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Mao QL, Yu ZH, Nie L, Wang FX, Dong YH, Qi XF. Gastrointestinal injury in cardiopulmonary bypass: current insights and future directions. Front Pharmacol 2025; 16:1542995. [PMID: 40356958 PMCID: PMC12067416 DOI: 10.3389/fphar.2025.1542995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Accepted: 04/14/2025] [Indexed: 05/15/2025] Open
Abstract
Cardiopulmonary bypass (CPB) is an essential component of cardiac surgery. As CPB technology continues to advance and innovate, it has enabled the expansion of surgical boundaries and the resolution of many previously inoperable challenges. However, the occurrence of various complications during CPB warrants attention, with their prevention and management being paramount. The gastrointestinal tract, directly connected to the external environment, is vulnerable not only to external factors but also to internal changes that may induce damage. Both preclinical and clinical research have demonstrated the incidence of gastrointestinal injuries following CPB, often accompanied by dysbiosis and abnormal metabolic outputs. Currently, interventions addressing gastrointestinal injuries following CPB remain insufficient. Although recent years have not seen notable progress in this field, emerging academic research underscores the essential role of the gut microbiome and its metabolic products in sustaining overall health and internal equilibrium. Notably, their significance as the body's "second genome" is increasingly recognized. Consequently, reevaluating the gastrointestinal damage post-CPB, alongside the associated dysbiosis and metabolic disturbances, is imperative. This reassessment carries substantial theoretical and practical implications for enhancing treatment strategies and bettering patient outcomes after CPB. This review aims to deliver a comprehensive synthesis of the latest preclinical and clinical research on CPB, address current challenges and gaps, and explore potential future research directions.
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Affiliation(s)
- Qi-Long Mao
- Department of Anesthesiology, Bazhong Central Hospital, Bazhong, Sichuan, China
| | - Zi-Hang Yu
- Department of Anesthesiology, Fushun County People’s Hospital, Zigong, Sichuan, China
| | - Liang Nie
- Department of Anesthesiology, Fushun County People’s Hospital, Zigong, Sichuan, China
| | - Fei-Xiang Wang
- Department of Anesthesiology, The Affiliated Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Yu-Hui Dong
- Department of Anesthesiology, Bazhong Central Hospital, Bazhong, Sichuan, China
| | - Xiao-Fei Qi
- Department of Anesthesiology, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
- Department of Anesthesiology, Women and Children’s Medical Center, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
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Kayali F, Sarodaya V, Shah HI, Hayat MY, Leung MST, Harky A. Predicting outcomes of mesenteric ischemia postcardiac surgery: A systematic review. J Card Surg 2022; 37:2025-2039. [PMID: 35488799 DOI: 10.1111/jocs.16516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/12/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This systematic review aims to identify predictors of outcomes of mesenteric ischemia in patients following cardiac surgery. METHODS A comprehensive literature search was done on EMBASE, PubMed, Ovid MEDLINE, and SCOPUS using keywords relating to bowel ischemia and cardiac surgery. Database search results were screened by at least two authors and 32 articles were selected for inclusion in this review. RESULTS Data on 1907 patients were analyzed. The mean age was 70.0 ± 2.99 years and the prevalence of bowel ischemia was 1.74%. Advanced age was a significant risk factor. 63.16% of patients reported were men, and 58.4% of patients died in hospital. There was heterogeneity in the reported significance of the following preoperative risk factors: hypertension, smoking status, type 2 diabetes mellitus, end-stage renal disease, preoperative left ventricular ejection fraction <35%. Cardiopulmonary bypass (CPB) time, preoperative/operative intra-aortic balloon pump (IABP) support, and inotrope usage were significantly associated with the development of mesenteric ischemia; however, other intraoperative factors including the type of cardiac surgery and duration of aortic cross-clamping had varying levels of reported significance. There were discrepancies in the reported significance of leukocytosis and metabolic acidosis (pH <7.3) as postoperative markers. Postoperative vasopressor use, prolonged ventilation time, and elevation in lactate, transaminases, creatinine, and intestinal fatty acid-binding protein (IFABP) levels were found to be strongly associated with bowel ischemia. CONCLUSION This systematic review found the strongest associations of mesenteric ischemia postcardiac surgery to be advanced age, CPB time, rise in lactate, transaminases, creatinine, and IFABP. IABP support, vasopressor, and inotrope use as well as prolonged ventilation were strongly linked too.
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Affiliation(s)
- Fatima Kayali
- UCLan Medical School, University of Central Lancashire, Preston, UK
| | - Varun Sarodaya
- Department of Critical Care Medicine, Barts Health NHS Trust, London, UK
| | - Hussain I Shah
- UCL Medical School, University College London, London, UK
| | - Muhammad Y Hayat
- Faculty of Medicine, St George's Hospital Medical School, London, UK
| | - Marco S T Leung
- Department of Surgery, Imperial Healthcare Trust, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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González-Pacheco H, Gopar-Nieto R, Torres-Machorro A, Pérez-Pinetta PE, Arias-Mendoza A. Acute Mesenteric Ischemia Prior to Emergency Cardiac Surgery for Infective Endocarditis: Can We Design a Strategy to Improve Outcomes? Cureus 2022; 14:e24532. [PMID: 35506119 PMCID: PMC9053355 DOI: 10.7759/cureus.24532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 12/03/2022] Open
Abstract
Infective endocarditis (IE) can be complicated by systemic embolization. Unfortunately, in some situations, it requires radical and urgent therapeutic approaches. Herein, we describe a case of IE complicated by acute mesenteric ischemia (AMI) due to septic embolism prior to emergent cardiac surgery. A previously healthy 38-year-old woman was admitted to our emergency department with a diagnosis of mitral valve IE. She presented with tachycardia and was tachypneic. In addition, a systolic murmur in the mitral area and Janeway lesions were documented. Transthoracic and transesophageal echocardiography confirmed large mobile vegetations on the mitral valve and the presence of mitral regurgitation. A thoracic computed tomography scan showed splenic and bilateral renal infarctions. Emergency mitral valve replacement was scheduled. Prior to surgery, AMI developed because of occlusion of the superior mesenteric artery (SMA). Endovascular treatment was performed with percutaneous aspiration, thrombectomy, and in situ fibrinolysis, yielding satisfactory results. Ten hours later, she underwent cardiac surgery. AMI developed postoperatively due to re-occlusion of the SMA, requiring an open laparotomy with mesenteric revascularization and extensive resection of the necrotic bowel. The patient died 18 days after hospitalization. In the IE setting, AMI is a very rare, potentially life-threatening complication. This case highlights the importance of recognizing this complication and designing a better therapeutic strategy to reduce the associated mortality rate.
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Impact of Pre-Procedural Mesenteric Artery Stenosis and Mesenteric Ischemia in Patients Undergoing Transcatheter Aortic Valve Replacement. J Thorac Cardiovasc Surg 2022; 164:1458-1471.e6. [DOI: 10.1016/j.jtcvs.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 11/20/2022]
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Stahl K, Rittgerodt N, Busch M, Maschke SK, Schneider A, Manns MP, Fuge J, Meyer BC, Hoeper MM, Hinrichs JB, David S. Nonocclusive Mesenteric Ischemia and Interventional Local Vasodilatory Therapy: A Meta-Analysis and Systematic Review of the Literature. J Intensive Care Med 2019; 35:128-139. [DOI: 10.1177/0885066619879884] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background:Intensive care patients with nonocclusive mesenteric ischemia (NOMI) show mortality rates of 70% to 90%. Besides emergency surgery, different interventional local vasodilatory treatment (LVT) attempts have been described. We performed a systematic review and a meta-analysis to evaluate feasibility, efficacy, and tolerability of LVT in patients with life-threatening NOMI.Methods:Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed until February 2019. Measured outcomes included immediate technical success rates (as indicated by mesenteric vasodilation on angiography or clinical improvement) and adverse events (AEs). Therapeutic efficacy was measured by the assessment of overall mortality.Results:Twelve studies (335 patients, 245 received LVT) from 1977 to 2018 were included. All studies were retrospective (4 comparative and 8 noncomparative). Different intra-arterial vasodilators (4× papaverine, 6× prostaglandin E1, 1× tolazoline/heparin, 1× tolazoline + iloprost) were reported. Initial technical success rate was 75.9% (95% confidence interval [CI], 55.1%-89%, P = .017) with an AE rate of 2.9% (95% CI: 1.3%-6.6%; P = .983). Overall mortality in LVT patients was 40.3% (95% CI: 28.7%-53%, P = .134). In 4 studies, outcomes were compared between patients receiving LVT to those who received standard of care (odds ratio for death in LVT patients was 0.261 [95% CI: 0.095-0.712, P = .009]).Conclusions:Local vasodilatory treatment appears to be safe in patients with NOMI and might have the potential to at least partially reverse mesenteric vasoconstriction features in control angiographies. However, with no randomized and prospective studies available yet, the overall quality of published studies has to be considered as low; therefore, it is not possible to draw generalizable conclusions from the present data concerning clinical end points. Its application might hold promise as a rescue treatment strategy and deserves further evaluation in randomized controlled trials.
