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Sobirov Jasur Gaybillaevich, MD, Senior Researcher, Department of Vascular Surgery, JSC «Republican Specialized Surgery Center named after academician V. Vakhidov» E-mail: [email protected] Bahritdinov Fazliddin Shamsitdinovich, MD, PhD, Head of the Department of Vascular Surgery E-mail: [email protected]
Prediction role of risk factors assessment to immediate results of surgical treatment of concomitant lesions
Abstract: The authors aim was to investigate the impact of risk factors by SMART assessing tool, on the immediate results of surgical treatment of patients with concomitant lesions of the aortic arch branches, terminal part of abdominal aorta and lower limb arteries.
Keywords: atherosclerosis, risk factors, tools of the scoring.
Introduction
There are a lot of ways of assessing the impact of both — various risk factors within the development processes of the course and outcomes from treatments taken for atherosclerosis. Assessing risks for each individual patient is crucial. Moreover, most of risk factors have an independent effect on atherosclerosis and related complications, which can be reduced through a course of treatment of the latter. Risk assessment tools help review the impact of individual risk factors and their focus on selection of an appropriate treatment which is based on the diagnostic methods applied [1; 2; 3; 4].
In the last 25-30 years developed dozens of risk assessment tools (methods, calculators) which include main predictors such as age, gender, systolic blood pressure, diabetes, smoking, cardiovascular diseases (myocardial infarction, angina pectoralis, stroke, arrhythmia (arterial fibrillation), left ventricular hypertrophy, cholesterol, etc. [4; 5; 6; 7; 8].
SMART study group (Second Manifestations ofARTerial disease) (2009) looked into the impact ofvarious risk factors in 800 patients with peripheral atherosclerosis and developed a sensitive
method for determining of a 1-5-year long risk of stroke, heart attack and death, with a statistical certainty (95 %CI) (tab. 2) [4].
Accordingly, the aim of study was to investigate the impact of risk factors by SMART assessing tool, on the immediate results of surgical treatment of patients with concomitant lesions of the aortic arch branches, terminal part of abdominal aorta and lower limb arteries.
Material and methods
Analyzed results of the assessment of risk factors by SMART of 181 patients operated with combined lesions of the aortic arch branches and lower limb arteries. All of them were operated in the Department of Vascular Surgery from 2000 to 2015. Patients were divided into three groups exposed to different surgical interventions at the initial stage: Group I — patients exposed to reconstruction of the aortic arch branches (31 patients); Group II — those operated on the terminal portion of the abdominal aorta and the arteries of the lower limb arteries (120 patients); and Group III — patients operated simultaneously on both arterial beds (30 patients). The age of the patients ranged between 51 and 70 years (average 60 ± 1), it is noteworthy that 97.2 % of all subjects were male patients (tab. 1).
Table 1. - Characteristics of patients per Group
Group I (n = 31) Group II (n = 120) Group III (n = 30)
Age 60 ± 1 61 ± 1 60 ± 1
Risk Factors 5.35 ± 0.28 5.24 ± 0.2 4.87 ± 0.27
SMART 326 ± 14 354 ± 9.3 328 ± 16
CLI*/ulcers ( %) 38.7 % 6.45 % 71.7 % 23.3 % 51.7 % 10.3 %
Stroke history ( %) 29 % 17.5 % 6.9 %
AIM* history ( %) 22.6 % 28.3 % 20.7 %
Hypertension ( %) 61.3 % 74.1 % 96.2 %
Diabetes mellitus ( %) 16.1 % 18.33 13. 8 %
Type of aorta ileac le- A 2 (6.45 %) 14(11.7 %) 2 (6.9 %)
sions by TASC II* ( %) B 9 (29 %) 14(11.7 %) 4(13.8 %)
C 2 (6.45 %) 8 (6.7 %) 6 (20.7 %)
D 11 (38 %) 71 (60 %) 10 (34.5 %)
Type of PAD* lesions by A 4(13 %) 3 (9.7 %) 15 (12.5 %) 11 (9.2 %) 2 (6.9 %) 4 (13.8 %)
TASC II B 8 (26 %) 4(13 %) 27 (22.5 %) 29 (24.2 %) 7 (24 %) 6 (5 %)
L/R* ( %) C 2 (6.4 %) 6 (19.3 %) 33 (27.5 %) 28 (23.3 %) 11 (38 %) 7 (5.8 %)
D 1 (3.2 %) 1 (3.2 %) 3 (2.5 %) 6 (5 %) 1 (3.4 %) 2 (1.7 %)
ABI* (left/right) 0.7 ± 0.06 0.73 ± 0.06 0.51 ± 0.03 0.5 ± 0.027 0.64 ± 0.05 0.56 ± 0.05
Notes: CLI — critical limb ischemia; AIM — acute myocardial infarction; TASC II — trans atlantic Society Consensus II; PAD — peripherial arterial disease; L/R — left/right; ABI — ankle brachial index.
