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OBJECTIVE: Patients with peripheral artery disease (PAD) and end-stage kidney disease are a high-risk population, and concomitant atherosclerosis in coronary arteries (CAD) or cerebral arteries (CVD) is common. The aim of the study was to assess long-term outcomes of PAD and the impact of coexistent CAD and CVD on outcomes. METHODS: The United States Renal Data System was used to identify patients with PAD within 6 months of incident dialysis. Four groups were formed: PAD alone, PAD with CAD, PAD with CVD, and PAD with CAD and CVD. PAD-specific outcomes (chronic limb-threatening ischemia, major amputation, percutaneous/surgical revascularization, and their composite, defined as major adverse limb events [MALE]) as well as all-cause mortality, myocardial infarction, and stroke were studied. RESULTS: The study included 106,567 patients (mean age, 71.2 years; 40.8% female) with a median follow-up of 546 days (interquartile range, 214-1096 days). Most patients had PAD and CAD (49.8%), 25.8% had PAD alone, and 19.2% had all three territories involved. MALE rate in patients with PAD was 22.3% and 35.0% at 1 and 3 years, respectively. In comparison to PAD alone, the coexistence of both CAD and CVD (ie, polyvascular disease) was associated with a higher adjusted rates of all-cause mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.24-1.31), myocardial infarction (HR, 1.78; 95% CI, 1.69-1.88), stroke (HR, 1.66; 95% CI, 1.52,1.80), and MALE (HR, 1.07; 95% CI, 1.04-1.11). CONCLUSIONS: Patients with end-stage kidney disease have a high burden of PAD with poor long-term outcomes, which worsen, in an incremental fashion, with the involvement of each additional diseased arterial bed.
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Enfermedad de la Arteria Coronaria , Fallo Renal Crónico , Infarto del Miocardio , Enfermedad Arterial Periférica , Accidente Cerebrovascular , Humanos , Femenino , Estados Unidos/epidemiología , Anciano , Masculino , Enfermedad Arterial Periférica/complicaciones , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/terapia , Infarto del Miocardio/etiología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Factores de Riesgo , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/diagnóstico , Fallo Renal Crónico/terapiaRESUMEN
Patients with type B aortic dissection (TBAD) often present as an emergency. Operative repair of TBAD can be indicated for selected patients in the setting of hemodynamic instability or rupture. Thoracic endovascular aortic repair of TBAD has achieved significant popularity. Variant aortic arch anatomy can present a significant clinical challenge in patients with an inadequate proximal landing zone for thoracic endovascular aortic repair. A three-stage, hybrid aortic arch debranching and endovascular repair of a ruptured TBAD in a patient with a bicarotid trunk and an aberrant right subclavian artery was successfully performed using a unique technical approach.
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BACKGROUND: Over the last decade, there has been a significant increase in the use of percutaneous left ventricular assist devices(p-LVADs). p-LVADs are being increasingly used during complex coronary interventions and for acute cardiogenic shock. These large bore percutaneous devices have a higher risk of vascular complications. We examined the vascular complication rates from the use of p-LVAD in a national database. METHODS: We conducted a secondary analysis of the National In-patient Sample (NIS) dataset from 2005 till 2015. We used the ICD-9-CM procedure codes 37.68 and 37.62 for p-LVAD placement regardless of indications. We investigated common vascular complications, defining them by the validated ICD 9 CM codes. χ2 test and t test were used for categorical and continuous variables, respectively for comparison. RESULTS: A total of 31,263 p-LVAD placements were identified during the period studied. A majority of patients were male (72.68%) and 64.44% were white. The overall incidence of vascular complications was 13.53%, out of which 56% required surgical treatment. Acute limb thromboembolism and bleeding requiring transfusion accounted for 27.6% and 21.8% of all vascular complications. Occurrence of a vascular complication was associated with significantly higher in-hospital mortality (37.77% vs. 29.95%, p < .001), length of stay (22.7 vs. 12.2 days, p < .001) and cost of hospitalization ($ 161,923 vs. $ 95,547, p < .001). CONCLUSIONS: There is a high incidence of vascular complications with p-LVAD placement including need for vascular surgery. These complications are associated with a higher in-hospital, LOS and hospitalization costs. These findings should be factored into the decision-making for p-LVAD placement.
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Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Implantación de Prótesis/efectos adversos , Implantación de Prótesis/instrumentación , Choque Cardiogénico/terapia , Enfermedades Vasculares/epidemiología , Función Ventricular Izquierda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Corazón Auxiliar/economía , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Incidencia , Pacientes Internos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Implantación de Prótesis/economía , Implantación de Prótesis/mortalidad , Medición de Riesgo , Factores de Riesgo , Choque Cardiogénico/economía , Choque Cardiogénico/mortalidad , Choque Cardiogénico/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología , Enfermedades Vasculares/economía , Enfermedades Vasculares/mortalidad , Enfermedades Vasculares/terapia , Adulto JovenRESUMEN
BACKGROUND/OBJECTIVES: Orbital atherectomy (OA) is routinely being used for plaque modification to facilitate percutaneous revascularization in patients with peripheral arterial disease (PAD) and arterial calcification. Guidewire fracture (GWF) during OA, though anecdotally described, has not been studied in a systematic manner. We conducted a review of the Manufacturer and User Facility Device Experience (MAUDE) database to study the reports of wire fracture and its management and consequences. METHODS: We queried the MAUDE database for all events involving the current generation of the OA device: "Diamondback 360 Peripheral Orbital Atherectomy System", and "Stealth 360° Orbital PAD System". RESULTS: We identified 62 reports of GWF during OA for PAD. The superficial femoral artery was the most commonly involved atherectomy site. The wire fractured at the soft tip in a majority of cases (68%). Embolized wire fragments were left in the patient in 36 cases (58%), retrieved percutaneously in 10 cases (16%), and trapped by a stent against the arterial wall in eight cases (13%). Lastly, eight patients (13%) underwent surgery for removal of the wire fragment. CONCLUSIONS: This is the first published report to study the complication of GWF during peripheral OA. GWF is an uncommon but has significant procedural and clinical consequences. It results in a high rate of ancillary rescue procedures (including surgery) and is associated with a higher risk of arterial thrombosis and complications from wire retrieval attempts. The risk of wire fracture may be avoided with carefully adherence to the IFU.
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Aterectomía/instrumentación , Cateterismo Periférico/instrumentación , Remoción de Dispositivos , Falla de Equipo , Migración de Cuerpo Extraño/terapia , Enfermedad Arterial Periférica/terapia , Dispositivos de Acceso Vascular , Aterectomía/efectos adversos , Cateterismo Periférico/efectos adversos , Bases de Datos Factuales , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/etiología , Sector de Atención de Salud , Humanos , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Factores de Riesgo , Resultado del TratamientoRESUMEN
Right-sided aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum is the second most common vascular ring. Aneurysms of the arch in its retroesophageal portion are rare. The surgical repair of a retroesophageal arch aneurysm poses a significant challenge because no single approach provides access to the whole arch and all of its branches. We describe a 39-year-old patient with aneurysmal dilatation of the retroesophageal arch who presented with airway obstruction. The arch aneurysm was repaired with a staged approach. A right-sided carotid-subclavian artery bypass was performed, followed by distal ascending aorta and aortic arch replacement under hypothermic circulatory arrest through a left thoracotomy.
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Aorta Torácica/anomalías , Aneurisma de la Aorta Torácica/cirugía , Paro Circulatorio Inducido por Hipotermia Profunda/métodos , Imagenología Tridimensional , Procedimientos Quirúrgicos Vasculares/métodos , Adulto , Obstrucción de las Vías Aéreas/diagnóstico , Obstrucción de las Vías Aéreas/etiología , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Angiografía/métodos , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Síndromes del Arco Aórtico/diagnóstico por imagen , Síndromes del Arco Aórtico/cirugía , Anomalías Cardiovasculares/diagnóstico por imagen , Anomalías Cardiovasculares/cirugía , Arterias Carótidas/cirugía , Trastornos de Deglución/diagnóstico por imagen , Trastornos de Deglución/cirugía , Estudios de Seguimiento , Humanos , Masculino , Medición de Riesgo , Arteria Subclavia/anomalías , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/cirugía , Toracotomía/métodos , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: Pelvic congestion syndrome (PCS) is difficult to diagnose, poorly understood, and often confused with other causes of chronic pelvic pain. Thus, gonadal vein reflux, its relation to lower extremity venous insufficiency (LEVI), and treatment remains controversial to physicians and payors. We present our experience with endovascular PCS treatment and hypothesize that properly selected patients can realize significant improvement. METHODS: A retrospective study of patients treated for PCS at our institution from 2008 to 2012 was performed. Diagnosis was made clinically by the presence of pelvic pain, dyspareunia, and/or perineal varicosities. Clinical parameters, procedural details, and follow-up were reviewed. A questionnaire including a visual analog scale was sent to patients. RESULTS: Diagnosis was made in 15 women (mean age, 36 years; mean parity, two). All had pelvic pain, 6 had dyspareunia, 14 had perineal varicosities, and 10 had concomitant LEVI. Fourteen had gonadal vein reflux (mean diameter, 7.4 mm) and pelvic varicosities at angiography and had coiling (n = 12) and/or Amplatzer plug (St. Jude Medical, Inc, St. Paul, Minn) (n = 4). One patient had stenting of a stenotic left common iliac vein. All patients with concomitant LEVI had successful appropriate treatment. Eight patients completed the questionnaire at a mean follow-up of 4 years. The mean pelvic pain score went from 9.375 to 1.875 post-procedure (P < .0001; Student t-test). Mean dyspareunia score went from 8.875 to 1.5 (P < .0001). Mean perineal varicosity pain score went from 9.285 to 1.285 (P < .0001). Two patients had recurrence with a mean pelvic pain score of 4.5 at a mean 21 months. On a five-point Likert scale, all patients were satisfied (one) or extremely satisfied (seven) with treatment. CONCLUSIONS: Endovascular PCS treatment offers excellent pelvic pain relief and patient satisfaction. Women with pelvic pain, dyspareunia, or perineal varicosities with gonadal vein reflux and pelvic varicosities or iliac vein stenosis should not be denied treatment. A significant number may have concomitant LEVI and should be screened accordingly.
