Obesity and the risk of heart failure

https://www.lfb.lv/files/ESVS-AAA-guidelines.pdf

Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery.

Abdominal aortic aneurysms (AAAs) are found in up to 8% of men aged >65 years, yet usually remain asymptomatic until they rupture. Rupture of an AAA and its associated catastrophic physiological insult carries overall mortality in excess of 80%, and 2% of all deaths are AAA-related. Pathologically, AAAs are associated with inflammation, smooth muscle cell apoptosis, and matrix degradation. Once thought to be a consequence of advanced atherosclerosis, accruing evidence indicates that AAAs are a focal representation of a systemic disease of the vasculature. Risk factors for AAAs include increasing age, male sex, smoking, and low HDL-cholesterol levels. Familial associations exist and although susceptibility genes have been described on the basis of candidate-gene studies, robust genetic studies have failed to discover causative gene mutations. The surgical management of AAAs has been revolutionized by minimally invasive endovascular repair. Ongoing randomized trials will establish whether endovascular repair confers a survival advantage over open surgery for patients with a ruptured AAA. In many countries, centralization of vascular surgical services has largely been driven by the improved outcomes of elective aneurysm surgery in specialized centers, the widespread adoption of endovascular techniques, and the introduction of screening programs.

Pathophysiology and epidemiology of abdominal aortic aneurysms

The effect of body mass index on major outcomes after vascular surgery.

• Factors related to risk of perioperative pulmonary complications include site of incision, obstructive lung disease, prolonged anesthesia time, smoking history with productive cough, and obesity. Hypercapnia is a consistent indicator of high risk. There is no difference between spinal and general anesthesia with regard to risk of pulmonary complications. In patients being evaluated for lung resection, high-risk indicators include predicted postoperative forced expiratory volume in one second of less than 1000 mL, hypercapnia, severe dyspnea on exertion, or advanced age when it is associated with advanced cardiopulmonary disease. Newer methods of assessing cardiopulmonary reserve may prove useful in identifying which patients with one or more of these risk factors are suitable operative candidates. Prevention of postoperative complications in chronic obstructive pulmonary disease patients should begin in the preoperative period with discontinuation of smoking at least eight weeks before surgery and vigorous pulmonary toilet in the 48 to 72 hours before surgery. Prophylactic lung expansion maneuvers can be effective in decreasing the incidence of postoperative atelectasis in high-risk patients undergoing high-risk operations. ( Arch Intern Med 1988;148:2120-2127)

Preoperative Pulmonary Evaluation

Purpose: To investigate outcomes in obese patients with abdominal aortic aneurysm (AAA) treated with elective open or endovascular repair (EVAR).Study Design: We compared the outcomes of obese patients with AAA treated with elective open repair and EVAR. Obesity was defined as a body mass index (BMI) ≥30 kg/m 2.Results: A total of 56 patients with a BMI ≥30 kg/m2 were identified for analysis (mean age 70 ± 8 years; mean BMI 34 ± 4 kg/m2, and 95% [n = 53] were male). Open surgery was performed in 55% (n = 31). The in-hospital complication rate (including nonsurvivors) was significantly increased after open repair compared with EVAR (26% vs 4%, P = .033). Mortality did not differ significantly during 3 years of follow-up (P = .816). Length of stay, intensive care unit (ICU) stay, and need for ventilation were significantly increased after open surgery compared with EVAR.Conclusions: We observed improved short-term outcomes among obese AAA patients after EVAR compared to open repair. Endovascular repair may ...

Abdominal aortic aneurysm repair in obese patients: improved outcome after endovascular treatment compared with open surgery.

Purpose:To evaluate the influence of obesity on outcomes after endovascular aneurysm repair (EVAR).Methods:A retrospective analysis was conducted of 80 patients (77 men; mean age 75.0±7.6 years) un...

Influence of obesity on in-hospital and midterm outcomes after endovascular repair of abdominal aortic aneurysm.

The purpose of our study was to evaluate outcomes in abdominal aortic aneurysm (AAA) patients with chronic obstructive pulmonary disease (COPD) undergoing open or endovascular abdominal aortic aneurysm repair (EVAR). We retrospectively examined the records of consecutive patients with AAA and COPD who underwent either open repair or EVAR between 2001 and 2008. In-hospital and follow-up outcomes were compared between open repair and EVAR using SPSS (SPSS Inc, Chicago, IL). Sixty-nine patients were included for analysis (mean age 71 +/- 1.0 years; 93% [n = 64] male). Open surgery was performed in 63% (n = 43). In-hospital mortality was 4%. All-cause mortality did not differ significantly between the open repair and EVAR groups during 3 years of follow-up (p = .491). In-hospital death and major complications occurred in 30% (n = 13) after open repair compared with 12% (n = 3) after EVAR (p = .075). Pneumonia occurred in 19% (n = 8) after open repair and in 0% after EVAR (p = .019); pneumonia was associated with increased mortality during the first year after AAA repair (log-rank test p = .003). Hospital length of stay was increased in the open repair group compared with the EVAR group (16 vs 5 days, p < .001), as was intensive care unit length of stay (11 vs 2 days, p < .001) and need for ventilation (61% vs 12%, p < .001). Patients with COPD and anatomically suitable AAAs should be preferentially offered EVAR.

Patients with abdominal aortic aneurysm and chronic obstructive pulmonary disease have improved outcomes with endovascular aneurysm repair compared with open repair.

A 77-year-old man with end-stage renal disease (ESRD) from lithium induced chronic interstitial nephritis, schizophrenia, and atrial fibrillation (on coumadin) had a left upper extremity basilic vein transposition fistula in place for dialysis access. Over 4 months of use, he had several sizable infiltrations during needling of the access. Several large aneurysms formed and there was limited space for needle placement, so he was admitted to the hospital for intervention. Physical examination revealed an enlarged, ecchymotic, and mildly tender left upper extremity with a preserved bruit and thrill along the length of the arteriovenous fistula. There were two long aneurysms measuring 2.5 and 3.5 cm in length. The decision was made to rest the arm and a tunneled double lumen dialysis catheter was placed. Two days later, he returned to interventional radiology for formal assessment of the fistula.

Nonoperative salvage of an aneurysmal arteriovenous fistula.

Pulmonary hypertension after surgical laminectomy: an easily missed cause of a high-output state.

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