OBJECTIVE

This study aims to determine the clinical profile and incidence of in-hospital outcomes of patients who underwent coronary artery bypass graft surgery (CABG) under the Philippine Health Insurance Corporation (Philhealth) Z Benefit Package (PZBP).

A retrospective descriptive cohort study. A review of medical records was done from July 2017 to October 2023 to collect data and in-hospital outcomes of patients who underwent CABG surgery under Z benefit package.

One hundred twenty-six patients were included in the study. The mean age of patients was 60 years and majority of them were male and came from NCR. Hypertension was the leading cause of comorbidity. The top two most common in-hospital outcomes were hospital-acquired pneumonia and postoperative atrial fibrillation. Most commonly observed caused of increased length in hospitalization was pneumonia. The mean Society of Thoracic Surgeons (STS) (operative mortality) and Euro scores were 1.04 ± 0.82 and 0.88 ± 0.56, respectively. All patients had successful surgical outcome with no mortality and an average length of stay in the hospital of six days.

This study will serve as a future reference to enhance screening criteria and improved in-hospital outcomes for those who will undergo CABG under Z benefit package. The study also showed insights on clinical profile and in-hospital outcomes of patients who underwent CABG in our own institution and this may give way to a larger scale of study involving multiple centers who also offer the said program.

BACKGROUND

Endovascular thrombectomy (EVT) is the gold standard of care for large vessel occlusion strokes, but is underutilized in developing countries.

This single-center retrospective study included patients who underwent EVT during the period of September 2018 to April 2023. Data collected were demographics, underlying co-morbidities, use of anti-thrombotics/coagulants, CT or MR ASPECTS, thrombolysis prior to EVT, technique, timing, TICI score, occlusion site, discharge and 90-day MRS.

Of the 1,595 stroke patients, 57 (3%) cases underwent EVT. The mean age was 65 with a male to female ratio of 6:5. Hypertension, atrial fibrillation, and diabetes were the common comorbidities. Majority of patients (90%, n=54) presented with moderate to severe disability (MRS 3-5). Majority were in the anterior circulation (89%, n=51). Stentriever technique was mostly used (59% n=34) with a 77% (n=44) recanalization rate. Early neurologic improvement (ENI) was seen in 7% (n=4), 2 of which translated to a favorable outcome after 90-days. Mortality occurred in 24% (n=14) of cases, mostly from neurological complications. 24% (n=14) had favorable outcome of MRS 0-2 after 90 days. Among those grouped in the unfavorable outcome, 53% (n=23) were MRS 3, still showing marked improvement of quality of life.

EVT outcomes in this study is aligned with the landmark trials which exhibited a number needed to treat of 2.8-7.4. This local data highlights that EVT is a possible and effective treatment for large vessel strokes despite wide gap in accessibility and use in the country.

Repair of complex aortic aneurysms such as those involving the thoracoabdominal and pararenal aorta presents a formidable challenge for surgeons with significant perioperative morbidity and mortality. A hybrid procedure combining renovisceral debranching with endovascular aneurysm exclusion has been developed as an alternative approach for high-risk patients. This paper reports our initial experience with hybrid repair for these complex aortic diseases in three high-risk patients.

Endovascular thrombectomy (EVT) has revolutionized the management of acute ischemic stroke (AIS) caused by large-vessel occlusion, significantly improving outcomes worldwide. This single-center case series evaluated the early outcomes of EVT in AIS patients treated at this institution, focusing on its implications within a low- or middleincome country setting. The study aimed to assess the feasibility, safety, and efficacy of EVT, analyzing premorbid comorbidities, time to treatment, revascularization rates, procedural complications, and clinical outcomes. Five consecutive cases of AIS due to large-vessel occlusion treated with EVT were analyzed. The patients in this series were aged 21 to 75 years, all with a baseline modified Rankin Scale (mRS) score of 0. The average NIH Stroke Scale (NIHSS) score on admission was 17. Four patients received Alteplase before EVT within four hours of symptom onset. Successful recanalization (TICI 2b-3) was achieved in all cases. Post-thrombectomy, two patients developed re-occlusion, with one resulting in mortality. Among the patients, 40% achieved a favorable outcome, defined as a modified Rankin Scale (mRS) score of 2 at three months. This initial experience demonstrates promising results in achieving successful recanalization and improving clinical outcomes in AIS patients with large-vessel occlusion. However, the study also highlights challenges such as procedural complications and post-thrombectomy re-occlusion, underscoring the need for ongoing evaluation and optimization of patient selection and procedural protocols in lowresource settings. Future studies with larger sample sizes are warranted to further validate these findings and refine EVT protocols tailored to local healthcare contexts.