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Affiliation(s)
- Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Nina Rittgerodt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Markus Busch
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Sabine K. Maschke
- Department of Diagnostic und Interventional Radiology, German Centre of Lung Research (DZL), Hannover, Germany
| | - Andrea Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Bernhard C. Meyer
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Marius M. Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Department of Diagnostic und Interventional Radiology, German Centre of Lung Research (DZL), Hannover, Germany
| | - Sascha David
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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Stahl K, Busch M, Maschke SK, Schneider A, Manns MP, Fuge J, Wiesner O, Meyer BC, Hoeper MM, Hinrichs JB, David S. A Retrospective Analysis of Nonocclusive Mesenteric Ischemia in Medical and Surgical ICU Patients: Clinical Data on Demography, Clinical Signs, and Survival. J Intensive Care Med 2019; 35:1162-1172. [PMID: 30909787 PMCID: PMC7536530 DOI: 10.1177/0885066619837911] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: To analyze demography, clinical signs, and survival of intensive care
patients diagnosed with nonocclusive mesenteric ischemia (NOMI) and to
evaluate the effect of a local intra-arterial prostaglandin therapy. Methods: Retrospective observational study screening 455 intensive care patients with
acute arterial mesenteric perfusion disorder in a tertiary care hospital
within the past 8 years. Lastly, 32 patients with NOMI were enrolled, of
which 11 received local intra-arterial prostaglandin therapy. The diagnosis
of NOMI was based on the clinical presentation and established biphasic
computed tomography criteria. Clinical and biochemical data were obtained 24
hours before, at the time, and 24 hours after diagnosis. Results: Patients were 60.5 (49.3-73) years old and had multiple comorbidities. Most
of them were diagnosed with septic shock requiring high doses of
norepinephrine (NE: 0.382 [0.249-0.627] μg/kg/min). The Sequential Organ
Failure Assessment (SOFA) score was 18 (16-20). A decrease in oxygenation
(Pao2/Fio2), pH, and bicarbonate and an increase in international
normalized ratio, lactate, bilirubin, leucocyte count, and NE dose were
early indicators of NOMI. Median SOFA score significantly increased in the
last 24 hours before diagnosis of NOMI (16 vs 18, P <
.0001). Overall, 28-day mortality was 75% (81% nonintervention vs 64%
intervention cohort; P = .579). Median SOFA scores 24 hours
after intervention increased by +5% in the nonintervention group and
decreased by 5.5% in the intervention group (P =
.0059). Conclusions: Our data suggest that NOMI is a detrimental disease associated with
progressive organ failure and a high mortality. Local intra-arterial
prostaglandin application might hold promise as a rescue treatment strategy.
These data encourage future randomized controlled trials are desirable.
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Affiliation(s)
- Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, 9177Hannover Medical School, Hannover, Germany
| | - Markus Busch
- Department of Gastroenterology, Hepatology and Endocrinology, 9177Hannover Medical School, Hannover, Germany
| | - Sabine K Maschke
- Department of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Andrea Schneider
- Department of Gastroenterology, Hepatology and Endocrinology, 9177Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, 9177Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), 9177Hannover Medical School, Hannover, Germany
| | - Olaf Wiesner
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), 9177Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), 9177Hannover Medical School, Hannover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover, Germany.,* Jan B. Hinrichs and Sascha David have contributed equally to this work
| | - Sascha David
- Department of Nephrology and Hypertension, 9177Hannover Medical School, Hannover, Germany.,* Jan B. Hinrichs and Sascha David have contributed equally to this work
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Arif R, Verch M, Farag M, Karck M. Mesenterialischämie nach herzchirurgischen Eingriffen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0217-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Jing HR, Luo FW, Liu XM, Tian XF, Zhou Y. Fish oil alleviates liver injury induced by intestinal ischemia/reperfusion via AMPK/SIRT-1/autophagy pathway. World J Gastroenterol 2018; 24:833-843. [PMID: 29467553 PMCID: PMC5807941 DOI: 10.3748/wjg.v24.i7.833] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/25/2017] [Accepted: 01/15/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate whether fish oil (FO) can protect liver injury induced by intestinal ischemia/reperfusion (I/R) via the AMPK/SIRT-1/autophagy pathway. METHODS Ischemia in Wistar rats was induced by superior mesenteric artery occlusion for 60 min and reperfusion for 240 min. One milliliter per day of FO emulsion or normal saline was administered by intraperitoneal injection for 5 consecutive days to each animal. Animals were sacrificed at the end of reperfusion. Blood and tissue samples were collected for analyses. AMPK, SIRT-1, and Beclin-1 expression was determined in lipopolysaccharide (LPS)-stimulated HepG2 cells with or without FO emulsion treatment. RESULTS Intestinal I/R induced significant liver morphological changes and increased serum alanine aminotransferase and aspartate aminotransferase levels. Expression of p-AMPK/AMPK, SIRT-1, and autophagy markers was decreased whereas tumor necrosis factor-α (TNF-α) and malonaldehyde (MDA) were increased. FO emulsion blocked the changes of the above indicators effectively. Besides, in LPS-stimulated HepG2 cells, small interfering RNA (siRNA) targeting AMPK impaired the FO induced increase of p-AMPK, SIRT-1, and Beclin-1 and decrease of TNF-α and MDA. SIRT-1 siRNA impaired the increase of SIRT-1 and Beclin-1 and the decrease of TNF-α and MDA. CONCLUSION Our study indicates that FO may protect the liver against intestinal I/R induced injury through the AMPK/SIRT-1/autophagy pathway.
