Clinical efficacy and safety of remote ischaemic preconditioning in selective vascular surgery: a systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIU Guangzu ¹ , LIU Hongxu ¹ , WEI Zhili ¹ , CHEN Hao ¹ , ZHANG Yalan ² , DONG Shuai ² ,  SONG Bing ^1,2

1. The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, P. R. China;
2. Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, 730000, P. R. China;

Corresponding author：

SONG Bing, Email: songbinldyy@163.com

Keywords：

Remote ischaemic preconditioning; selective vascular surgery; clinical efficacy; systematic review/meta-analysis

DOI：

10.7507/1007-4848.202307004

Video：

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Objective To systematically evaluate the clinical effects of remote ischaemic preconditioning (RIPC) in elective vascular surgery. Methods Electronic searches were conducted in The Cochrane Library, PubMed, EMbase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP Database, and the Chinese Biomedical Literature Database (CBM). Relevant randomized controlled trials (RCTs) were screened according to inclusion and exclusion criteria. Meta-analysis was performed using RevMan 5.3 software. Results A total of 15 studies involving 1,382 patients were included. The meta-analysis results showed no statistically significant difference between RIPC and non-RIPC groups in reducing perioperative mortality in elective vascular surgery. There were also no statistically significant differences between the two groups of vascular surgery patients regarding the incidence of myocardial infarction, renal injury, postoperative stroke, postoperative length of hospital stay, duration of surgery or total anesthesia time, or the incidence of limb injury, arrhythmia, heart failure, and pneumonia. Conclusion For patients undergoing elective vascular surgery, there are no significant differences between RIPC and non-RIPC in terms of perioperative mortality and other clinical endpoint outcomes.

