Enalapril premedication attenuates the blood pressure response to tracheal intubation and stabilizes postoperative blood pressure after controlled hypotension with sodium nitroprusside in neurovascular patients.
Oral premedication with enalapril, 0.1 mg/kg was compared with placebo in 22 patients subjected to craniotomy and ligation of an intracranial aneurysm or extirpation of an arteriovenous malformation. Balanced hypotensive anesthesia was used with sodium nitroprusside (SNP) as the main hypotensive agent. The hypertensive response to laryngoscopy and tracheal intubation was significantly attenuated by enalapril (p = 0.020). The mean blood pressure was lower and more stable in the intensive care unit after enalapril than after placebo (p = 0.044). The median SNP dose rate tended to be lower in the enalapril-pretreated patients [0.6 (range of 0-3.5) micrograms/kg/min] compared to the placebo group [1.4 (0.4-5.8) micrograms/kg/min] (p = 0.12). Concentrations of plasma catecholamines, vasopressin, and endothelin as well as serum osmolality, arterial blood gases, and plasma electrolytes and level of consciousness were repeatedly measured. Enalapril had no significant effects on these variables. Plasma renin activity was increased and serum angiotensin converting enzyme (ACE) activity was reduced in the expected manner by enalapril. We found premedication with an ACE inhibitor favorable for hypotensive anesthesia in neurovascular patients as assessed by the circulatory responses.
In this study the results of endovascular treatment of aortic aneurysms in Finland are presented and compared to the results of the Eurostar registry.
A total of 229 patients with aortic aneurysm were treated in five different Finnish centres during 1996-2000. The data of these patients were collected prospectively by surgeon or interventional radiologist involved. During the same period of time 2464 patients were registered in the Eurostar registry.
The procedure was performed successfully in 97% of patients in Finland, and the 30-day mortality was 0,9%. A graft limb thrombosis was detected in 9% of the patients in Finland. A permanent primary endoleak at the first 30-day control was seen in 23 patients (10%). During the follow-up 17 secondary endoleaks (7%) were detected. A secondary intervention was necessary in 26% of the patients. Three patients (1.3%) had late rupture of the abdominal aortic aneurysm.
According to the Finnish short-time results, endovascular treatment of aortic aneurysms is safe and associated with relatively low morbidity and mortality. The mid-term results are more disappointing with relatively many graft thromboses and endoleaks, and a frequent need of secondary interventions.
Incidence rate of arterial aneurysms is 3.4-4.6% of that of vascular diseases and has a tendency towards further increase. In National Research Center of Surgery, RAMS, 410 patients with arterial aneurysms of various localization were treated. The majority of the patients were men--221 (65.4%). Surgical procedures were performed in 338 (82.4%) patients. Reconstruction surgeries were performed in 273 (80.8%) patients, ligature surgeries--in 65 (19.2%) patients. In early postoperative period good results (recovery and improvement) were seen more often (p 10 years) were also better after reconstruction than after ligature surgeries.
To analyze the organ donation action in population-based neurointensive care of acute aneurysmal subarachnoid hemorrhage (aSAH) and to seek factors that would improve the identification of potential organ donors (PODs) and increase the donor conversion rate (DCR) after aSAH.
The Kuopio Intracranial Aneurysm Database, prospective since 1995, includes all aSAH patients admitted to the Kuopio University Hospital (KUH) from its defined Eastern Finnish catchment population. We analyzed 769 consecutive acute aSAH patients from 2005 to 2015, including their data from the Finnish Transplantation Unit and the national clinical registries. We analyzed PODs vs. actual donors among the 145 (19%) aSAH patients who died within 14 days of admission. Finland had implemented the national presumed consent (opt-out) within the study period in the end of 2010.
We retrospectively identified 83 (57%) PODs while only 49 (34%) had become actual donors (total DCR 59%); the causes for non-donorship were 15/34 (44%) refusals of consent, 18/34 (53%) medical contraindications for donation, and 1/34 (3%) failure of recognition. In 2005-2010, there were 11 refusals by near relatives with DCR 52% (29/56) and only three in 2011-2015 with DCR 74% (20/27). Severe condition on admission (Hunt and Hess grade IV or V) independently associated with the eventual POD status.
Nearly 20% of all aSAH patients acutely admitted to neurointensive care from a defined catchment population died within 14 days, almost half from cardiopulmonary causes at a median age of 69 years. Of all aSAH patients, 11% were considered as potential organ donors (PODs). Donor conversion rate (DCR) was increased from 52 to 74% after the national presumed consent (opt-out). Implicitly, DCR among aSAH patients could be increased by admitting them to the intensive care regardless of dismal prognosis for the survival, along a dedicated organ donation program for the catchment population.
