RESUMEN
BACKGROUND: Recently, open abdominal aortic aneurysm (AAA) repair (OSR) has become less common and will often be reserved for patients with more complex aortic anatomy. Despite improvements in patient management, the reduced surgical volume has raised concerns for potentially worsened outcomes in the contemporary era (2014-2019) compared with an earlier era in which OSR was more widely practiced (2005-2010). In the present study, we compared the 30-day outcomes of open AAA repair between these two eras. METHODS: The American College of Surgeons National Quality Improvement Program general database was queried for open AAA repair using the Current Procedural Terminology and International Classification of Diseases, 9th and 10th, codes. The cases were stratified into two groups by operation year: 2005 to 2010 (early) and 2014 to 2019 (contemporary). In each era, the cases were further divided into elective and ruptured groups. The 30-day outcomes, including mortality, major morbidity, postoperative sepsis, and unplanned reoperation, were compared between the contemporary and early eras in the elective and ruptured groups. Preoperative variables with a P value <.25 were adjusted for in the multivariate analysis. RESULTS: In the contemporary and early eras, 3749 and 3798 patients had undergone elective OSR and 1148 and 907 had undergone ruptured OSR, respectively. These samples were of similar sizes owing to the National Quality Improvement Program sampling process and our relatively strict inclusion criteria. In the contemporary era, fewer patients were elderly and fewer were smokers or had hypertension or dyspnea in the elective and rupture cohorts. More patients had had American Society of Anesthesiologists class >3 in the elective contemporary era (39% vs 24%; P < .0001). The contemporary elective repair group demonstrated increased 30-day mortality (3.7% vs 3.2%; adjusted odds ratio [aOR], 1.36; P = .006), major adverse cardiac events (5.7% vs 3.4%; aOR, 1.87; P < .0001), and bleeding requiring transfusion (58.5% vs 13.7%; aOR, 8.96; P < .0001). The incidence of pulmonary complications (12.1% vs 15.2%; aOR, 0.80; P = .02) and sepsis (3.7% vs 8.4%; aOR, 0.47; P < .0001) had decreased in the contemporary era, with a similar rate of unplanned reoperations (8.4% vs 7.7%; aOR, 1.16; P = .09). The incidence of renal complications in the contemporary era had increased, with a statistically significant difference. However, the absolute increase of <0.5% was likely not clinically relevant (5.5% vs 5.1%; aOR, 1.23; P = .049). In the ruptured cohort, contemporary repair was associated with increased 30-day mortality (41.4% vs 40%; aOR, 1.53; P < .0001), major adverse cardiac events (25.8% vs 12.8%; aOR, 2.49; P < .0001), and bleeding requiring transfusion (88.2% vs 27%; aOR, 23.03; P < .0001). The incidence of pulmonary complications (36.9% vs 48.1%; aOR, 0.67; P < .0001), sepsis (14.6% vs 23%; aOR, 0.75; P = .03), and unplanned reoperations (18.1% vs 22.7%; aOR, 0.74; P = .008) had decreased in the contemporary OSR group. No differences were detected in the incidence of renal complications. CONCLUSIONS: The 30-day mortality has worsened after open AAA repair in the elective and rupture settings despite the improvements in perioperative management over the years. These complications likely stem from increased bleeding events and major cardiac events, which were increased in the contemporary era.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Quirúrgicos Electivos/métodos , Procedimientos Endovasculares/métodos , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo/métodos , Anciano , Aneurisma de la Aorta Abdominal/epidemiología , Rotura de la Aorta/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Mega-fistulae are generalized aneurysmal dilations of a high flow (1500-4000 mL/min) autogenous arteriovenous (AV) access which may result in hemorrhage and/or high-output cardiac failure. Current treatments include ligation, ligation with prosthetic jump graft, and imbrication; however, these may not be suitable for advanced disease, or may result in loss of functioning access, poor cosmesis, or recurrence. We describe our early experience with a technique of complete mega-fistula resection and replacement with an early use prosthetic graft that both maintains existing AV access and eliminates the need for long-term catheter (LTC) placement; including lessons learned. METHODS: A single-center, retrospective review of medical records was conducted from March 2018-February 2021. Outcomes were technical success, LTC use, time to cannulation, and complications. Mega-fistulae were completely resected from the proximal to distal aneurysmal segment, including all pseudoaneurysms, followed by tunneling a prosthetic graft (Propaten later converted to Acuseal; W.L. Gore Assoc.) with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access. RESULTS: We had 100% immediate technical success (n=12). Pre-operative long-term catheters were placed in all eight Propaten patients; one was already placed in an Acuseal patient. Average time to cannulation was six weeks with Propaten and 4.5 days with Acuseal. At 30 days, three Propaten patients developed complications including one instance of skin necrosis, one seroma, and one hematoma. Two Acuseal patients developed complications including one central venous occlusion (CVO) and one graft infection. Of the six patients with long-term follow-up, five continue to use their access, however, two required thrombectomies and central venous angioplasties. One patient required a new contralateral access due to CVO. CONCLUSIONS: Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and may eliminate the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.
Asunto(s)
Aneurisma Falso/cirugía , Derivación Arteriovenosa Quirúrgica/métodos , Implantación de Prótesis Vascular/métodos , Prótesis Vascular , Oclusión de Injerto Vascular/cirugía , Anastomosis Quirúrgica , Femenino , Humanos , Masculino , Complicaciones Posoperatorias , Reoperación , Estudios Retrospectivos , Colgajos Quirúrgicos , Técnicas de Sutura , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: Open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) has often been reserved in contemporary practice for complex aneurysms requiring a suprarenal or supraceliac proximal clamp level. The present study investigated the associated 30-day outcomes of different proximal clamp levels in OSR of complex infrarenal/juxtarenal AAA in patients with normal renal function and those with chronic renal insufficiency (CRI). METHODS: All patients undergoing elective OSR of infrarenal and juxtarenal AAA were identified in the American College of Surgeons National Surgical Quality Improvement Program-targeted AAA database from 2012 to 2018. The patients were stratified into two cohorts (normal renal function [estimated glomerular filtration rate, ≥60 mL/min] and CRI [estimated glomerular filtration rate, <60 mL/min and no dialysis]) before further substratification into groups by the proximal clamp level (infrarenal, inter-renal, suprarenal, and supraceliac). The 30-day outcomes, including mortality, renal and pulmonary complications, and major adverse cardiovascular event rates, were compared within each renal function cohort between proximal clamp level groups using the infrarenal clamp group as the reference. Supraceliac clamping was also compared with suprarenal clamping. RESULTS: A total of 1284 patients with normal renal function and 524 with CRI were included in the present study. The proximal clamp levels for the 1808 patients were infrarenal for 1080 (59.7%), inter-renal for 337 (18.6%), suprarenal for 279 (15.4%), and supraceliac for 112 (6.2%). In the normal renal function cohort, no difference was found in 30-day mortality with any clamp level. Increased 30-day acute renal failure was only observed in the supraceliac vs infrarenal clamp level comparison (5.9% vs 1.5%; adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 1.04-5.18; P = .044). In the CRI cohort, supraceliac clamping was associated with an increased rate of renal composite complications (22.7% vs 5.6%; aOR, 8.81; 95% CI, 3.17-24.46; P < .001) and ischemic colitis (13.6% vs 3.0%; aOR, 4.78; 95% CI, 1.38-16.62; P = .014) compared with infrarenal clamping and greater 30-day mortality (13.6% vs 2.4%; aOR, 6.00; 95% CI, 1.14-31.55; P = .034) and renal composite complications (22.7% vs 10.8%; aOR, 2.87; 95% CI, 1.02-8.13; P = .047) compared with suprarenal clamping. Suprarenal clamping was associated with greater renal dysfunction (10.8% vs 5.6%; aOR, 2.77; 95% CI, 1.08-7.13; P = .035) compared with infrarenal clamping, with no differences in mortality. No differences were found in 30-day mortality or morbidity for inter-renal clamping compared with infrarenal clamping in either cohort. No differences were found in major adverse cardiovascular events with higher clamp levels in either cohort. CONCLUSIONS: In elective OSR of infrarenal and juxtarenal AAAs for patients with CRI, this study found a heightened mortality risk with supraceliac clamping and increased renal morbidity with suprarenal clamping, though these effects were not present for patients with normal renal function. Every effort should be made to keep the proximal clamp level as low as possible, especially in patients with CRI.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Tasa de Filtración Glomerular , Riñón/fisiopatología , Insuficiencia Renal Crónica/fisiopatología , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Comorbilidad , Constricción , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Endovascular repair of juxtarenal abdominal aortic aneurysms (JAAAs) with fenestrated grafts (fenestrated endovascular aneurysm repair [FEVAR]) has been reported to decrease operative mortality and morbidity compared with open surgical repair (OSR). However, previous comparisons of OSR and FEVAR have not necessarily included patients with comparable clinical profiles and aneurysm extent. Although FEVAR has often been chosen as the first-line therapy for high-risk patients such as the elderly, many patients will not have anatomy favorable for FEVAR. At present, a paucity of data has examined the operative outcomes of OSR in elderly patients for JAAAs relative to FEVAR. Therefore, we chose to perform a propensity-matched comparison of OSR and FEVAR for JAAA repair in patients aged ≥70 years. METHODS: Patients aged ≥70 years who had undergone elective nonruptured JAAA repairs from 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted endovascular aneurysm repair (EVAR) and AAA databases. Patients who had undergone FEVAR were identified in the targeted EVAR database as those who had received the Cook Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind). Because our study specifically examined JAAAs, those patients who had undergone OSR with supraceliac proximal clamping or concomitant renal/visceral revascularization were excluded. A 1:1 propensity-match algorithm matched the OSR and FEVAR patients by preoperative clinical and demographic characteristics, operative indications, and aneurysm extent. The 30-day outcomes, including mortality, major adverse cardiovascular events, and pulmonary and renal complications, were compared between the propensity-matched OSR and FEVAR groups. RESULTS: A 1:1 propensity match was achieved, and the final analysis included 136 OSR patients and 136 FEVAR patients. No significant differences were found in 30-day mortality (4.4% vs 3.7%; odds ratio [OR], 1.21; 95% confidence interval [CI], 0.36-4.06; P = .759) between the OSR and FEVAR groups. OSR was associated with a higher incidence of major adverse cardiovascular events compared with FEVAR; however, the trend was not statistically significant (8.1% vs 3.7%; OR, 2.31; 95% CI, 0.78-6.82; P = .131). Compared with FEVAR, the OSR group had significantly greater rates of pulmonary complications (19.1% vs 3.7%; OR, 6.19; 95% CI, 2.30-16.67; P < .001) and renal complications (8.1% vs 2.2%; OR, 3.90; 95% CI, 1.06-14.31; P = .040). CONCLUSIONS: In the samples assessed in the present study, the results with OSR of JAAAs in the elderly did not differ from those of FEVAR with respect to 30-day mortality despite a greater incidence of pulmonary and renal complications. Although FEVAR should remain the first-line therapy for JAAAs in elderly patients, OSR might be an acceptable alternative for select patients with anatomy unfavorable for FEVAR.
Asunto(s)
Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares/métodos , Arteria Renal/cirugía , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta/epidemiología , Aneurisma de la Aorta/prevención & control , Aneurisma de la Aorta Abdominal/mortalidad , Bases de Datos Factuales , Procedimientos Quirúrgicos Electivos , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Puntaje de Propensión , Estudios RetrospectivosRESUMEN
BACKGROUND: It is often hypothesized that failed prior endovascular intervention could adversely affect the outcome of subsequent infrainguinal bypass in the corresponding limb. However, this perception is not well supported in the literature because of conflicting data. The aim of this study is to address this controversial issue via analysis of a multicenter prospectively collected database. METHODS: Patients who underwent infrainguinal bypass for chronic limb threatening ischemia (CLTI) were identified in the targeted American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2017. These patients were stratified into 4 groups: first time femoral-popliteal bypass, femoral-popliteal bypass after failed prior endovascular revascularization, first time femoral-tibial bypass, and femoral-tibial bypass after failed prior endovascular revascularization. Thirty-day outcomes including mortality, graft patency, major amputations, and major organ dysfunction were measured. RESULTS: We identified 7,044 patients who underwent surgical bypasses for CLTI. Patients were mostly well matched among the 4 groups except for differences in sex, hypertension, and preoperative renal function. In terms of major adverse cardiovascular events and major adverse limb events, femoral-popliteal or femoral-tibial bypasses after failed prior endovascular intervention had comparable 30-day outcomes to first-time bypasses. However, patients with failed prior endovascular intervention had increased rates of postoperative wound infection, required significantly more blood transfusions, and had longer operative time. CONCLUSIONS: Failed prior endovascular intervention does not adversely affect 30-day outcomes of subsequent infrainguinal bypass surgery in mortality, limb salvage, or other major cardiovascular complications.
Asunto(s)
Procedimientos Endovasculares , Isquemia/cirugía , Enfermedad Arterial Periférica/cirugía , Injerto Vascular , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Enfermedad Crónica , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Tempo Operativo , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Insuficiencia del Tratamiento , Estados Unidos , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: Although fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. METHODS: All adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012-2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the "Cook Zenith Fenestrated" endograft. OSR cases were defined as those that required proximal clamp positions "above one renal" or "between SMA & renals." Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. RESULTS: There were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, P=0.001) and less likely to be smokers (25.8% vs 42.1%; Pâ¯=â¯0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups.Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; P=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; P=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; P<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; P=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P<0.0001; hospital stay: 3 days vs 8 days, P<0.0001). CONCLUSION: For patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Insuficiencia Renal Crónica/complicaciones , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/complicaciones , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Tasa de Filtración Glomerular , Humanos , Riñón/fisiopatología , Masculino , Complicaciones Posoperatorias/etiología , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/fisiopatología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Widespread adoption of endovascular therapy for the treatment of chronic limb-threatening ischemia has transformed the field of vascular surgery. In this modern era, we aimed to define where open surgical interventions are of greatest benefit for limb salvage. METHODS: Patients who underwent interventions for chronic limb-threatening ischemia were identified in the vascular-targeted lower extremity National Surgical Quality Improvement Program database for open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) from 2011 to 2017. Patients were further stratified based on the criteria of chronic limb-threatening ischemia (rest pain or tissue loss), and the location of the diseased arteries (femoropopliteal or tibioperoneal). The main outcomes measured included 30-day mortality, amputation, and major adverse cardiovascular events. RESULTS: A total of 17,193 patients were revascularized for chronic limb-threatening ischemia: 10,532 were OPEN and 6661 were ENDO. OPEN had higher 30-day mortality, major adverse cardiovascular events, pulmonary, renal dysfunction, and wound complications. However, OPEN resulted in significantly lower 30-day major amputation (3.8% vs. 5.0%, odds ratio (OR): 0.83 [0.72-0.97], P = .018). Subgroup analysis revealed a higher mortality rate in OPEN was observed only in tibioperoneal intervention for tissue loss. Major adverse cardiovascular event was higher in OPEN for most subgroups. OPEN for patients with tissue loss had significantly lower amputation rate than ENDO in both femoropopliteal and tibioperoneal subgroups (3.7% vs. 5.1%, OR: 0.76 [0.59-0.98], P = .036, and 4.7% vs. 6.6%, OR: 0.74 [0.57-0.96], P = .024, respectively). The benefit of open surgery in reducing the amputation rate was not seen in patients with rest pain. CONCLUSIONS: Open surgical intervention is associated with significantly better limb salvage than endovascular intervention in patients with tissue loss. Surgical options should be given more emphasis as the first-line option in this cohort of patients unless the cardiopulmonary risk is prohibitive.
Asunto(s)
Procedimientos Endovasculares , Isquemia/cirugía , Enfermedad Arterial Periférica/cirugía , Injerto Vascular , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Enfermedad Crónica , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Cicatrización de HeridasRESUMEN
BACKGROUND: Ischemic colitis after an open abdominal aortic aneurysm (AAA) repair remains a serious complication with a nationally reported rate of 1% to 6% in elective cases and up to 60% after an aneurysmal rupture. To prevent this serious complication, inferior mesenteric artery (IMA) replantation is performed at the discretion of the surgeon based on his or her intraoperative findings, despite the lack of clear evidence to support this practice. The purpose of this study was to determine whether replantation of the IMA reduces the risk of ischemic colitis and improves the overall outcome of AAA repair. METHODS: Patients who underwent open infrarenal AAA repair were identified in the multicenter American College of Surgeons National Surgical Quality Improvement Program Targeted AAA Database from 2012 to 2015. Emergency cases, patients with chronically occluded IMAs, ruptured aneurysms with evidence of hypotension, and patients requiring visceral revascularization were excluded. The remaining elective cases were divided into two groups: those with IMA replantation (IMA-R) and those with IMA ligation. We measured the 30-day outcomes including mortality, morbidity, and perioperative outcomes. A multivariable logistic regression model was used for data analysis, adjusting for clinically relevant covariates. RESULTS: We identified 2397 patients who underwent AAA repair between 2012 and 2015, of which 135 patients (5.6%) had ischemic colitis. After applying the appropriate exclusion criteria, there were 672 patients who were included in our study. This cohort was divided into two groups: 35 patients with IMA-R and 637 patients with IMA ligation. There were no major differences in preoperative comorbidities between the two groups. IMA-R was associated with increased mean operative time (319.7 ± 117.8 minutes vs 242.4 ± 109.3 minutes; P < .001). Examination of 30-day outcomes revealed patients with IMA-R had a higher rate of return to the operating room (20.0% vs 7.2%; P = .006), a higher rate of wound complications (17.1% vs 3.0%; P = .001), and a higher incidence of ischemic colitis (8.6% vs 2.4%; P = .027). There were no significant differences in mortality, pulmonary complications, or renal complications between the two groups. In multivariable analysis, IMA-R was a significant predictor of ischemic colitis and wound complications. CONCLUSIONS: These data suggest that IMA-R is not associated with protection from ischemic colitis after open AAA repair. The role of IMA-R remains to be identified.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Colitis Isquémica/prevención & control , Arteria Mesentérica Inferior/cirugía , Reimplantación , Anciano , Aneurisma de la Aorta Abdominal/mortalidad , Implantación de Prótesis Vascular/mortalidad , Colitis Isquémica/etiología , Colitis Isquémica/mortalidad , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reimplantación/efectos adversos , Reimplantación/mortalidad , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: Acceptable complication rates after carotid endarterectomy (CEA) are drawn from decades-old data. The recent Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated improved stroke and mortality outcomes after CEA compared with carotid artery stenting, with 30-day periprocedural CEA stroke rates of 3.2% and 1.4% for symptomatic (SX) and asymptomatic (ASX) patients, respectively. It is unclear whether these target rates can be attained in "normal-risk" (NR) patients experienced outside of the trial. This study was done to determine the contemporary results of CEA from a broader selection of NR patients. METHODS: The Society for Vascular Surgery (SVS) Vascular Registry was examined to determine in-hospital and 30-day event rates for NR, SX, and ASX patients undergoing CEA. NR was defined as patients without anatomic or physiologic risk factors as defined by SVS Carotid Practice Guidelines. Raw data and risk-adjusted rates of death, stroke, and myocardial infarction (MI) were compared between the ASX and SX cohorts. RESULTS: There were 3977 patients (1456 SX, 2521 ASX) available for comparison. The SX group consisted of more men (61.7% vs 57.0%; P = .0045) but reflected a lower proportion of white patients (91.3% vs 94.4%; P = .0002), with lower prevalence of coronary artery disease (P < .0001), prior MI (P < .0001), peripheral vascular disease (P = .0017), and hypertension (P = .029), although New York Heart Association grade >3 congestive heart failure was equally present in both groups (P = .30). Baseline stenosis >80% on duplex imaging was less prevalent among SX patients (54.2% vs 67.8%; P < .0001). Perioperative stroke rates were higher for SX patients in the hospital (2.8% vs 0.8%; P < .0001) and at 30 days (3.4% vs 1.0%; P < .0001), which contributed to the higher composite death, stroke, and MI rates in the hospital (3.6% vs 1.8; P = .0003) and at 30 days (4.5% vs 2.2%; P < .0001) observed in SX patients. After risk adjustment, the rate of stroke/death was greater among SX patients in the hospital (odds ratio, 2.05; 95% confidence interval, 1.18-3.58) although not at 30 days (odds ratio, 1.36; 95% confidence interval, 0.85-2.17). No in-hospital or 30-day differences were observed for death or MI by symptom status. CONCLUSIONS: The SVS Vascular Registry results for CEA in NR patients are similar by symptom status to those reported for CREST and may serve as a benchmark for comparing results of alternative therapies for treatment of carotid stenosis in NR patients outside of monitored clinical trials. The contemporary perioperative risk of stroke after CEA in NR patients continues to be higher for SX than for ASX patients.
Asunto(s)
Endarterectomía Carotidea , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/cirugía , Enfermedad Coronaria/complicaciones , Endarterectomía Carotidea/mortalidad , Femenino , Insuficiencia Cardíaca/complicaciones , Humanos , Hipertensión/complicaciones , Masculino , Infarto del Miocardio/complicaciones , Sistema de Registros , Factores de Riesgo , Sociedades Médicas , Accidente Cerebrovascular/epidemiología , Resultado del Tratamiento , Enfermedades Vasculares/complicacionesRESUMEN
OBJECTIVE: Data on the influence of contralateral carotid occlusion (CCO) on carotid endarterectomy (CEA) are conflicting and are absent for carotid artery stenting (CAS). This study evaluated the influence of CCO on CEA and CAS. METHODS: We evaluated patients with and without CCO in the Society for Vascular Surgery Vascular Registry. Primary outcome was a composite of periprocedural death, stroke, or myocardial infarction (MI) (major adverse cardiovascular events [MACE]) and its individual components. Further analysis was done to identify the influence, if any, of symptom status on outcomes. RESULTS: There were 1128 CAS and 666 CEA patients with CCO. CAS patients were more often symptomatic with a greater incidence of coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and New York Heart Association class >III. Absolute risk of periprocedural MACE (2.7% for CAS vs. 4.2% for CEA), death (1.1% for CAS vs. 0.7% for CEA), stroke (2.1% for CAS vs. 3.1% for CEA), and MI (0.3% for CAS vs. 0.6% for CEA) was statistically equivalent for both. This equivalence was maintained when patients with CCO were segregated according to symptom status and after adjusting for periprocedural risk. There were 16,646 patients without contralateral occlusion (5698 CAS; 10,948 CEA). Patients without contralateral occlusion with CEA have better outcomes in periprocedural MACE (1.8% for patients without contralateral occlusion vs 4.2% for patients with CCO), and stroke (1.1% for patients without contralateral occlusion vs. 3.1% for patients with CCO) (P < .0001 for both). In CAS patients, CCO did not significantly affect periprocedural MACE (3.2% for patients without contralateral occlusion vs. 2.7% for patients with CCO), death (0.8% for patients without contralateral occlusion vs. 1.0% for patients with CCO), stroke (2.3% for patients without contralateral occlusion vs. 2.1% for patients with CCO), or MI (0.6% for patients without contralateral occlusion vs. 0.3% for patients with CCO). In CEA patients, CCO increased MACE, primarily by increasing stroke rates in asymptomatic (0.7% vs. 2.0%; P = .0095) and symptomatic (1.7% vs. 4.9%; P = .0012) patients. CONCLUSIONS: Although CEA is preferred in patients without contralateral occlusion, regardless of symptom status, based on lower rates of periprocedural MACE, death, and stroke, the benefit of CEA is lost in patients with CCO because of increased stroke rates in CCO patients after CEA but not after CAS regardless of symptom status. The results of CAS and CEA in patients with CCO are equivalent and within acceptable American Heart Association guidelines.
Asunto(s)
Estenosis Carotídea/cirugía , Endarterectomía Carotidea/métodos , Infarto del Miocardio/epidemiología , Sistema de Registros , Sociedades Médicas/estadística & datos numéricos , Stents , Accidente Cerebrovascular/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Complicaciones Posoperatorias , Estudios Retrospectivos , Medición de Riesgo , Accidente Cerebrovascular/etiología , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto JovenRESUMEN
OBJECTIVES: This study attempted to identify trends in the use of endovascular aneurysm repair (EVAR) and outcomes in elective abdominal aortic aneurysm (AAA) repair over a 5-year period in a nationwide dataset, with specific attention to patients older than 80 years. METHODS: The Nationwide Inpatient Sample database was queried for elective AAA repair during 2005 to 2009. Number of EVAR cases, ratio of EVAR/open aneurysm repair (OAR), major clinical outcomes, and discharge status were analyzed by decade. Interval data were compared with analysis of variance (ANOVA) and proportions via chi-squared tests. RESULTS: A total of 174,714 AAA repairs (124,869 EVARs) were identified. The ratio of EVAR/OAR increased with increasing age. Between 2005 and 2009, the total number of AAA repairs increased by 21% (7,179 vs. 8,554) and EVARs increased by 50% (5,057 vs. 7,650; P < 0.05) in patients older than 80 years. In 2009, 85% of AAA repairs in patients older than 80 years were EVARs. Patients older than 80 years constituted 25% of the total EVAR cohort. Although the in-hospital mortality rate remained acceptable in all age groups, EVAR-associated mortality, length of stay, and discharge to a skilled nursing facility increased with each successive decade of life (P < 0.05). Rates of postoperative myocardial infarction and acute renal failure also increased with increasing age (P < 0.05). EVAR results are presented by decade. CONCLUSIONS: EVAR is being performed with increasing frequency in patients older than 80 years, with one-quarter of EVAR performed in patients aged 80 years and older in the current sample. Although mortality rates remain acceptable in this elderly population, EVAR and OAR are associated with an age-dependent increase in death, complications, and discharge to extended care facilities. These factors, in addition to long-term risk of aneurysm rupture, should be considered when evaluating the appropriateness of elective aneurysm repair in the elderly.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/tendencias , Procedimientos Endovasculares/tendencias , Pacientes Internos , Lesión Renal Aguda/etiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Bases de Datos Factuales , Procedimientos Quirúrgicos Electivos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/etiología , Alta del Paciente , Selección de Paciente , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
Transcervical carotid artery revascularization has emerged as an alternative to carotid endarterectomy and transfemoral carotid artery stenting. We present four cases for which we believe transcervical carotid artery revascularization was the only option to treat the lesions. Each case presented with specific technical challenges that were overcome by intraoperative planning that allowed for safe deployment of the Enroute stent (Silk Road Medical) with resolution of each patient's stenosis.
RESUMEN
We report on a young man who developed complicated pylephlebitis after foodborne illness. Despite antibiotics and resection of the focus of infectious colitis, he developed extensive small bowel infarction. He was treated with anticoagulation, local thrombolytic infusion, and resection of irreversibly ischemic small bowel. Thrombophilia workup demonstrated heterozygosity for factor V Leiden and the prothrombin G20210A mutation. The complications of pylephlebitis can be minimized by using systemic anticoagulation, thrombectomy, and/or local thrombolytic infusion along with antibiotics and surgical management of the infection. Evaluation for thrombophilic states should be considered, particularly if a patient does not respond to initial therapy.
Asunto(s)
Colitis/etiología , Enfermedades Transmitidas por los Alimentos/complicaciones , Isquemia/etiología , Vena Porta , Trombofilia/complicaciones , Tromboflebitis/etiología , Enfermedades Vasculares/etiología , Adulto , Antibacterianos/uso terapéutico , Anticoagulantes/uso terapéutico , Colectomía , Colitis/diagnóstico , Colitis/terapia , Colonoscopía , Análisis Mutacional de ADN , Factor V/genética , Enfermedades Transmitidas por los Alimentos/diagnóstico , Enfermedades Transmitidas por los Alimentos/terapia , Heterocigoto , Humanos , Isquemia/diagnóstico , Isquemia/terapia , Masculino , Isquemia Mesentérica , Mutación , Protrombina/genética , Terapia Trombolítica , Trombofilia/diagnóstico , Trombofilia/genética , Trombofilia/terapia , Tromboflebitis/diagnóstico , Tromboflebitis/terapia , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Enfermedades Vasculares/diagnóstico , Enfermedades Vasculares/terapiaRESUMEN
We report the 44-year follow-up of a 9-year-old girl who underwent a saphenous vein interposition graft in 1964 after suffering extensive pelvic trauma with complete disruption of the right common femoral artery. The patient recovered from this injury and experienced no disability or pain until 2008, when she suddenly developed numbness in the right leg. Evaluation at that time showed a new occlusion of the saphenous vein graft, and she underwent uneventful repeat revascularization with autogenous vein. To our knowledge, this 44-year patency is the longest reported for a saphenous vein graft.
Asunto(s)
Arteriopatías Oclusivas/cirugía , Arteria Femoral/lesiones , Traumatismos de la Pierna/cirugía , Vena Safena/trasplante , Procedimientos Quirúrgicos Vasculares/métodos , Accidentes de Tránsito , Anastomosis Quirúrgica , Femenino , Humanos , Traumatismos de la Pierna/diagnóstico por imagen , Persona de Mediana Edad , Radiografía , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: The purpose of this systematic review and meta-analysis was to synthesize the available evidence derived from randomized controlled trials (RCTs) regarding the relative efficacy and safety of endarterectomy vs stenting in patients with carotid artery disease. METHODS: We searched MEDLINE, EMBASE, Current Contents, and Cochrane CENTRAL through July 2010 to update previous systematic reviews. Two reviewers determined trial eligibility and extracted descriptive, methodologic, and outcome data (death, nonfatal stroke, and nonfatal myocardial infarction). Random-effects meta-analysis was used to pool relative risks and the I(2) statistic was used to assess heterogeneity. RESULTS: Thirteen RCTs proved eligible enrolling 7484 patients, of which 80% had symptomatic disease. Methodological quality was moderate to high, with better quality among RCTs published after 2008. Compared with carotid endarterectomy, stenting was associated with increased risk of any stroke (relative risk [RR], 1.45; 95% confidence interval [CI], 1.06-1.99; I(2) = 40%), decreased risk of periprocedural myocardial infarction (MI; RR, 0.43; 95% CI, 0.26- 0.71; I(2) = 0%), and nonsignificant increase in mortality (RR, 1.40; 95% CI, 0.85-2.33; I(2) = 5%). When analysis was restricted to the two most recent trials with the better methodology and more contemporary technique, we found stenting to be associated with a significant increase in the risk of any stroke (RR, 1.82; 95% CI, 1.35-2.45) and mortality (RR, 2.53; 95% CI, 1.27-5.08) and a nonsignificant reduction of the risk of MI (RR, 0.39; 95% CI, 0.12-1.23). For every 1000 patients opting for stenting rather than endarterectomy, 19 more patients would have strokes and 10 fewer would have MIs. Outcome data in asymptomatic patients were sparse and imprecise; hence, these conclusions apply primarily to symptomatic patients. CONCLUSION: Compared with endarterectomy, carotid artery stenting (CAS) significantly increases the risk of any stroke and decreases the risk of MI.
Asunto(s)
Angioplastia/instrumentación , Enfermedades de las Arterias Carótidas/terapia , Endarterectomía Carotidea , Stents , Angioplastia/efectos adversos , Angioplastia/mortalidad , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/mortalidad , Enfermedades de las Arterias Carótidas/cirugía , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Medicina Basada en la Evidencia , Humanos , Infarto del Miocardio/etiología , Selección de Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
Management of carotid bifurcation stenosis is a cornerstone of stroke prevention and has been the subject of extensive clinical investigation, including multiple controlled randomized trials. The appropriate treatment of patients with carotid bifurcation disease is of major interest to the community of vascular surgeons. In 2008, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, only one randomized trial, comparing carotid endarterectomy (CEA) and carotid stenting (CAS), had been published. Since that publication, four major randomized trials comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2008 guidelines with specific emphasis on six areas: imaging in identification and characterization of carotid stenosis, medical therapy (as stand-alone management and also in conjunction with intervention in patients with carotid bifurcation stenosis), risk stratification to select patients for appropriate interventional management (CEA or CAS), technical standards for performing CEA and CAS, the relative roles of CEA and CAS, and management of unusual conditions associated with extracranial carotid pathology. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system, as has been done with other Society for Vascular Surgery guideline documents.[corrected] The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as the first-line therapy.
Asunto(s)
Angioplastia/normas , Estenosis Carotídea/terapia , Endarterectomía Carotidea/normas , Sociedades Médicas/normas , Accidente Cerebrovascular/prevención & control , Angioplastia/efectos adversos , Angioplastia/instrumentación , Angioplastia/mortalidad , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/mortalidad , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Medicina Basada en la Evidencia , Humanos , Selección de Paciente , Medición de Riesgo , Factores de Riesgo , Stents , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Resultado del TratamientoRESUMEN
In 2008, the Society for Vascular Surgery published guidelines for the treatment of carotid bifurcation stenosis. Since that time, a number of prospective randomized trials have been completed and have shed additional light on the best treatment of extracranial carotid disease. This has prompted the Society for Vascular Surgery to form a committee to update and expand guidelines in this area. The review was done using the GRADE methodology.[corrected] The perioperative risk of stroke and death in asymptomatic patients must be below 3% to ensure benefit for the patient. Carotid artery stenting (CAS) should be reserved for symptomatic patients with stenosis 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as first line therapy. In this Executive Summary, we only outline the specifics of the recommendations made in the six areas evaluated. The full text of these guidelines can be found on the on-line version of the Journal of Vascular Surgery at http://journals.elsevierhealth.com/periodicals/ymva.
Asunto(s)
Angioplastia/normas , Estenosis Carotídea/terapia , Endarterectomía Carotidea/normas , Sociedades Médicas/normas , Accidente Cerebrovascular/prevención & control , Angioplastia/efectos adversos , Angioplastia/instrumentación , Angioplastia/mortalidad , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/mortalidad , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Medicina Basada en la Evidencia , Humanos , Selección de Paciente , Guías de Práctica Clínica como Asunto , Medición de Riesgo , Factores de Riesgo , Stents , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Resultado del TratamientoRESUMEN
INTRODUCTION: The Vascular Surgery Board (VSB) of the American Board of Surgery sought to answer the following questions: what is the scope of contemporary vascular surgery practice? Do current vascular surgery residents obtain training that is appropriate for their future career expectations and for successful Board certification? How effectively do practicing vascular surgeons incorporate emerging technologies and procedures into practice? METHODS: We analyzed the operative logs submitted to the VSB by recent vascular surgery residents applying for the Vascular Surgery Qualifying Examination (QE; 2006-2009) or by practicing vascular surgeons applying for the Vascular Surgery Recertification Examination (RE; 1995-2009). The relationship between reported operative experience and performance of the QE and RE was examined. RESULTS: There has been a threefold increase in the mean number of primary cases reported by both RE and QE applicants over the past 15 years and the increase in case volume has been driven largely by an increase in the number of endovascular procedures. Endovascular procedures have been broadly incorporated into the practice of most vascular surgeons applying for recertification. The number of major open surgical cases reported by recent QE applicants has remained unchanged over the period of observation. For QE applicants, the number of endovascular aneurysm repairs (EVARs) has reached a plateau at approximately 50 cases, whereas the mean number of open infrarenal aneurysm repairs has decreased for both QE and RE applicants, reflecting national trends favoring EVAR. There was a significant association between case volume and performance on the QE but not on the RE. CONCLUSION: Over the past 15 years, there has been a significant increase in the total number of operative cases reported to the VSB by both QE and RE applicants. Contrary to popular belief, the volume of major open vascular surgery reported by recent vascular surgery residents has remained relatively stable since 1994. Over the same time period, endovascular procedures have been rapidly incorporated into clinical practice by the majority of vascular surgeons applying for recertification by the VSB. Current vascular surgery residents receive a rich operative experience in both open and endovascular procedures that is reflective of contemporary practice.
Asunto(s)
Competencia Clínica , Educación de Postgrado en Medicina , Procedimientos Endovasculares/educación , Internado y Residencia , Procedimientos Quirúrgicos Vasculares/educación , Certificación , Distribución de Chi-Cuadrado , Competencia Clínica/estadística & datos numéricos , Educación de Postgrado en Medicina/estadística & datos numéricos , Procedimientos Endovasculares/estadística & datos numéricos , Humanos , Internado y Residencia/estadística & datos numéricos , Sistemas de Información en Quirófanos , Sociedades Médicas , Factores de Tiempo , Estados Unidos , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricosRESUMEN
AVFs differ in their characteristics, natural history, and response to interventions. These differences need to be considered when planning treatment. Endovascular treatments have emerged as a mainstay of treatment of all types of AVMs. They can be used as definitive therapy for acquired arteriovenous malformation, in remote or high-risk locations, and in elderly or otherwise debilitated patients. Endovascular control is often helpful in open repair of acquired AVF. Endovascular techniques are essential in the management of congenital AVF and are the first line of interventional therapy. In these cases, repeated interventions are the rule, and careful imaging and planning is the key to success.
Asunto(s)
Fístula Arteriovenosa/terapia , Procedimientos Endovasculares/métodos , Fístula Arteriovenosa/embriología , Fístula Arteriovenosa/fisiopatología , Volumen Sanguíneo , Humanos , Imagen por Resonancia Magnética , Examen Físico , Escleroterapia , Tomografía Computarizada por Rayos X , Ultrasonografía Doppler DúplexRESUMEN
A 26-year-old man presented with acute renal insufficiency, and severe lower extremity swelling. Computed tomographic scan revealed retroperitoneal lymphadenopathy encasing both ureters and the inferior vena cava. He underwent placement of ureteral stents to relieve the obstruction and afterward underwent lymph node biopsy, which revealed Kaposi's sarcoma. He subsequently was diagnosed with acquired immunodeficiency syndrome. Abdominal and lower extremity venous duplex ultrasound did not show any evidence of deep vein thrombosis. The inferior vena cava measured 3.5 mm in diameter and was encased by retroperitoneal lymphadenopathy. Bilateral transfemoral venography and intravascular ultrasound demonstrated significant compression of the inferior vena cava below the renal veins. Endovascular treatment was followed with primary stenting under intravascular ultrasound guidance. His symptoms improved with reduction in swelling. At 1-year follow-up, the patient was ambulatory with mild symptoms, and on venography the iliac vein and inferior vena cava stents were widely patent.