RESUMO
Endovascular reconstruction has become the standard treatment of chronic obstruction of large veins. Stenting is done with increasing frequency to treat iliac venous obstructions, with or without associated inferior vena caval or femoral vein occlusions. Open reconstruction with venous bypass is performed today in patients who fail attempts at venous stenting or who are not candidates for endovascular reconstructions. Patients with primary or secondary malignancies invading the vena cava undergo open caval reconstruction at the time of tumour excision. Open venous reconstructions are still preferred in patients with large vein injuries due to blunt or penetrating trauma or in those who suffer iatrogenic venous injuries. Hybrid reconstruction can be performed with endophlebectomy of the common femoral or femoral veins combined with iliofemoral stenting.
Assuntos
Procedimentos Endovasculares/métodos , Veia Ilíaca/cirurgia , Neoplasias/cirurgia , Stents , Doenças Vasculares/cirurgia , Veia Cava Inferior/cirurgia , Humanos , Veia Ilíaca/lesões , Neoplasias/complicações , Doenças Vasculares/etiologiaRESUMO
BACKGROUND: Locally recurrent rectal cancer involving the upper sacrum is generally considered a contra-indication to curative surgery. The aim of this study was to determine if a survival benefit was seen in patients undergoing high sacrectomy. METHODS: All patients with locally recurrent rectal cancer involving the sacrum above the 3rd sacral body between 1999 and 2007 were retrospectively reviewed. Kaplan-Meier survival analysis was performed. RESULTS: Nine patients were identified with a median age of 63 years. The proximal extent of sacral resection was through S2 (n = 6), S1 (n = 2), and L5-S1 (n = 1). All patients had R0 negative-margin resection. Median operative time was 13.7 hr, and median operative blood transfusion was 3.7 L. Thirty-day mortality was nil. Postoperative complications requiring surgical intervention occurred in three patients. Local re-recurrence in the pelvis occurred in one patient. The overall median survival was 31 months (range, 2-39 months). Three patients still alive are free of disease after 40, 76, and 101 months, respectively. Ultimately, all deaths were due to metastatic disease. CONCLUSIONS: High sacrectomy that achieves clear margins in patients with recurrent rectal cancer is safe and feasible. A majority will die of metastatic disease, but long-term survival may be possible in some patients.
Assuntos
Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/cirurgia , Neoplasias Retais/mortalidade , Neoplasias Retais/cirurgia , Sacro/cirurgia , Neoplasias da Coluna Vertebral/secundário , Neoplasias da Coluna Vertebral/cirurgia , Adulto , Idoso , Causas de Morte , Colostomia , Intervalo Livre de Doença , Estudos de Viabilidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Laparotomia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias da Coluna Vertebral/mortalidade , Derivação UrináriaRESUMO
FiberNet(®) is a second generation non-conventional embolization protection device (EPD) that purports to offer several advantages: ability to capture debris as small as 40 µm, more flexibility with placement and positioning in curved segments requiring a small landing zone, ability to conform to asymmetric vessels, and improved deliverability. The design features a low profile with large surface area to capture debris. Legitimate concerns include inducement of obstruction or low flow with debris capture and requirements in the IFU to aspirate during re-capture and device removal. Our goal was to compare the results of carotid artery stenting (CAS) using FiberNet(®) against a multi-center experience of CAS using other filter devices to identify any differences in technical success or event rates. FiberNet(®) (n=25) results were compared to all CAS cases performed at the Mayo Clinic in Rochester, MN, St Mary's/Duluth Clinic in MN, and North Central Heart Institute in Sioux Falls, SD (n=250) from March 2001 to December 2008. Chi-square or means were used to compare variables, as appropriate. Bivariate logistic regression was used to identify possible correlates of adverse outcome. Statistical significance was set at < 0.05. FiberNet(®) patients were more likely to be older (78.1+5.4 vs 73.6+9.4, p=0.019), female (48% vs 29%, p=0.047), and have peripheral vascular disease (84.0% vs 37.2%, p=0.025), and less likely to have diabetes (8.0% vs 29.8%, p=0.012) than patients in the comparison group. FiberNet(®) patients had more lesion calcification (40.0% vs 18.9%, p=0.014) and increased number of type 2 and 3 arches (44.2% vs 73.9%, p=0.006). Procedural success rate was 100% in both groups. None of the FiberNet(®) patients showed evidence of stagnant flow. The thirty-day outcome for TIA, CVA, or death was 4% in FiberNet(®) versus 4.8% in the comparison group (p NS). None of the independent variables - age gender, serum creatinine, arch complexity, lesion length, lesion calcium, lesion thrombus, PVD, diabetes, contralateral carotid occlusion, or ipsilateral carotid endarterectomy - predicted adverse events. Although FiberNet(®) patients had more lesion calcium and more challenging arch anatomy, procedural success and adverse events were comparable between groups. The advantages of FiberNet(®) can be applied to CAS with good technical results and may be a promising EPD for certain high-risk situations.
