RESUMO
OBJECTIVES: The management of patients with recurrent neck cancer invading the carotid artery is controversial. The aim of this study was to evaluate the overall survival and healthy survival years (QALY) as well as the patency of carotid revascularization after enbloc tumor resection followed by complementary radiotherapy. METHODS: From 2000 to 2016, 42 consecutive patients with recurrent neck cancer invading the carotid artery underwent resection of the tumor associated with reconstruction of the carotid artery with a PTFE prosthesis (n=31) or with a saphenous vein graft (n=11). In 11 cases, resection was associated with musculocutaneous flap coverage. The primary tumor was a squamous cell carcinoma of the larynx (20 patients) or of the pharynx (9 patients), undifferentiated carcinoma of unknown origin (10 patients) and anaplastic thyroid carcinoma (3 patients). All patients had postoperative radiotherapy (50-70Gy) supplemented in 16 of them by chemotherapy. Nine patients had metastatic dissemination at the time of reoperation with a recurrent tumor ulcerated to the skin in 5 of them. RESULTS: The combined 30-day mortality and stroke rate was nil. Postoperative morbidity included dysphagia (n=8), vocal cord paralysis (n=6), late wound healing delay (n=2), transient mandibular claudication (n=1) and partial necrosis of the musculocutaneous flap (n=1). No infection and no thrombosis of the bypass were observed during follow-up [median: 31 months, range: 8-167 months]. Twenty-one patients (50%) died from the consequences of the spread of cancer, which had become metastatic, but without local recurrence. The 5-year survival rate was 50.9±8.3%. The median healthy survival year (QALY) was 3.38 [95% CI: 1.70-4.54] with a significant difference between patients without metastasis at the time of reoperation [n=33; QALY=4.02] and those with metastases [n=9; QALY=0.43; P=0.005]. Healthy life expectancy was also significantly longer in patients with laryngeal cancer [n=20, QALY=4.95] compared to patients with other types of tumors [n=22, QALY=1.67; P=0.032]. CONCLUSION: In the absence of metastases, enbloc resection of recurrent neck cancers invading the carotid artery improves the duration and quality of patient survival.
Assuntos
Artérias Carótidas/cirurgia , Neoplasias de Cabeça e Pescoço/cirurgia , Recidiva Local de Neoplasia/cirurgia , Neoplasias Vasculares/cirurgia , Adulto , Idoso , Intervalo Livre de Doença , Feminino , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/mortalidade , Estudos Prospectivos , Taxa de Sobrevida , Neoplasias Vasculares/mortalidade , Neoplasias Vasculares/patologia , Procedimentos Cirúrgicos VascularesAssuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Procedimentos Endovasculares , Aorta Torácica/anatomia & histologia , Doenças da Aorta/complicações , Doenças da Aorta/diagnóstico , Doenças da Aorta/epidemiologia , Procedimentos Endovasculares/efeitos adversos , Humanos , Complicações Pós-Operatórias/prevenção & controleAssuntos
Artéria Femoral , Stents , Diabetes Mellitus , Humanos , Artéria Poplítea , Resultado do TratamentoRESUMO
OBJECTIVES: The aim was to evaluate the safety and efficacy of heparin reversal with protamine after completion of carotid endarterectomy (CEA), summarising the available data from both randomised and non-randomised studies. METHODS: The study was a meta-analysis. Pooled odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated for the outcomes of stroke and wound haematoma among patients receiving or not receiving protamine after CEA. Meta-regression analysis was performed to examine whether the documented differences were modified by potentially meaningful patient related or procedure related predictors, namely publication year, general anesthesia used, number of patients treated, mean age (years), males, neurological symptoms, use of patch, and use of shunt. RESULTS: Seven studies were included in the meta-analysis reporting on 3,817 patients receiving protamine after CEA and 6,070 patients not receiving protamine for heparin reversal. Only one study was randomised. A statistically significant reduction in wound haematoma requiring re-operation was recorded after heparin reversal with protamine in patients undergoing CEA (OR, 0.42, 95% CI, 0.22-0.80, p = .008). In contrast, no significant difference was observed in stroke rates between groups of patients that received and did not receive protamine (OR, 0.71, 95% CI, 0.49-1.03, p = .07). Meta-regression analysis did not reveal any significant effect mediated by the modifiers examined. CONCLUSION: On the basis of the available data, heparin reversal with protamine seems to reduce the risk of wound haematoma, without increasing the risk of procedural stroke. However, taking into account the limitations of the analysis, further studies are needed to increase the level of evidence provided by the current meta-analysis.
Assuntos
Endarterectomia das Carótidas/métodos , Antagonistas de Heparina/uso terapêutico , Hemorragia Pós-Operatória/prevenção & controle , Protaminas/uso terapêutico , Acidente Vascular Cerebral/induzido quimicamente , Endarterectomia das Carótidas/efeitos adversos , Humanos , Acidente Vascular Cerebral/etiologiaRESUMO
OBJECTIVE/BACKGROUND: To evaluate the long-term outcome of renal revascularization by ex vivo renal artery reconstruction and autotransplantation for renal artery branch aneurysms (RABAs). METHODS: Between 1991 and 2015, 67 ex vivo renal artery reconstructions with kidney autotransplantation were performed in 55 adults (mean age 47 years) and 10 children to repair 87 RABAs. The main underlying disease was fibromuscular dysplasia in 34 patients. Other etiologies were systemic congenital disease in eight patients, spontaneous dissecting aneurysms in five, iatrogenic aneurysms in three, atheromatous aneurysms in two and unknown etiology in 13. Median RABA diameter was 20.5 mm. Fifty-three patients (82%) were hypertensive, 60 had normal renal function and no patient was on hemodialysis. Seven patients (11%) were operated on after failure of an endovascular procedure. The mean number of renal artery branches repaired per patient was 3.5 and multiple aneurysms were treated in 14 patients (22%). The hypogastric artery was used in 41 patients, the saphenous vein in 18, the superficial femoral artery in five and a combination of different materials in three. RESULTS: No deaths occurred during the first 30 days. Primary patency at 30 days was 90.8% following to six early thromboses. Three patients (5%) were lost to follow up. No other thrombosis occurred. At 8 years, the primary and primary-assisted patency were 88% and 91%, respectively. Survival was 95% at 9 years. Among the 53 hypertensive patients, two were lost to follow up. At 9 years, 22 (43%) were cured and nine (18%) were improved with a significant reduction of antihypertensive medication (p < .05). The pre-operative modification of the diet in renal disease (MDRD) clearance was 93 ± 29 mL/minute, the immediate post-operative MDRD was 94 ± 33 mL/minute, and at the end of follow up it was 86 ± 26 mL/minute (p > .05). CONCLUSION: Ex vivo renal artery reconstruction for complex RABAs eliminates the risk of rupture, confers a benefit to hypertension, and preserves renal function with a satisfactory long-term patency.
Assuntos
Fístula Arteriovenosa/cirurgia , Rim/cirurgia , Artéria Renal/cirurgia , Transplante Autólogo , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Displasia Fibromuscular/complicações , Displasia Fibromuscular/cirurgia , Humanos , Hipertensão Renovascular/cirurgia , Rim/irrigação sanguínea , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Tempo , Transplante Autólogo/efeitos adversos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Adulto JovemRESUMO
OBJECTIVE/BACKGROUND: To compare the post-operative and mid-term outcomes of laparoscopic aortic surgery with those of conventional aortic surgery performed by a surgical team trained in laparoscopic aortic surgery. METHODS: A prospective study was conducted between January 2006 and December 2011 with 228 consecutive patients having undergone aortic bypass surgery for either an abdominal aortic aneurysm (n = 139) or occlusive aorto-iliac disease (n = 89). Conventional open aortic surgery was carried out in 145 patients, and total laparoscopic repair in 83 patients. The composite primary end point measure grouped together the following adverse events (AEs): (1) any deaths < 30 days or later deaths related to the operation; (2) post-operative hemorrhage necessitating reoperation; (3) myocardial infarction ≤ 30 days; (4) stroke ≤ 30 days; (5) post-operative respiratory failure necessitating re-intubation or assisted ventilation ≥ 4 days; (6) aortic prosthesis infection; (7) aortic prosthesis occlusion; (8) any re-operation related to aortic surgery. In order to diminish bias attributable to the absence of randomization, the two surgical groups were matched by a propensity score enabling analysis of 50 pairs of patients having presented with identical pre-operative characteristics. Univariate analysis of the AE occurring during the first 30 post-operative days was followed by multivariate analysis through logistic regression. The rate of AE during follow up was calculated using the Kaplan-Meier method and the roles of the different co-variables were analyzed using the Cox model. RESULTS: Univariate analysis of the groups adjusted for propensity score showed that laparoscopic repair was associated with a significantly higher risk of AE over the first 30 post-operative days (p = .03). Logistic regression analysis showed that laparoscopic aortic technique (odds ratio [OR] 4.50; p = .01) and coronary artery disease (OR 4.67; p = .02) were independently related to the occurrence of an AE during the post-operative period. The occurrence of AEs during follow up was analyzed using the Cox model. Only two variables, laparoscopic aortic surgery (hazard ratio [HR] 4.40; p = .002) and coronary artery disease (HR 2.70, p = .02), were independently associated with the occurrence of an AE during follow up. The small number of patients included prevented a separate analysis with regard to aneurysmal and occlusive aortic disease. CONCLUSION: This study suggests that even with a well trained surgical team, the laparoscopic approach increases the risk for AEs observed in the course of aortic surgery. ClinicalTrials.gov Identifier: NCT02325700.
Assuntos
Aorta Abdominal/cirurgia , Laparoscopia/métodos , Idoso , Aneurisma da Aorta Abdominal/cirurgia , Arteriopatias Oclusivas/cirurgia , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Estudos Prospectivos , Resultado do TratamentoAssuntos
Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/economia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/economia , Implante de Prótese Vascular/instrumentação , Prótese Vascular/economia , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Custos Hospitalares , Stents/economia , Feminino , Humanos , MasculinoAssuntos
Angiografia Coronária , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , MasculinoAssuntos
Angiografia Coronária , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , MasculinoRESUMO
OBJECTIVES: To evaluate the potential benefit of systematic preoperative coronary-artery angiography followed by selective coronary-artery revascularization on the incidence of myocardial infarction (MI) in patients undergoing carotid endarterectomy (CEA) without a previous history of coronary artery disease (CAD). METHODS: We randomised 426 patients who were candidates for CEA, with no history of CAD, a normal electrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n = 216) all patients underwent coronary angiography before CEA. In group B (n = 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years. RESULTS: In group A, coronary angiography revealed significant coronary artery stenosis in 68 patients (31.5%). Among them, 66 underwent percutaneous Intervention (PCI) prior to CEA and 2 received combined CEA and coronary-artery bypass grafting (CABG). Postoperatively, no MI was observed in group A, whereas 6 MI occurred in group B, one of which was fatal (p = .01). During the study period, 3 MI occurred in group A (1.4%) and 33 were observed in group B (15.7%), 6 of which were fatal. The Cox model demonstrated a reduced risk of MI for patients in group A receiving coronary angiography (HR,.078; 95% CI, 0.024-0.256; p < .001). In addition, patients with diabetes and patients <70 years presented with an increased risk of MI. Survival analysis at 6 years by Kaplan-Meier estimates was 95.6 ± 3.2% in Group A and 89.7 ± 3.7% in group B (Log Rank = 6.54, p = .01). CONCLUSIONS: In asymptomatic coronary-artery patients, systematic coronary angiography prior to CEA followed by selective PCI or CABG significantly reduces the incidence of late MI and increases long-term survival. (ClinicalTrials.gov number, NCT02260453).