RESUMO
BACKGROUND: The ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) previously reported that pharmacomechanical catheter-directed thrombolysis (PCDT) did not prevent postthrombotic syndrome (PTS) in patients with acute proximal deep vein thrombosis. In the current analysis, we examine the effect of PCDT in ATTRACT patients with iliofemoral deep vein thrombosis. METHODS: Within a large multicenter randomized trial, 391 patients with acute deep vein thrombosis involving the iliac or common femoral veins were randomized to PCDT with anticoagulation versus anticoagulation alone (No-PCDT) and were followed for 24 months to compare short-term and long-term outcomes. RESULTS: Between 6 and 24 months, there was no difference in the occurrence of PTS (Villalta scale ≥5 or ulcer: 49% PCDT versus 51% No-PCDT; risk ratio, 0.95; 95% CI, 0.78-1.15; P=0.59). PCDT led to reduced PTS severity as shown by lower mean Villalta and Venous Clinical Severity Scores ( P<0.01 for comparisons at 6, 12, 18, and 24 months), and fewer patients with moderate-or-severe PTS (Villalta scale ≥10 or ulcer: 18% versus 28%; risk ratio, 0.65; 95% CI, 0.45-0.94; P=0.021) or severe PTS (Villalta scale ≥15 or ulcer: 8.7% versus 15%; risk ratio, 0.57; 95% CI, 0.32-1.01; P=0.048; and Venous Clinical Severity Score ≥8: 6.6% versus 14%; risk ratio, 0.46; 95% CI, 0.24-0.87; P=0.013). From baseline, PCDT led to greater reduction in leg pain and swelling ( P<0.01 for comparisons at 10 and 30 days) and greater improvement in venous disease-specific quality of life (Venous Insufficiency Epidemiological and Economic Study Quality of Life unit difference 5.6 through 24 months, P=0.029), but no difference in generic quality of life ( P>0.2 for comparisons of SF-36 mental and physical component summary scores through 24 months). In patients having PCDT versus No-PCDT, major bleeding within 10 days occurred in 1.5% versus 0.5% ( P=0.32), and recurrent venous thromboembolism over 24 months was observed in 13% versus 9.2% ( P=0.21). CONCLUSIONS: In patients with acute iliofemoral deep vein thrombosis, PCDT did not influence the occurrence of PTS or recurrent venous thromboembolism. However, PCDT significantly reduced early leg symptoms and, over 24 months, reduced PTS severity scores, reduced the proportion of patients who developed moderate-or-severe PTS, and resulted in greater improvement in venous disease-specific quality of life. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00790335.
Assuntos
Anticoagulantes/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Veia Femoral/cirurgia , Veia Ilíaca/cirurgia , Trombólise Mecânica/efeitos adversos , Síndrome Pós-Trombótica/epidemiologia , Doença Aguda , Adulto , Anticoagulantes/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/etiologiaRESUMO
Between September 2008 and August 2017, 36 patients (mean age 56 y; range, 30-89 y) underwent transvenous biopsy of suspected tumor thrombus or perivascular tumor. Intravascular biopsy was pursued because of inaccessible percutaneous access in 9 patients (25%) and as part of a planned revascularization procedure in 27 patients (75%). Histopathologic results showed malignancy in 26 patients (72%) and benign etiologies in 10 patients (28%). No patients required repeat biopsy. There were no complications related to the biopsy procedure. The present series suggests that transvenous biopsy is a safe and accurate method of intravascular and perivascular mass tissue sampling.