1.	Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J, 2018, 39(9): 763-816.
2.	Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg, 2018, 67(1): 2-77.
3.	Walsh SR, Tang TY, Sadat U, et al. Remote ischemic preconditioning in major vascular surgery. J Vasc Surg, 2009, 49(1): 240-243.
4.	Rokosh RS, Starnes BW, Chaikof EL. Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: repair of an abdominal aortic aneurysm. J Vasc Surg, 2021, 73(5): 1485-1487.
5.	Halliday A, Bulbulia R, Bonati LH, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet, 2021, 398(10305): 1065-1073.
6.	Londero LS, Høgh A, Houlind K, et al. Danish trends in major amputation after vascular reconstruction in patients with peripheral arterial disease 2002-2014. Eur J Vasc Endovasc Surg, 2019, 57(1): 111-120.
7.	Yei K, Mathlouthi A, Naazie I, et al. Long-term outcomes associated with open vs endovascular abdominal aortic aneurysm repair in a medicare-matched database. JAMA Netw Open, 2022, 5(5): e2212081.
8.	Schermerhorn ML, Buck DB, O'Malley AJ, et al. Long-term outcomes of abdominal aortic aneurysm in the medicare population. N Engl J Med, 2015, 373(4): 328-338.
9.	Carden DL, Granger DN. Pathophysiology of ischaemia-reperfusion injury. J Pathol, 2000, 190(3): 255-266.
10.	Seal JB, Gewertz BL. Vascular dysfunction in ischemia-reperfusion injury. Ann Vasc Surg, 2005, 19(4): 572-584.
11.	Yang B, Fung A, Pac-Soo C, et al. Vascular surgery-related organ injury and protective strategies: update and future prospects. Br J Anaesth, 2016, 117 Suppl 2: ii32-ii43.
12.	Przyklenk K, Bauer B, Ovize M, et al. Regional ischemic 'preconditioning' protects remote virgin myocardium from subsequent sustained coronary occlusion. Circulation, 1993, 87(3): 893-899.
13.	Penna C, Comità S, Tullio F, et al. Challenges facing the clinical translation of cardioprotection: 35 years after the discovery of ischemic preconditioning. Vascul Pharmacol, 2022, 144: 106995.
14.	Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation, 1986, 74(5): 1124-1136.
15.	Lang JA, Kim J. Remote ischaemic preconditioning-translating cardiovascular benefits to humans. J Physiol, 2022, 600(13): 3053-3067.
16.	Gutiérrez Castillo D, San Norberto García EM, García Rivera E, et al. Effect of remote ischemic preconditioning on the incidence of contrast-induced nephropathy in patients undergoing endovascular aneurysm repair (remote ischemic preconditioning-endovascular aneurysm repair study). Ann Vasc Surg, 2022, 86: 338-348.
17.	Garcia S, Rector TS, Zakharova M, et al. Cardiac remote ischemic preconditioning prior to elective vascular surgery (CRIPES): a prospective, randomized, sham-controlled phase Ⅱ clinical trial. J Am Heart Assoc, 2016, 5(10): e003916.
18.	Healy DA, Boyle E, McCartan D, et al. A multicenter pilot randomized controlled trial of remote ischemic preconditioning in major vascular surgery. Vasc Endovascular Surg, 2015, 49(8): 220-227.
19.	Kepler T, Kuusik K, Lepner U, et al. Remote ischaemic preconditioning attenuates cardiac biomarkers during vascular surgery: a randomised clinical trial. Eur J Vasc Endovasc Surg, 2020, 59(2): 301-308.