RESUMO
Surgically correctable causes of hypertension are uncommon. Simultaneous occurrence of 2 such causes in the same individual is extremely rare. The authors describe a 25-year-old woman with congenital erythrocytosis, renal artery stenosis, and a paraganglioma. The possible mechanisms of renal artery stenosis in the presence of a catecholamine-secreting tumor are discussed.
Assuntos
Hipertensão Renovascular/etiologia , Neoplasias Renais/complicações , Paraganglioma/complicações , Obstrução da Artéria Renal/complicações , Adulto , Feminino , Humanos , Neoplasias Renais/cirurgia , Imageamento por Ressonância Magnética , Paraganglioma/cirurgia , Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/diagnóstico , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: Infected aortic aneurysms are rare, difficult to treat, and associated with significant morbidity. The purpose of this study was to review the management and results of patients with infected aortic aneurysms and identify clinical variables associated with poor outcome. METHODS: The clinical data and early and late outcomes of 43 patients treated for infected aortic aneurysms during a 25-year period (1976-2000) were reviewed. Variables were correlated with risk of aneurysm-related death and vascular complications, defined as organ or limb ischemia, graft infection or occlusion, and anastomotic or recurrent aneurysm. RESULTS: Infected aneurysms were infrarenal in only 40% of cases. Seventy percent of patients were immunocompromised hosts. Ninety-three percent had symptoms, and 53% had ruptured aneurysms. Surgical treatment was in situ aortic grafting (35) and extra-anatomic bypass (6). Operative mortality was 21% (9/42). Early vascular complications included ischemic colitis (3), anastomotic disruption (1), peripheral embolism (1), paraplegia (1), and monoparesis (1). Late vascular complications included graft infection (2), recurrent aneurysm (2), limb ischemia (1), and limb occlusion (1). Mean follow-up was 4.3 years. Cumulative survival rates at 1 year and 5 years were 82% and 50%, respectively, significantly lower than survival rates for the general population (96% and 81%) and for the noninfected aortic aneurysm cohort (91% and 69%) at same intervals. Rate of survival free of late graft-related complications was 90% at 1 year and 5 years, similar to that reported for patients who had repair of noninfected abdominal aortic aneurysms (97% and 92%). Variables associated with increased risk of aneurysm-related death included extensive periaortic infection, female sex, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location (P <.05). For risk of vascular complications, extensive periaortic infection, female sex, leukocytosis, and hemodynamic instability were positively associated (P <.05). CONCLUSION: Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. However, late outcome is surprisingly favorable, with no aneurysm-related deaths and a low graft-related complication rate, similar to standard aneurysm repair. In situ aortic grafting is a safe and durable option in most patients.