Assuntos
Cateterismo Periférico , Procedimentos Endovasculares , Trombose/patologia , Neoplasias Vasculares/patologia , Veias/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Cateterismo Periférico/efeitos adversos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Humanos , Michigan , Pessoa de Meia-Idade , Invasividade Neoplásica , Flebografia/métodos , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Trombose/diagnóstico por imagem , Ultrassonografia de Intervenção , Neoplasias Vasculares/diagnóstico por imagem , Veias/diagnóstico por imagemRESUMO
OBJECTIVE: The objective of our study was to report the technique, complications, and clinical outcomes of interventional radiology-operated cholecystoscopy with stone removal for the management of symptomatic cholelithiasis. MATERIALS AND METHODS: Ten (77%) men and three (23%) women (mean age, 65 years) with symptomatic cholelithiasis underwent cholecystostomy followed by interventional radiology-operated cholecystoscopy with stone removal. Major comorbidities precluding cholecystectomy included prior cardiac, pulmonary, or abdominal surgery; cirrhosis; sepsis with hyponatremia; seizure disorder; developmental delay; and cholecystoduodenal fistula. Cholecystostomy access, time between cholecystostomy and cholecystoscopy, endoscopic and fragmentation devices used, technical success, procedure time, fluoroscopy time, complications, length of hospital stay, time between cholecystoscopy and cholecystostomy removal, follow-up, and acute cholecystitis recurrence were recorded. RESULTS: Eleven (85%) patients underwent transhepatic cholecystostomy, and two (15%) patients underwent transperitoneal cholecystostomy. The mean time from cholecystostomy to cholecystoscopy was 151 days. Flexible endoscopy was used in eight (62%) patients, rigid endoscopy in three (23%), and both flexible and rigid in two (15%). Electrohydraulic lithotripsy was used in eight procedures, nitinol baskets in seven, ultrasonic lithotripsy in two, and percutaneous thrombectomy devices in one. Primary technical success was achieved in 11 (85%) patients, and secondary technical success was achieved in 13 (100%) patients. The mean procedure time was 164 minutes, and the mean number of procedures required to clear all gallstones was 1. One (8%) patient developed acute pancreatitis, and one (8%) patient died of gastrointestinal hemorrhage. The median hospital length of stay after cholecystoscopy was 1 day for postoperative monitoring. The mean time between cholecystoscopy and cholecystostomy removal was 39 days. One (8%) patient developed recurrent acute cholecystitis 1095 days after cholecystoscopy. CONCLUSION: Interventional radiology-operated cholecystoscopy may serve as an effective method for percutaneous gallstone removal in patients with multiple comorbidities precluding cholecystectomy.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/métodos , Endoscopia do Sistema Digestório , Radiografia Intervencionista , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Recidiva , Resultado do TratamentoRESUMO
In the setting of portal hypertension, the body responds by creating portosystemic venous shunts, which may lead to the development of varices. Endoscopic treatment of these varices is often warranted to prevent catastrophic bleeding. During the course of variceal treatment, 1 or more portosystemic shunts may be sacrificed, which may acutely exacerbate portal hypertension and reduce systemic venous return. This report describes percutaneous creation of a mesocaval shunt and balloon-occluded retrograde transvenous obliteration (BRTO) in a patient with cavernous transformation of the portal vein. The patient had previously undergone an unsuccessful attempt at transjugular intrahepatic portosystemic shunt (TIPS) creation with postoperative bleeding requiring splenectomy. As TIPS was not feasible, creation of a percutaneous mesocaval shunt provided an alternate pathway for portosystemic decompression, facilitating safe treatment of gastric varices with BRTO via a gastrorenal shunt. These procedures were performed simultaneously to reduce the risk of variceal bleeding from acute changes in portal venous pressures and redirect blood flow through the shunt to maintain patency. This is the first reported case of combined mesocaval shunt placement and BRTO in a single session.
Assuntos
Oclusão com Balão , Embolização Terapêutica , Procedimentos Endovasculares/métodos , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Hipertensão Portal/terapia , Angiografia por Tomografia Computadorizada , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/fisiopatologia , Feminino , Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/fisiopatologia , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Hipertensão Portal/fisiopatologia , Pessoa de Meia-Idade , Flebografia/métodos , Pressão na Veia Porta , Resultado do TratamentoRESUMO
This is a retrospective study of 9 consecutive female patients who underwent ureteral embolization via a "sandwich" technique with two vascular plugs and N-butyl cyanoacrylate glue for ureteral fistulae unresponsive to urinary diversion. Average age was 61 years (range, 39-77 y), average duration of diversion was 48 days (range, 2-120 d), and average follow-up was 11 months (range, 4-23 mo). Seven patients (78%) experienced immediate resolution of urinary leakage, and the other 2 (22%) required unilateral repeat treatment for resolution of leakage. Symptom resolution lasted throughout the follow-up period for all patients. Bilateral internal iliac artery pseudoaneurysms developed in 1 patient and were treated with embolization and stent placement.