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Affiliation(s)
- Hui-Rong Jing
- Department of General Surgery, Second Affiliated Hospital of Dalian Medical University, Dalian 116023, Liaoning Province, China
| | - Fu-Wen Luo
- Department of General Surgery, Second Affiliated Hospital of Dalian Medical University, Dalian 116023, Liaoning Province, China
| | - Xing-Ming Liu
- Department of General Surgery, Second Affiliated Hospital of Dalian Medical University, Dalian 116023, Liaoning Province, China
| | - Xiao-Feng Tian
- Department of General Surgery, Second Affiliated Hospital of Dalian Medical University, Dalian 116023, Liaoning Province, China
| | - Yun Zhou
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian 116023, Liaoning Province, China
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Tseng J, Loper B, Jain M, Lewis AV, Margulies DR, Alban RF. Predictive factors of mortality after colectomy in ischemic colitis: an ACS-NSQIP database study. Trauma Surg Acute Care Open 2017; 2:e000126. [PMID: 29766117 PMCID: PMC5887781 DOI: 10.1136/tsaco-2017-000126] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 01/09/2023] Open
Abstract
Background Surgical intervention for ischemic colitis is associated with significant postoperative morbidity and mortality. Predictive factors of adverse outcomes have been reported in the literature, but are based on small sample populations. We sought to identify risk factors for mortality after emergent colectomy for ischemic colitis using a clinical outcomes database. Methods The American College of Surgeons National Surgical Quality Improvement Project database was queried from 2010 to 2015 to identify emergent colectomies performed for ischemic colitis using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. Univariate and multivariate logistic regression analysis was used to identify independent risk factors associated with increased risk of mortality. Results A total of 4548 patients undergoing emergent colectomies for ischemic colitis were identified. Overall, 30-day postoperative mortality was 25.3%. On univariate analysis, preoperative risk factors associated with a higher rate of mortality include dyspnea, functional status, ventilator dependency, history of chronic obstructive pulmonary disease, ascites, congestive heart failure exacerbation, hypertension, dialysis dependency, cancer, open wounds, chronic steroids, weight loss >10%, transfusions within 72 hours before surgery, septic shock and duration from hospital admission to surgery. Factors that were significant for mortality on logistic regression analysis include elderly age, poor functional status, multiple comorbidities, septic shock, blood transfusion, acute renal failure and the duration of time from hospital admission to surgery. Conclusions Postoperative morbidity and mortality rates for ischemic colitis remain significantly high. Identification of risk factors may help patient selection for surgical interventions, and make informed decisions with patients and family members. Although it is certainly challenging, early diagnosis and prompt surgical intervention for patients with ischemic colitis may improve outcomes. Study type and level of evidence Therapeutic/care management, level II
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Brandi Loper
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Monica Jain
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Azaria V Lewis
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rodrigo F Alban
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Andersen LW. Lactate Elevation During and After Major Cardiac Surgery in Adults: A Review of Etiology, Prognostic Value, and Management. Anesth Analg 2017; 125:743-752. [PMID: 28277327 DOI: 10.1213/ane.0000000000001928] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elevated lactate is a common occurrence after cardiac surgery. This review summarizes the literature on the complex etiology of lactate elevation during and after cardiac surgery, including considerations of oxygen delivery, oxygen utilization, increased metabolism, lactate clearance, medications and fluids, and postoperative complications. Second, the association between lactate and a variety of outcomes are described, and the prognostic role of lactate is critically assessed. Despite the fact that elevated lactate is strongly associated with many important outcomes, including postoperative complications, length of stay, and mortality, little is known about the optimal management of postoperative patients with lactate elevations. This review ends with an assessment of the limited literature on this subject.
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Affiliation(s)
- Lars W Andersen
- From the *Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; †Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; ‡Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; and §Department of Medicine, Regional Hospital Holstebro, Aarhus University, Holstebro, Denmark
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Jaitly V, Klein K, Tint H, Chen A, Allison P, Akkanti B, Loyalka P, Castillo B. Intra-Pericardial Use of Recombinant Factor VIIa in a Patient With Acute Hemorrhagic Pericardial Effusion Following Transcutaneous Aortic Valve Replacement-A Case Report. Lab Med 2017; 48:262-265. [PMID: 28934519 DOI: 10.1093/labmed/lmx048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Perioperative bleeding can be a serious life-threatening complication in adult patients undergoing cardiac surgery, given the older age and additional comorbidities present in this patient population. The standard treatment options include transfusion of blood components and surgical re-exploration. We report the first case of an elderly female patient treated with local administration of recombinant factor VIIa (rFVIIa) for intractable hemorrhagic pericardial effusion, which developed following a transcutaneous aortic valve replacement (TAVR) procedure for severe aortic stenosis. No thromboembolic phenomena or adverse effects were observed. Local administration of rFVIIa is an efficacious treatment option for cardiac surgery patients as opposed to systemic administration of rFVIIa, use of massive blood products, or surgical re-exploration.
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Affiliation(s)
- Vanya Jaitly
- The University of Texas Health Science Center at Houston, Department of Pathology and Laboratory Medicine
| | - Kimberly Klein
- The University of Texas Health Science Center at Houston, Department of Pathology and Laboratory Medicine
| | - Hlaing Tint
- The University of Texas Health Science Center at Houston, Department of Pathology and Laboratory Medicine
| | | | | | - Bindu Akkanti
- The University of Texas Health Science Center at Houston, Internal Medicine
| | - Pranav Loyalka
- The University of Texas Health Science Center at Houston, Center for Advanced Heart Failure
| | - Brian Castillo
- The University of Texas Health Science Center at Houston, Department of Pathology and Laboratory Medicine
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Ogi K, Sanui M, Iizuka Y, Aomatsu A, Nakashima I, Hamamoto K, Okochi T, Lefor AK. Successful treatment of nonocclusive mesenteric ischemia after aortic valve replacement with continuous arterial alprostadil infusion: A case report. Int J Surg Case Rep 2017; 35:8-11. [PMID: 28414997 PMCID: PMC5394210 DOI: 10.1016/j.ijscr.2017.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/28/2017] [Accepted: 03/28/2017] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Nonocclusive mesenteric ischemia (NOMI) after surgery has an extremely poor prognosis with a mortality rate of 30-100%. We report a patient with NOMI following aortic valve replacement who failed to improve despite continuous intra-arterial infusion of papaverine, but was successfully treated with alprostadil (prostaglandin E1 [PGE1]) infusion. PRESENTATION OF CASE The patient is a 77-year-old man who underwent aortic valve replacement. Due to elevated serum lactate levels five hours after intensive care unit admission, superior mesenteric arteriography was performed, establishing the diagnosis of NOMI. Although continuous intra-arterial infusion of papaverine was begun, lactate levels remained elevated. Repeat angiography and laparotomy revealed extensive ischemic changes of the intestine. The vasodilator was changed to PGE1, which improved arterial spasm. The patient ultimately needed an ileocecal resection, but the extent of the resection was limited with concomitant PGE1 administration. DISCUSSION In the present patient, although NOMI was unresponsive to appropriate treatment including intra-arterial infusion of papaverine, continuous intra-arterial infusion of PGE1 salvaged most of the intestine. CONCLUSIONS In a patient with recurrent NOMI despite appropriate treatment including intra-arterial infusion of papaverine, continuous intra-arterial infusion of PGE1 may limit the extent of intestinal resection needed. Continuous intra-arterial infusion of PGE1 may be a useful treatment for patients with refractory NOMI.
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Affiliation(s)
- Kunio Ogi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiyaku, Saitama, Saitama, 330-8503, Japan.
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiyaku, Saitama, Saitama, 330-8503, Japan.
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiyaku, Saitama, Saitama, 330-8503, Japan.
| | - Akinori Aomatsu
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiyaku, Saitama, Saitama, 330-8503, Japan.
| | - Ikue Nakashima
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiyaku, Saitama, Saitama, 330-8503, Japan.
| | - Kohei Hamamoto
- Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiyaku, Saitama, Saitama, 330-8503, Japan.
| | - Tomohisa Okochi
- Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiyaku, Saitama, Saitama, 330-8503, Japan.
| | - Alan K Lefor
- Department of Surgery, Jichi medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
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Arif R, Farag M, Zaradzki M, Reissfelder C, Pianka F, Bruckner T, Kremer J, Franz M, Ruhparwar A, Szabo G, Beller CJ, Karck M, Kallenbach K, Weymann A. Ischemic Colitis after Cardiac Surgery: Can We Foresee the Threat? PLoS One 2016; 11:e0167601. [PMID: 27977704 PMCID: PMC5157983 DOI: 10.1371/journal.pone.0167601] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 11/16/2016] [Indexed: 01/29/2023] Open
Abstract
Introduction Ischemic colitis (IC) remains a great threat after cardiac surgery with use of extracorporeal circulation. We aimed to identify predictive risk factors and influence of early catecholamine therapy for this disease. Methods We prospectively collected and analyzed data of 224 patients, who underwent laparotomy due to IC after initial cardiac surgery with use of extracorporeal circulation during 2002 and 2014. For further comparability 58 patients were identified, who underwent bypass surgery, aortic valve replacement or combination of both. Age ±5 years, sex, BMI ± 5, left ventricular function, peripheral arterial disease, diabetes and urgency status were used for match-pair analysis (1:1) to compare outcome and detect predictive risk factors. Highest catecholamine doses during 1 POD were compared for possible predictive potential. Results Patients’ baseline characteristics showed no significant differences. In-hospital mortality of the IC group with a mean age of 71 years (14% female) was significantly higher than the control group with a mean age of 70 (14% female) (67% vs. 16%, p<0.001). Despite significantly longer bypass time in the IC group (133 ± 68 vs. 101 ± 42, p = 0.003), cross-clamp time remained comparable (64 ± 33 vs. 56 ± 25 p = 0.150). The majority of the IC group suffered low-output syndrome (71% vs. 14%, p<0.001) leading to significant higher lactate values within first 24h after operation (55 ± 46 mg/dl vs. 31 ± 30 mg/dl, p = 0.002). Logistic regression revealed elevated lactate values to be significant predictor for colectomy during the postoperative course (HR 1.008, CI 95% 1.003–1.014, p = 0.003). However, Receiver Operating Characteristic Curve calculates a cut-off value for lactate of 22.5 mg/dl (sensitivity 73% and specificity 57%). Furthermore, multivariate analysis showed low-output syndrome (HR 4.301, CI 95% 2.108–8.776, p<0.001) and vasopressin therapy (HR 1.108, CI 95% 1.012–1.213, p = 0.027) significantly influencing necessity of laparotomy. Conclusion Patients who undergo laparotomy for IC after initial cardiac surgery have a substantial in-hospital mortality risk. Early postoperative catecholamine levels do not influence the development of an IC except vasopressin. Elevated lactate remains merely a vague predictive risk factor.
