RESUMO
BACKGROUND: Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (≤48 hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE). METHODS: A retrospective analysis was performed using prospectively collected data from all consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI), surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale (NIHSS) score variation, and functional outcome at 90 days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE). RESULTS: A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85 ± 5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31 ± 6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3 months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS ≤ 2). CONCLUSIONS: Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes.
Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Ataque Isquêmico Transitório/etiologia , Acidente Vascular Cerebral/etiologia , Idoso , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/mortalidade , Avaliação da Deficiência , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/mortalidade , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The timing of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) is still a controversial issue. The aim of this study was to assess the safety of early carotid interventions in patients treated with thrombolysis for acute ischemic stroke. METHODS: A retrospective analysis was performed using prospectively collected data from consecutive patients who underwent CEA for symptomatic internal carotid artery stenosis within 14 days after the index neurological event during the period from January 2013 to July 2016. Patients who had undergone IVT before CEA were identified. The primary outcome measures were any stroke and death rate at 30 days, symptomatic intracerebral hemorrhage and surgical site bleeding requiring intervention. RESULTS: A total of 93 patients were included for the final analysis. Among these, 13 (14.0%) patients had undergone IVT before CEA while 80 (86.0%) patients had CEA only. The median time interval between IVT and CEA was 2 days (range: 0-13). A subgroup of 6 patients underwent CEA within 24 hours of administration of IVT. The 30-day combined stroke and death rate was 7.7% (1 of 13) among patients undergoing IVT before CEA and 5.0% (4 of 80) among those undergoing CEA only (P = 0.690). In the IVT group, there were no cerebral hemorrhages or significant surgical site bleeding events requiring reintervention. CONCLUSIONS: Our experience indicates that CEA performed early after IVT for acute ischemic stroke, aiming not only to reduce the risk of stroke recurrence but also to achieve neurological improvement by reperfusion of the ischemic penumbra, may be safe and can lead to favorable outcomes.
Assuntos
Isquemia Encefálica/tratamento farmacológico , Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Tempo para o Tratamento , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with an extremely poor prognosis. The best treatment approach in this setting is still unknown. The aim of our study was to evaluate the efficacy, safety, and outcomes of emergent surgical revascularization of acute extracranial ICA occlusion in patients with minor to severe ischemic stroke. METHODS: A retrospective analysis was performed using prospectively collected data of consecutive patients who underwent carotid thromboendarterectomy for symptomatic acute ICA occlusion during the period from January 2013 to December 2015. Primary outcomes were disability at 90 days assessed by the modified Rankin Scale (mRS) and neurological deficit at discharge assessed using the National Institute of Health Stroke Scale (NIHSS). Secondary outcomes were the recanalization rate, 30-day overall mortality, and any intracerebral bleeding. RESULTS: During the study period, a total of 6 patients (5 men and 1 woman) with a median age of 64 years (range: 58-84 years) underwent emergent reconstruction for acute symptomatic ICA occlusion within a median of 5.4 hours (range: 2.9-12.0 hours) after symptoms onset. The median presenting NIHSS score was 10.5 points (range: 4-21). Before surgery, 4 patients (66.7%) had been treated by systemic recombinant tissue plasminogen activator lysis. The median time interval between initiation of intravenous thrombolysis and carotid thromboendarterectomy was 117.5 minutes (range: 65-140 minutes). Patency of the ICA was achieved in all patients. On discharge, the median NIHSS score was 2 points (range: 0-11 points). There was no postoperative intracerebral hemorrhage and zero 30-day mortality rate. At 3 months, 5 patients (83.3%) had a good clinical outcome (mRS ≤ 2). CONCLUSION: Patients presenting with minor to severe ischemic stroke syndromes due to isolated extracranial ICA occlusion may benefit from emergent carotid revascularization. Thorough preoperative neuroimaging is essential to aid in selecting eligible candidates for acute surgical intervention.
Assuntos
Isquemia Encefálica/etiologia , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Acidente Vascular Cerebral/etiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Angiografia Digital , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Angiografia Cerebral/métodos , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Avaliação da Deficiência , Emergências , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Imagem de Perfusão/métodos , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
The left renal vein (LRV) reimplantation into the distal inferior vena cava is considered to be the gold standard of care for symptomatic nutcracker syndrome (NCS). The vast majority of these surgical procedures are performed by open surgery. Experiences with minimally invasive laparoscopic surgery in this field are very limited. We present a case of a 17-year-old boy with NCS in whom the transposition of the LRV was done laparoscopically. The patient suffered from left flank pain, painful left-sided varicocele, microscopic hematuria, proteinuria, and oligoasthenospermia. There were no intraoperative complications, and the postoperative course was uneventful. At 12-month follow-up, hematuria, left flank pain, and left testicular pain resolved. Duplex ultrasonography revealed patent LRV. Laparoscopic LRV transposition appears to be safe, feasible, and has favorable postoperative course.
Assuntos
Laparoscopia , Síndrome do Quebra-Nozes/cirurgia , Veias Renais/cirurgia , Adolescente , Humanos , Masculino , Flebografia/métodos , Síndrome do Quebra-Nozes/diagnóstico , Síndrome do Quebra-Nozes/fisiopatologia , Veias Renais/diagnóstico por imagem , Veias Renais/fisiopatologia , Reimplante , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Grau de Desobstrução Vascular , Veia Cava Inferior/cirurgiaRESUMO
We report 2 cases of recurrent pulmonary embolism (PE) in popliteal venous aneurysm (PVA). Patients were 78-year-old and 72-year-old women. Both were initially seen for acute PE. Saccular and fusiform PVAs were diagnosed in each patient based on duplex ultrasound. However, despite anticoagulation therapy, both patients had PE. At the time of the event, 1 patient was receiving inadequate dose of low-molecular-weight heparin. The other patient was treated with warfarin and had adequate international normalized ratio at the time of re-embolism, and thus, an inferior vena cava filter was inserted. Both patients underwent successful aneurysm resection without any additional thromboembolic events.