RESUMEN
Aortic dissection and rupture are triggered by decreased vascular wall strength and/or increased mechanical loads. We investigated the role of mTOR signaling in aortopathy using a well-described model of angiotensin II-induced dissection, aneurysm, or rupture of the suprarenal abdominal aorta in Apoe-deficient mice. Although not widely appreciated, nonlethal hemorrhagic lesions present as pseudoaneurysms without significant dissection in this model. Angiotensin II-induced aortic tears result in free rupture, contained rupture with subadventitial hematoma (forming pseudoaneurysms), dilatation, or healing, while the media invariably thickens regardless of mural tears. Medial thickening results from smooth muscle cell hypertrophy and extracellular matrix accumulation, including matricellular proteins. Angiotensin II activates mTOR signaling in vascular wall cells, and inhibition of mTOR signaling by rapamycin prevents aortic rupture but promotes dissection. Decreased aortic rupture correlates with decreased inflammation and metalloproteinase expression, whereas extensive dissection correlates with induction of matricellular proteins that modulate adhesion of vascular cells. Thus, mTOR activation in vascular wall cells determines whether aortic tears progress to dissection or rupture. Previous mechanistic studies of aortic aneurysm and dissection by angiotensin II in Apoe-deficient mice should be reinterpreted as clinically relevant to pseudoaneurysms, and mTOR inhibition for aortic disease should be explored with caution.
Asunto(s)
Aneurisma Falso/prevención & control , Aneurisma de la Aorta Torácica/prevención & control , Rotura de la Aorta/prevención & control , Regulación de la Expresión Génica , Inhibidores mTOR/farmacología , Serina-Treonina Quinasas TOR/genética , Aneurisma Falso/genética , Aneurisma Falso/metabolismo , Angiotensina II/toxicidad , Animales , Aneurisma de la Aorta Torácica/genética , Aneurisma de la Aorta Torácica/patología , Rotura de la Aorta/genética , Modelos Animales de Enfermedad , Progresión de la Enfermedad , Masculino , Ratones , Ratones Endogámicos C57BL , Ratones Noqueados para ApoE , ARN/genética , Serina-Treonina Quinasas TOR/antagonistas & inhibidores , Serina-Treonina Quinasas TOR/biosíntesisRESUMEN
OBJECTIVES: Aneurysms are generally the result of dilation of all 3 layers of the vessel wall, and pseudoaneurysms are the result of localized extravasation of blood that is contained by surrounding tissue. Since there is still no recommended protocol to decrease aneurysm formation and progression, we hypothesised that intramural delivery of TGF ß1 hydrogel can decrease aneurysm and pseudoaneurysm formation and progression. MATERIALS: Male C57BL/6 J mice (12-14 wk), SD rats (200 g) and pig abdominal aortas were used, and hydrogels were fabricated by the interaction of sodium alginate (SA), hyaluronic acid (HA) and CaCO3. METHODS: A CaCl2 adventitial incubation model in mice and a decellularized human great saphenous vein patch angioplasty model in rats were used. TGF ß1 hydrogel was intramurally delivered after CaCl2 incubation in mice; at day 7, the abdomen in some mice was reopened, and TGF ß1 hydrogel was injected intramurally into the aorta. In rats, TGF ß1 hydrogel was delivered intramurally after patch angioplasty completion. Tissues were harvested at day 14 and analysed by histology and immunohistochemistry staining. The pig aorta was also intramurally injected with hydrogel. RESULTS: In mice, rhodamine hydrogel was still found between the medium and adventitia at day 14. In the mouse aneurysm model, there was a thicker wall and smaller amount of elastin breaks in the TGF ß1 hydrogel-delivered groups both at day 0 and day 7 after CaCl2 incubation, and there were larger numbers of p-smad2- and TAK1-positive cells in the TGF ß1 hydrogel-injected groups. In the rat decellularized human saphenous vein patch pseudoaneurysm model, there was a higher incidence of pseudoaneurysm formation when the patch was decellularized using 3% SDS, and delivery of TGF ß1 hydrogel could effectively decrease the formation of pseudoaneurysm formation and increase p-smad2 and TAK1 expression. In pig aortas, hydrogels can be delivered between the medium and adventitia easily and successfully. CONCLUSIONS: Intramural delivery of TGF ß1 hydrogel can effectively decease aneurysm and pseudoaneurysm formation and progression in both mice and rats, and pig aortas can also be successfully intramurally injected with hydrogel. This technique may be a promising drug delivery method and therapeutic choice to decrease aneurysm and pseudoaneurysm formation and progression in the clinic.