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Affiliation(s)
- Rawa Arif
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
- * E-mail:
| | - Mina Farag
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Christoph Reissfelder
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstr. Dresden, Germany
| | - Frank Pianka
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Jamila Kremer
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Maximilian Franz
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Gabor Szabo
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Carsten J. Beller
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Klaus Kallenbach
- Department of Cardiac Surgery, HaerzZenter-INCCI, rue Ernest-Barblé, Luxembourg, Luxembourg
| | - Alexander Weymann
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
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Tilsed JVT, Casamassima A, Kurihara H, Mariani D, Martinez I, Pereira J, Ponchietti L, Shamiyeh A, Al-Ayoubi F, Barco LAB, Ceolin M, D'Almeida AJG, Hilario S, Olavarria AL, Ozmen MM, Pinheiro LF, Poeze M, Triantos G, Fuentes FT, Sierra SU, Soreide K, Yanar H. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg 2016; 42:253-70. [PMID: 26820988 PMCID: PMC4830881 DOI: 10.1007/s00068-016-0634-0] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria. METHODS A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group. RESULTS The resultant recommendations are presented in this paper. CONCLUSIONS The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.
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Affiliation(s)
- J V T Tilsed
- Surgery Health Care Group, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK.
| | - A Casamassima
- Emergency Department, Istituto Clinico Città Studi, Milan, Italy
| | - H Kurihara
- Emergency Surgery and Trauma Unit, Humanitas Research Hospital, Rozzano, Italy
| | - D Mariani
- Department of General Surgery, Ospedale di Legnano, Milan, Italy
| | - I Martinez
- Servicio de Cirugía General y Digestiva, Hospital Universitario de Torrevieja, Torrevieja, Spain
| | - J Pereira
- Surgery 1-Tondela-Viseu Hospital Centre, Viseu, Portugal
| | - L Ponchietti
- Department of Surgery, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, UK
| | - A Shamiyeh
- 2nd Surgical Department, Kepler University Clinic Linz, Linz, Austria
| | - F Al-Ayoubi
- Division of Trauma and Acute Care Surgery, Mafraq Hospital, Abu Dhabi, United Arab Emirates
| | - L A B Barco
- Department of Angiology and Vacular Surgery, University Hospital of Torrevieja, Torrevieja, Spain
| | - M Ceolin
- Emergency Surgery and Trauma Unit, Humanitas Research Hospital, Rozzano, Italy
| | - A J G D'Almeida
- Department of General Surgery, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - S Hilario
- 2nd Surgical Department, Santo André Hospital, Leiria, Portugal
| | - A L Olavarria
- Servicio de Cirugía General y Digestiva, Hospital Galdakao Usansolo, Vizcaya, Spain
| | - M M Ozmen
- Department of Surgery, Medical School, Hacettepe University, 06100, Ankara, Turkey
| | - L F Pinheiro
- General Surgery Department, Hospital São Teotónio, Viseu, Portugal
| | - M Poeze
- Department of Surgery/Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - G Triantos
- Department of General Surgery, Rhodes General Hospital, Rhodes, Greece
| | - F T Fuentes
- General Surgery 2 and Emergency Surgery, University General Hospital Gregorio Marañón, Madrid, Spain
| | - S U Sierra
- Department of Surgery, Galdakao-Usansolo Hospital, Galdakao, Vizcaya, Spain
| | - K Soreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - H Yanar
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Çapa, Istanbul, Turkey
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Gefäßerkrankungen und -komplikationen im Rahmen von Herzoperationen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-015-0006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sastry P, Hardman G, Page A, Parker R, Goddard M, Large S, Jenkins DP. Mesenteric ischaemia following cardiac surgery: the influence of intraoperative perfusion parameters. Interact Cardiovasc Thorac Surg 2014; 19:419-24. [PMID: 24939960 DOI: 10.1093/icvts/ivu139] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Mesenteric ischaemia (MesI) remains a rare but lethal complication following cardiac surgery. Previously identified risk factors for MesI mortality (age, poor left ventricular (LV) function, cardiopulmonary bypass time and blood loss) are non-specific and cannot necessarily be modified. This study aims to identify potentially modifiable risk factors for MesI mortality through analysis of peri- and intraoperative perfusion data. METHODS Patients who underwent cardiac surgery between 2006 and 2011 at Papworth Hospital were retrospectively divided into 3 outcome categories: death caused by MesI; death due to other causes and survival to discharge. A published MesI risk calculator was used to estimate risk of MesI for each patient and then to create 3 cohorts of matched patients from each outcome group. Pre-, intra- and postoperative variables were collected and conditional logistic regression methods were used to identify parameters associated specifically with MesI deaths after cardiac surgery. RESULTS A total of 10 409 patients underwent cardiac surgery between 2006 and 2011. The incidence of MesI was 0.3% (30 patients). Two hundred and sixty-one patients died of non-MesI causes and 10 118 survived. It was possible to identify 25 patients in each group at equivalent risk of MesI. The following parameters were found to be associated with MesI mortality: recent myocardial infarction [odds ratio (OR) 4.98, 95% confidence interval (CI) 1.58-15.71, P = 0.01], standard EuroSCORE (OR 1.12, 95% CI 1.03-1.21, P = 0.01), vasopressor dose on bypass (OR 1.28, 95% CI 1.04-1.57, P = 0.02), metaraminol dose on bypass (OR 1.52, 95% CI 1.12-2.06, P = 0.01) and lowest documented mean arterial pressure (OR 0.90, 95% CI 0.83-0.97, P = 0.01). No other intraoperative perfusion-related parameters (e.g. flow, average activated clotting time or pressure) were associated with MesI mortality. CONCLUSIONS Our study not only confirms previously known predictive factors, but also demonstrates a new association between intraoperative vasopressor use and MesI mortality.
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Affiliation(s)
- Priya Sastry
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Gillian Hardman
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Aravinda Page
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Richard Parker
- Department of Public Health and Primary Care, Centre for Applied Medical Statistics, Robinson Way, UK
| | - Martin Goddard
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Stephen Large
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
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Genstorfer J, Schäfer J, Kettelhack C, Oertli D, Rosenthal R. Surgery for ischemic colitis: outcome and risk factors for in-hospital mortality. Int J Colorectal Dis 2014; 29:493-503. [PMID: 24425619 DOI: 10.1007/s00384-013-1819-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgery for ischemic colitis is associated with high perioperative morbidity and mortality, but the risk factors for mortality and major surgical complications are unclear. METHODS In this retrospective single institution cohort study of all patients undergoing colorectal surgery for histologically proven ischemic colitis between 2004 and 2010, we evaluated surgical outcomes and risk factors for in-hospital mortality and major surgical complications. RESULTS For the 100 patients included in the study, in-hospital mortality was 54 %; major surgical complications, defined as anastomotic leakage or rectal stump and stoma complications, occurred in 16 %. In the multivariable analysis, hospital death was more likely in patients with right-sided (odds ratio [OR] 3.8; 95 % confidence interval [CI] 1.2, 12; P = 0.022) or pan-colonic ischemia (OR 11; 95 % CI 2.8, 39; P < 0.001), both relative to left-sided ischemia. Decreased preoperative pH level (OR 2.5 per 0.1 decrease; 95 % CI 1.5, 4.1; P < 0.001) and prior cardiac or aortic surgery (OR 2.4; 95 % CI 0.82, 6.8; P = 0.109) were further important risk factors for in-hospital mortality. Major postoperative surgical complications were more likely in patients with ischemic alterations at the resection margin of the histological specimen (OR 3.7; 95 % CI 1.2, 11; P = 0.022). CONCLUSIONS Colonic resection for ischemic colitis is associated with high in-hospital mortality, especially in patients with right-sided or pan-colonic ischemia. In patients developing acidosis, early laparotomy is essential. Since resection margins' affection seems to be underestimated upon surgery, resections should be performed wide enough within healthy tissue.