Assuntos
Aneurisma Infectado/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Idoso , Aneurisma Infectado/diagnóstico , Aneurisma Infectado/mortalidade , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular , Feminino , Seguimentos , Humanos , Masculino , Fatores de Risco , Fatores de TempoRESUMO
The purpose of this study was to examine the technical aspects of intraoperative duplex ultrasound (DUS) following carotid endarterectomy (CEA), suggest criteria to differentiate significant lesions requiring immediate surgical revision from normal or benign defects, and evaluate how frequently intraoperative DUS provides useful or unsuspected information. A retrospective study was performed on all patients who had both CEA and intraoperative carotid DUS between January 1, 1990, and January 1, 1995. A total of 155 DUS examinations were performed in 149 patients. Findings were grouped into three categories: normal; minor/insignificant lesions; and hemodynamically significant lesions based on the presence or absence of elevated peak systolic velocities, visible stenosis/thrombus, or intimal flap/dissection. Postoperative status was correlated with intraoperative DUS findings. Ninety-one (59%) examinations performed on 87 patients produced normal findings. Forty-seven (30%) examinations performed on 45 patients showed minor abnormalities consisting of insignificant residual plaque, residual external carotid artery stenoses, small intimal flaps, elevated velocities with no associated anatomic lesion, or an arterial kink. Fourteen patients (9%) had significant findings requiring immediate surgical revision. These consisted of large intimal flaps or dissection in six patients, marked residual plaque and significant stenosis in five patients, thrombus in two patients, and a kink in one patient. Three additional patients (2%) had significant findings but were not revised for various reasons. No significant difference was identified in morbidity or mortality rates between those patients with normal findings, those patients with minor technical defects, and those patients with significant abnormalities undergoing immediate surgical revision. However, two of three patients who had significant abnormalities within the common carotid artery that were not revised suffered perioperative ipsilateral strokes. Intraoperative DUS is a safe and accurate method to assess the technical adequacy of CEA. Intraoperative DUS showed significant lesions in 11% of patients. Identification and immediate repair of significant technical defects may decrease perioperative complication rate and long-term restenosis rate.
Assuntos
Endarterectomia das Carótidas , Cuidados Intraoperatórios , Ultrassonografia Doppler Dupla , Idoso , Velocidade do Fluxo Sanguíneo/fisiologia , Artéria Carótida Primitiva/diagnóstico por imagem , Artéria Carótida Primitiva/cirurgia , Artéria Carótida Externa/diagnóstico por imagem , Artéria Carótida Externa/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/complicações , Estenose das Carótidas/fisiopatologia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Análise de SobrevidaRESUMO
OBJECTIVE: Rupture of abdominal aortic aneurysms (AAAs) remains lethal. In a report of patients treated in the 1980s, we recommended aggressive management. Our continued experience prompted us to reevaluate this policy. METHODS: We reviewed clinical variables affecting outcome, morbidity, mortality, and trends in mortality of all patients managed at our institution with ruptured AAAs between January 2, 1980, and November 30, 1998. RESULTS: The study group included 413 consecutive patients, 339 men and 74 women. The mean age was 74.3 years (range, 49-96); 116 (28%) patients were older than 80 years. AAA was diagnosed before rupture in 119 (29%) patients. Eighty (19%) patients had preoperative cardiac arrest. Twenty-nine (7%) patients died before operation; 65 (17%) died during the operation. The surgical mortality rate (30-day) was 37%; the overall mortality rate was 45% and was higher in women (68%) than in men (40%) (P <.001). Advanced age, APACHE (Acute Physiology and Chronic Health Evaluation) II score, initial hematocrit, and preoperative cardiac arrest were associated multivariately with 30-day mortality rates by means of stepwise logistic regression (P <.05). Twelve (23%) of 53 patients with cardiac arrest survived the operation. Logistic regression, adjusted for age, sex, and APACHE II score, demonstrated a decrease in overall and 30-day mortality rates (P <.001) over 18 years. The mean overall mortality rate was 51% from 1980 to 1984 and 42% from 1994 to 1998. CONCLUSIONS: The mortality rate of ruptured AAAs remains excessive, despite improvement over 18 years. Patients older than 80 years with shock or cardiac arrest have the highest mortality rate and should be evaluated for possible endovascular treatment. Because the diagnosis of AAA was unknown in more than 70% of patients, screening of the high-risk population and elective repair are recommended.