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PURPOSE: To determine the feasibility, effects, and complications of a resorbable inferior vena cava (IVC) filter in a porcine model. MATERIALS AND METHODS: Ten handmade, dual-filtration level, resorbable IVC filters were produced and gas sterilized. A dual-filtration cone was constructed using polyglycolic acid polymer strands oriented in a staggered cone formation with the apex of the cone in a cephalad orientation in relation to the IVC. IVC fixation was accomplished using a nitinol Z-stent, which was not resorbable. Operative insertion employing a paramedian incision, infrarenal vena caval dissection, venotomy, and device insertion using an 8-F rigid sheath was performed on 10 Yorkshire-type pigs (> 50 lb). Percutaneous delivery was not performed because of cost constraints. The IVC filters were operatively removed en bloc 6 weeks after implantation, and the pigs were euthanized. The IVC specimens were subsequently analyzed grossly and using light microscopy. RESULTS: In 9 (90%) of the 10 retrieved devices, the filtration cones were completely dissolved. One device (10%) had a retained strand of filtration cone material completely incorporated into the caval wall, excluded from luminal flow. Significant inflammatory response was appreciated from the specimen histology, and significant collagen deposition was observed, especially on trichrome staining. The intima and media of 9 of 10 specimens were two to three times normal thickness. Significant reactive change was also appreciated in the pericaval lymph nodes that were taken in the specimen. One pig (10%) developed a postoperative wound infection requiring treatment. CONCLUSIONS: Resorbable IVC filters are feasible and could be used for specific patient populations. This study outlines the need for further research of bioabsorbable polymers, absorption mechanics in the vascular system, absorption times, efficacy models, and practical application.
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Implantes Absorbibles , Ácido Poliglicólico , Filtros de Vena Cava , Vena Cava Inferior/cirugía , Implantes Absorbibles/efectos adversos , Animales , Colágeno/metabolismo , Remoción de Dispositivos , Estudios de Factibilidad , Inflamación/etiología , Ensayo de Materiales , Modelos Animales , Diseño de Prótesis , Infección de la Herida Quirúrgica/etiología , Porcinos , Factores de Tiempo , Filtros de Vena Cava/efectos adversos , Vena Cava Inferior/metabolismo , Vena Cava Inferior/patologíaRESUMEN
BACKGROUND: Patient quality outcomes are a major focus of the health care industry. It is unknown what effect involvement in graduate medical education (GME) has on patient outcomes. The purpose of this study is to begin to examine whether GME involvement in postoperative care impacts patient quality outcomes. METHODS: The retrospective cohort included all patients who underwent a nonemergent colectomy from January 1, 2007 to January 1, 2008 at a 2-hospital system. Data collected included patient demographics, patient quality outcomes, complications, and GME involvement. Patient quality outcomes were based on compliance with the Surgical Care Improvement Project (SCIP) guidelines. RESULTS: A total of 159 nonemergent colectomies were analyzed. The GME group accounted for 116 (73%) patients. A significant difference was found in several SCIP process-based measures of quality when comparing the GME group with the non-GME group. Postoperative antibiotics were more likely to be stopped within 24 hours (p = 0.010), and preoperative heparin and postoperative deep vein thrombosis (DVT) prophylaxis were more likely to be administered (p < 0.001). Additionally, patients in the GME group showed improved quality outcomes as there were significantly fewer postoperative complications (p < 0.001) and a shorter duration of stay (p = 0.008). The use of gastrointestinal prophylaxis was more common in the non-GME group (p = 0.002). No significant differences were observed between the 2 groups in respect to age, sex, diabetes, preoperative antibiotics, antibiotics, 1 hour before surgery, postoperative antibiotics, and continuation of home beta blockade. CONCLUSIONS: GME at teaching institutions has a positive impact on patient quality outcomes. At our institution, many of the SCIP measurable outcomes had improved compliance if an attending physician participated in the GME program.
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Educación de Postgrado en Medicina , Cuerpo Médico de Hospitales/normas , Evaluación de Resultado en la Atención de Salud , Calidad de la Atención de Salud , Adulto , Anciano , Anciano de 80 o más Años , Competencia Clínica , Colectomía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Estudios RetrospectivosRESUMEN
This is a report of a patient with an atrial septal defect with right-to-left shunting, flail tricuspid valve, and complete heart block secondary to blunt chest trauma after a motor vehicle accident. The patient surgically repaired with pericardial recreation of atrial septum, bioprosthetic tricuspid valve replacement, and pacemaker insertion. The patient had minimal problems during the hospital course and subsequently made a full postsurgical recovery.