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Affiliation(s)
- Jörg Genstorfer
- Department of Surgery, University Hospital Basel, Basel, Switzerland,
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Warwick R, Mediratta N, Chalmers J, McShane J, Shaw M, Poullis M. Virchow’s triad and intestinal ischemia post cardiac surgery. Asian Cardiovasc Thorac Ann 2014; 22:927-34. [DOI: 10.1177/0218492314522252] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Intestinal ischemia is associated with a very high mortality rate. We combined the principles of Virchow’s triad to produce preoperative and postoperative models for the development of intestinal ischemia. Methods A single institutional study was undertaken involving 18,325 consecutive patients from April 1997 to March 2012. Univariate and multivariate analysis was performed. Results Mortality was 87% in 91 patients who developed bowel ischemia. Multivariate logistic regression demonstrated that age, peripheral vascular disease, intraaortic balloon pump support, female sex, and preexisting renal failure were significant determinates of intestinal ischemia preoperatively. Logistic regression demonstrated that age, peripheral vascular disease, creatine kinase-MB level, reoperation for bleeding, and blood product usage were significant determinates of intestinal ischemia postoperatively. Conclusions Potentially remedial causes of intestinal ischemia include blood product usage, reoperation for bleeding, and creatine kinase-MB release. Age, female sex, peripheral vascular disease, intraaortic balloon pump usage, and preexisting renal failure are fixed risk factors. Despite the continuing trend of reduced blood product usage in the field of cardiac surgery, the increase in patients’ risk factors will mean that incidences of intestinal ischemia may increase in the future.
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Affiliation(s)
| | | | | | | | - Matthew Shaw
- Liverpool Heart and Chest Hospital, Liverpool, UK
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Karhausen J, Stafford-Smith M. The role of nonocclusive sources of acute gut injury in cardiac surgery. J Cardiothorac Vasc Anesth 2013; 28:379-91. [PMID: 24119676 DOI: 10.1053/j.jvca.2013.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Indexed: 12/16/2022]
Affiliation(s)
- Jörn Karhausen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Guzmán-de la Garza FJ, Ibarra-Hernández JM, Cordero-Pérez P, Villegas-Quintero P, Villarreal-Ovalle CI, Torres-González L, Oliva-Sosa NE, Alarcón-Galván G, Fernández-Garza NE, Muñoz-Espinosa LE, Cámara-Lemarroy CR, Carrillo-Arriaga JG. Temporal relationship of serum markers and tissue damage during acute intestinal ischemia/reperfusion. Clinics (Sao Paulo) 2013; 68:1034-8. [PMID: 23917671 PMCID: PMC3715035 DOI: 10.6061/clinics/2013(07)23] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 03/30/2013] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE It is essential to identify a serological marker of injury in order to study the pathophysiology of intestinal ischemia reperfusion. In this work, we studied the evolution of several serological markers after intestinal ischemia reperfusion injury in rats. The markers of non-specific cell damage were aspartate aminotransferase, alanine aminotransaminase, and lactic dehydrogenase, the markers of inflammation were tumor necrosis factor alpha, interleukin-6, and interleukin-1 beta, and the markers of intestinal mucosal damage were intestinal fatty acid binding protein and D-lactate. We used Chiús classification to grade the histopathological damage. METHODS We studied 35 Wistar rats divided into groups according to reperfusion time. The superior mesenteric artery was clamped for 30 minutes, and blood and biopsies were collected at 1, 3, 6, 12, 24, and 48 hours after reperfusion. We plotted the mean ± standard deviation and compared the baseline and maximum values for each marker using Student's t-test. RESULTS The maximum values of interleukin-1 beta and lactic dehydrogenase were present before the maximal histopathological damage. The maximum tumor necrosis factor alpha and D-lactate expressions coincided with histopathological damage. Alanine aminotransaminase and aspartate aminotransferase had a maximum expression level that increased following the histopathological damage. The maximum expressions of interluken-6 and intestinal fatty acid binding protein were not significantly different from the Sham treated group. CONCLUSION For the evaluation of injury secondary to acute intestinal ischemia reperfusion with a 30 minute ischemia period, we recommend performing histopathological grading, quantification of D-lactate, which is synthesized by intestinal bacteria and is considered an indicator of mucosal injury, and quantification of tumor necrosis factor alpha as indicators of acute inflammation three hours after reperfusion.
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Abstract
This article reviews the presentation, diagnosis, evaluation, and treatment of the various forms of mesenteric ischemia, including acute and chronic ischemia. In addition, nonocclusive mesenteric ischemia and median arcuate ligament compressive syndrome are covered. The goals are to provide a structured and evidence-based framework for the evaluation and management of patients with these intestinal ischemia syndromes. Special attention is given to avoiding typical pitfalls in the diagnostic and treatment pathways. Operative techniques are also briefly discussed, including an evidence-based review of newer endovascular techniques.
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The impact of selective visceral perfusion on intestinal macrohemodynamics and microhemodynamics in a porcine model of thoracic aortic cross-clamping. J Vasc Surg 2012; 56:149-58. [DOI: 10.1016/j.jvs.2011.11.126] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 11/15/2011] [Accepted: 11/19/2011] [Indexed: 11/18/2022]
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Pang PYK, Sin YK, Lim CH, Su JW, Chua YL. Outcome and survival analysis of intestinal ischaemia following cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15:215-8. [PMID: 22566510 DOI: 10.1093/icvts/ivs181] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Intestinal ischaemia is an uncommon (<1%) but serious complication of cardiac surgery with a mortality rate exceeding 50%. Diagnosis of this potentially lethal condition can be difficult and requires a high index of suspicion. The purpose of this study was to analyse the outcomes and prognostic factors in patients who develop intestinal ischaemia following cardiac surgery. METHODS In a retrospective review from August 1999 to December 2010, we identified 31 out of 9925 (0.31%) consecutive patients who developed acute intestinal ischaemia following cardiac surgery at our tertiary centre. RESULTS The overall mortality was 71.0%. The operative mortality was 65.4% in patients who underwent a laparotomy. Survivors of this complication had surgical intervention earlier (7.4 ± 4.9 h) compared with the non-survivors (13.9 ± 11.1 h). A total of 35 perioperative variables were analysed. A univariate analysis identified 12 variables associated with an increased risk of mortality. Logistic multivariate analysis identified the preoperative logistic EuroSCORE and the base excess at the point of diagnosis of intestinal ischaemia as significant predictors of mortality. These factors may aid prognostication in this group of patients. CONCLUSIONS Despite the high mortality rates associated with intestinal ischaemia following cardiac surgery, early diagnosis and surgical intervention remain the only effective means to reduce mortality.