Objective: To describe the treatment outcomes of patients who underwent coronary artery bypass grafting (CABG) with vein patch angioplasty with internal mammary artery (IMA) grafting of the diffusely diseased left anterior descending (LAD) coronary artery. Methods: This is a retrospective observational study of 26 patients who have undergone vein patch angioplasty of the LAD coronary artery with IMA grafting in three centers by a single surgeon from January 2012 to August 2017. The demographic profile, intraoperative data, and postoperative outcome (including in-hospital mortality and morbidity, perioperative myocardial infarction, and NYHA functional classification) were recorded. Continuous variables were expressed as means with standard deviation and categorical variables summarized as frequencies and percentages. Student’s t-test was used to compare the preoperative versus postoperative mean NYHA functional class. Results: There were 22 (85%) males and 4 (15%) females with a mean age of 62 years (range: 34 to 82). Twentyfive patients (96%) had a three-vessel disease, and one (4%) had a two-vessel disease. Nine patients (35%) had a preoperative myocardial infarction. The mean cardiopulmonary bypass and aortic-cross clamp times were 156 and 118 minutes, respectively. The mean number of vessels grafted was 4.12. Multiple arterial grafting was used in seven patients (27%). There were two in-hospital mortalities (7.7%) and three morbidities (11.5%), including reoperation for bleeding, acute kidney injury, and leg wound infection. Six patients (23%) developed postoperative atrial fibrillation. No patient developed perioperative myocardial infarction. The mean ICU stay was three days, and the mean hospital stay was 10.27 days. The mean NYHA functional class improved from 2.85 preoperatively to 1.5 postoperatively (p<0.00001). Among patients with improvement, postoperative NYHA improved by two functional classes in 38% and by one functional class in 62%. Conclusion Vein patch angioplasty is a valuable technique for diffuse coronary stenosis of the LAD artery with acceptable early results.
Coronary Artery Bypass

OBJECTIVE

To describe the treatment outcomes of patients who underwent Percutaneous Transluminal Angioplasty (PTA) for Central Vein Occlusive Disease (CVOD) in end-stage kidney disease and determine the association between patient profile and treatment outcomes.

A single-institution, retrospective review of patients aged 18 and above with end-stage kidney disease who underwent PTA for CVOD in the University of the Philippines - Philippine General Hospital (UP-PGH) from January 1, 2013, to December 31, 2022, was performed. These patients’ demographic and clinical profiles were evaluated using means, frequencies, and percentages. The relationship between patient profile and success of PTA was assessed using Chi-square and Mann-Whitney U tests.

One hundred one patients were included in the study. Eighty-two had a first intervention, and 19 had a recurrent first intervention. The mean age was 49.8 years, with forty-six (45.5%) males and fifty-five (54.5%) females. The most common comorbidity was hypertension (59.4%). This was followed by diabetes (35.6%), chronic glomerulonephritis (18.8%), and NSAID nephropathy (4.9%). Other comorbidities include lupus nephritis, urate nephropathy, and polycystic kidney disease. The interval between symptoms and intervention ranged from two weeks to ninety-six weeks. Eleven patients (10.9%) had an arterio-venous fistula (AVF) before initiating dialysis and did not have a history of dialysis catheter use. Temporary catheters comprise most of the central vein catheters (CVC) (84.2%), while tunneled catheters were a minority (8.9%). The overall central line insertions of one hundred one patients were one hundred fifty-five, most via the right internal jugular vein (86%). There was a total of one hundred twenty-seven lesions seen during venography. Most of these lesions were in the left Innominate vein (38.6%, 39/101) and the right innominate vein (32.7%, 33/101). The most common type of lesion was stenosis (47.5%), followed by abrupt occlusions (31.7%) and tapered occlusions (20.8%). The overall success rate of PTA was 74.2%. In the second intervention for recurrence (n=19), the success rate was 78.9% (15/19). Third-time intervention in three patients was all successful. The success rate in stenotic, tapered, and abrupt lesions were 100%, 85.7%, and 28.1%, respectively. Symptomfree intervals ranged from twelve to one hundred ninetytwo weeks. After a failed intervention, a new fistula or graft was the most common access option (50%). This was followed by central catheter (38.5%), venous bypass (7.7%), and peritoneal dialysis catheter (3.8%). Morbidity was 0.99%. The in-hospital mortality was zero.

Overall PTA success rate for non-recurrent and first operation of recurrent patients with CVOD was high (74%). Stenotic type of lesions were the best vessels to dilate. Failure of PTA was directly related to previous right subclavian catheter insertion, multiple central vein catheter insertions, lesions in the right innominate vein, and an abrupt type of central vein occlusion. The current strategy of PTA for CVOD is both safe and effective. Early AVF creation can prevent patients from requiring multiple catheter insertions and developing CVOD. The right internal jugular vein is the optimal choice for access, while subclavian vein access should be avoided.

Protein S deficiency causing arterial ischemic stroke during pregnancy is uncommon. Delay or omission of treatment with perfusion therapies may worsen outcomes for both the mother and the fetus. In this paper, we report a case of an early pregnant woman with protein S deficiency and multiple history of chronic cerebrovascular disease who underwent successful thrombolysis and mechanical thrombectomy. The patient is a 35-year-old woman, eight weeks pregnant, with a history of protein S deficiency and chronic cerebrovascular disease, presenting with rightsided weakness and aphasia. Initial National Institutes of Health Stroke Scale was 10 with cranial magnetic resonance imaging findings of acute infarcts on the left caudate, lentiform nucleus, insula, and frontal lobe with a large vessel occlusion on the proximal M1 segment of the left middle cerebral artery. Intravenous thrombolysis and mechanical thrombectomy were performed with complete recanalization. The patient improved and delivered without any complications after 8 months. Protein S deficiency can contribute to arterial thrombosis including ischemic stroke. Arterial ischemic stroke and large vessel occlusion can cause significant disability if not treated appropriately. Reperfusion therapies in pregnant women show favorable outcomes and should be performed if the benefits outweigh the risks.

BACKGROUND

Primary percutaneous coronary intervention (PPCI) may be complicated by heavy intracoronary thrombus burden leading to decrease in myocardial perfusion and increase in infarct size. The current meta-analysis aims to investigate the clinical outcomes of aspiration thrombectomy (AT) with intracoronary tirofiban during PPCI.

A systematic search for randomized controlled trials that evaluate the safety and efficacy of AT with intracoronary tirofiban in ST-elevation myocardial infarction (STEMI) patients who underwent PPCI was done using PubMed, MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov., and Herdin PH. Studies included those published between 2010 and 2023 and involved human subjects. Search terms included “aspiration thrombectomy,” “intracoronary tirofiban,” “primary percutaneous coronary intervention,” and “STEMI patients.”

Four randomized controlled trials (n = 490 participants) were included in this metaanalysis comparing AT with intracoronary tirofiban versus AT alone in STEMI patients undergoing PPCI. The results revealed no statistically significant difference in ST-segment resolution (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.97–1.08; P = 0.41, I2 = 0%), myocardial blush grade 2–3, (RR, 1.04; 95% CI, 0.97–1.12; P = 0.22, I2 = 62%), and Thrombolysis In Myocardial Infarction 3 flow (RR, < 1.0; 95% CI, 0.95–1.04; P = 0.87).

The occurrence of major adverse cardiovascular events did not significantly differ between the two groups (RR, 0.46; 95% CI, 0.19–1.09; P = 0.08, I2 = 0%). There was no statistically significant difference in terms of bleeding when combining intracoronary tirofiban to standard medical therapy (RR, 1.35; 95% CI, 0.64–2.84; P = 0.78, four trials [490 patients]).

In PPCI, major adverse cardiovascular event outcomes of AT with intracoronary tirofiban were similar to those for AT alone in terms of improving myocardial perfusion in STEMI patients without increasing the risk for bleeding. Our meta-analysis suggests that AT alone may be the more acceptable standard during PPCI when encountering heavy thrombus burden. Future validated studies may help further investigate the strategy of adding tirofiban during AT.

Repair of complex aortic aneurysms such as those involving the thoracoabdominal and pararenal aorta presents a formidable challenge for surgeons with significant perioperative morbidity and mortality. A hybrid procedure combining renovisceral debranching with endovascular aneurysm exclusion has been developed as an alternative approach for high-risk patients. This paper reports our initial experience with hybrid repair for these complex aortic diseases in three high-risk patients.
Human ; Male ; Aged: 65-79 yrs old ; Middle Aged: 45-64 yrs old ; aorta ; aortic aneurysm ; endovascular procedures

Humans ; Retrospective Studies ; Cardiopulmonary Bypass/adverse effects* ; Coronary Artery Bypass/adverse effects* ; Coronary Artery Disease/surgery* ; Acute Kidney Injury/etiology* ; Postoperative Complications ; Risk Factors ; Treatment Outcome