Assuntos
Embolização Terapêutica/métodos , Embucrilato/uso terapêutico , Dispositivo para Oclusão Septal , Doenças Ureterais/terapia , Adulto , Idoso , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: The objective of our study was to describe an association between the radiographic appearance of distressed intravascular implants and venous stenosis or occlusion and to determine the success of reparative endovascular procedures. MATERIALS AND METHODS: Seventy-eight patients with distressed stents or inferior vena cava (IVC) filters characterized by pursing (short-axis contracture), straightening, longitudinal contraction (long-axis contracture), or fracture were identified from retrospective review of a venous registry for the period from February 2004 to October 2016. Patients originally presented with superior vena cava (SVC) syndrome (n = 25), arm swelling (n = 16), iliocaval thrombosis (n = 21), and lower extremity deep venous thrombosis (n = 16), and stents were initially placed in 65 and filters in 13. Implants were located in the IVC (n = 24), subclavian vein (n = 16), brachiocephalic vein (n = 15), common iliac vein (n = 10), multiple veins (n = 4), axillary vein (n = 4), common femoral vein (n = 3), SVC (n = 1), and internal jugular vein (n = 1). Implants included Wallstents in 63 patients; Smart stents in two patients; and Celect Platinum, Denali, Greenfield, and Trapease IVC filters in two, three, two, and six patients, respectively. Venographic indication, distress type, time from initial normal placement to identification of distress, venographic finding (patent, mild stenosis, high-grade stenosis, or occlusion), treatment, revascularization outcome, and complications were recorded. RESULTS: The mean time to distress was 23 months. Fifty-two (67%) patients underwent venography for symptoms and 26 (33%) for surveillance. Forty-five (58%) implants were pursed; 19 (24%), straightened; nine (12%), contracted; and five (6%), fractured. Venography depicted 48 (62%) high-grade stenoses, 19 (24%) complete occlusions, and six (8%) mild stenoses. Of the 73 patients who underwent an intervention, 29 (40%) underwent angioplasty, 15 (21%) underwent angioplasty and stenting, 15 (21%) underwent sharp recanalization, and five (7%) underwent thrombolysis. Revascularization was successful in 67 (92%). Three minor complications occurred. CONCLUSION: Distressed intravascular implants are associated with high-grade venous stenosis or occlusion. Reparative interventions are usually technically successful.
Assuntos
Oclusão de Enxerto Vascular/diagnóstico por imagem , Stents , Filtros de Veia Cava , Veia Cava Inferior/diagnóstico por imagem , Trombose Venosa/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Flebografia , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução Vascular , Trombose Venosa/etiologia , Trombose Venosa/terapia , Adulto JovemRESUMO
Superior vena cava (SVC) syndrome, characterized by facial and arm swelling, is most frequently caused by intrathoracic malignancies. Decompression may be achieved with endovenous stent placement. Polytetrafluoroethylene-covered stents have shown to have higher long-term cumulative patency rates compared with uncovered stents for the treatment of malignant SVC syndrome. Unfortunately, polytetrafluoroethylene-covered stents are not readily available worldwide. Moreover, the existing armamentarium, including balloon-expandable iCAST stents (maximum diameter 10 mm) and heparin-coated Viabahn stent-graft endoprostheses (maximum diameter 13 mm), is too small to adequately treat malignant obstruction of the SVC. This report describes a patient with SVC syndrome and SVC tumor thrombus secondary to recurrent nonseminomatous germ cell carcinoma of the mediastinum treated with a Gianturco Z-stent-fixed modified EXCLUDER abdominal aortic aneurysm iliac limb endoprosthesis.
