Browsing by Author "Naidoo, Nadraj G"

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    Open Access
    Metabolic profile and post-operative outcomes in contemporary patients with peripheral arterial disease and critical limb ischaemia
    (2018) Wu, Lily; Naidoo, Nadraj G
    Background: Peripheral arterial disease (PAD) is an established occlusive disease of the peripheral arteries and is not uncommon in the elderly. Atherosclerosis accounts for 90% of the pathology. Only 15% of affected individuals become symptomatic. Most symptomatic individuals present with intermittent claudication (IC). Only a small proportion (1%) of affected individuals present with critical limb ischaemia (CLI). Revascularization aimed at limb salvage, and recovery of ambulation and independent living is the ultimate therapeutic option for the advanced form of PAD (CLI). Traditionally, the success of revascularization for CLI has been defined by graft patency rates and limb salvage rates. Functional outcomes such as ischaemic wound healing and recovery of ambulatory function for independent living have been the focus in more recent publications. However, these assessments do not consider the patients' pre-operative metabolic profile as a predictor of postoperative outcomes. Purpose: The purpose of this study was to determine, in a prospective manner, the influence of preoperative metabolic profile on post-operative outcomes in contemporary patients with peripheral arterial disease presenting with critical limb ischaemia at a tertiary hospital in South Africa. Methods: All consecutive patients, ≥ 18 years, with CLI admitted to the vascular unit at Groote Schuur Hospital over a two-year period (1st January, 2015 to 31st December, 2016) with reconstructable disease were recruited for the study. Written informed consent was obtained from all participants. Revascularization entailed either open surgical revascularization, endovascular interventions or both (hybrid procedures). Data was analyzed according to the clinical level of disease and the type of surgical intervention. Post-operative outcome measures were determined. Primary endpoints (functional and technical outcomes) • Ambulatory recovery at six months and one year • Complete ischaemic wound healing at six months and one year • Limb salvage rate at six months and one year • Primary graft patency rate at six months and one year Secondary endpoint • The influence of pre-operative metabolic profile on the post-operative outcomes The association between pre-operative metabolic profile and post-operative outcomes was determined by Pearson Chi-square statistical test and logistic regression model. Results: A total of 73 consecutive patients were recruited for this study with a mean age of 58 ± 9 years (Range: 30 - 75 years). Seventeen patients (23.3%) had rest pain and 56 (76.7%) had tissue loss [Minor tissue loss was 47 (64.4%) and major tissue loss was 9 (12.3%)]. Current smokers and previous smokers constituted 86% of the sample population with a male to female ratio of approximately 1:1. Our study population was generally overweight based on the BMI. There was high prevalence of abdominal obesity and high body fat for both males and females. Recovery of ambulatory status was 69% and 67% at six months and one year follow-up respectively. The rate of ischaemic wound healing at six months and one year was 48.2% and 75.0% respectively. Surgical site sepsis was the most common local wound complication. Limb salvage rate was 78% and 79% at six months and one year respectively. Overall primary graft patency at six months was 69.0% but reduced to 60.0% at one year. Major amputation rate at one year was 21%. Most of the postoperative wound-related complications occurred among patients with diabetes. More diabetic patients had major amputations compared to non-diabetic patients (57.9% vs 42.1%). One year amputation-free survival (AFS) was 69.9%. There were no statistically significant associations between metabolic profile of patients and post-operative clinical outcomes. Conclusion: Demographics, co-morbidities, and procedural details of our study population, reflected a relatively younger population with CLI. The profile of this contemporary vascular surgery patients is that of overweight, high abdominal obesity, and high prevalence of smoking among both gender. The technical and functional outcomes observed in this study are consistent with available western literature. Diabetes was associated with prolonged ischaemic wound healing, higher risk of major amputation and local wound complications. A statistically significant association was not found between patients' metabolic profile and post-operative outcome but this could be due to the small sample size and short follow up period.
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    Outcomes after thoracic endovascular aortic repair (TEVAR) in patients with traumatic thoracic aortic injuries (TTAI) - a single center retrospective review
    (2018) Chinyepi, Nkhabe; Naidoo, Nadraj G
    Background: Blunt and penetrating traumatic thoracic aortic injuries constitute surgical emergencies that are attended with high mortality rates. Most patients do not survive long enough, post injury, to reach a hospital. On-site mortality rates may approach approximately 85%. Two main treatment options for blunt thoracic aortic injuries (BTAI) are open surgery and thoracic endovascular repair (TEVAR). Penetrating thoracic aortic injuries (PTAI) have a higher mortality than blunt trauma, with patients often only reaching the hospital in extremis. Most will require early intervention. Currently TEVAR is rapidly evolving as the standard of care for thoracic aortic injuries (TAI) at many centres, primarily due to the emerging evidence of lower mortality and morbidity trends in comparison to open surgery (1–4). Methods: From December 2006 to December 2016, 34 patients (30 blunt trauma, 4 penetrating trauma) with traumatic aortic injuries (grades I-IV) were treated with thoracic aortic stent-grafts in the Groote Schuur Hospital Vascular Unit, Cape Town. We assessed the technical and clinical outcomes following TEVAR in these patients. Results: The 30- day mortality rate was 5.8%, corresponding to 2 deaths both associated with the index trauma-related fatal strokes. The overall mortality rate was 11.8% (4/34): three deaths were due to major strokes and one death was related to pulmonary complications. Conclusion: TEVAR after TAI is associated with significantly lower procedural and postoperative mortality. The 30 day and overall mortality after TEVAR in our unit is comparable to international standards. Even though there is a paucity of literature on PTAI, TEVAR has low peri-procedural adverse events and is safe in selected patients.
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    A retrospective audit into the morbidity and mortality of open abdominal aortic aneurysm repair at Groote Schuur Hospital, Cape Town
    (2017) Mhlanga, Gugulethu Tsakani Jenny; Piercy, Jenna L; Naidoo, Nadraj G
    Background: Open AAA repair is a major, high risk surgery and is associated with significant morbidity and mortality. Current literature quotes an overall mortality of ruptured AAA at 85-90%, including those who do not reach the operating theatre. Mortality of elective AAA repairs is 4-8%. Many patients presenting with abdominal aortic aneurysms are elderly and have pre-existing medical conditions, therefore putting them at high risk for numerous post-operative complications, such as acute kidney injury, pulmonary and cardiac complications. These complications lead to potentially increased ICU and hospital stays. Objectives: To the author's knowledge, an audit into the morbidity and mortality at Groote Schuur Hospital has not yet been formally performed. Such a retrospective audit will be useful in establishing where this hospital stands in terms of mortality, as compared with published data from international centres. In terms of morbidity, this research focused on the development of acute kidney injury following AAA repair. Methods: The study design was an observational retrospective file audit, of both emergency and elective open abdominal aortic aneurysm repairs. 90 case reports of operations performed between October 2006 and December 2014 were analysed. The primary outcome measure was the incidence and causes of perioperative (30-day) mortality. The secondary outcome measure was the incidence of acute kidney injury and renal replacement therapy (RRT). We further analysed whether cross-clamp time and anatomical classification of the aneurysm had any effect on the subsequent need for RRT, utilising the Mann-Whitney test. Results: Of the 90 patients, 76.7% were male (n=69). The study population had a mean age of 64.9 years. Overall perioperative (30-day) mortality of both emergency and elective cases was 15 out of 90 cases (16.6%); the mortality for emergency cases was 12 out 31 (38.7%), as compared to 3/59 (5.1%). Seventeen patients (18.9%) developed KDIGO stage 3 AKI, and RRT was instituted in 12 cases (13.3% of all patients); seven patients survived, and no patients were dialysis-dependent on hospital discharge. AKI was not significantly associated with abdominal aortic cross-clamp time (46 minutes vs. 38 minutes, p=0.9021), but was significantly associated with anatomical classification of the aneurysm (supra-/juxtarenal vs. infrarenal, p=0.037). Conclusions: In comparison with research from international centres, this study population was predominantly male, with a similar age profile to that quoted. The bulk of the perioperative mortality was from emergency AAA repairs, with the mortality associated with elective open AAA surgical repair being within the ranges quoted in international literature. Of the patients who received RRT, there was a mortality of 41.6%. There were many limitations in this study, as the population analysed was extremely heterogeneous, owing to the small sample size. There is great potential for further research, especially into the outcomes of open versus endovascular repairs of AAAs.