OBJECT: With increasing use of endovascular procedures, the number of aneurysms treated surgically will decline. In this study the authors review complications related to the surgical treatment of aneurysms and address the issue of maintaining quality standards on a national level. METHODS: A prospective, nonselected amalgamation of every aneurysm case treated in five of six neurosurgical centers in Sweden during 1 calendar year was undertaken (422 patients; 7.4 persons/100,000 population/year). The treatment protocols at these institutions were very similar. Outcome was assessed using clinical end points. In this series, 84.1% of the patients underwent surgery, and intraoperative complications occurred in 30% of these procedures. Poor outcome from technical complications was seen in 7.9% of the surgically treated patients. Intraoperative aneurysm rupture accounted for 60% and branch sacrifice for 12% of all technical difficulties. Although these complications were significantly related to aneurysm base geometry and the competence of the surgeon, problems still occurred apparently at random and also in the best of hands (17%). The temporary mean occlusion time in the patients who suffered intraoperative aneurysm rupture was twice as long as the temporary arrest of blood flow performed to aid dissection. CONCLUSIONS: The results obtained in this series closely reflect the overall management results of this disease and support the conclusion that surgical complications causing a poor outcome can be estimated on a large population-based scale. Intraoperative aneurysm rupture was the most common and most devastating technical complication that occurred. Support was found for a more liberal use of temporary clips early during dissection, regardless of the experience of the surgeon. Temporary regional interruption of arterial blood flow should be a routine method for aneurysm surgery on an everyday basis. A random occurrence of difficult intraoperative problems was clearly shown, and this factor of unpredictability, which is present in any preoperative assessment of risk, strengthens the case for recommending neuroprotection as a routine adjunct to virtually every aneurysm operation, regardless of the surgeon's experience.
The aim was to study the epidemiology and outcomes of popliteal artery aneurysm (PA) treated surgically.
Among 110,000 procedures registered prospectively in the Swedish Vascular Registry (Swedvasc), there were 717 primary operations for PA among 571 patients. Patient records were reviewed and data validated against other registries.
The median age of the patients was 71 years; 5.8 per cent were women. Among 264 legs treated urgently, 235 had acute ischemia and 24 had rupture. Of patients with unilateral PA, 28.1 per cent had an aortic aneurysm, 8.4 per cent an iliac aneurysm and 9.4 per cent a femoral aneurysm. Extra-popliteal aneurysms were more common when the PAs were bilateral (P = 0.004). The rate of limb loss within 1 year of operation was 8.8 per cent; 12.0 per cent for symptomatic and 1.8 per cent for asymptomatic limbs (P
Aneurysms of the posterior cerebral artery (PCA) are uncommon. Because of their low incidence, only 5 series with more than 30 patient cases have been reported. The treatment of PCA aneurysms is challenging because of the high frequency of fusiform aneurysms and closeness to important neuroanatomic structures.
A total of 121 patients with 135 PCA aneurysms were reviewed. The clinical and radiologic data, treatment strategies, and 1-year outcomes were analyzed. Patients with giant aneurysms, associated aneurysms, and aneurysms on arteriovenous malformation-feeding PCAs were considered as complex cases. Outcomes were categorized into 3 groups: good (modified Rankin Scale [mRS], score 0-1), moderate (mRS score, 2-4), and poor (mRS score, 5-6).
There were 52 ruptured (39%) and 83 unruptured (61%) PCA aneurysms in 121 patients, with the following distribution: P1 (n = 53), P1/2 (n = 39), P2 (n = 28), and P3 (n = 15). The incidence of fusiform PCA aneurysms was high (24%). Microsurgical treatment was applied to 63 aneurysms and endovascular treatment to 19 aneurysms; 55 aneurysms were treated conservatively. The following treatment results were achieved: for patients with unruptured PCA aneurysms, n = 19; 12 good outcomes, 63%; 6 moderate, 31%; 1 poor, 1%; for patients with ruptured PCA aneurysms, n = 27; 10 good, 37%; 9 moderate, 33%; 8 poor, 30%; and for patients with complex neurovascular diseases and PCA aneurysms, n = 96; 42 good, 43%; 40 moderate, 42%; 14 poor, 15%.
Aneurysms of the PCA are infrequent and often associated with other vascular diseases. Microsurgery and endovascular treatment are effective for the occlusion of PCA aneurysms. The preservation or reconstruction of the parent vessel is crucial for favorable treatment outcomes.
In a group of 381 patients who were operated on for coarctation of the aorta 34 (8.9%) were found to have an aneurysm of the aorta in the zone of the correction in the late-term postoperative period. The frequency of aneurysm formation was greater in patients with flap plastics. Fifteen patients underwent a second operation for aneurysm of the aorta, 2 (13.3%) of them died. In the group of patients who were not operated on 6 (31.6%) died.
It is shown that various complications occurring after surgical treatment of dissecting aneurysms of the ascending aorta with or without aortic insufficiency depend mainly on the methods of correction applied and the etiology of the disease. As the result of the study the authors conclude that the Bentall-De Bono and Cabroe's operations are radical methods for surgical management of dissecting aneurysms of the ascending aorta irrespective of the etiology of the disease. Wide introduction of these operative methods into the clinical practice led to an essential decrease of hospital mortality and the frequency of complications in the immediate and late-term postoperative period.