Assuntos
Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Neoplasias do Mediastino/complicações , Neoplasias Embrionárias de Células Germinativas/complicações , Stents , Síndrome da Veia Cava Superior/cirurgia , Neoplasias Testiculares/complicações , Implante de Prótese Vascular/métodos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/métodos , Humanos , Masculino , Neoplasias do Mediastino/secundário , Pessoa de Meia-Idade , Neoplasias Embrionárias de Células Germinativas/secundário , Flebografia/métodos , Desenho de Prótese , Síndrome da Veia Cava Superior/diagnóstico por imagem , Síndrome da Veia Cava Superior/etiologia , Neoplasias Testiculares/patologia , Resultado do TratamentoRESUMO
Type II Abernethy malformations, characterized by side-to-side portosystemic shunting with preserved intrahepatic portal venous system, have been treated with shunt closure surgically and endovascularly. Three-dimensional printing has been used to develop highly accurate patient-specific representations for surgical and endovascular planning and intervention. This innovation describes 3-dimensional printing to successfully close a flush-oriented type II Abernethy malformation with discrepant dimensions on computed tomography, conventional venography, and intravascular ultrasound, using a 12-mm Amplatzer atrial septal occluder device.
Assuntos
Procedimentos Endovasculares/instrumentação , Modelos Anatômicos , Modelos Cardiovasculares , Modelagem Computacional Específica para o Paciente , Veia Porta/anormalidades , Impressão Tridimensional , Dispositivo para Oclusão Septal , Malformações Vasculares/terapia , Angiografia Digital , Criança , Angiografia por Tomografia Computadorizada , Humanos , Circulação Hepática , Masculino , Flebografia/métodos , Veia Porta/diagnóstico por imagem , Veia Porta/fisiopatologia , Desenho de Prótese , Resultado do Tratamento , Ultrassonografia de Intervenção , Malformações Vasculares/diagnóstico por imagem , Malformações Vasculares/fisiopatologiaRESUMO
Portal vein thrombosis occurs in 1.4% of pediatric liver transplant candidates and 3.7% of liver transplant recipients. While portal vein recanalization without and with portal vein stenting has been described in adult transplant candidates and recipients, it has never been described in the pediatric transplant population. This report presents a pediatric liver transplant recipient with portal hypertension secondary to portal vein thrombosis successfully managed with transsplenic access and subsequent portal vein recanalization and stenting.
Assuntos
Embolização Terapêutica/métodos , Varizes Esofágicas e Gástricas/terapia , Hipertensão Portal/terapia , Transplante de Fígado , Veia Porta , Stents , Trombose Venosa/terapia , Criança , Diagnóstico por Imagem , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Feminino , Humanos , Hipertensão Portal/diagnóstico por imagem , Jejuno , Baço , Trombose Venosa/diagnóstico por imagemRESUMO
In recent decades, there have been numerous advances in the management of liver cancer, cirrhosis, and diabetes mellitus. Although these diseases are wide ranging in their clinical manifestations, each can potentially be treated by exploiting the blood flow dynamics within the portal venous system, and in some cases, adding cellular therapies. To aid in the management of these disease states, minimally invasive transcatheter portal venous interventions have been developed to improve the safety of major hepatic resection, to reduce the untoward effects of sequelae from end-stage liver disease, and to minimize the requirement of exogenously administered insulin for patients with diabetes mellitus. This state of the art review therefore provides an overview of the most recent data and strategies for utilization of preoperative portal vein embolization, transjugular intrahepatic portosystemic shunt placement, balloon retrograde transvenous obliteration, and islet cell transplantation.
Assuntos
Oclusão com Balão/métodos , Diagnóstico por Imagem , Embolização Terapêutica/métodos , Transplante das Ilhotas Pancreáticas/métodos , Hepatopatias/terapia , Pancreatopatias/terapia , Veia Porta , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Humanos , Seleção de PacientesRESUMO
PURPOSE: To assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV). MATERIALS AND METHODS: A single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31-79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23-83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV. RESULTS: The technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25). CONCLUSIONS: BRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.
Assuntos
Oclusão com Balão/métodos , Varizes Esofágicas e Gástricas/cirurgia , Hemorragia Gastrointestinal/cirurgia , Veia Porta/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Feminino , Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Recidiva , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Two patients presented with bleeding duodenal varices secondary to mesenteric and portal vein chronic occlusion. After a failed transhepatic recanalization, a combined transmesenteric and transhepatic approach was used to recanalize the chronic portal and mesenteric venous obstruction. The occluded segment was treated with transmesenteric stent placement in one patient and stent placement and coil embolization of varices in the second patient. Follow-up imaging and endoscopy showed decompression of the duodenal varices in both patients and absence of further bleeding episodes.
Assuntos
Duodeno/irrigação sanguínea , Embolização Terapêutica , Hemorragia Gastrointestinal/terapia , Oclusão Vascular Mesentérica/terapia , Veias Mesentéricas , Veia Porta , Varizes/terapia , Adulto , Angiografia Digital , Doença Crônica , Tomografia Computadorizada de Feixe Cônico , Embolização Terapêutica/instrumentação , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Oclusão Vascular Mesentérica/complicações , Oclusão Vascular Mesentérica/diagnóstico , Oclusão Vascular Mesentérica/fisiopatologia , Veias Mesentéricas/diagnóstico por imagem , Veias Mesentéricas/fisiopatologia , Flebografia/métodos , Veia Porta/diagnóstico por imagem , Veia Porta/fisiopatologia , Stents , Resultado do Tratamento , Varizes/diagnóstico , Varizes/etiologia , Grau de Desobstrução VascularRESUMO
PURPOSE: To report the outcomes following catheter angiography with or without embolization in patients with acute upper gastrointestinal nonvariceal hemorrhage (UGINH). MATERIALS AND METHODS: A review of electronic medical records was performed to identify all potential patients for this study between 2001 and 2011. Patients with first-time UGINH who required angiographic localization and endovascular treatment were included. Patients with variceal bleeding and prior surgical or endovascular intervention for the gastrointestinal system were excluded. Society of Interventional Radiology guidelines and American College of Radiology "appropriateness criteria" reporting standards were followed. RESULTS: We identified 74 patients (men/women=46/28) with a mean age of 60 years. Thirty-four patients were found to have active bleeding on angiography. One patient from this group did not undergo embolization because of an angiographic diagnosis of aortoenteric fistula. Technical failure was encountered in 2/34 patients; therefore, the technical success of embolization was 94%. Forty of 74 patients showed no angiographic evidence of active bleeding; 18 patients underwent prophylactic embolization using endoscopically placed clips as targets; and 22 patients had no embolotherapy. Thus, we grouped the patients into 3 groups: (1) therapeutic embolization; (2) prophylactic/empiric embolization; and (3) no embolotherapy groups. The clinical success of embolization was 67% to 68% in the therapeutic embolization group and 67% in the prophylactic embolization group. Early rebleeding rates were 33.8%, 51.6%, 33.3%, and 12% among all the patients, the therapeutic embolization group, the prophylactic embolization group, and the no endovascular treatment group, respectively. Mortality was significantly high in patients with advanced age (P=0.001), cerebrovascular disorders (P=0.037), and positive angiography (P=0.026), even when clinical success was achieved. CONCLUSIONS: Acute UGINH remains a clinical challenge with increased mortality rates, even with high technical success rates. Patients with negative findings on angiography have lower early rebleeding rates than patients with active bleeding during angiography or endoscopy-guided prophylactic/empiric embolization.
Assuntos
Angiografia/métodos , Embolização Terapêutica/métodos , Hemorragia Gastrointestinal/terapia , Radiografia Intervencionista/métodos , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo/métodos , Feminino , Seguimentos , Hemorragia Gastrointestinal/mortalidade , Hemorragia Gastrointestinal/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: We performed balloon-occluded retrograde transvenous obliteration in three consecutive patients with small gastric varices without indwelling balloon catheter occlusion. Foam of 3% sodium tetradecyl sulfate mixed with iodized oil and room air was injected retrograde through the gastrorenal shunt, followed by a thick absorbable gelatin sponge (Gelfoam, Pfizer) plug under only 10-minute balloon occlusion. CONCLUSION: Because complete obliteration of gastric varices was achieved in all patients without any complications, our technique is considered to be safe and effective for small gastric varices.
Assuntos
Oclusão com Balão/métodos , Varizes Esofágicas e Gástricas/terapia , Escleroterapia/métodos , Adulto , Idoso , Feminino , Esponja de Gelatina Absorvível/uso terapêutico , Humanos , Óleo Iodado/uso terapêutico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Soluções Esclerosantes/uso terapêutico , Tetradecilsulfato de Sódio/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Carotid artery stenting (CAS) for high-risk individuals is accepted practice. An impaired fasting hyperglycemia (IFG) is often associated with poor procedural outcomes after other percutaneous procedures. The clinical outcomes of CAS for patients with elevated fasting blood sugar (FBS) are not well defined. METHODS: A database of patients undergoing CAS was sampled from 2000 to 2009. An IFG was defined as plasma glucose > 110 mg/dL. Life table analyses were performed to assess time-dependent outcome differences between those patients with and without IFG. The outcomes of freedom from restenosis, occlusion, death, recurrent symptoms, and neurologic event were calculated. Cox proportional hazard analysis or Fisher's exact test was performed to identify factors associated with outcomes. RESULTS: During the study period 322 patients underwent 345 CAS procedures. The mean follow-up was 4.6 years. A total of 196 patients (61%) were male. The indications for CAS were neurologic symptoms in high-risk patients in 23% and asymptomatic high-risk in the remainder. Fifty-nine percent had an IFG but only 30% had a history of diabetes mellitus (DM). Patients with an IFG were more likely to suffer a major adverse event (MAE; death, myocardial infarction, stroke; 12% vs. 26%, ≤ 110 vs. > 110, respectively, at 5 years, P = 0.021 by chi-squared analysis) in the 90-day perioperative period. By life table analysis, there were no differences between normal and IFG patients with regards to freedom from occlusion or target vessel revascularization. The long-term MAE rate was significantly worse in patients with an IFG, driven by decreased survival and stroke rates. Patients carrying the diagnosis of DM had equivalent outcomes to non-DM patients (67 ± 5% vs. 62 ± 7%, ≤ 110 vs. >110, respectively, at 5 years, P = 0.84). The presence of metabolic syndrome and/or the combination of diabetes and metabolic syndrome in the IFG group were drivers of increasing poor MAE rates. CONCLUSIONS: Patients with IFG undergoing CAS are at a greater risk for periprocedural morbidity and worse MAE in both the short and long term. The diagnosis of DM does not have a similar impact on outcomes. A current IFG, as opposed to a history of DM, should be considered an important risk factor when determining the suitability for CAS.
Assuntos
Glicemia/análise , Estenose das Carótidas/cirurgia , Stents , Acidente Vascular Cerebral/prevenção & controle , Idoso , Estenose das Carótidas/diagnóstico , Comorbidade , Diagnóstico por Imagem , Jejum , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
PURPOSE: Careful case selection and preparation can prevent most cardiopulmonary arrest (CPA) in the interventional radiology (IR) suite. A series of CPAs was analyzed to provide insight into risk factors for these events. MATERIALS AND METHODS: A single-institution CPA database was used to identify all code team activations from January 1, 2005, to May 30, 2011, in the IR department. Medical records were searched for medical history, American Society of Anesthesiologists (ASA) classification, moderate sedation, and outcomes. Procedural data and procedure classification was acquired from the HI-IQ database. RESULTS: There were 36,489 procedures and 23 CPAs during the study period. Of the 23 patients with CPAs, 12 (52%) were male and 11 (48%) female, and average age was 57 years ± 19 (standard deviation). Risk factors included a 56% incidence of diabetes mellitus, 48% incidence of hypertension, and 78% incidence of renal failure. Of the patients with kidney disease, 56% were chronically dialysis-dependent, and an additional 9% were undergoing central venous catheter placement for new hemodialysis. Seventy-eight percent had ASA status of III or greater, and 57% underwent moderate sedation during the procedure. Relative risk of a CPA during dialysis shunt interventions versus arterial interventions was 3.6 (95% confidence interval, 1.0-11.3; P = .045). Eight of 23 (35%) died: one (12%) during resuscitation and seven (88%) after resuscitation (P = .070). CONCLUSIONS: The most common comorbidity of patients with CPA in IR was kidney disease, and the most patients who had CPA underwent dialysis access-related procedures.
Assuntos
Cateterismo/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Parada Cardíaca/etiologia , Radiografia Intervencionista/efeitos adversos , Adulto , Idoso , Reanimação Cardiopulmonar , Cateterismo/mortalidade , Cateterismo Venoso Central , Comorbidade , Sedação Consciente , Procedimentos Endovasculares/mortalidade , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Humanos , Incidência , Nefropatias/epidemiologia , Nefropatias/terapia , Masculino , Pessoa de Meia-Idade , Radiografia Intervencionista/mortalidade , Diálise Renal , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: In this article, we focus on the vascular complications related to liver, pancreas, and kidney transplantation. CONCLUSION: Long term allograft survival of solid organ transplantation depends on early intervention of complications. Noninvasive imaging with ultrasound, CT, and MRI allows accurate diagnosis of complications and aids in treatment planning.