20.	Li C, Li YS, Xu M, et al. Limb remote ischemic preconditioning for intestinal and pulmonary protection during elective open infrarenal abdominal aortic aneurysm repair: a randomized controlled trial. Anesthesiology, 2013, 118(4): 842-852.
21.	Mouton R, Pollock J, Soar J, et al. Remote ischaemic preconditioning versus sham procedure for abdominal aortic aneurysm repair: an external feasibility randomized controlled trial. Trials, 2015, 16: 377.
22.	Hausenloy DJ, Yellon DM. Ischaemic conditioning and reperfusion injury. Nat Rev Cardiol, 2016, 13(4): 193-209.
23.	Kleinbongard P, Skyschally A, Heusch G. Cardioprotection by remote ischemic conditioning and its signal transduction. Pflugers Arch, 2017, 469(2): 159-181.
24.	Murphy N, Vijayan A, Frohlich S, et al. Remote ischemic preconditioning does not affect the incidence of acute kidney injury after elective abdominal aortic aneurysm repair. J Cardiothorac Vasc Anesth, 2014, 28(5): 1285-1292.
25.	Thomas KN, Cotter JD, Williams MJ, et al. Repeated episodes of remote ischemic preconditioning for the prevention of myocardial injury in vascular surgery. Vasc Endovascular Surg, 2016, 50(3): 140-146.
26.	Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med, 2002, 21(11): 1539-1558.
27.	Ali ZA, Callaghan CJ, Lim E, et al. Remote ischemic preconditioning reduces myocardial and renal injury after elective abdominal aortic aneurysm repair: a randomized controlled trial. Circulation, 2007, 116(11 Suppl): I98-I105.
28.	Roy D M, Pande S D, Aw T C, et al. Remote ischemic preconditioning in prevention of contrast induced nephropathy in patients undergoing lower limb angioplasty revascularization for peripheral arterial disease: a randomized control trial. J Surg Res. 2021, 4(1): 85-94.
29.	王鹏飞, 董礼全, 熊小檍, 等. 上肢远端缺血预处理减轻重度颈动脉狭窄支架植入患者的脑损伤. 临床荟萃, 2014, 29(1): 21-24.Wang PF, Dong LQ, Xiong XY, et al. Upper extremity remote ischemic preconditioning relieves cerebral injury of patients with undergoing severe carotid stenosis stent implantation. Clin Focus, 2014, 29(1): 21-24.
30.	Walsh SR, Sadat U, Boyle JR, et al. Remote ischemic preconditioning for renal protection during elective open infrarenal abdominal aortic aneurysm repair: randomized controlled trial. Vasc Endovascular Surg, 2010, 44(5): 334-340.
31.	Walsh SR, Nouraei SA, Tang TY, et al. Remote ischemic preconditioning for cerebral and cardiac protection during carotid endarterectomy: results from a pilot randomized clinical trial. Vasc Endovascular Surg, 2010, 44(6): 434-439.
32.	Zhao W, Meng R, Ma C, et al. Safety and efficacy of remote ischemic preconditioning in patients with severe carotid artery stenosis before carotid artery stenting: a proof-of-concept, randomized controlled trial. Circulation, 2017, 135(14): 1325-1335.
33.	Hess DC, Blauenfeldt RA, Andersen G, et al. Remote ischaemic conditioning-a new paradigm of self-protection in the brain. Nat Rev Neurol, 2015, 11(12): 698-710.
34.	Fleming TR, Powers JH. Biomarkers and surrogate endpoints in clinical trials. Stat Med, 2012, 31(25): 2973-2984.

1. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J, 2018, 39(9): 763-816.
2. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg, 2018, 67(1): 2-77.
3. Walsh SR, Tang TY, Sadat U, et al. Remote ischemic preconditioning in major vascular surgery. J Vasc Surg, 2009, 49(1): 240-243.
4. Rokosh RS, Starnes BW, Chaikof EL. Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: repair of an abdominal aortic aneurysm. J Vasc Surg, 2021, 73(5): 1485-1487.
5. Halliday A, Bulbulia R, Bonati LH, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet, 2021, 398(10305): 1065-1073.
6. Londero LS, Høgh A, Houlind K, et al. Danish trends in major amputation after vascular reconstruction in patients with peripheral arterial disease 2002-2014. Eur J Vasc Endovasc Surg, 2019, 57(1): 111-120.
7. Yei K, Mathlouthi A, Naazie I, et al. Long-term outcomes associated with open vs endovascular abdominal aortic aneurysm repair in a medicare-matched database. JAMA Netw Open, 2022, 5(5): e2212081.
8. Schermerhorn ML, Buck DB, O'Malley AJ, et al. Long-term outcomes of abdominal aortic aneurysm in the medicare population. N Engl J Med, 2015, 373(4): 328-338.
9. Carden DL, Granger DN. Pathophysiology of ischaemia-reperfusion injury. J Pathol, 2000, 190(3): 255-266.
10. Seal JB, Gewertz BL. Vascular dysfunction in ischemia-reperfusion injury. Ann Vasc Surg, 2005, 19(4): 572-584.
11. Yang B, Fung A, Pac-Soo C, et al. Vascular surgery-related organ injury and protective strategies: update and future prospects. Br J Anaesth, 2016, 117 Suppl 2: ii32-ii43.
12. Przyklenk K, Bauer B, Ovize M, et al. Regional ischemic 'preconditioning' protects remote virgin myocardium from subsequent sustained coronary occlusion. Circulation, 1993, 87(3): 893-899.
13. Penna C, Comità S, Tullio F, et al. Challenges facing the clinical translation of cardioprotection: 35 years after the discovery of ischemic preconditioning. Vascul Pharmacol, 2022, 144: 106995.
14. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation, 1986, 74(5): 1124-1136.
15. Lang JA, Kim J. Remote ischaemic preconditioning-translating cardiovascular benefits to humans. J Physiol, 2022, 600(13): 3053-3067.
16. Gutiérrez Castillo D, San Norberto García EM, García Rivera E, et al. Effect of remote ischemic preconditioning on the incidence of contrast-induced nephropathy in patients undergoing endovascular aneurysm repair (remote ischemic preconditioning-endovascular aneurysm repair study). Ann Vasc Surg, 2022, 86: 338-348.
17. Garcia S, Rector TS, Zakharova M, et al. Cardiac remote ischemic preconditioning prior to elective vascular surgery (CRIPES): a prospective, randomized, sham-controlled phase Ⅱ clinical trial. J Am Heart Assoc, 2016, 5(10): e003916.
18. Healy DA, Boyle E, McCartan D, et al. A multicenter pilot randomized controlled trial of remote ischemic preconditioning in major vascular surgery. Vasc Endovascular Surg, 2015, 49(8): 220-227.
19. Kepler T, Kuusik K, Lepner U, et al. Remote ischaemic preconditioning attenuates cardiac biomarkers during vascular surgery: a randomised clinical trial. Eur J Vasc Endovasc Surg, 2020, 59(2): 301-308.
20. Li C, Li YS, Xu M, et al. Limb remote ischemic preconditioning for intestinal and pulmonary protection during elective open infrarenal abdominal aortic aneurysm repair: a randomized controlled trial. Anesthesiology, 2013, 118(4): 842-852.
21. Mouton R, Pollock J, Soar J, et al. Remote ischaemic preconditioning versus sham procedure for abdominal aortic aneurysm repair: an external feasibility randomized controlled trial. Trials, 2015, 16: 377.
22. Hausenloy DJ, Yellon DM. Ischaemic conditioning and reperfusion injury. Nat Rev Cardiol, 2016, 13(4): 193-209.
23. Kleinbongard P, Skyschally A, Heusch G. Cardioprotection by remote ischemic conditioning and its signal transduction. Pflugers Arch, 2017, 469(2): 159-181.
24. Murphy N, Vijayan A, Frohlich S, et al. Remote ischemic preconditioning does not affect the incidence of acute kidney injury after elective abdominal aortic aneurysm repair. J Cardiothorac Vasc Anesth, 2014, 28(5): 1285-1292.
25. Thomas KN, Cotter JD, Williams MJ, et al. Repeated episodes of remote ischemic preconditioning for the prevention of myocardial injury in vascular surgery. Vasc Endovascular Surg, 2016, 50(3): 140-146.
26. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med, 2002, 21(11): 1539-1558.
27. Ali ZA, Callaghan CJ, Lim E, et al. Remote ischemic preconditioning reduces myocardial and renal injury after elective abdominal aortic aneurysm repair: a randomized controlled trial. Circulation, 2007, 116(11 Suppl): I98-I105.
28. Roy D M, Pande S D, Aw T C, et al. Remote ischemic preconditioning in prevention of contrast induced nephropathy in patients undergoing lower limb angioplasty revascularization for peripheral arterial disease: a randomized control trial. J Surg Res. 2021, 4(1): 85-94.
29. 王鹏飞, 董礼全, 熊小檍, 等. 上肢远端缺血预处理减轻重度颈动脉狭窄支架植入患者的脑损伤. 临床荟萃, 2014, 29(1): 21-24.Wang PF, Dong LQ, Xiong XY, et al. Upper extremity remote ischemic preconditioning relieves cerebral injury of patients with undergoing severe carotid stenosis stent implantation. Clin Focus, 2014, 29(1): 21-24.
30. Walsh SR, Sadat U, Boyle JR, et al. Remote ischemic preconditioning for renal protection during elective open infrarenal abdominal aortic aneurysm repair: randomized controlled trial. Vasc Endovascular Surg, 2010, 44(5): 334-340.
31. Walsh SR, Nouraei SA, Tang TY, et al. Remote ischemic preconditioning for cerebral and cardiac protection during carotid endarterectomy: results from a pilot randomized clinical trial. Vasc Endovascular Surg, 2010, 44(6): 434-439.
32. Zhao W, Meng R, Ma C, et al. Safety and efficacy of remote ischemic preconditioning in patients with severe carotid artery stenosis before carotid artery stenting: a proof-of-concept, randomized controlled trial. Circulation, 2017, 135(14): 1325-1335.
33. Hess DC, Blauenfeldt RA, Andersen G, et al. Remote ischaemic conditioning-a new paradigm of self-protection in the brain. Nat Rev Neurol, 2015, 11(12): 698-710.
34. Fleming TR, Powers JH. Biomarkers and surrogate endpoints in clinical trials. Stat Med, 2012, 31(25): 2973-2984.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

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