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1.
J Vasc Surg ; 77(6): 1700-1709.e2, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-36787807

RESUMO

OBJECTIVE: Recent studies have highlighted that race and socioeconomic status serve as important determinants of disease presentation and perioperative outcomes in carotid artery disease. However, these investigations only focus on individual factors of social disadvantage, and fail to account for community factors that may drive disparities. Area Deprivation Index (ADI) is a validated measure of neighborhood adversity that offers a more comprehensive assessment of social disadvantage. We examined the impact of ADI ranking on carotid artery disease severity, management, and postoperative outcomes. METHODS: We identified patients who underwent carotid endarterectomy (CEA), transfemoral carotid artery stenting (tfCAS), and transcarotid artery revascularization (TCAR) in the Vascular Quality Initiative registry between 2016 and 2020. Patients were assigned ADI scores of 1 to 100 based on zip codes and grouped into quintiles, with higher quintiles reflecting increasing adversity. Outcomes assessed included disease presentation, intervention type, and discharge patterns. Logistic regression was used to evaluate independent associations between ADI quintiles and these outcomes. RESULTS: Among 91,904 patients undergoing carotid revascularization, 9811 (10.7%) were in the lowest ADI quintile (Q1), 18,905 (20.6%) in Q2, 25,442 (27.7%) in Q3, 26,099 (28.4%) in Q4, and 11,647 (12.7%) in Q5. With increasing ADI quintiles, patients were more likely to present with symptomatic disease (Q5, 52.1% vs Q1, 46.6%; P < .001), and stroke vs transient ischemic attack (Q5, 63.1% vs Q1, 53.5%; P < .001); they also more frequently underwent CAS vs CEA (Q5, 46.4% vs Q1, 33.9%; P < .001), and specifically tfCAS vs TCAR (Q5, 54.2% vs Q1, 33.9%; P < .001). In adjusted analyses, higher ADI quintiles remained as independent risk factors for presenting with symptomatic disease and stroke and undergoing CAS and tfCAS. Across ADI quintiles, patients were more likely to experience death (Q5, 0.8% vs Q1, 0.4%; P < .001), stroke/death (Q5, 2.1% vs Q1, 1.6%; P = .001), failure to discharge home (Q5, 11.5% vs Q1, 8.0%; P < .001) and length of stay >2 days (Q5, 33.3% vs Q1, 26.3%; P < .001) following revascularization. CONCLUSIONS: Among carotid revascularization patients, those with greater neighborhood social disadvantage had greater disease severity and more frequently underwent tfCAS. These patients also had higher rates of death and stroke/death, were less frequently discharged home, and had prolonged hospital stays. Greater efforts are needed to ensure that patients in higher ADI quintiles undergo better carotid surveillance and are treated appropriately for their carotid artery disease.


Assuntos
Doenças das Artérias Carótidas , Estenose das Carótidas , Procedimentos Endovasculares , Acidente Vascular Cerebral , Humanos , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/terapia , Estenose das Carótidas/complicações , Alta do Paciente , Procedimentos Endovasculares/efeitos adversos , Medição de Risco , Stents/efeitos adversos , Estudos Retrospectivos , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/terapia , Doenças das Artérias Carótidas/complicações , Acidente Vascular Cerebral/etiologia , Artéria Femoral
2.
J Vasc Surg ; 78(6): 1439-1448.e2, 2023 12.
Artigo em Inglês | MEDLINE | ID: mdl-37657687