Various risk factors including age (above 60), sex, smoking, obesity, hypertension, chronic bronchitis, heart failure and stroke detected through the anamnesis were taken into account when assessing the patients. All patients appeared to have nearly five risk factors.
In view to define possible impairments of the arterial beds the patients were exposed to a series of diagnostic tests, such as
ultrasound investigation of main arteries, ECG, echocardiography, MRI, MSCT angiography and X-ray contrast angiography.
All of them were identified by risk assessment SMART techniques and the findings were compared with the immediate results of surgical treatment of these patients. This calculation used a well-known table on the SMART (Table 2).
Table 2. - Risk assessment chart for SMART
Score chart Indexation Score
Age above 55 years Every yearsX 8 +
Presence or history of cerebrovascular disease If yes + 86 +
Presence or history of heart disease If yes + 86 +
Systolic Arterial pressure +
Smoking If yes + 107 +
Creatinine mmol/l. +
Sum + -
LDC-L mmol/l. X 74 -
Ankle-brachial index (ABI) ABI X 157 -
Subtract -
Summary score
Summary risk 1-year 5-year
Low > 100 0 % 1 %
Middle 101-225 1 % 5 %
High 226-350 3 % 12 %
Very high > 351 10 % 28 %
Results complications of the immediate and late postoperative period.
Risk assessment using SMART techniques proved that over In I group patients average score was 325.98 ± 13.9, in II Group — 85 % of patients had high and top levels of risk of developing 354.64 ± 9.38, and in III group respectively 327.2 ± 16.27 (Tab.3). Table 3. - Distribution of patients according to SMART risk assessment technique
Group/score Average score Middle risk High risk Very high risk
I-group 325.98 ± 13.9 4(12.9 %) 14 (45.2 %) 13 (41.9 %)
II-group 354.2 ± 9.3 10 (8.3 %) 52 (43.3 %) 58 (48. 4 %)
III-group 328.4 ± 16.03 4(13.3 %) 12 (40 %) 14(46.7 %)
Assessment by SMART indicate that, the first group ofpatients with proximal (SMART=272 ± 15.2) and distal (SMART = 341.6 ± 12.5) type oflesions ofaortic arch branches statistically significantly differed (P < 0.05). This status is reflected in the next objective results of surgical
treatment, so as in the proximal type there were no complications. But in the distal type of aortic arch branches lesions, in 3 (9.7 %) cases occurred complications. There was an acute myocardial infarction and acute cerebrovascular accident (in the ratio 1:2) (tab. 4).
In second group of patients at the immediate postoperative period occurred 8 (13.3 %) complication. Four (6,67 %) ofthem with shunt thromboses operated with good results. And in 3 (2.5 %) of them, on the background of the cases of thrombosis aorto-femoral bypass (AFB, there was an acute myocardial infarction (acute cardiovascular insufficiency) with a fatal end. Complications analysis showed that, died patients initially had SMART score 300.2; 457.4 and 499.5, respectively, which initially had high level of risk of complications by SMART (table 4).
Discussion
Initially SMART study group (2009) used this tool so as long term prediction model for patients with established PAD [4]. But our study was directed to learn information value for concomitant atherosclerotic lesions. The main finding of our study is that the risk assessment tool of SMART, usably to predict immediate results of the surgical treatment of patients with concomitant atherosclerotic lesions.
The study revealed that such factors as cardiac (myocardial infarction, angina, heart failure, atrial arrhythmia), vascular (aortic aneurysm, intermittent claudication, pain at rest, ischemic ulcers), somatic (diabetes mellitus, metastatic tumors, renal hepatic failure), and urgent surgeries may have a significant impact on long-term outcomes of surgical treatments (p < 0.01, 95 % CI), however neither referring to a female gender (p = 0.48) nor to a white race (p = 0.99) did have such an impact [8; 9].
After 10 years of a research on 905 asymptomatic atherosclerotic patients, Laura G. et all. (2000) found out that the mono-variation analysis performed based on only 6 factors (age, sex, systolic blood pressure (SBP), pulse pressure (PP), total cholesterol, HDL-C) had a significant effect (P < 0.05) within a disease course. Based on the multivariate modeling the researchers identified that the progression of stenosis largely depended on the pulse pressure and HDL. The risk level' increase by 1.12 times is caused by the increased PD by 10 mm. Hg., while a decrease in HDL-C by 10 mg/dL causes the risk level increment by 1.2 times [10].
The incidence rate of cardiovascular complications in patients with diabetes mellitus is several times higher (ischemic stroke
In the third group at the immediate postoperative period occurred 4 (13.3 %) complications. Three of them, so as bleeding and intestinal obstruction, impossible to predict before operations. At last one (3.3 %) case after reconstruction (CEA + aorto-bifem-oral bypass) occured shunt thrombosis with irreversible ischemia, about what was produced amputation of the left lower limb. In this patient 4 days after surgery occurred an acute myocardial infarction with fatal end (tab. 4). This patient initially is referred to very high risk group of developing complications (SMART- 438.3).
(IS) - 1.4; Myocardial infarction (MI) - 2.4; angina (heart failure) - 2; chronic lower limb ischemia (CLLI) - 8; cardiovascular disease (CVD) - 6-fold) than in patients with no diabetes [1].
Welten G. et all. (2007) 2 268 patients studied cardiac risk (Lee Index) which includes a 6 characteristics (high-risk surgery, ischemic heart disease (coronary artery disease), history of myocardial infarction, chronic cerebrovascular insufficiency, chronic renal failure (CRF), diabetes mellitus). The result showed that the Li index does not include a sufficient number of risk factors and little informative patients over 70 years [12].
According to previous researches described in scientific literature both — the scope and the severity of surgery operations in this particular category ofpatients — affect immediate and late outcomes; all interventions are therefore categorized as low-, medium-, high- and top risk level interventions. Welten G., et all. (2007) proved significant differences in numerous MACEs (major adverse cardiac event) depending on an operation risk level: 2.4 % - low, 11.6 % - medium, 12.3 % — high and 24 % - top [12].
Jonston S. et all. studied 4 799 patients with transient ischemic attack (TIA), which have been inspected within 48 hours ofthe onset of the disease and developed based on a scale of 6 cohorts ABCD2. Scale ABCD2 — is rapid clinical tool that helps to predict the early risk of stroke within the first 2, 7 and 90 days after TIA. Recently, it has been found that the scale is also useful in predicting the risk of recurrent stroke in the first few hours after a small stroke or TIA [12].
Pros N. et all. (2013) proposed a method for risk assessment at the patient discharge from hospital to determine the annual mortality
Table 4. - Characteristics of the complicated patients per groups
Group I: 3 cases complicated by 31, but no mortality
Operation Risk Factors SMART CLI/ul-cers Stroke history AIM history TASC II Complication
CEA* 7 297.5 + + - -DD Stroke
CEA 4 271.5 - + - -/-B Stroke
CEA 4 292.5 + - - DAC AIM
Group II: 8 (6.7 %) cases complicated by 120, and 3 (2.5 %) of them with lethal end
AFB* 7 499.5 + - - BBB Lethal end
FPB* 5 300.21 + - - A-C Lethal end
Endo CIA* 9 457.4 - + + A - Lethal end
AFB 6 405 + - - DAA Stroke
AFB 4 227 + - - D - thromboses
AFB 3 268 + - - DDD thromboses
AFB 5 428 + - - DCC thromboses
AFB 6 343 + - - C-C thromboses
Group III: 4 (13.3 %) cases complicated by 30, and 1 (3.3 %) mortality
CEA+AFB 5 438.3 + - + D-C lethal end
CEA + Lumbal Sympatectomy 3 219 + - - -/-D Retroperitoneal bleeding
CEA+FPB 7 260.7 - - - -CA erosive bleeding
CEA+AFB 3 172 - - - D-/- Intestinal obstruction
Notes: CEA — carotid, endarterectomy, AFB — aortae femoral bypass, FPB — femoro-popliteal by pass, Endo CIA — endovascular intervention in common ileac artery.
and complications. Analysis methods in 640 patients with peripheral atherosclerosis showed that the incidence of complications are at low risk (< 0) in 2 % ofcases, with an average (0.5-2) - 12.8 %, with a high (2.5-4) - 23 %, and very high (< 4.5) - at 42.2 % cases (C - 0.76) [13].
Numerous methods listed above can only help assess the impact of risk factors on a disease course. Each tool has its own limitations. Studies revealed that all cardiovascular diseases and the majority of subjects initially entered at high risk group.
Conclusions
Thus, patients with combined lesions of arterial beds initially treated in a group with high risk for complications such as myocardial infarction, ischemic stroke and mortality. Application assessment SMART technique allows to predict possible complications in the postoperative period. Patients with a high grade of SMART score must pass before operating, adequate therapy directed to the elimination of risk factors.
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Sobirov Jasur Gaybillaevich, MD, Senior Researcher, Department of vascular surgery, JSC «Republican Specialized Surgery Center named after academician V. Vakhidov» E-mail: [email protected] Bahritdinov Fazlitdin Shamsitdinovich, MD, PhD, Head of the Vascular Surgery Department E-mail: [email protected]
Types of aortic arch branches lesions in the patients with concomitant atheroscleroses
Abstract:
Objectives: to study types of lesions of the aortic arch branches of the patients with concomitant lesions of the aortic arch
branches, terminal part of the abdominal aorta and lower limb arteries.
Material and methods. analyzed the results of examination of181 operated patients with concomitant lesions of aortic arch
branches and lower limb arteries. All patients were divided into three groups: Group one — patients who underwent the first
stage of the reconstruction carried out in the aortic arch branches (number of patients — 31 (17.1 %)); Group two — patients
