Postoperative glucocorticoid enhances recovery after endovascular aortic repair for chronic type B aortic dissection: a single-center experience

Mengtao Wu, Lei Zhang, Junmin Bao, Zhiqing Zhao, Qingsheng Lu, Rui Feng, Chao Song, Jian Zhou, Zaiping Jing, Mengtao Wu, Lei Zhang, Junmin Bao, Zhiqing Zhao, Qingsheng Lu, Rui Feng, Chao Song, Jian Zhou, Zaiping Jing

Abstract

Background: Thoracic endovascular aortic repair (TEVAR) has been chosen as a less invasive alternative for type B aortic dissections (TBADs). However, the therapeutic effect of TEVAR has been challenged by postoperative adverse events, which were induced by inflammatory response. Glucocorticoids have been widely used because of the powerful and effective anti-inflammatory properties. Nevertheless, the prognostic effect of glucocorticoids after TBAD patients underwent TEVAR remains unclear. The objective of this study was to assess the potential effect of postoperative glucocorticoids on the prognosis of TEVAR for TBADs.

Methods: A total of 92 chronic TBADs patients underwent TEVAR with epidural anesthesia between June 2012 and June 2014 was retrospectively reviewed. The patients were stratified into dexamethasone (DXM) and non-dexamethasone group (N-DXM). The indications for TEVAR were as following: malperfusion (n = 28); contained or impending rupture (n = 17); persistent intractable chest/back pain (n = 32); refractory hypertension (n = 15).

Results: No 30-day mortality and incision infection occurred in each group. The postoperative pain score on the second day was significantly higher in N-DXM group (3.60 ± 0.21 versus 4.83 ± 0.32, P = 0.001). The differences of white blood cell, body temperature and heart rate were pronounced in both groups judged by the peak values (13.01 ± 0.58 × 10(9)/L versus 10.04 ± 0.61 × 10(9)/L, 37.67 ± 0.08 °C versus 37.92 ± 0.09 °C and 89.06 ± 1.21 bpm versus 95.95 ± 1.70 bpm, P = 0.002, 0.04 and 0.001, respectively). The white blood cells in DXM group significantly increased on the second and third postoperative day (P = 0.009 and 0.023), while the body temperature and heart rate showed an apparent decline on the second (P = 0.001 and 0.028), third (P = 0.007 and 0.005) and fourth postoperative days (P = 0.024 and 0.018). However, the changes of false lumen volumes and the endoleak incidence at 3-month follow-up were comparable in the two groups. No significant difference of post-implantation syndrome was observed either.

Conclusions: Although postoperative prophylactic glucocorticoids administration was unable to influence mortality, incision infection or the change of false lumen volumes, it enabled to enhance the recovery of vital signs and alleviate the postoperative pain. A prospective, randomized controlled trial has been registered (NCT02523300), which will be warranted before prophylactic administration of glucocorticoids after TEVAR procedure could be recommended in the clinical work.

Keywords: Aortic dissection; Endovascular repair; Glucocorticoid; Prognosis.

Figures

Fig. 1
Fig. 1
Flow diagram of included patients. DXM dexamethasone group, N-DXM non-dexamethasone group, TBAD stanford type B aortic dissection, TEVAR thoracic endovascular aortic repair
Fig. 2
Fig. 2
Curve charts of white blood cell, body temperature and heart rate on the preoperative day and the initial five postoperative days. BPM beat per minute, DXM dexamethasone group, N-DXM non-dexamethasone group, Postop postoperative, Preop preoperative
Fig. 3
Fig. 3
Luminal volume calculations by the dedicated three-dimensional Aquarius Workstation CT-image processing software. a the process of three-dimensional image reconstruction; b changes in false lumen volumes in N-DXM and DXM groups; c and d, preoperative aortic morphology in DXM and N-DXM groups, respectively; e and f postoperative aortic morphology in DXM and N-DXM groups, respectively. DXM dexamethasone group, N-DXM non-dexamethasone group