Asunto(s)
Aneurisma Falso/prevención & control , Aorta Abdominal/efectos de los fármacos , Aneurisma de la Aorta Abdominal/prevención & control , Portadores de Fármacos , Factor de Crecimiento Transformador beta1/administración & dosificación , Aneurisma Falso/metabolismo , Aneurisma Falso/patología , Animales , Aorta Abdominal/metabolismo , Aorta Abdominal/patología , Aneurisma de la Aorta Abdominal/metabolismo , Aneurisma de la Aorta Abdominal/patología , Preparaciones de Acción Retardada , Dilatación Patológica , Modelos Animales de Enfermedad , Progresión de la Enfermedad , Composición de Medicamentos , Hidrogeles , Quinasas Quinasa Quinasa PAM/metabolismo , Masculino , Ratones Endogámicos C57BL , Fosforilación , Ratas Sprague-Dawley , Proteína Smad2/metabolismo , Sus scrofaRESUMEN
OBJECTIVE: Our specific aim was to introduce the TachoSil binding suturing technique for renal cell carcinoma (RCC) patients when closing the parenchymal defect after tumor excision during laparoscopic partial nephrectomy (LPN), which is a novel technique for reducing the risk of developing subsequent pseudoaneurysm (PA). METHODS: We identified 113 pT1aN0M0 RCC patients who underwent LPN at our institution. Eighty-one (72%) patients underwent the suturing procedure without binding TachoSil, whereas 32 (28%) patients underwent renorraphy with the renal defect closed together with TachoSil. The vascular complications were evaluated by computed tomography or magnetic resonance imaging with enhanced contrast material at the first visit after LPN. We conducted Fischer's exact test to determine risk factors for transcatheter arterial embolization (TAE). RESULTS: The median age was 55 (36-86) years old and the median follow-up time was 65 (12-147) months. In the overall population, there were 11 (11%) patients who underwent TAE because they developed PA. All 11 patients exhibited the imaging findings of PA, and were all from the conventional suturing group. In contrast, no patients for whom the TachoSil binding method was used had any significant findings on imaging (14% vs. 0%). Based on the analysis to determine risk factors for TAE due to PA development, the TachoSil binding suturing technique was one of the significant indicators for reducing the risk of developing PA. CONCLUSIONS: Our study demonstrated that the TachoSil binding suturing technique might reduce the development of PA after LPN. Prospective randomized study and comparison to the standard 2 or 3-layer renorrhaphy is needed to prove its actual value.
Asunto(s)
Aneurisma Falso/prevención & control , Carcinoma de Células Renales/cirugía , Fibrinógeno/uso terapéutico , Neoplasias Renales/cirugía , Riñón/cirugía , Nefrectomía/métodos , Complicaciones Posoperatorias/prevención & control , Técnicas de Sutura , Suturas , Trombina/uso terapéutico , Anciano , Anciano de 80 o más Años , Combinación de Medicamentos , Femenino , Estudios de Seguimiento , Humanos , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
OBJECTIVE: To present our experience using the early unclamping technique for robotic partial nephrectomy with particular attention to delayed complications, namely pseudoaneurysm and urine leak. We hypothesized that early hilar unclamping allows for improved control of end arteries and renorrhaphy after tumor resection, reducing overall delayed complications after partial nephrectomy with no increased risk of blood transfusion. METHODS: This single institution retrospective review of a prospectively maintained database includes patients undergoing robotic partial nephrectomy with early unclamping technique for presumed renal malignancy between 2009 and 2018. Patient demographics and perioperative parameters are described, particularly rates of pseudoaneurysm and urine leak. Results are compared to previously published partial nephrectomy studies using various clamping and renorrhaphy techniques. RESULTS: Four hundred and sixty three patients were included in the study. Mean operative time and warm ischemia time were 186 and 14.7 minutes, respectively. Mean estimated blood loss was 242 cc. Thirty-day postoperative complication rate was 14.7%, with 88% of these Clavien I-II. Urine leak occurred in 1 patient (0.2%) undergoing a simultaneous partial nephrectomy and pyelothitotomy for partial staghorn stone. Postoperative transfusion rate was 1.33% and our pseudoaneurysm rate was 0%. CONCLUSION: The early unclamping technique for robotic partial nephrectomy is reliable and safe, with low pseudoaneurysm and urine leak rates which compare favorably to other published techniques.
Asunto(s)
Aneurisma Falso/prevención & control , Neoplasias Renales/cirugía , Nefrectomía/métodos , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Robotizados/métodos , Incontinencia Urinaria/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma Falso/epidemiología , Constricción , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Factores de Tiempo , Incontinencia Urinaria/epidemiología , Adulto JovenRESUMEN
BACKGROUND: This study characterized the anterior medial malleolar artery (AMMA) branching from the anterior tibial artery (ATA) to identify problems in anterior ankle arthroscopy possibly contributing to injury to the AMMA. METHODS: Barium was injected into 12 adult cadaveric feet via the external iliac artery and the origin and branching direction of the AMMA were identified on computed tomography. RESULTS: The AMMA originated from the level of the ankle joint and below and above the ankle joint line (AJL) in 4 (33.3%), 6 (50.0%), and 1 (8.3%) specimen, respectively. Mean distance from the AJL to the branching point of the AMMA on the sagittal plane was 2.5 mm distal to the AJL. Mean angle between the distal longitudinal axis of the ATA and AMMA was 83.2°. CONCLUSIONS: This study established the origin and branching of the AMMA from the ATA. The AMMA should be examined carefully during ankle arthroscopy. LEVELS OF EVIDENCE: Level IV: Cadaveric study.
Asunto(s)
Articulación del Tobillo/irrigación sanguínea , Arterias/anatomía & histología , Cadáver , Arterias Tibiales/anatomía & histología , Aneurisma Falso/etiología , Aneurisma Falso/prevención & control , Articulación del Tobillo/diagnóstico por imagen , Arterias/diagnóstico por imagen , Artroscopía/efectos adversos , Bario , Humanos , Arterias Tibiales/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Pseudoaneurysm (PSA) is a rare complication (0.2%) after transpedal arterial access (TPA) for endovascular treatment of peripheral arterial disease, occurring only in the posterior tibial artery (PTA) likely related to the anatomy of the vessel leading to unfavorable circumstances for adequate hemostasis. We describe a novel patent hemostasis protocol for TPA access to avoid PSA. METHODS: We prospectively studied 586 patients with symptomatic PAD who underwent 1038 peripheral procedures between 02/2016 and 02/2017 via TPA (dorsalis pedis artery (DP)/anterior tibial artery (ATA), PTA or peroneal artery (PA)). Hemostasis for the DP/ATA was achieved with the Vasostat™ device, while TR Band™ was used for PTA/PA, as per our new protocol (figure). Patent hemostasis technique was confirmed using Doppler. RESULTS: Of the 1038 procedures, 733 (88% interventional) were done via the DP/ATA, 176 (92% interventional) were done via the PTA and 129 (64% interventional) were via the PA. The incidence of PSA related to any access site was 0.0%. All access sites were patent on Doppler ultrasound at 30â¯day follow up. CONCLUSION: PSA associated with TPA is very rare, it can be easily prevented with the above described patent hemostasis protocol while preserving the patency of the access site. CONDENSED ABSTRACT: Pseudoaneurysm (PSA) is a rare complication (0.2%) after transpedal arterial access (TPA). We describe a novel patent hemostasis protocol for TPA access to avoid PSA. We prospectively studied 586 patients with symptomatic PAD who underwent 1038 endovascular procedures via TPA (dorsalis pedis artery (DP)/anterior tibial artery (ATA), PTA or peroneal artery (PA)). Hemostasis for the DP/ATA was achieved with the Vasostat™ device, while TR Band™ was used for PTA/PA, as per our new protocol (figure). Patent hemostasis technique was confirmed using Doppler. The incidence of PSA related to any access site was 0.0%. All access sites were patent on Doppler ultrasound at 30â¯day follow up. PSA associated with TPA is very rare, it can be easily prevented with the above described patent hemostasis protocol while preserving the patency of the access site.
Asunto(s)
Aneurisma Falso/prevención & control , Cateterismo Periférico , Procedimientos Endovasculares , Hemorragia/prevención & control , Técnicas Hemostáticas/instrumentación , Enfermedad Arterial Periférica/terapia , Arterias Tibiales , Lesiones del Sistema Vascular/prevención & control , Anciano , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/epidemiología , Cateterismo Periférico/efectos adversos , Procedimientos Endovasculares/efectos adversos , Femenino , Hemorragia/epidemiología , Técnicas Hemostáticas/efectos adversos , Humanos , Masculino , Ciudad de Nueva York/epidemiología , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/epidemiología , Estudios Prospectivos , Punciones , Factores de Riesgo , Arterias Tibiales/diagnóstico por imagen , Factores de Tiempo , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/epidemiologíaRESUMEN
OBJECTIVES: To assess the safety and efficacy of arteriotomy closure with the intravascular FemoSeal vascular closure device (VCD; St. Jude Medical) compared to manual compression in patients undergoing diagnostic cardiac catheterization via the common femoral artery. BACKGROUND: There is limited evidence on the performance of individual contemporary VCDs compared to manual compression. METHODS: This is a subanalysis of 3018 patients who underwent transfemoral diagnostic coronary angiography and were randomly assigned to arteriotomy closure with either the intravascular FemoSeal VCD or manual compression within the investigator-initiated, large-scale, randomized, multicenter, open-label ISAR-CLOSURE trial. Primary endpoint was the composite of access-site related vascular complications at 30 days. Secondary endpoints were time to hemostasis and repeat manual compression. RESULTS: Vascular access-site complications were lower in patients assigned to the FemoSeal VCD compared to manual compression (6.0% vs 7.9%; P=.04), driven by a lower incidence of hematomas in the FemoSeal group (4.3% vs 6.8%; P<.01). Pseudoaneurysm rates were comparable in both groups (1.5% vs 1.5%; P=.88). Time to hemostasis was significantly shortened with the FemoSeal VCD compared to manual compression (0.5 min [IQR, 0.2-1.0 min] vs 10 min [IQR, 10-15 min]; P<.001). However, repeat manual compression was increased with the FemoSeal VCD (1.5% vs 0.7%; P=.03). CONCLUSION: In patients undergoing transfemoral diagnostic coronary angiography, the use of the FemoSeal VCD is associated with shortened time to hemostasis and a reduction in vascular access-site complications driven by fewer hematomas when compared to manual compression.
Asunto(s)
Aneurisma Falso , Cateterismo Periférico , Angiografía Coronaria , Arteria Femoral/cirugía , Hematoma , Complicaciones Posoperatorias/prevención & control , Dispositivos de Cierre Vascular , Aneurisma Falso/etiología , Aneurisma Falso/prevención & control , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/métodos , Angiografía Coronaria/efectos adversos , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico , Femenino , Hematoma/etiología , Hematoma/prevención & control , Técnicas Hemostáticas , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Dispositivos de Cierre Vascular/efectos adversos , Dispositivos de Cierre Vascular/clasificaciónRESUMEN
AIMS AND BACKGROUND: Although guideline recommendations have shifted towards a transradial route, femoral puncture is still an established vascular access, especially for complex coronary interventions. The FemoSeal™ vascular closure device (FVCD) helps to reduce femoral compression time and access site complications after removal of the catheter sheath. To ensure safe use, an angiography of the femoral artery prior to FVCD deployment is recommended by the manufacturer. We postulate that omitting this angiography does not relevantly increase the risk for vascular complications. METHODS AND RESULTS: In this retrospective analysis of an all-comers population (nâ¯= 1923) including patients receiving a percutaneous coronary intervention (PCI), we could show that combined vascular complication rates without femoral angiography were low (primary endpoint 4.6%) and comparable to a randomized clinical trial that did perform angiography of the vascular access site in a cohort of patients receiving diagnostic coronary angiography only. In addition to this analysis, we could demonstrate that patients with an acute coronary syndrome, receiving periprocedural anticoagulation or anti-platelet therapy had an increased risk for the formation of arterial pseudoaneurysms; however, we did not observe any ischemic vascular event after FVCD deployment. CONCLUSION: Closure of the femoral access site after coronary angiography using the FVCD can be safely performed without femoral angiography; however, due to an increased risk for the formation of pseudoaneurysms we recommend the transradial access in situations with increased bleeding risk.
Asunto(s)
Aneurisma Falso/prevención & control , Angiografía Coronaria , Arteria Femoral/diagnóstico por imagen , Intervención Coronaria Percutánea/métodos , Punciones , Dispositivos de Cierre Vascular , Anciano , Aneurisma Falso/etiología , Austria , Vendajes de Compresión , Femenino , Humanos , Masculino , Persona de Mediana Edad , Arteria Radial , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: Pseudoaneurysms remain a significant complication after vascular procedures. We hypothesized that TGF-ß (transforming growth factor-ß) signaling plays a mechanistic role in the development of pseudoaneurysms. APPROACH AND RESULTS: Rat aortic pericardial patch angioplasty was associated with a high incidence (88%) of pseudoaneurysms at 30 days, with increased smad2 phosphorylation in small pseudoaneurysms but not in large pseudoaneurysms; TGF-ß1 receptors were increased in small pseudoaneurysms and preserved in large pseudoaneurysms. Delivery of TGF-ß1 via nanoparticles covalently bonded to the patch stimulated smad2 phosphorylation both in vitro and in vivo and significantly decreased pseudoaneurysm formation (6.7%). Inhibition of TGF-ß1 signaling with SB431542 decreased smad2 phosphorylation both in vitro and in vivo and significantly induced pseudoaneurysm formation by day 7 (66.7%). CONCLUSIONS: Normal healing after aortic patch angioplasty is associated with increased TGF-ß1 signaling, and recruitment of smad2 signaling may limit pseudoaneurysm formation; loss of TGF-ß1 signaling is associated with the formation of large pseudoaneurysms. Enhancement of TGF-ß1 signaling may be a potential mechanism to limit pseudoaneurysm formation after vascular intervention.
Asunto(s)
Aneurisma Falso/prevención & control , Angioplastia/instrumentación , Aorta/cirugía , Aneurisma de la Aorta/prevención & control , Materiales Biocompatibles Revestidos , Pericardio/trasplante , Factor de Crecimiento Transformador beta1/administración & dosificación , Cicatrización de Heridas/efectos de los fármacos , Aneurisma Falso/etiología , Aneurisma Falso/metabolismo , Aneurisma Falso/patología , Angioplastia/efectos adversos , Animales , Aorta/metabolismo , Aorta/patología , Aneurisma de la Aorta/etiología , Aneurisma de la Aorta/metabolismo , Aneurisma de la Aorta/patología , Células Cultivadas , Masculino , Ratones , Nanopartículas , Fosforilación , Diseño de Prótesis , Ratas Wistar , Transducción de Señal/efectos de los fármacos , Proteína Smad2/metabolismo , Factores de TiempoRESUMEN
BACKGROUND: Transpedal access is increasingly utilized for peripheral vascular catheterization. There is a paucity of data on the use of radial hemostasis devices as an alternative to manual compression for achievement of hemostasis after this approach. OBJECTIVE: To compare safety and efficacy of two hemostasis devices following transpedal catheterization for lower extremity revascularization for peripheral arterial disease. METHODS: A consecutive cohort of patients with bilateral Rutherford 2-5 disease who underwent transpedal catheterization for peripheral vascular interventions were retrospectively analyzed. In each patient, retrograde tibial artery access was obtained, a 4 French sheath was placed, and all revascularization was performed via tibial access. In all patients, a TR Band™ (Terumo Medical, n = 215) and/or VasoStat™ (Forge Medical, n = 99) were used to apply puncture site compression, following removal of the tibial sheath until hemostasis was achieved. Safety and efficacy of each device was compared. RESULTS: Puncture site hemostasis was achieved in all patients within 2 hours of sheath removal facilitating early discharge. Two access site pseudoaneurysms occurred within 30 days of revascularization, one of which followed TR Band™ placement and the other following VasoStat™ placement (P = 0.53). Each patient was successfully treated with ultrasound-guided thrombin injection. Loss of access site patency by duplex ultrasound occurred in 2 patients following the TR Band™ and a single patient following the VasoStat™ (P = 1.0). CONCLUSION: Both the TR Band™ and the VasoStat™ were effective in achieving hemostasis following transpedal catheterization with low rates of complications.
Asunto(s)
Aneurisma Falso , Cateterismo Periférico , Hemostasis Quirúrgica , Técnicas Hemostáticas/instrumentación , Enfermedad Arterial Periférica , Complicaciones Posoperatorias , Arterias Tibiales/cirugía , Anciano , Aneurisma Falso/diagnóstico , Aneurisma Falso/etiología , Aneurisma Falso/prevención & control , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/métodos , Investigación sobre la Eficacia Comparativa , Femenino , Hemostasis Quirúrgica/efectos adversos , Hemostasis Quirúrgica/instrumentación , Hemostasis Quirúrgica/métodos , Humanos , Extremidad Inferior/irrigación sanguínea , Masculino , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/cirugía , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/prevención & control , Resultado del TratamientoRESUMEN
With the promotion of standard radical resection of gastric cancer, the incidence of postoperative pseudoaneurysm is significantly increasing. Both the patient's own factors and iatrogenic factors are accoutable. Surgeons should clarify the causes of pseudoaneurysm, pay attention to the clinical symptoms and signs, and treat the patients appropriately. In order to avoid the occurrence of postoperative pseudoaneurysm, surgeons should carefully evaluate the preoperative conditions, perform precision operation and reduce the morbidity of postoperative infection and fistula.
Asunto(s)
Aneurisma Falso/prevención & control , Gastrectomía , Neoplasias Gástricas/cirugía , Humanos , Incidencia , Morbilidad , Complicaciones Posoperatorias/prevención & controlRESUMEN
OBJECTIVE: We evaluate the prevalence of complications and failure rates between the most commonly used "active" anchoring vascular closure device (VCD), AngioSeal™ and the "passive" anchoring VCD, Mynx™, in all-comers undergoing percutaneous coronary intervention (PCI). METHODS: A total of 4,074 patients between 2008 and 2014, representing an era when both devices were available, were included. Thirty-two percent were acute coronary syndromes (37% STEMI). VCD choice was at the operator's discretion and included AngioSeal (n = 2,910) or Mynx (1,164). Cardiogenic shock or patients receiving intra-aortic balloon pumps were excluded. Safety was assessed by vascular complications defined as either vascular injury (perforation, dissection, acute limb ischemia, arteriovenous fistula, pseudoaneurysm with thrombin injection, or surgical repair) or access-site bleed (hemoglobin droP >3 g/dL requiring transfusion, retroperitoneal bleed, or hematoma >5 cm, or the composite of both. Efficacy was evaluated by device failure and defined as inability to achieve immediate hemostasis or use of additional hemostatic mechanisms. Outcomes at 30-days were evaluated. RESULTS: Groups (AngioSeal vs Mynx) were fairly balanced with regards to bleeding risk factors of gender (male, 65% vs 66%), body mass index (30 ± 6 vs 30 ± 7), heart failure class III/IV (5% vs 6%), chronic kidney disease (15% vs 17%), use of glycoprotein IIb/IIIa inhibitor (5% vs 4%), or bivalirudin (86% vs 88%), all P >0.5. The AngioSeal group was slightly younger (64 ± 12 vs 65 ± 12, P < 0.001) with less peripheral arterial disease (11.3% vs 13.9%, P = 0.03), and increased 7F sheath use compared with Mynx (59% vs 22%, P < 0.001). Safety and efficacy outcomes were similar between groups. CONCLUSIONS: AngioSeal and Mynx appear to be equally safe and efficacious VCDs following PCI. The passive anchoring system may prove desirable as no intra-arterial anchor remains upon device removal.
Asunto(s)
Síndrome Coronario Agudo/cirugía , Hemostasis Quirúrgica/instrumentación , Intervención Coronaria Percutánea/efectos adversos , Hemorragia Posoperatoria/cirugía , Dispositivos de Cierre Vascular , Anciano , Aneurisma Falso/etiología , Aneurisma Falso/prevención & control , Investigación sobre la Eficacia Comparativa , Femenino , Hemostasis Quirúrgica/métodos , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/métodos , Factores de Riesgo , Resultado del Tratamiento , Dispositivos de Cierre Vascular/efectos adversos , Dispositivos de Cierre Vascular/clasificaciónRESUMEN
AIM OF THE STUDY: Delayed hemorrhage, though rare, remains a significant source of morbidity and mortality after pancreaticoduodenectomy (PD). An important cause of this delayed hemorrhage is erosion or pseudoaneurysm formation of the gastroduodenal artery (GDA) by pancreatic enzymes and adjacent intra-abdominal sepsis. So protection of the GDA stump may avoid this devastating complication. PATIENTS AND METHODS: This is a retrospective observational study. All patients, who underwent a PD between August 2007 and December 2014, were included in the study. We used pedicled falciform ligament flap to protect the GDA stump. After PD, pedicled falciform ligament flap was spread widely over the skeletonized hepatic artery including the GDA stump and was fixed to the surrounding retroperitoneal connective tissue. This procedure allowed complete separation of the GDA stump from the pancreatic stump. RESULTS: We performed 182 cases of PD during the study period. Although, 27 (15%) patients developed pancreatic fistula and six patients developed intra-abdominal abscess, no one experienced hemorrhage due to erosion or pseudoaneurysm formation of the GDA. CONCLUSION: The present surgical option seems to be an effective measure for the prevention of erosion and pseudoaneurysm formation of the GDA after PD.
Asunto(s)
Aneurisma Falso/prevención & control , Arteria Hepática/cirugía , Ligamentos/cirugía , Pancreaticoduodenectomía/métodos , Hemorragia Posoperatoria/prevención & control , Colgajos Quirúrgicos , Adulto , Anciano , Aneurisma Falso/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/etiología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: To determine the influence of the early unclamping technique on the risk of renal artery pseudoaneurysm during robot-assisted laparoscopic partial nephrectomy. METHODS: From January 2013 to October 2014, 96 patients underwent robot-assisted laparoscopic partial nephrectomy for renal masses at Tokyo Women's Medical University Hospital, Tokyo, Japan. Computed tomography angiography was carried out 3-4 days after surgery. Early in the series, renal hilum was left unclamped and renorrhaphy was subsequently carried out (conventional unclamping technique). An early unclamping technique has been used since November 2013. RESULTS: A total of 61 patients underwent robot-assisted laparoscopic partial nephrectomy with early unclamping, and 35 patients underwent robot-assisted laparoscopic partial nephrectomy with conventional unclamping. Ischemia time was significantly shorter in the early unclamping group (16.5 vs. 23.1 min; P < 0.01). The early unclamping group showed a significantly lower incidence of asymptomatic renal artery pseudoaneurysm relative to the conventional unclamping group (11.4% vs. 28.6%; P = 0.03). Multivariate analysis showed that the early unclamping technique was a significant independent factor in reducing the risk of renal artery pseudoaneurysm (hazard ratio 0.27; P = 0.01). CONCLUSIONS: The present findings suggest that an early unclamping technique might reduce ischemic time and risk of renal artery pseudoaneurysm. The absence of arterial bleeding before renorrhaphy is likely to be a key step in preventing renal artery pseudoaneurysm during robot-assisted laparoscopic partial nephrectomy.
Asunto(s)
Aneurisma Falso/prevención & control , Riñón/irrigación sanguínea , Nefrectomía/métodos , Arteria Renal , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Angiografía , Femenino , Humanos , Laparoscopía/efectos adversos , Masculino , Persona de Mediana Edad , Nefrectomía/efectos adversos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Isquemia Tibia/efectos adversos , Isquemia Tibia/métodosRESUMEN
Following interventional radiology procedures, bleeding can occur in 0.5 to 4% of the cases. Risk factors are related to the patient, to the procedure, and to the end organ. Bleeding is treated usually by interventional radiologists and consists mainly of embolization. Bleeding complications are preventable: before the procedure by checking hemostasis, during the procedure by ensuring the accurate puncture site (with ultrasound or fluoroscopy guidance) or by treating the puncture path using gelatin sponge, curaspon(®), biological glue or thermocoagulation, and after the procedure by carefully monitoring the patients.
Asunto(s)
Hemorragia/etiología , Anciano , Aneurisma Falso/etiología , Aneurisma Falso/prevención & control , Aneurisma Falso/terapia , Biopsia/efectos adversos , Ablación por Catéter , Cateterismo/efectos adversos , Cateterismo/métodos , Quimioembolización Terapéutica , Embolización Terapéutica/métodos , Femenino , Arteria Femoral , Hemorragia/prevención & control , Hemorragia/terapia , Humanos , Masculino , Punciones , Radiología Intervencionista/métodos , Factores de Riesgo , Tomografía Computarizada por Rayos XRESUMEN
STUDY DESIGN: Case report and review of the literature. OBJECTIVE: To prevent and manage a suspected iatrogenic vertebral artery injury during a cervical spine anterior approach. SUMMARY OF BACKGROUND DATA: The anterior spine approach is a common surgery with few complications. One of the rare but significant risks is vertebral artery injury. Consequences of vertebral artery injuries are often delayed. Therefore, it is essential to prevent this complication and to know how when exploring after a suspected vertebral artery injury. METHODS: Report of a case and review of the literature. A 61-year-old woman presented with a cervical schwannoma involving the C5-C6 foramen. She had undergone surgery 22 years before by the posterior approach. We performed an anterior cervical approach. After 12 days, a vertebral artery pseudo-aneurysm occurred. Our review of the literature is focalized on vertebral artery injuries during cervical surgery by the anterior approach. RESULTS: The patient was treated by coil embolization with a good outcome. To our knowledge, only 6 cases of vertebral artery pseudo-aneurysm after surgery have been reported in the literature. CONCLUSION: According to the literature, vertebral artery pseudo-aneurysms resulting in anterior cervical approach are rare but their consequences could be severe. Prevention begins by detailed surgical planning. Peroperative imaging is helpful. Any suspected vertebral artery injury should postpone a contralateral approach before angiographic imaging.
Asunto(s)
Aneurisma Falso/etiología , Aneurisma Falso/prevención & control , Procedimientos Endovasculares/efectos adversos , Neurilemoma/cirugía , Complicaciones Posoperatorias/prevención & control , Neoplasias de la Columna Vertebral/cirugía , Arteria Vertebral , Adulto , Aneurisma Falso/terapia , Vértebras Cervicales/cirugía , Embolización Terapéutica , Femenino , Humanos , Complicaciones Posoperatorias/terapiaRESUMEN
OBJECTIVE: We sought to elucidate the risks for access site-related complications (ASCs) after percutaneous lower extremity revascularization and to evaluate the benefit of routine ultrasound-guided access (RUS) in decreasing ASCs. METHODS: We reviewed all consecutive percutaneous revascularizations (percutaneous transluminal angioplasty or stent) performed for lower extremity atherosclerosis at our institution from 2002 to 2012. RUS began in September 2007. Primary outcome was any ASC (bleeding, groin or retroperitoneal hematoma, vessel rupture, or thrombosis). Multivariable logistic regression was used to determine predictors of ASC. RESULTS: A total of 1371 punctures were performed on 877 patients (43% women; median age, 69 [interquartile range, 60-78] years) for claudication (29%), critical limb ischemia (59%), or bypass graft stenosis (12%) with 4F to 8F sheaths. There were 72 ASCs (5%): 52 instances of bleeding or groin hematoma, nine pseudoaneurysms, eight retroperitoneal hematomas, two artery lacerations, and one thrombosis. ASCs were less frequent when RUS was used (4% vs 7%; P = .02). Multivariable predictors of ASC were age >75 years (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.7; P = .03), congestive heart failure (OR, 1.9; 95% CI, 1.1-1.3; P = .02), preoperative warfarin use (OR, 2.0; 95% CI, 1.1-3.5; P = .02), and RUS (OR, 0.4; 95% CI, 0.2-0.7; P < .01). Vascular closure devices (VCDs) were not associated with lower rates of ASCs (OR, 1.1; 95% CI, 0.6-1.9; P = .79). RUS lowered ASCs in those >75 years (5% vs 12%; P < .01) but not in those taking warfarin preoperatively (10% vs 13%; P = .47). RUS did not decrease VCD failure (6% vs 4%; P = .79). CONCLUSIONS: We were able to decrease the rate of ASCs during lower extremity revascularization with the implementation of RUS. VCDs did not affect ASCs. Particular care should be taken with patients >75 years old, those with congestive heart failure, and those taking warfarin.
Asunto(s)
Angioplastia de Balón/efectos adversos , Arteria Femoral/diagnóstico por imagen , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/terapia , Ultrasonografía Intervencional , Anciano , Aneurisma Falso/etiología , Aneurisma Falso/prevención & control , Angioplastia de Balón/instrumentación , Boston , Distribución de Chi-Cuadrado , Femenino , Arteria Femoral/lesiones , Hematoma/etiología , Hematoma/prevención & control , Hemorragia/etiología , Hemorragia/prevención & control , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Enfermedad Arterial Periférica/diagnóstico , Punciones , Estudios Retrospectivos , Factores de Riesgo , Stents , Trombosis/etiología , Trombosis/prevención & control , Factores de Tiempo , Resultado del Tratamiento , Dispositivos de Cierre Vascular , Lesiones del Sistema Vascular/etiología , Lesiones del Sistema Vascular/prevención & controlRESUMEN
BACKGROUND: Access site hematomas and pseudoaneurysms are the most frequent complications of peripheral vascular intervention (PVI); however, their incidence and risk factors remain unclear. METHODS AND RESULTS: We retrospectively analyzed data from the multicenter Vascular Quality Initiative on 22 226 patients who underwent 27 048 PVI from August 2007 to May 2013. Primary end points included incidence and predictors of access site complications (ASCs), length of postprocedural hospitalization, discharge status, and 30-day and 1-year mortality. ASC complicated 936 procedures (3.5%). Of these, 74.4% were minor complications, 9.7% were moderate requiring transfusion, 5.4% were moderate requiring thrombin injection, and 10.5% were severe requiring surgery. Predictors of ASC were age >75 years, female sex, white race, no prior PVI, nonfemoral arterial access site, >6-Fr sheath size, thrombolytics, arterial dissection, fluoroscopy time >30 minutes, nonuse of vascular closure device, bedridden preoperative ambulatory status, and urgent indication. Mean hospitalization was longer after procedures complicated by ASC (1.2±1.6 versus 1.9±1.9 days; range, 0-7 days; P=0.002). Severity of ASC correlated with higher rates of discharge to rehabilitation/nursing facilities compared with home discharge. Patients with severe ASC had higher 30-day mortality (6.1% versus 1.4%; P<0.001), and those with moderate ASC requiring transfusion had elevated 1-year mortality (12.1% versus 5.7%; P<0.001). CONCLUSIONS: Several factors independently predict ASC after PVI. Appropriate use of antithrombotic therapies and vascular closure device in patients at increased risk of ASC may improve post-PVI outcomes.
Asunto(s)
Aneurisma Falso/epidemiología , Cateterismo Periférico/efectos adversos , Hematoma/epidemiología , Anciano , Aneurisma Falso/diagnóstico , Aneurisma Falso/mortalidad , Aneurisma Falso/prevención & control , Aneurisma Falso/terapia , Anticoagulantes/uso terapéutico , Transfusión Sanguínea , Cateterismo Periférico/instrumentación , Cateterismo Periférico/mortalidad , Femenino , Fibrinolíticos/uso terapéutico , Hematoma/diagnóstico , Hematoma/mortalidad , Hematoma/prevención & control , Hematoma/terapia , Humanos , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM: Suture line dehiscence and pseudoaneurysm formation is one of the leading causes of late reoperation after surgical repair of acute type A aortic dissection (AAD). A sandwich technique can affect the need of reoperation. We sought to assess the late outcomes (mortality and reoperation) of a modified reinforced sandwich technique in conventional AAD repair. METHODS: Retrospective review of 63 consecutive patients undergoing AAD repair between 2003 and 2013. Aortic anastomosis was performed with a modified reinforced sandwich technique using Hemashield strips and two-layer polypropylene continuous and interrupted mattress sutures. RESULTS: Marfan syndrome was diagnosed in five (8%) and bicuspid aortic valve in three patients (5%). Twenty-one patients (33%) had preoperative cardiogenic shock necessitating inotropic support. Replacement of the ascending aorta with aortic valve preservation was performed in 58 (92%) and hemiarch replacement in five patients (8%). Four patients died during initial hospitalization, yielding a hospital mortality of 6%. Median follow-up duration was 73 months (range, 1-124). Kaplan-Meier survival rates were 94 ± 3%, 84 ± 5%, and 59 ± 11% at 1, 5, and 10 years. One patient (1.7%) required proximal reoperation 44 months after AAD repair because of progressive dilatation of the aortic root. No patient had severe aortic regurgitation or pseudoaneurysm after AAD repair. Actuarial freedom from reoperation at 1, 5, and 10 years was 100%, 97%, and 97%. CONCLUSIONS: A reinforced sandwich technique was a good technique resulting in a low incidence of late reoperation and pseudoaneurysm formation.
Asunto(s)
Aneurisma Falso/epidemiología , Aorta/cirugía , Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Complicaciones Posoperatorias/epidemiología , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/métodos , Disección Aórtica/mortalidad , Aneurisma Falso/prevención & control , Aneurisma de la Aorta/mortalidad , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Tasa de Supervivencia , Técnicas de Sutura , Resultado del TratamientoRESUMEN
BACKGROUND: The role of vascular closure devices (VCDs) in patients having percutaneous coronary intervention (PCI) is controversial, and recommendations for use vary. OBJECTIVE: To examine the use of and outcomes associated with VCDs in real-world practice. DESIGN: Observational cohort study. SETTING: 32 hospitals in Michigan that participate in a large multicenter quality improvement collaborative. PATIENTS: Consecutive patients having emergent and nonemergent PCI from 2007 to 2009. MEASUREMENTS: Vascular complications and the need for transfusion. RESULTS: Of the 85 048 PCIs performed during the study that met the inclusion criteria, 28 528 (37%) procedures used VCDs. In propensity score-matched analysis, VCDs were associated with reductions in vascular complications (odds ratio [OR], 0.78 [95% CI, 0.67 to 0.90]; P = 0.001) and postprocedure transfusions (OR, 0.85 [CI, 0.74 to 0.96]; P = 0.011). These findings were consistent across many prespecified subgroups except for patients with a body mass index (BMI) less than 25 kg/m2 and those treated with platelet glycoprotein (GP) IIb/IIIa inhibitors, in whom the benefit of VCDs over manual closure was attenuated. When the specific subtypes of vascular complications were evaluated, VCDs were associated with fewer hematomas (OR, 0.69 [CI, 0.58 to 0.83]; P < 0.001) or pseudoaneurysms (OR, 0.54 [CI, 0.38 to 0.76]; P < 0.001) but an increase in the odds of retroperitoneal bleeding (OR, 1.57 [CI, 1.12 to 2.20]; P = 0.009). LIMITATION: Unmeasured confounding cannot be excluded despite the study having measured and balanced many confounders. CONCLUSION: Vascular closure devices were associated with a significant reduction in vascular complications and need for transfusion in this large cohort of patients having transfemoral PCI. This benefit was lost in patients receiving GP IIb/IIIa inhibitors and those with normal or lean BMI and was counterbalanced by a small increase in the more serious risk for retroperitoneal bleeding.