (TAVI) is a less invasive procedure. We conducted a health technology assessment (HTA) of TAVI for patients with severe aortic valve stenosis at low surgical risk, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding TAVI, and patient preferences and values.
METHODS
We used the 2016 Health Quality Ontario HTA on TAVI as a source of eligible studies and performed a systematic literature search for studies published since the 2016 review. Eligible primary studies identified both through the 2016 HTA and through our complementary literature search were used in a de novo analysis. We assessed the risk of bias of each included study using the Cochrane risk-of-bias tool and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria.An applicable, previously conducted cost-effectiveness analysis was available, so we did not conduct a primary economic evaluation. We analyzed the budget impact of publicly funding TAVI in people at low surgical risk in Ontario. We also performed a literature survey of the quantitative evidence of preferences and values of patients for TAVI. The Canadian Agency for Drugs and Technologies in Health (CADTH) conducted a review to evaluate the qualitative literature on patient and provider preferences and values for TAVI. To contextualize the potential value of TAVI, we spoke with people with severe aortic valve stenosis.
RESULTS
We identified two randomized controlled trials that compared TAVI (transfemoral route) and SAVR in patients with severe aortic valve stenosis at low surgical risk. Both studies have an ongoing follow-up of 10 years, but 1-year and limited 2-year follow-up results are currently available. At 30 days, compared with SAVR, TAVI had a slightly lower risk of mortality (risk difference -0.8%, 95% confidence interval [CI] -1.5% to -0.1%, GRADE: Moderate) and disabling stroke (risk difference -0.8%, 95% CI -1.8% to -0.2%, GRADE: Moderate), and resulted in more patients with symptom improvement (risk difference 11.8%, 95% CI 8.2% to 15.5%, GRADE: High) and in a greater improvement in quality of life (GRADE: High). At 1 year, TAVI and SAVR were similar with regard to mortality (GRADE: Low), although TAVI may result in a slightly lower risk of disabling stroke (GRADE: Moderate). Both TAVI and SAVR resulted in a similar improvement in symptoms and quality of life at 1 year (GRADE: Moderate). Compared with SAVR, TAVI had a higher risk of some complications and a lower risk of others.Device-related costs for TAVI (about $25,000) are higher than for SAVR (about $6,000). A published cost-effectiveness analysis conducted from an Ontario Ministry of Health perspective showed TAVI to be more expensive and, on average, slightly more effective (i.e., it was associated with more quality-adjusted life-years [QALYs]) than SAVR. Compared with SAVR, the incremental cost-effectiveness ratios (ICERs) were $27,196 per QALY and $59,641 per QALY for balloon-expandable and self-expanding TAVI, respectively. Balloon-expandable TAVI was less costly (by $2,330 on average) and slightly more effective (by 0.02 QALY on average) than self-expanding TAVI. Among the three interventions, balloon-expandable TAVI had the highest probability of being cost-effective. It was the preferred option in 53% and 59% of model iterations, at willingness-to-pay values of $50,000 and $100,000 per QALY, respectively. Self-expanding TAVI was preferred in less than 10% of iterations. The budget impact of publicly funding TAVI in Ontario is estimated to be an additional $5 to $8 million each year for the next 5 years. The budget impact could be significantly reduced with reductions in the device price.We did not find any quantitative or qualitative evidence on patient preferences and values specific to the low-risk surgical group. Among a mixed or generally high-risk and population, people typically preferred the less invasive nature and the faster recovery time of TAVI compared with SAVR, and people were satisfied with the TAVI procedure. Patients with severe aortic valve stenosis at low surgical risk and their caregivers perceived that TAVI minimized pain and recovery time. Most patients who had TAVI returned to their usual activities more quickly than they would have if they had had SAVR. Our direct patient and caregiver consultations indicated a preference for TAVI over SAVR.
CONCLUSIONS
Both TAVI (transfemoral route) and SAVR resulted in improved patient symptoms and quality of life during the 1 year of follow-up. The TAVI procedure is less invasive and resulted in greater symptom improvement and quality of life than SAVR 30 days after surgery. The TAVI procedure also resulted in a small improvement in mortality and disabling stroke at 30 days. At 1 year, TAVI and SAVR were similar with regard to mortality, although TAVI may result in a slightly lower risk of disabling stroke. According to the study authors, longer follow-up is needed to better understand how long TAVI valves last and to draw definitive conclusions on the long-term outcomes of TAVI compared with SAVR beyond 1 year.The TAVI procedure might be cost-effective for patients at low surgical risk; however, there is some uncertainty in this result. We estimated that the additional cost to provide public funding for TAVI in people with severe aortic valve stenosis at low surgical risk would range from about $5 million to $8 million over the next 5 years.Among a mixed or generally high-risk population, people typically preferred the less invasive nature and the faster recovery time of TAVI compared with SAVR.
Topics: Aged; Aortic Valve Stenosis; Cost-Benefit Analysis; Heart Valve Prosthesis Implantation; Humans; Ontario; Quality of Life; Quality-Adjusted Life Years; Risk Assessment; Severity of Illness Index; Technology Assessment, Biomedical; Transcatheter Aortic Valve Replacement
PubMed: 33240455
DOI: No ID Found -
Taiwanese Journal of Obstetrics &... Oct 2018Pelvic lymphadenectomy procedure is included as part of the standard protocol of radical hysterectomy for women with early-stage cervical cancer (Stage IA to IB1)....
Pelvic lymphadenectomy procedure is included as part of the standard protocol of radical hysterectomy for women with early-stage cervical cancer (Stage IA to IB1). However, an important sequel to lymphadenectomy procedure is the possible occurrence of lymphedema in the lower abdomen and lower extremities. Previous researches also find that women with lymphedema experience many emotional impacts, including depression, anxiety, and adjustment problems. Only approximately 10% of women with clinical stage IB cervical carcinoma were involved with metastatic disease. If we could better define the relevant lymphatic nodes that must be removed, it is then possible to limit routinely performed lymphadenectomy for regional nodal metastasis in the pelvis, and hence reduce the need for extended surgical staging (para-aortic lymphadenectomy). We systematically reviewed a body of literature and updated available information concerning the current progress on the application of sentinel lymph node biopsy in women with early-stage cervical cancer. All detection methods (preoperative injection of radiocolloid tracer, intraoperative injection of blue dye, or a combination of both techniques) demonstrated reasonable sensitivity (with a few exceptions), high specificity, low false-negative rate and high negative predictive value. The review of the literature in this paper should convince the readers that sentinel lymph node biopsy has the potential to improve the quality of life and the possibility to maintain relapse-free survival for women with cervical cancer. The proper identification of negative sentinel lymph node allows individualized therapy and may preclude the need of lymphadenectomy procedure in most of these women.
Topics: Female; Humans; Hysterectomy; Lymph Node Excision; Lymphatic Metastasis; Lymphedema; Neoplasm Recurrence, Local; Neoplasm Staging; Quality of Life; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Uterine Cervical Neoplasms
PubMed: 30342641
DOI: 10.1016/j.tjog.2018.08.003