Assuntos
Angiografia/métodos , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/etiologia , Transplante de Órgãos/efeitos adversos , Doenças Vasculares/diagnóstico , Doenças Vasculares/etiologia , Vísceras/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transplante de Órgãos/diagnóstico por imagem , Transplante de Órgãos/patologia , Resultado do Tratamento , Vísceras/diagnóstico por imagem , Vísceras/patologiaRESUMO
OBJECTIVE: The purpose of this study is to compare the technical success of transjugular intrahepatic portosystemic shunt (TIPS) in transplanted versus nontransplanted livers and to assess the clinical outcome of TIPS in liver transplant recipients. MATERIALS AND METHODS: A retrospective audit of patients receiving a TIPS was performed in two institutions during 1996-2009. The technical success of the TIPS was compared for transplanted versus nontransplanted livers. Clinical success was defined as graft survival longer than 1 month with improvement in symptoms. The cohort was divided into grafts that survived less than 3 months versus 3 months or more. The model for end-stage liver disease (MELD) scores and portosystemic gradients before and after TIPS creation were evaluated for predictive value for graft survival. The TIPS stent type, MELD scores and portosystemic gradients before and after TIPS creation, and causes of liver disease were evaluated for their predictive value for ascites response after TIPS creation. RESULTS: Thirty-nine TIPS in transplanted livers were found, representing 5.5% (39/715) of all TIPS procedures performed and 2.0% (39/1992) of all liver transplant recipients. Ninety percent of TIPS in transplanted livers had ascites. The median time from transplant to creation of the TIPS was 29 months (2-127 months). The median MELD score was 16 before and 22 after the TIPS procedure. The technical success rates for TIPS were 97% (38/39) in transplanted livers versus 97% (657/676) in nontransplanted livers (p = 1.00). Intent-to-treat clinical success rates were 36% for all indications versus 31% for ascites only. There were no predictors for ascites response. Six-, 12-, and 24-month graft survival rates were 43%, 32%, and 22%, respectively. One-year graft survival for a MELD score less than 17 versus a score of 17 or higher was 54% versus 8%, respectively (p < 0.05). CONCLUSION: Transplantation does not pose a technical challenge to TIPS creation. One third of patients have a favorable outcome. MELD score is the only predictor of graft survival.
Assuntos
Transplante de Fígado , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Adolescente , Adulto , Idoso , Feminino , Sobrevivência de Enxerto , Encefalopatia Hepática/cirurgia , Humanos , Hipertensão Portal/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: To report the outcomes associated with endovascular therapy for patients with chronic mesenteric ischemia (CMI). METHODS: A retrospective review of patients who underwent endovascular therapy for CMI between April 1981 and September 2009 at a single institution was performed. Procedural details, mesenteric arteries treated, technical and clinical success rates, outcomes per patient and per vessel were assessed. RESULTS: In 166 patients treatment was attempted using a variety of balloon and stent platforms during the 28-year period. The technical success rate was 97% per patient and 94% per vessel. The technical success rate of stenting (99.4%) was higher than for percutaneous transluminal angioplasty (PTA; 86%; P = 0.0001). Immediate clinical improvement was seen in 146 out of 166 (88.2%). The type of guidewire or device platform, brachial vs. femoral artery access, balloon and/or stent diameters used, and stenosis vs. occlusion had no statistical impact on mortality or the primary patency of any mesenteric artery outcomes. The outcome of the superior mesenteric artery (SMA) with PTA appears to be superior to that of stenting (P = 0.014). CONCLUSION: Technical success rates are improved with the use of stents; however, PTA use in the SMA seems to offer better primary patency rates. KEY POINTS: ⢠Superior mesenteric artery (SMA) stenosis is often responsible for ischaemic symptoms. ⢠Treatment with percutaneous transluminal angioplasty (PTA) seems superior to stenting ⢠Although technical success rates are improved with the use of stents. ⢠Higher mortality in the elderly and those presenting with nausea/vomiting/bloody stools.