Assuntos
Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/mortalidade , Ruptura Aórtica/cirurgia , APACHE , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosAssuntos
Falso Aneurisma/tratamento farmacológico , Pé Diabético/cirurgia , Pé/irrigação sanguínea , Oclusão de Enxerto Vascular/tratamento farmacológico , Isquemia/cirurgia , Trombina/administração & dosagem , Veias/transplante , Idoso , Anastomose Cirúrgica , Falso Aneurisma/diagnóstico por imagem , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Injeções Intralesionais , Isquemia/diagnóstico por imagem , Masculino , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/cirurgia , UltrassonografiaRESUMO
PURPOSE: Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience. METHODS: The clinical data of all patients who underwent venous reconstruction for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalignant disease between January 1985 and June 1999 were retrospectively reviewed. Patients were classified, and outcomes were compared according to the guidelines of the Joint Vascular Societies. RESULTS: Forty-two patients, 23 males and 19 females (mean age, 40 years; range, 16-81), underwent 44 venous reconstructions. Thirty-six patients had limb swelling or venous claudication, 38 had pain, and 14 had healed or active ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC occlusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylene (ePTFE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 cavoatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow-up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studies averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma procedures had a 4-year patency rate of 83%. The secondary patency rate of iliocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The secondary patency was lower in patients with an arteriovenous fistula (P =.023). All ePTFE grafts had a 45% patency rate at 2 years, not significantly different from saphenous vein grafts (83%, P =.16). Clinical scores improved with graft patency (median, 0.0 vs 1.5; P =.044). CONCLUSIONS: Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTFE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial.
Assuntos
Veia Femoral/cirurgia , Veia Ilíaca/cirurgia , Doenças Vasculares/cirurgia , Veias/transplante , Veia Cava Inferior/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Constrição Patológica/diagnóstico , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Doenças Vasculares/diagnóstico , Grau de Desobstrução VascularRESUMO
OBJECTIVES: Assessments of outcome after reconstruction for critical limb ischemia frequently ignore functional result and long-term morbidity and mortality. This study was undertaken to identify factors affecting long-term clinical outcome and survival after pedal bypass grafting. METHODS: The clinical data of 256 consecutive patients who underwent pedal bypass grafting for critical limb ischemia over a 12-year period were retrospectively analyzed. RESULTS: A total of 174 men and 82 women (median age, 70 years; range, 30-91 years) underwent 280 pedal bypass graft placements with autologous vein. Seventy-five percent of the patients were diabetic, and 20% had renal insufficiency (serum creatinine level > 2 mg/dL). The in-hospital mortality rate was 1.6% (4/256). The mean follow-up was 2.7 years (range, 0.1-10.1 years). Rates of primary and secondary patency, limb salvage, and survival at 5 years were 58%, 71%, 78%, 60%, respectively. A total of 160 limbs (57%) required additional interventions. Nineteen early graft thrombectomies/revisions and nine early amputations were performed. One hundred thirty-eight late interventions included 31 graft salvage procedures, 27 wound debridements, and 34 minor and 42 major amputations. At last follow-up or death, 219 (78%) limbs were being used for ambulation. End-stage renal disease (ESRD) and composite vein grafts predicted limb loss (P <.001, P <.001, respectively). Overall survival at 5 years was 60%. Survival after amputation was 79%, 53%, and 26% at 1, 3, and 5 years. Amputation and ESRD predicted higher mortality (P =.014, P =.0001, respectively). CONCLUSIONS: Pedal bypass grafting resulted in good functional limb salvage, but at the expense of multiple interventions in more than half the cases. ESRD and composite vein graft were associated with poor long-term limb salvage. Amputation after bypass grafting was associated with significantly worse long-term survival.
Assuntos
Implante de Prótese Vascular , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Artérias/cirurgia , Feminino , Seguimentos , Pé/irrigação sanguínea , Humanos , Isquemia/mortalidade , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Taxa de Sobrevida , Veias/transplanteRESUMO
PURPOSE: To determine the accuracy of elliptic centric contrast material-enhanced magnetic resonance (MR) angiography by using conventional angiography as the reference standard. MATERIALS AND METHODS: Fifty patients were examined prospectively with contrast-enhanced MR angiography and conventional angiography. The two examinations were performed within 1 week of each other. Two patients underwent conventional angiography of only one carotid artery, which yielded 98 arteries for comparison. RESULTS: With conventional angiography as the reference standard and by using a 70% threshold for internal carotid arterial diameter stenosis, maximum intensity projection (MIP) images had a sensitivity of 93.3%, specificity of 85.1%, and accuracy of 87.6%, whereas reformatted transverse source images had a sensitivity of 83.3%, specificity of 97.0%, and accuracy of 92.8%. Interobserver variability for conventional angiograms was 0.97, for MIP images was 0.91, and for source images was 0.90. The contrast-enhanced MR angiographic technique had a sensitivity of 88.9% and specificity of 58.1% for the presence of irregularity and/or ulceration. All 50 examinations were triggered appropriately so that minimal or no venous signal intensity was depicted. CONCLUSION: Contrast-enhanced elliptic centric three-dimensional MR angiography offers high-spatial-resolution, venous-suppressed images of the carotid arteries that appear to be adequate to replace conventional angiography in most patients examined prior to carotid endarterectomy.
