Purpose The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (> 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72 h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1–3) days vs. 3 (Q1-Q3, 1–6) days) and hospital length of stay (median 14 (Q1-Q3, 9–24) days vs. 10 (Q1-Q3, 7–17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-023-07169-7.

"Surgical stress response" is tissue damage postsurgery, leading to a systemic response (inflammation, sympathetic upregulation, and release of vasoactive chemicals), which is typically measured by C-reactive protein (CRP). We assessed arterial stiffness and heart rate variability (HRV)-additional parameters reflecting autonomic and vascular functions-in this response and their potential associations with postoperative complications. In 47 participants undergoing abdominal surgery, CRP, arterial stiffness, and HRV were measured pre- and postoperatively (days 1 and 2). C-reactive protein was significantly higher postoperatively in participants experiencing complications but not preoperatively. Compared to participants without complications, those with complications had increased HRV and pnn50 (time domain) and tendency toward increasing low-frequency/high-frequency ratio (frequency domain) on postoperative day 2. Therefore, time and frequency domain HRV parameters show perioperative changes in relation to complication development. These findings suggest the applicability of this noninvasive technology to a variety of abdominal operations. Larger studies need to confirm these findings.

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The TAVI-procedure was performed under loco-regional anesthesia by cervical block. The left common carotid artery (CCA) was surgically exposed by low small cervicotomy and a 3 minutes carotid clamping test was realized in order to evaluate patient's neurological status. A 6-Fr sheath was inserted through the left CCA. The aortic stenosis was crossed using a JR4 catheter with a Terumo straight stiff guidewire. The catheter was pushed into the left ventricle and the guidewire exchanged with an Amplatz Super Stiff. The Edwards sheath was inserted through the left CCA and aortic balloon valvuloplasty was performed. The Edwards Sapien3 transcatheter aortic valve was then advanced using Edwards Certitude delivery system across the calcified aortic valve. The prosthesis was deployed under rapid ventricular pacing at 180/min with excellent seating and no paravalvular leak. The delivery catheter and the sheath were removed, the left CCA was closed and the clamp removed after de-airing.

Background and Aim: Transcarotid TAVR under loco-regional anesthesia represents a new alternative peripheral route for patients without femoral or subclavian access options and poor candidates for thoracotomy. We report a case of a successful TAVR via left occluded carotid axis. Methods: A very frail class NYHA IV 83-year-old man with several comorbidities was referred for treatment of severe aortic stenosis. Transfemoral TAVR was excluded because of severe peripheral vascular disease. At Angio-CT scan both subclavians arteries and the ascending aorta were widely calcified. The right internal carotid artery (ICA) had 50% of stenosis. The left ICA was chronically occluded with permeability of ipsilateral common carotid artery (CCA). The Heart Team concluded that left CCA was the preferred conduit for TAVR. The procedure was performed under loco-regional anesthesia by cervical block and bilateral cerebral oximetry was continuously monitored. Left CCA was surgically exposed by low cervicotomy and a 3-minutes carotid clamping test was realized to evaluate patient's neurological status and oximetry. Aortic balloon valvuloplasty was performed and a 29-mm Edwards Sapien3 transcatheter aortic valve was deployed under 5-seconds rapid pacing at 180/min with excellent seating and no paravalvular leak. Results: The patient was monitored 12-hours in intensive care unit and transferred to rehabilitation clinic in second post-operative day. Any cerebrovascular or access-related complications occurred. Conclusions: In frail patients with femoral contraindication and associated occluded internal carotid axis, the ipsilateral common transcarotid access represents a safe approach for TAVR, even in presence of a non-significant contralateral carotid stenosis.