References

    1. Sachs T, Pomposelli F, Hagberg R, Hamdan A, Wyers M, Giles K, et al. Open and endovascular repair of type b aortic dissection in the nationwide inpatient sample. J Vasc Surg. 2010;52:860–6. doi: 10.1016/j.jvs.2010.05.008.
    1. Luebke T, Brunkwall J. Outcome of patients with open and endovascular repair in acute complicated type b aortic dissection: a systematic review and meta-analysis of case series and comparative studies. J Cardiovasc Surg (Torino) 2010;51:613–32.
    1. Hanna JM, Andersen ND, Ganapathi AM, McCann RL, Hughes GC. Five-year results for endovascular repair of acute complicated type b aortic dissection. J Vasc Surg. 2014;59:96–106. doi: 10.1016/j.jvs.2013.07.001.
    1. Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, Rehders TC, et al. Randomized comparison of strategies for type b aortic dissection: the investigation of stent grafts in aortic dissection (instead) trial. Circulation. 2009;120:2519–28. doi: 10.1161/CIRCULATIONAHA.109.886408.
    1. Voûte MT1, Bastos Gonçalves FM, van de Luijtgaarden KM, Klein Nulent CG, Hoeks SE, Stolker RJ, et al. Stent graft composition plays a material role in the postimplantation syndrome. J Vasc Surg. 2012;56:1503–9. doi: 10.1016/j.jvs.2012.06.072.
    1. Videm V, Ødegård A, Myhre HO. Iohexol-induced neutrophil myeloperoxidase release and activation upon contact with vascular stent-graft material: a mechanism contributing to the postimplantation syndrome? J Endovasc Ther. 2003;10:958–67. doi: 10.1177/152660280301000520.
    1. Arnaoutoglou E, Papas N, Milionis H, Kouvelos G, Koulouras V, Matsagkas MI. Post-implantation syndrome after endovascular repair of aortic aneurysms: need for postdischarge surveillance. Interac Cardiovasc Thorac Surg. 2010;11:449–54. doi: 10.1510/icvts.2010.242628.
    1. Rhen T, Cidlowski JA. Antiinflammatory action of glucocorticoids — new mechanisms for old drugs. N Engl J Med. 2005;353:1711–23. doi: 10.1056/NEJMra050541.
    1. Owens CD, Gasper WJ, Walker JP, Alley HF, Conte MS, Grenon SM. Safety and feasibility of adjunctive dexamethasone infusion into the adventitia of the femoropopliteal artery following endovascular revascularization. J Vasc Surg. 2014;59:1016–24. doi: 10.1016/j.jvs.2013.10.051.
    1. Orci LA, Toso C, Mentha G, Morel P, Majno PE. Systematic review and meta-analysis of the effect of perioperative steroids on ischaemia-reperfusion injury and surgical stress response in patients undergoing liver resection. Br J Surg. 2013;100:600–9. doi: 10.1002/bjs.9035.
    1. Srinivasa S, Kahokehr AA, Yu TC, Hill AG. Preoperative glucocorticoid use in major abdominal surgery: systematic review and meta-analysis of randomized trials. Ann Surg. 2011;254:183–91. doi: 10.1097/SLA.0b013e3182261118.
    1. Lunn TH, Kehlet H. Perioperative glucocorticoids in hip and knee surgery - benefit vs. Harm? A review of randomized clinical trials. Acta Anaesthesiol Scand. 2013;57:823–34. doi: 10.1111/aas.12115.
    1. Schäcke H, Döcke W-D, Asadullah K. Mechanisms involved in the side effects of glucocorticoids. Pharmacol Ther. 2002;96:23–43. doi: 10.1016/S0163-7258(02)00297-8.
    1. Morikage N, Esato K, Zenpo N, Fujioka K, Takenaka H. Is endovascular treatment of abdominal aortic aneurysms less invasive regarding the biological responses? Surg Today. 2000;30:142–6. doi: 10.1007/PL00010062.
    1. Eggebrecht H, Mehta RH, Metozounve H, Huptas S, Herold U, Jakob HG, et al. Clinical implications of systemic inflammatory response syndrome following thoracic aortic stent-graft placement. J Endovasc Ther. 2008;15:135–43. doi: 10.1583/07-2284.1.
    1. Ker CR, Ho MC, Huang JW, Hsieh CC, Chen HM. Pyrexia of postimplantation syndrome for patients undergoing (thoracic) endovascular aortic repair. Thorac Cardiovasc Surg. 2015;63:126–33. doi: 10.1055/s-0034-1373900.
    1. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) Eur Heart J. 2014;35:2873–926. doi: 10.1093/eurheartj/ehu281.
    1. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med. 2001;8:1153–7. doi: 10.1111/j.1553-2712.2001.tb01132.x.
    1. Chen J, Hillman K, Bellomo R, Flabouris A, Finfer S, Cretikos M. The impact of introducing medical emergency team system on the documentations of vital signs. Resuscitation. 2009;80:35–43. doi: 10.1016/j.resuscitation.2008.10.009.