Assuntos
Estenose das Carótidas/diagnóstico por imagem , Angiografia por Ressonância Magnética/métodos , Idoso , Idoso de 80 Anos ou mais , Angiografia , Meios de Contraste , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
Use of pedal bypass can salvage limbs of patients with critical ischemia. The aim of this study was to evaluate the results of surgical revascularization of pedal arteries in diabetic patients and to assess the impact of diabetes on long-term outcome. We performed a retrospective analysis of all consecutive pedal bypasses done between January 1, 1987 and December 31, 1997. Demographic data, surgical indications, operative variables, and postoperative results including graft patency and limb salvage were compared between diabetic and nondiabetic patients. The results of this comparison showed that pedal bypass can safely and effectively relieve critical ischemia in diabetic patients. Diabetics have less early graft thrombosis and superior long-term graft patency. Despite higher incidence of renal insufficiency or failure and more tissue loss, diabetics can achieve similar excellent limb salvage rates. This outcome justifies aggressive revascularization of pedal arteries in diabetic as well as nondiabetic patients with critical limb ischemia.
Assuntos
Implante de Prótese Vascular , Angiopatias Diabéticas/cirurgia , Pé/irrigação sanguínea , Isquemia/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiopatias Diabéticas/mortalidade , Feminino , Seguimentos , Oclusão de Enxerto Vascular/mortalidade , Humanos , Isquemia/mortalidade , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Aortic fenestration is rarely required for patients with acute or chronic aortic dissection. To better define its role and the indications for its use and to evaluate its success at relieving organ or limb malperfusion, we reviewed our experience with direct fenestration of the aorta. METHODS: A retrospective analysis of all consecutive aortic fenestrations performed between January 1, 1979, and December 31, 1999, was performed. Fourteen patients, 12 men and two women (mean age, 59.6 years; range, 43-81), underwent fenestration of the aorta. All patients were hypertensive and had a history of tobacco use. By Stanford classification, there were three type A and 11 type B patients. In the acute dissection group (n = 7), indications for surgery were malperfusion in six patients (leg ischemia, 4; renal ischemia, 5; bowel ischemia, 3) and intra-abdominal bleeding from rupture in two. In the chronic dissection group (n = 7), indications for surgery were abdominal aortic aneurysm in 4 patients (infrarenal, 3; pararenal, 1), thoracoabdominal aneurysm in 1, hypertension from coarctation of the thoracic aorta in 1, and aortic occlusion with disabling claudication in 1. RESULTS: Emergency aortic fenestration was performed in seven patients (surgically for 6 and percutaneously for 1). Fenestration level was infrarenal in four and pararenal in three. Concomitant abdominal aortic graft replacement was performed in four patients, combined with ascending aortic replacement (n = 1) and bilateral aortorenal bypasses (n = 1). In two patients, acute fenestration was performed for organ malperfusion after prior proximal aortic replacement (ascending aorta, 1; descending thoracic aorta, 1). Seven elective aortic fenestrations were performed for chronic dissection (descending thoracic aorta, 2; paravisceral aorta, 2; infrarenal aorta, 2 and pararenal aorta, 1). Concomitant aortic replacement was performed in six patients (abdominal aorta, 5; thoracoabdominal aorta, 1). Fenestration was successful at restoring flow in all 10 patients with malperfusion. Operative mortality for emergency fenestration was 43% (3/7). The three deaths that occurred were of patients with anuria or bowel ischemia, or both. There were no postoperative deaths for elective fenestration. At a mean follow-up of 5.1 years, there were no recurrences of malperfusion and no false aneurysm formations at the fenestration site. CONCLUSION: Fenestration of the aorta can effectively relieve organ or limb ischemia. Bowel ischemia and anuria are indicators of dismal prognosis and emergency fenestration in these patients carries a high mortality. Elective fenestration combined with aortic replacement can be performed safely in chronic dissection. Aortic fenestration is indicated for carefully selected patients with malperfusion and offers durable benefits.