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Affiliation(s)
- Philip Y K Pang
- Department of Cardiothoracic Surgery, National Heart Centre, Singapore, Singapore
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Vitin AA, Metzner JI. Anesthetic management of acute mesenteric ischemia in elderly patients. Anesthesiol Clin 2009; 27:551-67, table of contents. [PMID: 19825492 DOI: 10.1016/j.anclin.2009.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ischemic insult to the splanchnic vasculature can jeopardize bowel viability and lead to devastating consequences, including bowel necrosis and gangrene. Although acute mesenteric ischemia (AMI) may occur at any age, the elderly are most commonly affected due to their higher incidence of underlying systemic pathology, most notably atherosclerotic cardiovascular disease. Treatment options include pharmacology-based actions, endovascular, and surgical interventions. AMI remains a life-threatening condition with a mortality rate of 60% to 80%, especially if intestinal infarction has occurred and surgical intervention becomes emergent. Early recognition and an aggressive therapeutic approach are essential if the usually poor outcome is to be improved. Anesthetic management is complex and must account for comorbid disease as well as the patient's presumptive acute deterioration. Blood pressure support typically involves careful, but often massive, fluid resuscitation and may also additionally require pharmacologic support.
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Affiliation(s)
- Alexander A Vitin
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98195-6540, USA.
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Sommer CM, Radeleff BA. A novel approach for percutaneous treatment of massive nonocclusive mesenteric ischemia: tolazoline and glycerol trinitrate as effective local vasodilators. Catheter Cardiovasc Interv 2009; 73:152-5. [PMID: 19156878 DOI: 10.1002/ccd.21811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nonocclusive mesenteric ischemia (NOMI) generally affects patients with low cardiac output, resulting in splanchnic hypoperfusion. It includes all forms of mesenteric ischemia without vessel occlusion and makes up between 20 and 30% of all cases of acute mesenteric ischemia. We present the case of a 84-year-old man with a history of total atrioventricular block developing NOMI. This was diagnosed by percutaneous selective catheter arteriography (PSCA), which demonstrated remarkable abrupt termination of the jejunal vasculature and multiple severe spasms of the colonic arteries. Control PSCA after local intraarterial vasodilator therapy (LIVT) with tolazoline and glycerol trinitrate documented an excellent therapeutic result with a completely unremarkable vasculature. Although LIVT was complicated by severe cardiovascular complications inclusive of cardiac arrest with the need of cardiopulmonary resuscitation, the patient fully recovered and was discharged after implantation of a cardiac pacemaker in good clinical condition 7 days later.
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Luckner G, Jochberger S, Mayr VD, Knotzer H, Pajk W, Wenzel V, Friesenecker B, Lorenz I, Dünser MW. Vasopressin as adjunct vasopressor for vasodilatory shock due to non-occlusive mesenteric ischemia. Anaesthesist 2009; 55:283-6. [PMID: 16328472 DOI: 10.1007/s00101-005-0958-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We present the case of an 83-year-old patient who underwent cardiac surgery and developed postoperative non-occlusive mesenteric ischemia (NOMI), which was treated with a local intra-arterial papaverine and prostaglandin E1 infusion. After successful mesenteric reperfusion, a multiple organ dysfunction syndrome with severe cardiovascular failure developed. High norepinephrine dosages (1.09 microg/kg body weight/min) and catecholamine-related complications (tachycardiac atrial fibrillation) required initiation of supplementary argininevasopressin (AVP) infusion (4 U/h). AVP stabilized vasodilatory shock, ensured adequate gut perfusion pressure and had no adverse clinical or angiographic effects on restitution of gut integrity. In conclusion, after reperfusion of NOMI in this patient, adjunct AVP therapy combined with local vasodilator infusion was beneficial as a potentially life-saving vasopressor.
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Affiliation(s)
- G Luckner
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria. Guenter.Luck n
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Abboud B, Daher R, Sleilaty G, Madi-Jebara S, El Asmar B, Achouch R, Jebara V. Is prompt exploratory laparotomy the best attitude for mesenteric ischemia after cardiac surgery? Interact Cardiovasc Thorac Surg 2008; 7:1079-1083. [PMID: 18815161 DOI: 10.1510/icvts.2008.176271] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Mesenteric ischemia following cardiac surgery is a life-threatening complication. Early identification of patients may help optimizing management and improving outcome. Between January 2000 and July 2007, surgical exploration was realized when mesenteric ischemia was suspected after coronary-artery bypass grafts (CABG). Patients were divided in two groups according to diagnosis confirmation upon laparotomy. Peri-operative predictors of complication and death were analyzed. Of 1634 consecutive patients, 13 (0.8%) developed acute abdomen with suspicion of mesenteric ischemia. Seven (0.4%) underwent resection for ischemic lesions (group 1), of whom two were during a second look laparotomy. The other six patients had normal bowel (group 2). Both groups were comparable according to preoperative status, clinical signs, biological and radiological findings. Delays to laparotomy were 13.7+/-19.0 and 51.4+/-29.0 h in group 1 and 2, respectively (P=0.02). Mortality rates were 46.1% (6/13) overall, 42.8% for group 1 and 50% for group 2. All deaths occurred within the first nine postoperative days. Mesenteric ischemia following CABG is a fatal complication in almost half the cases. Diagnostic tools and timely laparotomy still need to be optimized. Low threshold-based strategy for prompt surgical intervention is efficient for both diagnosis and treatment.
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Affiliation(s)
- Bassam Abboud
- Department of General Surgery, Hotel Dieu de France Hospital, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon.
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Abboud B, Daher R, Boujaoude J. Acute mesenteric ischemia after cardio-pulmonary bypass surgery. World J Gastroenterol 2008; 14:5361-5370. [PMID: 18803347 PMCID: PMC2744158 DOI: 10.3748/wjg.14.5361] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 07/14/2008] [Accepted: 07/21/2008] [Indexed: 02/06/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a highly-lethal surgical emergency. Several pathophysiologic events (arterial obstruction, venous thrombosis and diffuse vasospasm) lead to a sudden decrease in mesenteric blood flow. Ischemia/reperfusion syndrome of the intestine is responsible for systemic abnormalities, leading to multi-organ failure and death. Early diagnosis is difficult because the clinical presentation is subtle, and the biological and radiological diagnostic tools lack sensitivity and specificity. Therapeutic options vary from conservative resuscitation, medical treatment, endovascular techniques and surgical resection and revascularization. A high index of suspicion is required for diagnosis, and prompt treatment is the only hope of reducing the mortality rate. Studies are in progress to provide more accurate diagnostic tools for early diagnosis. AMI can complicate the post-operative course of patients following cardio-pulmonary bypass (CPB). Several factors contribute to the systemic hypo-perfusion state, which is the most frequent pathophysiologic event. In this particular setting, the clinical presentation of AMI can be misleading, while the laboratory and radiological diagnostic tests often produce inconclusive results. The management strategies are controversial, but early treatment is critical for saving lives. Based on the experience of our team, we consider prompt exploratory laparotomy, irrespective of the results of the diagnostic tests, is the only way to provide objective assessment and adequate treatment, leading to dramatic reduction in the mortality rate.
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Antolovic D, Koch M, Hinz U, Schöttler D, Schmidt T, Heger U, Schmidt J, Büchler MW, Weitz J. Ischemic colitis: analysis of risk factors for postoperative mortality. Langenbecks Arch Surg 2008; 393:507-12. [PMID: 18286300 DOI: 10.1007/s00423-008-0300-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 01/31/2008] [Indexed: 01/01/2023]
Abstract
BACKGROUND Ischemic colitis is a disease with high postoperative mortality when surgery is necessary. The definition of risk factors for perioperative mortality, which is currently lacking in the literature, could be helpful in clinical decision making and in optimizing perioperative treatment. MATERIALS AND METHODS Based on a prospective database, 85 consecutive patients undergoing surgery for ischemic colitis between November 04, 2001 and October, 26, 2004 at the Department of Surgery, University of Heidelberg, were included in this study. The influence of different known factors on perioperative mortality such as age, type of operation, blood loss, comorbidities, hospital course, and complications was tested by univariate and multivariate analysis. RESULTS Sixty-seven percent of patients were operated as emergency cases (within 24 h after surgical evaluation). About half of the patients underwent subtotal or total colectomy and 80% had stoma creation. Twenty-two percent of patients developed surgical complications and 47% of patients died in the further postoperative course. Univariate analysis showed underlying cardiovascular diseases, American Society of Anesthesiologists (ASA) status, emergency surgery, total colectomy, elevated intraoperative blood loss and intraoperative allogeneic blood transfusion or transfusion of fresh frozen plasma to be associated with an increased postoperative mortality. Multivariate analysis confirmed ASA status > III, emergency surgery, and blood loss to be independently associated with postoperative mortality in ischemic colitis. CONCLUSIONS The mortality of patients requiring surgery for ischemic colitis will remain high as the majority of afflicted patients are patients with significant comorbidities in a reduced general condition. But earlier diagnosis and measures to reduce blood loss may contribute to improving the overall outcome.
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Affiliation(s)
- Dalibor Antolovic
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
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31
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Kaplan N, Yagmurdur H, Kilinc K, Baltaci B, Tezel S. The protective effects of intravenous anesthetics and verapamil in gut ischemia/reperfusion-induced liver injury. Anesth Analg 2007; 105:1371-8, table of contents. [PMID: 17959968 DOI: 10.1213/01.ane.0000284696.99629.3a] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND We investigated the protective effects of IV anesthetics and verapamil in gut ischemia/reperfusion-induced liver injury. METHODS Forty male Wistar Albino rats were randomly assigned to four groups of 10 rats each. Anesthesia was induced and maintained with propofol in Groups 1 and 3 and with thiopental in Groups 2 and 4 during the experiment. All animals developed intestinal ischemia after occlusion of the superior mesenteric artery for 30 min. Reperfusion was induced by removal of the microvascular clamp and was allowed to continue for 120 min. The animals in Groups 3 and 4 were given verapamil 10 min before reperfusion. Liver and ileum samples were taken for measurement of malondialdehyde (MDA) and histopathologic examination before ischemia and 30 and 120 min after reperfusion. Blood samples were also obtained for measurement of plasma tumor necrosis factor-alpha and interleukin-6 levels. RESULTS Gut ischemia/reperfusion-induced significant increases in MDA contents of liver and gut and serum cytokines, consistent with histopathologic injury scores. Propofol effectively stabilized the MDA levels and decreased the tissue injury scores of the liver and gut. Tumor necrosis factor-alpha and interleukin-6 levels increased less in the propofol groups than in the thiopental groups. There was no additive preventive effect of verapamil on propofol. The addition of verapamil to thiopental was effective in decreasing the serum cytokines and liver MDA content. CONCLUSION Propofol may offer advantages by inhibiting lipid peroxidation and inflammatory cytokine production in an animal model of gut ischemia/reperfusion-induced liver injury.
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Affiliation(s)
- Necat Kaplan
- Ministry of Health Ankara Research and Training Hospital, Ankara, Turkey
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32
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Khan JH, Lambert AM, Habib JH, Broce M, Emmett MS, Davis EA. Abdominal Complications After Heart Surgery. Ann Thorac Surg 2006; 82:1796-801. [PMID: 17062250 DOI: 10.1016/j.athoracsur.2006.05.093] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2005] [Revised: 05/24/2006] [Accepted: 05/26/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Up to 3% of patients undergoing heart surgery suffer from an intraabdominal complication (IAC). These complications carry a high mortality besides adding to the morbidity and cost. This review was undertaken to see if a subset of patients with increased risk of IAC could be identified. METHODS Medical records of 7,731 consecutive patients undergoing heart surgery in a single center were screened for identification of postoperative IAC. One hundred and twenty (120) cases were found. One hundred and six (106) cases were compared with the same number of matched controls. RESULTS Significant predictors of the development of IAC were increased cardiopulmonary bypass times (> 99 minutes), peripheral vascular disease, chronic steroid use, and low left ventricular ejection fraction. Patients on postoperative antiplatelet therapy or warfarin had a lower risk of IAC. Significant predictors of mortality in IAC were increased cardiopulmonary bypass times (> or = 120 minutes.), use of inotropes, cerebral vascular disease, and incremental age. CONCLUSIONS A subset of patients can be identified who are at higher risk for IAC and an associated adverse outcome. Patients who have prolonged cardiopulmonary bypass, have a low left ventricular ejection fraction, are on steroids, and suffer from other vascular disease should be observed carefully for development of IAC. Postoperative anticlotting strategies may be helpful. Early diagnosis and intervention are essential for improving outcomes in cases of IAC.
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Affiliation(s)
- Jamal H Khan
- Charleston Area Medical Center, Charleston, West Virginia, USA.
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33
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Katz MG, Schachner A, Ezri T, Kravtsov V, Freidman V, Hauptman E, Sasson L. Nonocclusive Mesenteric Ischemia after off-Pump Coronary Artery Bypass Surgery: A word of Caution. Am Surg 2006. [DOI: 10.1177/000313480607200307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present a series of five cases of off-pump coronary artery bypass surgery complicated with fatal nonocclusive mesenteric ischemia. We review a total of 489 patients aged 65 and older (mean age 74.9 ± 3.2 years) who underwent off-pump coronary artery bypass surgery. The diagnosis of nonocclusive mesenteric ischemia was confirmed by computed tomography-angiography and/or selective angiography of the superior mesenteric artery, or intraoperatively. Three patients underwent laparotomy with bowel resection. In two cases, resection of bowel was not feasible. Of the possible predisposing factors, we found that four of the patients (two preoperative and two perioperative) had received epinephrine and two had an intra-aortic balloon counter pulsation due to acute myocardial infarction and cardiogenic shock. All patients were over 65 years of age, and all had acute anterior wall myocardial infarction and hemodynamic instability or postmyo-cardial infarction unstable angina. Nonocclusive mesenteric ischemia is a difficult clinical entity to recognize, has no clear-cut effective management, has a poor prognosis as a result of low cardiac output, and can be aggravated by off-pump coronary artery bypass grafting.
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Affiliation(s)
| | - Arie Schachner
- The Angela & Sami Shamoon Cardiothoracic Surgery Department
| | - Tiberiu Ezri
- Departments of Anesthesia, The Edith Wolfson Medical Center, Holon, Israel, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Outcomes Research™ Institute, Louisville, Kentucky
| | - Vladimir Kravtsov
- Departments of Pathology, The Edith Wolfson Medical Center, Holon, Israel, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Freidman
- Departments of Radiology, The Edith Wolfson Medical Center, Holon, Israel, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eli Hauptman
- The Angela & Sami Shamoon Cardiothoracic Surgery Department
| | - Lior Sasson
- The Angela & Sami Shamoon Cardiothoracic Surgery Department
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Braun JP, Schroeder T, Buehner S, Jain U, Döpfmer U, Schuster J, Bas S, Schimke I, Dohmen PM, Lochs H, Konertz W, Spies C. Small-dose epoprostenol decreases systemic oxygen consumption and splanchnic oxygen extraction during normothermic cardiopulmonary bypass. Anesth Analg 2006; 102:17-24. [PMID: 16368799 DOI: 10.1213/01.ane.0000184818.32635.fd] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Normothermic, nonpulsatile cardiopulmonary bypass (CPB) impairs systemic and splanchnic oxygen transport and increases gastrointestinal permeability. It is an important therapeutic goal to avoid splanchnic dysoxia during CPB. Small-dose prostacyclin therapy improves splanchnic oxygen transport and microcirculation in septic patients. In this study, we sought to determine if during cardiac surgery, the prostacyclin analog epoprostenol improves the balance of systemic and splanchnic oxygen transport. Eighteen patients undergoing cardiac valve replacement were randomized to receive either epoprostenol (3 ng x kg(-1) x min(-1)) or placebo during, and for 1 hour after, surgery. Systemic and splanchnic oxygen delivery, consumption, and extraction and arterial, mixed venous, and hepato-venous lactate concentrations were measured before, during, and after CPB. Gastrointestinal permeability was measured 1 day before and 1 day after surgery using the triple sugar permeability test. During CPB, the epoprostenol group had decreased systemic oxygen consumption and splanchnic oxygen extraction (P = 0.024). These effects were not present 1 hour after the end of epoprostenol infusion. The study was not adequately powered to determine whether epoprostenol altered the trend towards increased lactate metabolism and increased postoperative gastrointestinal permeability, nor could we demonstrate any differences between groups in clinically relevant end-points. In conclusion, these findings suggest that during normothermic CPB, small-dose epoprostenol therapy may reduce systemic oxygen consumption and splanchnic oxygen extraction.
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Affiliation(s)
- Jan-Peter Braun
- Departments of Anesthesiology and Intensive Care, Charité University Hospital, Charité-University Medicine Berlin, Germany.
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Karamlou T, Landry GJ, Taylor LM, Moneta GL. Epidemiology and Pathophysiology. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Yun AJ, Lee PY, Bazar KA. Can thromboembolism be the result, rather than the inciting cause, of acute vascular events such as stroke, pulmonary embolism, mesenteric ischemia, and venous thrombosis?: a maladaptation of the prehistoric trauma response. Med Hypotheses 2005; 64:706-16. [PMID: 15694686 DOI: 10.1016/j.mehy.2004.08.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2004] [Accepted: 08/24/2004] [Indexed: 01/14/2023]
Abstract
Thromboembolism is considered the inciting cause of many vascular disorders including acute coronary syndrome (ACS), ischemic stroke, pulmonary embolism (PE), deep vein thrombosis (DVT), and mesenteric ischemia. Adrenergia and inflammation are known to accompany these conditions, particularly among arterial thromboembolic disorders, but the teleologic basis of these associations remains poorly understood. We argue that thromboembolism may sometimes be the result, rather than the cause, of acute vascular events, and may be precipitated by underlying adrenergia. Thromboembolic events are most prone to occur during parts of the circadian, seasonal, lifespan, and reproductive cycles with sympathetic dominance, as well as during behavioral, exertional, physiologic, and iatrogenic activation of sympathetic stress. Molecular evidence suggests that adrenergia and inflammation can promote coagulation and lead to co-activation of the pathways. Acute vascular events that occur without angiographic evidence of occlusion suggest that some infarcts may be attributable to adrenergia alone. "Embolic" disorders may represent asynchronous systemic phenomena rather than clot migration. During acute thromboembolism, downstream tissue hypoxia can activate maladaptive self-propelling cycles of sympathetic bias, inflammation, and coagulation. The counterproductive co-activation of these pathways may reflect a maladaptive interlink forged during the primordial evolution of trauma physiology. Their rapid co-mobilization enables rapid control of hemorrhage, microbial defense, and perfusion maintenance during trauma, but the pathways may behave maladaptively in the setting of modern diseases where endothelial injury may be more often precipitated by smoking, diabetes, dyslipidemia, or hypertension. Sympathetic blockade is already employed in ACS, and beta-blockers are used as antihypertensives to prevent stroke. Our hypothesis suggests that the benefits of beta-blockers in stroke may be independent of antihypertensive effects, and that adrenergia may represent a target for managing all thromboembolic disorders, independent of anti-coagulative and thrombolytic therapies. Perhaps reducing adrenergia, rather than maintaining high cerebral perfusion pressure, may represent a counterintuitive strategy for treating stroke and for reducing reperfusion injury. Plausible mechanisms by which autonomic dysfunction may induce venous thrombosis are discussed, especially in those with baroreceptor dysfunction, immobilization, or dehydration. Unexplained hypercoagulability of cancer may also operate through tumor-induced adrenergia and inflammation.
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Affiliation(s)
- Anthony J Yun
- Department of Radiology, Stanford University, 470 University Avenue, Palo Alto, CA 94301, USA.
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37
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Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am 2002; 86:1357-1399. [PMID: 12510457 DOI: 10.1016/s0025-7125(02)00080-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Major breakthroughs in catheter, guidewire, and other angiographic equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. Similarly, the interventional radiologist can treat acute intestinal ischemia safely and effectively with selective catheterization and papaverine administration and treat chronic mesenteric ischemia by percutaneous angioplasty and stent placement. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is critical in managing GI bleeding and intestinal ischemia, particularly in patients at high risk or presenting as diagnostic dilemmas.
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Affiliation(s)
- Zvi Lefkovitz
- Department of Radiology, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, NY, USA
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38
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Boffa DJ, Tak V, Jansson SL, Ko W, Krishnasastry KV. Atheroemboli to superior mesenteric artery following cardiopulmonary bypass. Ann Vasc Surg 2002; 16:228-30. [PMID: 11972257 DOI: 10.1007/s10016-001-0064-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Intestinal ischemia after open heart surgery is an uncommon but often fatal complication. The ischemia is generally seen in the context of a low-flow state, and less frequently is associated with an occlusion in the mesenteric circulation. We report a case of intestinal ischemia caused by an atheroemboli in a patient who had an intraaortic balloon pump (IABP) placed during a coronary artery bypass graft (CABG).
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Affiliation(s)
- Daniel J Boffa
- Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY 10021, USA.
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39
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Abstract
A clinically feasible method for assessing regional splanchnic perfusion is still lacking. Methods used for research purposes demonstrate that the effects of current therapies on splanchnic perfusion are not predictable in intensive care patients with and without ARDS. Tonometry, laser Doppler flowmetry, and spectrophotometry have been used to assess splanchnic perfusion. Combining the available methods in different parts of the gastrointestinal tract may help assess splanchnic perfusion more accurately in the near future.
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Affiliation(s)
- Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital Inselspital, Bern, Switzerland.
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40
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Towfigh S, Heisler T, Rigberg DA, Hines OJ, Chu J, McFadden DW, Chandler C. Intestinal ischemia and the gut-liver axis: an in vitro model. J Surg Res 2000; 88:160-4. [PMID: 10644483 DOI: 10.1006/jsre.1999.5767] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Sustained intestinal ischemic injury often leads to shock and multiorgan failure, mediated in part by a cytokine cascade. Animal models have also identified a central role of Kupffer cells in amplification of cytokines following intestinal ischemia. To better understand this gut-liver axis, we developed an in vitro model. MATERIALS AND METHODS Kupffer cells were isolated from rat livers by arabinogalactan gradient ultracentrifugation and adherence purification. Cells were grown in RPMI medium in 5% CO(2). Rat intestinal epithelial cells, IEC-6, were cultured under normoxic or anoxic (90% N(2), 10% CO(2)) conditions for 2, 12, and 24 h. Kupffer cells were then grown in the conditioned medium of the IEC-6 cultures. After 24 h, the medium was replaced with fresh medium. This final Kupffer cell supernatant was tested for tumor necrosis factor alpha and interleukin-6 production by ELISA. Trypan blue exclusion was performed to assess cell viability. RESULTS Intestinal and Kupffer cells remained viable during the experimental time. Production of both tumor necrosis factor alpha and interleukin-6 by Kupffer cells increased with increasing ischemia time of the intestinal cells. CONCLUSIONS Consistent with animal studies of intestinal ischemia, this study found an increase in cytokine production by Kupffer cells following hypoxia of intestinal cells. This in vitro model offers a new tool to study the expression of cytokines, proteins, and messengers involved in the cascade of events that follow intestinal ischemia.
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Affiliation(s)
- S Towfigh
- Department of Surgery, Sepulveda Veterans Administration Medical Center, North Hills, California 91343, USA
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Liolios A, Oropello JM, Benjamin E. Gastrointestinal complications in the intensive care unit. Clin Chest Med 1999; 20:329-45, viii. [PMID: 10386260 DOI: 10.1016/s0272-5231(05)70145-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pathologic conditions affecting the abdomen are a significant cause of morbidity and mortality in the intensive care unit, but their importance is not widely recognized. This article presents several aspects of abdominal pathology that can occur in intensive care unit patients. This pathology may have a considerable impact on the prognosis and survival of the critically ill patient. The diagnostic contribution of laboratory tests and imaging is discussed. Conditions such as the abdominal compartment syndrome, acute mesenteric ischemia, gastrointestinal bleeding, diarrhea, abdominal sepsis, complications of entereal and parenteral nutrition, and ileus in critically ill patients are also reviewed.
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Affiliation(s)
- A Liolios
- Department of Surgery, Mount Sinai Medical Center, City University of New York, New York, USA
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42
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Hepatosplanchnic perfusion. Curr Opin Crit Care 1999. [DOI: 10.1097/00075198-199906000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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