    1. Harrison GA, Jacques T, McLaws M-L, Kilborn G. Combinations of early signs of critical illness predict in-hospital death—the soccer study (signs of critical conditions and emergency responses) Resuscitation. 2006;71:327–34. doi: 10.1016/j.resuscitation.2006.05.008.
    1. Rousseau P. Pain as the fifth vital sign. Arch Surg. 2008;143:98.
    1. Morone NE, Weiner DK. Pain as the fifth vital sign: exposing the vital need for pain education. Clin Ther. 2013;35:1728–32. doi: 10.1016/j.clinthera.2013.10.001.
    1. Oderda G. Challenges in the management of acute postsurgical pain. Pharmacotherapy. 2012;32:6S–11S. doi: 10.1002/j.1875-9114.2012.01177.x.
    1. Hengge UR, Ruzicka T, Schwartz RA, Cork MJ. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006;54:1–15. doi: 10.1016/j.jaad.2005.01.010.
    1. Dieleman JM, Nierich AP, Rosseel PM, van der Maaten JM, Hofland J, Diephuis JC, et al. Intraoperative high-dose dexamethasone for cardiac surgery: a randomized controlled trial. JAMA. 2012;308:1761–7. doi: 10.1001/jama.2012.14144.
    1. Wang AS, Armstrong EJ, Armstrong AW. Corticosteroids and wound healing: clinical considerations in the perioperative period. Am J Surg. 2013;206:410–7. doi: 10.1016/j.amjsurg.2012.11.018.
    1. Abdelmalak BB, Bonilla AM, Yang D, Chowdary HT, Gottlieb A, Lyden SP, et al. The hyperglycemic response to major noncardiac surgery and the added effect of steroid administration in patients with and without diabetes. Anesth Analg. 2013;116:1116–22. doi: 10.1213/ANE.0b013e318288416d.
    1. de la Motte L, Kehlet H, Vogt K, Nielsen CH, Groenvall JB, Nielsen HB, et al. Preoperative methylprednisolone enhances recovery after endovascular aortic repair: a randomized, double-blind, placebo-controlled clinical trial. Ann Surg. 2014;260:540–8. doi: 10.1097/SLA.0000000000000895.
    1. Gerasimidis T, Sfyroeras G, Trellopoulos G, Skoura L, Papazoglou K, Konstantinidis K, et al. Impact of endograft material on the inflammatory response after elective endovascular abdominal aortic aneurysm repair. Angiology. 2005;56:743–53. doi: 10.1177/000331970505600612.
    1. Gabriel EA, Locali RF, Romano CC, Duarte AJ, Palma JH, Buffolo E. Analysis of the inflammatory response in endovascular treatment of aortic aneurysms. Eur J Cardiothorac Surg. 2007;31:406–12. doi: 10.1016/j.ejcts.2006.11.053.
    1. De La Motte L, Vogt K, Panduro Jensen L, Groenvall J, Kehlet H, Veith Schroeder T, et al. Incidence of systemic inflammatory response syndrome after endovascular aortic repair. J Cardiovasc Surg (Torino) 2011;52:73–9.
    1. Norwood MG, Bown MJ, Lloyd G, Bell PR, Sayers RD. The clinical value of the systemic inflammatory response syndrome (SIRS) in abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2004;27:292–8. doi: 10.1016/j.ejvs.2003.12.007.
    1. Weng M, Sun Z, Miao C. Corticosteroid induce leukocytosis during the pain management. Pain Med. 2014;15:1645–6. doi: 10.1111/pme.12510.
    1. Brotman DJ, Girod JP, Posch A, Jani JT, Patel JV, Gupta M, et al. Effects of short-term glucocorticoids on hemostatic factors in healthy volunteers. Thromb Res. 2006;118:247–52. doi: 10.1016/j.thromres.2005.06.006.
    1. Johannesdottir SA, Horváth-Puhó E, Dekkers OM, Cannegieter SC, Jørgensen JO, Ehrenstein V, et al. Use of glucocorticoids and risk of venous thromboembolism: a nationwide population-based case–control study. JAMA Intern Med. 2013;173:743–52. doi: 10.1001/jamainternmed.2013.122.
    1. Squizzato A, Gerdes VE, Ageno W, Buller HR. The coagulation system in endocrine disorders: a narrative review. Intern Emerg Med. 2007;2:76–83. doi: 10.1007/s11739-007-0026-X.
    1. van Zaane B, Nur E, Squizzato A, Gerdes VE, Büller HR, Dekkers OM, et al. Systematic review on the effect of glucocorticoid use on procoagulant, anti-coagulant and fibrinolytic factors. J Thromb Haemost. 2010;8:2483–93. doi: 10.1111/j.1538-7836.2010.04034.x.
    1. Conrad MF, Crawford RS, Kwolek CJ, Brewster DC, Brady TJ, Cambria RP. Aortic remodeling after endovascular repair of acute complicated type b aortic dissection. J Vasc Surg. 2009;50:510–7. doi: 10.1016/j.jvs.2009.04.038.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera