RESUMO
BACKGROUND: As a result of the increasing life expectancy of the western population, the number of older patients with chronic limb-threatening ischemia (CLTI) seeking medical care is growing. Our objective was to describe the characteristics of a consecutive series of nonagenarian patients with CLTI and evaluate the outcomes of their management. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with CLTI attended at our institution between 2005 and 2019. Primary endpoints were 1-year limb salvage and survival rates. RESULTS: A total of 171 patients were included (mean age 92.7, 51.5% women), of which in 59 (34.5%) primary major amputation (n = 10) or palliative care (n = 49) was indicated at presentation because of severe dementia (n = 30, 50.8%), knee retraction (n = 17, 28.8%), terminal condition (n = 13, 22%) or a non-salvageable foot (n = 28, 47.4%). In the remaining 112 (65.5%), the need for a revascularization was further assessed finally performing A) conservative treatment/minor amputation (n = 57, 50.9%), B) revascularization (n = 50, 44.6%) or C) direct major amputation (n = 5, 4.4%), with 1-year limb salvage and survival rates of 93.1 and 57.4%, respectively. Predictive factors for lower survival included age >92 years (HR = 1,59, p = 0.041), hemoglobin <10.5 mg/dL (HR 2,34, p < 0.001), congestive heart failure (HR = 1.65, p = 0.036), non-severe dementia (HR 3,11, p < 0.001) and current mobility with wheelchair (HR 1,74, p = 0.014). CONCLUSION: Nearly one-third of nonagenarian patients with CLTI have a direct indication for amputation or palliative care at presentation. In the remaining, a judicious approach with conservative treatment, minor amputation or revascularization procedures yields excellent limb salvage rates. Survival is, however, the cornerstone of these patients. It can be predicted with certain clinical factors which may help decision-making.
Assuntos
Demência , Procedimentos Endovasculares , Doença Arterial Periférica , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Isquemia Crônica Crítica de Membro , Demência/etiologia , Feminino , Humanos , Isquemia/etiologia , Isquemia/cirurgia , Salvamento de Membro , Masculino , Nonagenários , Doença Arterial Periférica/complicações , Doença Arterial Periférica/cirurgia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
AIM: The need to adjust the indications of elective abdominal aortic aneurysm (AAA) repair among patients with a limited life-span deserves a specific evaluation for octogenarians. The aim of this study was to compare the postoperative results and the long-term survival after endovascular repair of abdominal aortic and/or iliac aneurysms (EVAR) in octogenarians compared with patients under 80 years of age. METHODS: Retrospective analysis of 241 consecutive patients who underwent an elective EVAR between 2000 and 2017. EVAR was not considered among patients with clear life-limiting conditions. Patients receiving other than commercially standard infra-renal endoprostheses were excluded. RESULTS: Seventy patients (29.0%) were octogenarians. They had a lower rate of active smoking (10.0% vs. 30.4%, P < 0.001) and a higher prevalence of previous cerebrovascular disease (21.4% vs. 11.7%, P = 0.055) than younger patients. Thirty-day/in-hospital complication and mortality rates were not significantly higher among octogenarians when compared with younger patients (24.3% vs. 16.9% and 2.9% vs. 2.4%, respectively). Octogenarians had a lower long-term survival at 1, 3 and 5 years (92.6% vs. 93.3%, 67.7% vs. 78.0% and 39.3% vs. 60.6%, P = 0.039) in the bivariate analysis. However, an age ≥ 80 years per se was not an independent predictor of survival after adjustment for confounding factors. CONCLUSION: An age above 80 years was not associated with an increased risk of postoperative complications or long-term mortality. Our results suggest that EVAR can be considered in elderly patients without a clear life-limiting condition and with a suitable aneurysm anatomy. Geriatr Gerontol Int 2021; 21: 392-397.
Assuntos
Aneurisma da Aorta Abdominal , Procedimentos Endovasculares , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/cirurgia , Humanos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoAssuntos
Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Aneurisma Ilíaco/cirurgia , Reoperação/métodos , Implante de Prótese Vascular/instrumentação , Progressão da Doença , Procedimentos Endovasculares/instrumentação , Humanos , Aneurisma Ilíaco/patologia , Artéria Ilíaca , Pessoa de Meia-Idade , Reoperação/instrumentação , Stents , Resultado do TratamentoRESUMO
INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) has become the preferred option for treatment of thoracic aortic pathology, but lack of vascular access options is a common contraindication to TEVAR. CASE REPORT: The authors report a case of a 67 year old male patient with multiple revascularisation procedures: bilateral axillofemoral bypass and thoracic aortofemoral bypass, both occluded. An anastomotic pseudoaneurysm of the thoracic aorta developed and detected on computed tomography angiography (CTA). A femoral artery approach could not be performed because of complete occlusion of both iliac arteries. A left subclavian artery approach was performed and through a Dacron prosthetic graft extension anastomosed to the proximal segment of the occluded axillofemoral bypass a distal component of a Zenith Alpha endograft (Cook®) was successfully deployed upside down. There was a good seal without endoleaks and no complications. CONCLUSION: In patients with aortic bypass systematic follow up is important to detect anastomotic pseudoaneurysm and prevent its related complications. TEVAR may be offered for the treatment of thoracic aortic aneurysm pathology even in patients with a lack of vascular access. In the absence of a standard iliofemoral approach, use of an alternative subclavian approach may be considered. The reduction of the carrier system profiles allows performance of TEVAR with safety and efficiency.
Assuntos
Falso Aneurisma/terapia , Fístula Arteriovenosa/terapia , Biópsia/efeitos adversos , Embolização Terapêutica/métodos , Rejeição de Enxerto/patologia , Hematoma/etiologia , Rim/patologia , Complicações Pós-Operatórias/terapia , Artéria Renal/lesões , Veias Renais/lesões , Transplantes/patologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/patologia , Falso Aneurisma/etiologia , Angiografia/métodos , Fístula Arteriovenosa/etiologia , Cateterismo , Feminino , Hematoma/diagnóstico por imagem , Hematúria/etiologia , Humanos , Transplante de Rim , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Artéria Renal/diagnóstico por imagem , Veias Renais/diagnóstico por imagem , UltrassonografiaRESUMO
The rich and diverse heritage of the management of vascular injuries in the 45 independent European countries prevents the authors from revealing a uniform picture of the European experience, but some trends are clearly emerging. In countries with a low incidence of penetrating trauma and increasing use of interventional vascular procedures, the proportion of iatrogenic vascular trauma exceeds 40% of all vascular injuries, whereas on other parts of the continent, armed conflicts are still a major cause of vascular trauma. National vascular registries, mostly in the Scandinavian countries, produce useful, nationwide data about vascular trauma and its management but suffer still from inadequate data collection. Despite a relatively low incidence of vascular trauma in most European countries, the results are satisfactory, probably in most cases because of active and early management by surgeons on call, whether with vascular training or not, treating all kinds of vascular surgical emergencies. In some countries, attempts at developing a trauma and emergency surgical specialty, including expertise in the management of vascular injuries, are on their way.