RESUMO

OBJECTIVE: Transcarotid artery revascularization (TCAR) has emerged as an effective method for carotid artery stenting. However, anatomic eligibility for TCAR is most often limited by an inadequate clavicle-to-carotid bifurcation length of <5 cm. Preoperative clavicle-to-carotid bifurcation distances may be underestimated when using conventional straight-line measurements on computed tomographic angiography (CTA) imaging. We therefore compared clavicle-to-carotid bifurcation lengths as measured by straight-line CTA, center-line CTA, and intraoperative duplex ultrasound (US), to assess potential differences. METHODS: We conducted a single-center, retrospective review of consecutive TCAR procedures performed between 2016 and 2019 for atherosclerotic carotid disease. For each patient, we compared clavicle-to-carotid bifurcation lengths measured by straight-line CTA, center-line CTA using TeraRecon image reconstruction, and intraoperative duplex US with neck extension and rotation. We further assessed patient and imaging characteristics in individuals with a ≥0.5 cm difference among the measurement methods. In particular, common carotid artery (CCA) tortuosity, defined as the inability to visualize the entire CCA from clavicle to carotid bifurcation on both a single coronal and sagittal imaging cut, was examined as a contributing factor for these discrepancies. RESULTS: Of the 70 TCAR procedures identified, 46 had all three imaging modalities available for review. The median clavicle-to-carotid bifurcation length was found to be 6.4 cm (interquartile range [IQR], 5.4-6.7 cm) on straight-line CTA, 7.0 cm (IQR, 6.0-7.5 cm) on intraoperative duplex US, and 7.2 cm (IQR, 6.5-7.5 cm) on center-line CTA (P < .001). Patients with a ≥0.5 cm difference between their straight-line CTA and either their intraoperative duplex US or center-line CTA measurements were more likely to have tortuous CCAs (60.0% vs 19.1%; P = .01; 51.4% vs 0.0%; P = .01). There were no notable differences in age, gender, prior neck/cervical spine surgery, or neck immobility among these individuals. In patients with tortuous CCAs, duplex US and center-line CTA measurements added 1.0 cm (IQR, 0.6-1.5 cm) and 1.1 cm (IQR, 0.9-1.6 cm) more in length than straight-line CTA measurements, respectively. There was a strong linear correlation between the additional lengths provided by duplex US measurements and those provided by center-line CTA measurements for each individual within the tortuous CCA group (r = 0.83). CONCLUSIONS: The use of straight-line CTA during preoperative planning can underestimate the clavicle-to-carotid bifurcation lengths in patients undergoing carotid revascularization, particularly in those with tortuous CCAs. Both duplex US performed with extended-neck surgical positioning and center-line CTA provide similar and longer carotid length measurements, and should be utilized in patients with tortuous carotid vessels to better determine TCAR anatomic eligibility.


Assuntos
Estenose das Carótidas , Humanos , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Clavícula , Stents , Procedimentos Cirúrgicos Vasculares , Artéria Carótida Primitiva
3.
J Vasc Surg ; 78(3): 614-623, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-37257669

RESUMO

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) of metachronous thoracic aortic aneurysms (M-TAAs) following previous infrarenal abdominal aortic aneurysm (AAA) repair has been associated with higher spinal cord ischemia (SCI) risk compared with TEVAR of primary thoracic aortic aneurysms (TAAs). However, data on the impact of the type of prior infrarenal aortic repair on outcomes are scarce. In this study, we examined perioperative outcomes and long-term mortality following TEVAR M-TAA compared with primary TEVAR of TAA. METHODS: We identified all Vascular Quality Initiative (VQI) patients who underwent TEVAR of TAA in the descending thoracic aorta from 2013 to 2022. Only patients undergoing primary TEVAR or TEVAR following infrarenal open (OAR) or endovascular (EVAR) repair were included. We performed univariate analyses to identify differences in baseline and procedural characteristics, and multivariable analyses for perioperative outcomes and 5-year mortality using logistic and Cox regression, respectively. RESULTS: We included 1493 patients who underwent primary TEVAR (81%) or TEVAR following prior OAR (9.0%) or prior EVAR (9.7%). Compared with primary TEVAR, patients undergoing TEVAR M-TAA were older, more commonly male, white, and had higher rates of hypertension, smoking, and renal dysfunction. Patients with M-TAA were more likely to be asymptomatic and have larger diameters at presentation but were exposed to greater contrast volume and procedural times relative to primary TEVAR patients. Following risk-adjustment, compared with primary TEVAR, TEVAR after prior EVAR was associated with higher perioperative mortality (9.7% vs 3.9%; odds ratio [OR], 5.3; 95% confidence interval [CI], 2.3-12; P < .001) and 5-year mortality (40% vs 24%; hazard ratio [HR], 2.1; 95% CI, 1.4-3.1; P = .001). Specifically, among octogenarians (n = 375; 25%), the perioperative and 5-year mortality differences were even more pronounced (perioperative mortality: 17% vs 8.4%; OR, 6.7; 95% CI, 2.2-21; P = .001; 5-year mortality: 50% vs 27%; HR, 3.0; 95% CI, 1.5-5.7; P = .010). However, in-hospital complications, including SCI (2.6% vs 2.8%; OR, 1.2; 95% CI, 0.33-3.3; P = .77), were not notably different. In contrast, TEVAR after previous OAR was associated with comparable perioperative mortality (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.32-3.8; P = .73), 5-year mortality (28% vs 24%; HR, 1.3; 95% CI, 0.80-2.1; P = .54), and in-hospital complications, including SCI (2.6% vs 0.7%; OR, 0.21; 95% CI, 0.01-1.1; P = .16). CONCLUSIONS: Patients undergoing TEVAR of M-TAAs after prior EVAR, particularly octogenarians, have higher perioperative and 5-year mortality and therefore, represent a high-risk group. Future efforts should strive to discern the underlying factors leading to these poorer outcomes; meanwhile, these findings emphasize the need for careful patient selection and appropriate preoperative counseling in these high-risk individuals.


Assuntos
Aneurisma da Aorta Abdominal , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Isquemia do Cordão Espinal , Idoso de 80 Anos ou mais , Humanos , Masculino , Correção Endovascular de Aneurisma , Fatores de Risco , Medição de Risco , Procedimentos Endovasculares/efeitos adversos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Fatores de Tempo , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Resultado do Tratamento , Estudos Retrospectivos
4.
J Vasc Surg ; 73(2): 484-493, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32615284

RESUMO

OBJECTIVE: Persistent type II endoleaks (T2ELs) after endovascular aneurysm repair (EVAR) with sac growth have been associated with adverse events, including rupture. Whereas intervention in the presence of aneurysm growth has become an accepted treatment paradigm for T2ELs, the efficacy and clinical success of such interventions remain unclear. Therefore, we examined the treatment patterns and clinical outcomes of patients undergoing T2EL interventions after EVAR. METHODS: We performed a retrospective review of all patients treated for expanding aneurysm sacs with T2ELs after EVAR at an academic medical center between 2006 and 2017. The primary outcomes assessed were need for repeated intervention; intervention types; and achievement of clinical success, defined as stable aneurysm sac size on computed tomography angiography after treatment. RESULTS: Fifty-six patients underwent 119 interventions, of which 107 (90%) were technically successful. The median time from EVAR to index T2EL procedure was 37 months (interquartile range, 17-56 months), and the median follow-up time from first T2EL procedure was 27 months (interquartile range, 10-51 months). The most common index procedure was transarterial lumbar embolization (64%), followed by transarterial inferior mesenteric artery (20%), transcaval (14%), and translumbar embolization (1.8%). Thirty-three (59%) patients required further procedures for persistent aneurysm sac expansion. For subsequent T2EL interventions, the most common endovascular procedure was transarterial lumbar embolization (21%), followed by transcaval (21%), translumbar (11%), and transarterial inferior mesenteric artery embolization (8.6%). Twelve patients (21%) were found to have loss of proximal or distal seal on subsequent imaging and required graft extensions to stabilize aneurysm sac size. Ten patients (18%) ultimately underwent graft explantation or sacotomy with oversewing of the endoleak source. Freedom from any endoleak-related reintervention was 57% at 1 year and 36% at 3 years. Freedom from open treatment was 93% at 1 year and 82% at 3 years. Of the 44 patients with ≥6-month follow-up, 39 (89%) achieved clinical success. However, only 11 patients (25%) achieved clinical success without any further reintervention, and 29 patients (66%) achieved clinical success without open treatment. CONCLUSIONS: Despite high technical success, endoleak recurrence after T2EL treatment is common, and multiple interventions are often needed to stabilize aneurysm sac size in patients diagnosed with T2EL-associated sac growth. Notably, one in five patients treated for T2ELs was discovered, on further evaluation, to have proximal or distal seal zone loss that necessitated repair to achieve sac stability. Thus, thorough assessment of all endoleak types should be performed in patients with T2ELs associated with sac growth before T2EL treatment to ensure appropriate care and to minimize ineffective interventions.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Remoção de Dispositivo , Embolização Terapêutica , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Padrões de Prática Médica , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Remoção de Dispositivo/efeitos adversos , Embolização Terapêutica/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Recidiva , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
5.
Circ Res ; 124(4): 647-661, 2019 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-30763206

RESUMO

Aneurysmal disease can affect any segment of the aorta, from the aortic root to the aortic bifurcation. The treatment of aortic aneurysms has evolved dramatically in the past 3 decades, with the introduction of endovascular aneurysm repair using stent grafts causing a major paradigm shift in the field of aortic aneurysm surgery. While the technical details of the management of aortic aneurysms vary greatly depending on the location of an aneurysm, the principles remain the same. Successful aortic aneurysm treatment depends on either open replacement or endovascular exclusion of the aneurysmal segment with healthy artery proximal and distal to the repair. Major aortic branches of the arch and visceral segment add additional technical complexity to aneurysms involving these regions. Even as endovascular repair becomes the primary treatment modality for most aortic aneurysms, open repair remains an essential treatment modality in many circumstances. Additionally, long-term results of endovascular repair suggest that younger patients with long life expectancy and low-perioperative risk may benefit more from open repair. Therefore, technical expertise in both endovascular and open treatment is necessary for a comprehensive aortic aneurysm surgery practice.


Assuntos
Aneurisma Aórtico/cirurgia , Procedimentos Endovasculares/métodos , Enxerto Vascular/métodos , Animais , Aneurisma Aórtico/epidemiologia , Aneurisma Aórtico/patologia , Endoleak/epidemiologia , Endoleak/prevenção & controle , Procedimentos Endovasculares/efeitos adversos , Humanos , Enxerto Vascular/efeitos adversos
6.
Ann Vasc Surg ; 77: 338-342, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34464731

RESUMO

We developed a novel technique using an endovascular snare system to stabilize target vessel cannulation via transfemoral access during fenestrated and branched endovascular aortic aneurysm repair (FBEVAR) in patients with challenging target vessel anatomy. This technique uses a snare, an outer sheath, and an inner delivery sheath to facilitate target vessel cannulation and stenting during FBEVAR. With the outer sheath positioned in the lower end of the partially deployed aortic graft and the delivery sheath within, a large snare is advanced through the outer sheath and over the outside of the delivery sheath until it reaches the curved portion of the delivery sheath at the level of the target vessel. The snare is then tightened to provide stability and maintain proper curvature and alignment of the delivery sheath while the target vessel is selected and stented. Following successful passage, the snare is loosened and removed from the body via the outer sheath. This snare technique is a simple, effective, and inexpensive tool that can be used for difficult target vessel cannulation during FBEVAR.


Assuntos
Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Cateterismo Periférico/instrumentação , Procedimentos Endovasculares/instrumentação , Artéria Femoral , Stents , Dispositivos de Acesso Vascular , Aneurisma Aórtico/diagnóstico por imagem , Implante de Prótese Vascular/efeitos adversos , Cateterismo Periférico/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Artéria Femoral/diagnóstico por imagem , Humanos , Desenho de Prótese , Resultado do Tratamento
7.
J Vasc Surg ; 69(5): 1452-1460, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30853384

RESUMO

OBJECTIVE: Transcarotid artery revascularization (TCAR) has emerged as an alternative to transfemoral carotid artery stenting (tfCAS). We investigated the proportion of carotid arteries undergoing revascularization procedures that would be eligible for TCAR based on anatomic criteria and how many arteries at high anatomic risk for tfCAS would be amenable to TCAR. METHODS: We performed a retrospective review of consecutive patients who underwent carotid endarterectomy or carotid stenting between 2012 and 2015. Patients were excluded if computed tomography angiography of the neck was not performed within 6 months of the procedure. We assessed TCAR eligibility on the basis of the instructions for use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif) and high anatomic risk for tfCAS on the basis of anatomic factors known to make carotid cannulation more difficult or hazardous. RESULTS: Of the 118 patients and 236 carotid arteries identified, 12 carotid arteries were excluded for presence of an occluded internal carotid artery (ICA). Of the remaining 224 carotid arteries, 72% were eligible for TCAR on the basis of the instructions for use criteria; 100% had 4- to 9-mm ICA diameters, 100% had ≥6-mm common carotid artery (CCA) diameter, 75% had ≥5-cm clavicle to carotid bifurcation distance, and 96% lacked significant CCA puncture site plaque. In addition, 7% of carotid arteries had bifurcation anatomy unfavorable for stenting; thus, of the entire cohort of arteries examined, 68% were eligible for TCAR. Hyperlipidemia (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.7-26; P < .01), chronic obstructive pulmonary disease (OR, 3.5; 95% CI, 1.5-8.3; P < .01), and older age (OR, 1.1; 95% CI, 1.0-1.1; P < .01) were independently associated with TCAR ineligibility, whereas white race (OR, 0.2; 95% CI, 0.0-1.0; P = .048) and beta-blocker use (OR, 0.3; 95% CI, 0.1-0.7; P < .01) were independently associated with TCAR eligibility. In addition, 24% of carotid arteries were considered to be at high risk for tfCAS for the presence of a type III aortic arch (7.6%), severe aortic calcification (3.3%), tandem CCA lesions (7.1%), moderate to severe stenosis at the carotid ostium (8.9%), and tortuous distal ICA precluding embolic filter placement (4.5%). Active smoking (OR, 4.4; 95% CI, 1.9-10; P < .01), hyperlipidemia (OR, 4.0; 95% CI, 1.2-14; P = .03), and older age (OR, 1.1; 95% CI, 1.0-1.1; P = .02) were independently associated with tfCAS ineligibility, whereas preoperative aspirin (OR, 0.1; 95% CI, 0.0-0.4; P < .001) or clopidogrel (OR, 0.3; 95% CI, 0.1-0.8; P = .01) use was associated with tfCAS eligibility. Of the arteries that were considered to be at high risk for tfCAS, 69% were eligible for TCAR. CONCLUSIONS: The majority of carotid arteries in individuals selected for revascularization meet TCAR eligibility, making TCAR a viable treatment option for many patients.


Assuntos
Angioplastia/instrumentação , Estenose das Carótidas/terapia , Cateterismo Periférico , Definição da Elegibilidade , Artéria Femoral , Stents , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Cateterismo Periférico/efeitos adversos , Tomada de Decisão Clínica , Angiografia por Tomografia Computadorizada , Dispositivos de Proteção Embólica , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/instrumentação
8.
Ann Vasc Surg ; 56: 87-96, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30342206

RESUMO

BACKGROUND: The radial approach to cardiac procedures has become increasingly common. Although previous studies have suggested a favorable risk profile, serious complications can occur. The purpose of this study is to examine the incidence, subsequent treatment, and outcome of all suspected significant neurovascular complications following transradial cardiac procedures at a large US hospital. METHODS: We reviewed all patients who underwent a left heart catheterization, coronary angiogram, or percutaneous coronary intervention via the transradial approach at a single large academic medical center in the United States between 2010 and 2016. Consultations to the vascular and hand surgery services were examined to assess demographic variables, risk factors, presenting symptoms, subsequent treatment, and outcome of all serious complications. RESULTS: A total of 9,681 radial access cardiac procedures were performed during the study period. