RESUMO
Robotic thymectomy with the da Vinci robotic system is the latest development in the surgery of thymic gland. Thymectomy for myasthenia gravis is best offered to patients with seropositive acetylcholine receptor antibodies and who are seronegative for muscle-specific kinase protein. The robotic operation technique is indicated in all patients with myasthenia gravis in association with a resectable thymoma, typically Masaoka-Koga stages I and II.
Assuntos
Miastenia Gravis/cirurgia , Robótica/métodos , Timectomia/métodos , Timoma/cirurgia , Neoplasias do Timo/cirurgia , Humanos , Miastenia Gravis/complicações , Timoma/complicações , Neoplasias do Timo/complicaçõesRESUMO
OBJECTIVE: To investigate the effect of aneurysm size on long-term survival after endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). METHODS: Retrospective study of all consecutive patients treated with EVAR for AAA at a single institution. RESULTS: One hundred and nineteen patients (mean age 71, range 45-91) underwent EVAR during a 4-year period. The mean maximal aneurysm diameter was 58 mm (range 34-93 mm). Mean follow-up was 34 months (range 1-80). Cox regression analysis after controlling for age, renal function, coronary disease, and smoking showed a 4.9-fold higher risk of death for patients with preoperative aneurysm size ≥ 60 mm as compared to patients with aneurysm size <60 mm. No aneurysm-related deaths occurred during the follow-up. CONCLUSION: This present study provides evidence that aneurysm size ≥60 mm is independently associated with worse survival during follow-up.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Distribuição de Qui-Quadrado , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Alemanha , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: The aim of the present study was to analyse the short-term results of treatment of internal iliac artery aneurysms (IIAA). METHODS: In a prospective single-centre cohort study all patients with IIAA (symptomatic or maximal diameter >/=30 mm) were evaluated for endovascular repair, which included coil embolization of the run-off vessels and coverage of the orifice of the IIAA with a stent graft. Open repair was performed with aneurysm excision or aneurysmorrhaphy. Outcome criteria were technical and clinical success and complications of treatment. RESULTS: In a period of 40 months 11 patients underwent operation for 12 IIAA. Nine aneurysms were repaired endovascularly and three with open repair. Coil embolization was routinely performed in all cases. At a median follow up of 18 months, technical and clinical success was 100%. Major complications included two early limb thromboses, a contrast-agent-induced nephropathy, and an intraoperative ureteric injury. CONCLUSION: Despite the limited number of patients, the present series, with good short-term results, further supports the trend towards endovascular repair of suitable IIAA.
Assuntos
Aneurisma/cirurgia , Artéria Ilíaca , Idoso , Idoso de 80 Anos ou mais , Implante de Prótese Vascular , Embolização Terapêutica , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Stents , Procedimentos Cirúrgicos VascularesRESUMO
OBJECTIVE: To prospectively evaluate diagnostic accuracy of first pass and combined first pass and steady state high-spatial-resolution whole-body magnetic resonance (MR) angiography with a blood pool contrast agent for quantification of arterial stenosis in different vascular territories. MATERIALS AND METHODS: After Institutional Review Board approval and informed consent, 50 patients with known 50% or greater stenosis in at least one vascular territory; as shown by the standard-of-reference (14 digital subtraction angiographies, 4 computed tomographies, 32 ultrasound examinations), were included. The patients underwent MR angiography at 1.5 Tesla, using a standardized nonbody-weight-adapted i.v. bolus injection of 11 mL gadofosveset trisodium. First pass imaging with 4 different table positions in a whole-body MR scanner (MAGNETOM Avanto, Siemens Healthcare), using individual circulation time determined by a test bolus, was performed. Steady state imaging was performed using an isometric spatial resolution of 1.0 mm. Image quality was rated. Each vascular segment in MR angiography was evaluated by 2 independent and blinded reviewers and the stenosis degree was compared with the preferred standard-of-reference, using a 5-point scale. Differences between first pass and combined MR angiography were assessed with a 95% confidence interval (CI) by applying the adjusted modified chi(2) test. Changes in therapy based on the whole-body examination strategy were evaluated. RESULTS: The number of nondiagnostic territories was 24 of 197 (12.2%) for first pass MR angiography and decreased to 3 of 197 (1.5%) after addition of steady state MR angiography. The diagnostic accuracy for quantification of arterial stenosis in combined MR angiography (94.7%; 95% CI: 92.4-97.1) was superior to first pass MR angiography (81.7%; 95% CI: 73.7-89.8; statistically significant). Patient management was changed in 12 of 49 patients, in 7 of 12 patients the change was applied to an additional lesion detected by the whole-body examination strategy. CONCLUSION: The quantification and detection of arterial stenosis is improved by the steady state high-resolution gadofosveset trisodium-enhanced MR angiography. Additional lesions detected by whole-body examination strategy or differences in stenosis quantification may lead to changes in therapy.
Assuntos
Arteriopatias Oclusivas/diagnóstico , Gadolínio , Aumento da Imagem/métodos , Imageamento por Ressonância Magnética/métodos , Compostos Organometálicos , Imagem Corporal Total/métodos , Adulto , Idoso , Meios de Contraste , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
INTRODUCTION: Above knee (AK) femoropopliteal bypass remains a sufficient and durable therapy for long occlusions of the superficial femoral artery in the era of endovascular repair. A novel, precuffed expanded polytetrafluoroethylene (ePTFE) graft that was designed for AK femoropopliteal bypass (Dynaflo, Bard Peripheral Vascular Inc, Tempe, Ariz) has been available for clinical use since March 2005, promising better patency rates by optimizing the hemodynamic patterns within the distal anastomosis. METHODS: A prospective, multicenter, nonrandomized study was performed to investigate the clinical results of the Dynaflo graft. Primary end points were patency rates, limb salvage, and complications. RESULTS: Between March 2005 and August 2007, the Dynaflo graft was used in 135 AK bypasses in 134 patients (110 men) with a mean age of 66 years. Indication for revascularization was claudication in 99 (73%) and critical ischemia in 36 (27%). With a mean follow-up of 18 months the 6-, 12- and 24-month primary patency rates were 90%, 83% and 72.5% and the secondary patency rates were 93%, 88.6% and 82.2%, respectively. The cumulative limb salvage rate at 24 months was 95%. Complications were observed in 39 patients (29%), with bypass failure (29 cases) and significant thrombus accumulation at the distal anastomosis (4 cases) being the most severe. CONCLUSION: This study presents the first clinical results of a novel ePTFE graft for supragenicular revascularization. The implantation of the Dynaflo graft seems to be safe and feasible for AK bypass, achieving acceptable medium-term patency rates. Nevertheless, long-term results have to be awaited, and prospective comparative studies are warranted.
Assuntos
Arteriopatias Oclusivas/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Artéria Femoral/cirurgia , Politetrafluoretileno , Artéria Poplítea/cirurgia , Idoso , Angiografia Digital , Tornozelo/irrigação sanguínea , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/fisiopatologia , Pressão Sanguínea , Implante de Prótese Vascular/efeitos adversos , Artéria Braquial/fisiopatologia , Constrição Patológica , Estudos de Viabilidade , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Alemanha , Oclusão de Enxerto Vascular/etiologia , Humanos , Salvamento de Membro , Masculino , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Estudos Prospectivos , Desenho de Prótese , Recuperação de Função Fisiológica , Trombose/etiologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Caminhada , CicatrizaçãoRESUMO
Deep femoral artery aneurysms are a rarity among arterial aneurysms. Based on a selected case of a patient who was treated at our clinic, clinical images are presented and treatment options are discussed.
Assuntos
Aneurisma/diagnóstico , Artéria Femoral , Idoso de 80 Anos ou mais , Aneurisma/cirurgia , Angiografia Digital , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
Complete thymectomy (Thx) is a crucial part of treatment for myasthenia gravis (MG) and thymoma. The discussion about the necessity of radical, complete Thx and reduced invasiveness has led to no less than 14 different surgical approaches for Thx. The latest development is robotic-assisted surgery. Though its impact on minimally invasive surgery is not yet clear, it seems to be most promising for surgery in remote, narrow anatomical regions like the mediastinum. One hundred six consecutive robotic-assisted thymectomies (rThx) with the da Vinci robotic surgical system were performed between January 2003 and April 2007 in a prospective single-center study. Postoperative morbidity was recorded according to the Myasthenia Gravis Foundation of America (MGFA) classification. With zero mortality, the overall postoperative morbidity rate was 2%. The cumulative complete stable remission rate of MG was > 40% for all patients, and there was no statistical difference as compared to non-thymomatous MG patients. The cumulative rate of minimal manifestations (MM0-MM3) according to the MGFA classification showed a postoperative improvement in quality of life for most of the patients. The da Vinci robotic system allowed for technical refinements of the well-defined operation technique of thoracoscopic Thx (tThx). From the technical point of view, rThx has advantages for mediastinal dissection. rThx had a shorter learning curve. There might be better outcome results for rThx in MG patients, as compared with nonrobotic tThx. Therefore, rThx is a promising technique for minimally invasive Thx.
Assuntos
Miastenia Gravis/cirurgia , Toracoscopia/métodos , Timectomia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miastenia Gravis/classificação , Miastenia Gravis/patologiaRESUMO
Cystic adventitial disease is a rare non-atheromatous cause of popliteal artery disease. We report a case of a 54-year-old patient with claudication of the right calf caused by cystic adventitial disease. Intra-operatively, a communication between the adventitia and the knee joint was identified. Connections between the adventitial cyst and the nearby joint have been reported in the literature that support the developmental theory. This theory suggests that cystic adventitial disease is a developmental manifestation of mucin-secreting cells derived from the mesenchyme of the adjacent joint. This case is the first, to our knowledge, in which a communication between joint and adventitia has been clearly documented by operative findings.
Assuntos
Arteriopatias Oclusivas/complicações , Tecido Conjuntivo/patologia , Claudicação Intermitente/etiologia , Artéria Poplítea/patologia , Cisto Popliteal/diagnóstico , Arteriopatias Oclusivas/etiologia , Arteriopatias Oclusivas/patologia , Tecido Conjuntivo/cirurgia , Humanos , Claudicação Intermitente/patologia , Articulação do Joelho/patologia , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/cirurgia , Cisto Popliteal/complicações , Cisto Popliteal/etiologia , Cisto Popliteal/patologia , Cisto Popliteal/cirurgia , Veia Safena/transplante , Resultado do Tratamento , Procedimentos Cirúrgicos VascularesRESUMO
Therapeutic angiogenesis represents a novel approach to treat critical limb ischemia when revascularization is no more an option. The clinical use of the vascular endothelial growth factor is questioned, because of its side effects. This study was designed to identify and characterize human immunodeficiency virus type 1 (HIV-1) Tat-derived peptides based on their pro-angiogenic properties. A series of Tat-derived peptides were synthesized containing mutations in the basic domain. To minimize side effects Tat peptides were selected exerting no effects on the proteasome and on the viability of human umbilical vein endothelial cells (HUVEC). Tatpep5, 15, and 16 increased the endogenous levels of the pro-angiogenic transcription factors c-Jun and SP-1 as well as the production of the plasminogen activator inhibitor-1 (PAI-1) by HUVEC. A significant induction of endothelial cell invasion was observed upon treatment of HUVEC with Tat peptides. In addition, selected Tat peptides induced tube formation by HUVEC as visualized and quantified in a Matrigel matrix. Our data demonstrate that the selected Tat peptides fulfill essential criteria for pro-angiogenic substances. They represent the basis for the development of novel pro-angiogenic drugs for future therapeutic angiogenesis, which might be applied for treatment of unreconstructible critical limb ischemia.
Assuntos
Indutores da Angiogênese/farmacologia , Produtos do Gene tat/farmacologia , HIV-1/genética , Fragmentos de Peptídeos/farmacologia , Indutores da Angiogênese/síntese química , Indutores da Angiogênese/química , Indutores da Angiogênese/uso terapêutico , Movimento Celular/efeitos dos fármacos , Células Cultivadas/efeitos dos fármacos , Colágeno , Combinação de Medicamentos , Avaliação Pré-Clínica de Medicamentos , Células Endoteliais/efeitos dos fármacos , Fator 2 de Crescimento de Fibroblastos/farmacologia , Regulação da Expressão Gênica/efeitos dos fármacos , Produtos do Gene tat/síntese química , Produtos do Gene tat/uso terapêutico , Genes jun , Genes tat , Humanos , Isquemia/tratamento farmacológico , Laminina , Morfogênese , Fragmentos de Peptídeos/síntese química , Fragmentos de Peptídeos/química , Fragmentos de Peptídeos/genética , Fragmentos de Peptídeos/uso terapêutico , Inibidor 1 de Ativador de Plasminogênio/biossíntese , Inibidor 1 de Ativador de Plasminogênio/genética , Complexo de Endopeptidases do Proteassoma/efeitos dos fármacos , Estrutura Terciária de Proteína , Proteoglicanas , Proteínas Proto-Oncogênicas c-jun/biossíntese , Fator de Transcrição Sp1/biossíntese , Fator de Transcrição Sp1/genética , Veias Umbilicais/citologia , Produtos do Gene tat do Vírus da Imunodeficiência HumanaRESUMO
Primary malignant tumors of the aorta are extremely rare. The case of a 64-year-old woman who presented with peripheral embolism to both femoropopliteal arteries is reported. The search for a source revealed a polypoid lesion severely narrowing the lumen of the distal thoracic aorta. Differential diagnosis included thrombus and primary aortic tumor. Extirpation of the tumorous lesion was performed. Histologic examination revealed intimal aortic sarcoma of endothelial cell origin. Although the liver was the only site of suspected metastases at the time of operation, during the 18-month follow-up until the patient's death, generalized metastatic spread had developed. This case report thus demonstrates the generally poor prognosis of this rare variety of aortic sarcoma, in particular when symptoms have already occurred.