Assuntos
Aorta/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Procedimentos Cirúrgicos Eletivos , Tratamento de Emergência , Feminino , Humanos , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Procedimentos Cirúrgicos VascularesRESUMO
A case of delayed postoperative visual loss due to bilateral traumatic carotid artery dissection is presented. In patients with a major craniofacial injury due to a high-speed motor vehicle accident, we suggest that carotid artery duplex ultrasonography be used in the initial evaluation for possible carotid artery dissection. Magnetic resonance imaging of the head and neck with magnetic resonance angiography should be performed subsequently if indicated. Early diagnosis and initiation of therapy can minimize complications.
Assuntos
Dissecção Aórtica/etiologia , Cegueira/etiologia , Lesões das Artérias Carótidas/complicações , Traumatismos Craniocerebrais/complicações , Doenças do Nervo Óptico/complicações , Acidentes de Trânsito , Adulto , Dissecção Aórtica/diagnóstico por imagem , Lesões das Artérias Carótidas/diagnóstico por imagem , Lesões das Artérias Carótidas/etiologia , Traumatismos Craniocerebrais/etiologia , Diagnóstico Diferencial , Feminino , Humanos , Imageamento por Ressonância Magnética , Doenças do Nervo Óptico/etiologia , Tomografia Computadorizada por Raios X , UltrassonografiaRESUMO
OBJECTIVES: Resection and replacement of the inferior vena cava (IVC) to remove malignant disease is a formidable procedure. Since our initial report with IVC replacement for malignancy, we have maintained an aggressive approach to these patients. The purpose of this review is to update our experience with regard to patient selection, operative technique, and early and late outcome. METHODS: All patients who had IVC replacement for primary (n = 2) or secondary (n = 27) vena cava tumors from April 1990 to May 1999 were reviewed. Tumor location and type, clinical presentation, the segment of IVC replaced, graft patency, performance status of the patient, and tumor recurrence and survival data were collected. Late follow-up data were available for all but one patient. The IVC was replaced in 28 patients with large diameter (> or =14 mm) externally supported ePTFE grafts and with a panel graft of superficial femoral vein in the other. Three patients had a femoral arteriovenous fistula. Graft patency was determined before hospital dismissal and in follow-up by vena cavography, computed tomography, ultrasonography, or magnetic resonance imaging. RESULTS: There were 18 women and 11 men, with a mean age of 53.1 years (range, 16-88 years). Over one half of patients had symptoms from their tumor. IVC replacement was at the suprarenal segment in 15 patients, of whom 13 had concomitant major hepatic resection, at the infrarenal segment in 10, at both caval segments in three, and at the renal vein confluence in one. There were two early deaths (6.9%). One patient died intraoperatively of coagulopathy during liver resection and suprarenal IVC replacement. The other death occurred 4 months postoperatively, from multisystem organ failure that resulted in graft infection and occlusion. Twelve patients had one or more major complications- cardiopulmonary problems in five; bleeding in five; chylous ascites or large pleural effusions in two patients each; and lower extremity edema with tibial vein thrombosis in one. The mean follow-up was 2.8 years (range, 2.7 months to 6.3 years). Two late graft occlusions occurred: one at 7.5 months, the other, from tumor recurrence, at 6.3 years. There have been no other late graft-related complications. All 11 late deaths were caused by the progression of malignant disease. Of 16 survivors, 12 have no evidence of disease and four have either regional or distant metastatic recurrence. Initial postoperative performance status was good or excellent for most survivors. CONCLUSIONS: Aggressive surgical management may offer the only chance for cure or palliation of symptoms for patients with primary or secondary IVC tumors. Our experience suggests that vena cava replacement may be performed safely with low graft-related morbidity and good patency in carefully selected patients.
Assuntos
Implante de Prótese Vascular , Neoplasias Vasculares/cirurgia , Veia Cava Inferior/cirurgia , Adolescente , Adulto , Idoso , Implante de Prótese Vascular/métodos , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/estatística & dados numéricos , Causas de Morte , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia , Neoplasias Vasculares/diagnóstico por imagem , Neoplasias Vasculares/mortalidade , Neoplasias Vasculares/patologia , Veia Cava Inferior/diagnóstico por imagemRESUMO
OBJECTIVE: Great vessel reconstruction for arterial occlusive disease has been shown to be a durable procedure. The purpose of this report is the examination of the influence of cause and risk factors on outcomes for the identification of patients who may be better treated with endovascular techniques or other surgical approaches. METHODS: Data for patients who underwent aortic-origin great vessel reconstruction between 1988 and 1998 were reviewed. The data were analyzed with Fisher exact test, life-table analysis, and log-rank test. RESULTS: Ninety-two vessels underwent revascularization in 58 patients (15 men, 43 women; mean age, 54 years; age range, 20 to 82 years). Etiology was atherosclerosis obliterans (n = 40; 69%), Takayasu's arteritis (n = 13; 22%), radiation arteritis (RA; n = 4; 7%), and mediastinal fibrosis (n = 1; 2%). The symptoms were cerebrovascular (n = 25), upper extremity (n = 8), or both (n = 23), and two patients were asymptomatic. The bypass grafting was performed with single-limb synthetic grafts (n = 23) or grafts plus side arms (n = 28). Seven patients underwent innominate endarterectomy. The mean follow-up period was 45 months (range, 0 to 126 months). The perioperative stroke (n = 4; 7%) and death (n = 2; 3%) rates were not related to the cause of disease. The patients with creatinine levels of 2 or more (n = 4) had a combined perioperative stroke/death rate of 50% (vs 7% for patients with healthy creatinine levels; P <.05). The patients with hypercoagulable states (ie, thrombophilia; n = 6) had an increased perioperative stroke rate (33% vs 4% for patients without hypercoagulable states; P <.05) and an increased late thrombosis rate. The primary and secondary graft patency rates at 5 years were 80% +/- 7% and 91% +/- 5%, respectively. Patients with RA had a greater risk of stroke or death at 3 years (33% free of stroke or death vs 79% for patients with atherosclerosis obliterans and 92% for patients with Takayasu's arteritis; P =.02) and an increased major late infection rate (50% vs 2% for all others; P =.01). CONCLUSION: Patients with thrombophilia and renal insufficiency have increased perioperative stroke and stroke/death rates, respectively. Patients with RA have an increased incidence rate of late major infection, which directly contributes to an increased rate of stroke or death. Patients with thrombophilia have an increased rate of late graft thrombosis. These patient conditions should be approached cautiously, and some patients may benefit from endovascular therapy.
Assuntos
Aorta/cirurgia , Implante de Prótese Vascular , Procedimentos de Cirurgia Plástica , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/estatística & dados numéricos , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Incidência , Tábuas de Vida , Masculino , Pessoa de Meia-Idade , Procedimentos de Cirurgia Plástica/mortalidade , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique. METHODS: The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103). RESULTS: Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection. CONCLUSIONS: Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.
Assuntos
Aorta/cirurgia , Implante de Prótese Vascular/métodos , Prótese Vascular/efeitos adversos , Infecções Relacionadas à Prótese/cirurgia , Abscesso/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Biofilmes , Implante de Prótese Vascular/efeitos adversos , Colágeno , Feminino , Artéria Femoral/cirurgia , Seguimentos , Gelatina , Oclusão de Enxerto Vascular/etiologia , Humanos , Artéria Ilíaca/cirurgia , Fístula Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Poliésteres , Complicações Pós-Operatórias , Recidiva , Reoperação , Estudos Retrospectivos , Rifampina/administração & dosagem , Rifampina/uso terapêutico , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Autogenous bypass grafts to pedal arteries have successfully salvaged limbs and restored function in patients with critical ischemia. The benefits of secondary interventions to save failing or already failed grafts remains uncertain. METHODS: A retrospective analysis was made of consecutive pedal bypasses performed between 1987 and 1998. Patency and limb salvage by life-table analysis and variables affecting outcome were compared with the log-rank test. RESULTS: Two hundred thirteen patients, 144 males, 69 females (mean age 68 years, range 30 to 91) underwent pedal bypass grafting in 228 limbs using autogenous vein grafts (nonreversed saphenous vein, n = 190; reversed, n = 15; composite, n = 23). One-hundred fifty-seven patients were diabetic, 34 had renal insufficiency (serum creatinine >2.0), and 14 were on dialysis. Gangrene or ulceration were present in 224 patients, rest pain in 24. Cumulative primary and secondary patency rates were 57% and 67% at 5 years. Limb salvage was 78% at 5 years. Secondary interventions in 46 patients included patch angioplasty/surgical revision (n = 28), thrombectomy (n = 15), thrombolysis (n = 11), and balloon angioplasty (n = 6). Patency in 19 of 26 (73%) failed grafts and in 19 of 20 (95%) failing grafts could be restored initially. Cumulative 2-year patency and limb salvage rates following reinterventions were 36% and 58%, respectively. Patency rates and limb salvage for failed grafts (7%, 44%) were significantly worse than those for failing grafts (81%, 77%; P <0.0001, P <0.05, respectively). All patients with renal insufficiency who underwent reinterventions for failed or failing grafts required major amputation within 1 year (P <0.0001 versus those without renal insufficiency). CONCLUSION: Autogenous pedal bypass grafts are durable operations with excellent long-term patency and limb salvage rates. Revision of failing grafts has been effective using both endovascular and surgical techniques. Failed grafts have poor long-term patency and moderate limb salvage rates, and our data do not justify secondary procedures to attempt to save failed grafts in patients with renal insufficiency.
Assuntos
Pé/irrigação sanguínea , Isquemia/cirurgia , Veias/transplante , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Angioplastia , Angioplastia com Balão , Artérias/cirurgia , Complicações do Diabetes , Feminino , Seguimentos , Pé/cirurgia , Úlcera do Pé/complicações , Gangrena , Sobrevivência de Enxerto , Humanos , Tábuas de Vida , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/complicações , Retratamento , Estudos Retrospectivos , Veia Safena/transplante , Trombectomia , Terapia Trombolítica , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND AND PURPOSE: Several prospective trials have shown that ischemic stroke can be prevented by performing an endarterectomy in patients with high-grade carotid stenosis. Our purpose was to ascertain the frequency of carotid artery tandem lesions and to determine whether their presence alters the surgeon's decision to perform an endarterectomy. METHODS: We retrospectively reviewed the cerebral angiograms obtained between January 1994 and June 1996 in 853 patients with carotid occlusive disease. Studies were analyzed for the presence of internal carotid artery (ICA) stenosis as well as for tandem lesions (defined as > or = 50% diameter stenosis) within the common carotid artery, carotid siphon, or proximal intracranial arteries. The frequency of intracranial saccular aneurysms was determined. RESULTS: Six hundred seventy-two of the 853 patients had a carotid bifurcation stenosis of 70% or greater or underwent an endarterectomy. Of these, a carotid siphon stenosis of 50% or greater was noted in 65 patients (9.7%) and was ipsilateral to an ICA stenosis in 37 patients (5.5%). A common carotid stenosis was present in 29 patients (4.3%), ipsilateral to an ICA stenosis in 14 patients (2.1%). A stenosis of 50% or greater within the proximal intracranial circulation was present in 28 patients (4.2%), ipsilateral to an ICA stenosis in 15 patients (2.2 %). Four patients had tandem stenoses at more than one site. Tandem stenoses in the siphon or intracranial segments were noted in 13.5% with a bifurcation stenosis and in 8.8% of those with no bifurcation stenosis. Endarterectomy was performed in 48 of the 66 patients with tandem stenotic lesions. CONCLUSION: The presence of a tandem lesion infrequently alters the surgeon's decision to perform an endarterectomy. However, the importance of detecting tandem stenoses cannot be underestimated, since they may have important implications for long-term medical management in symptomatic patients.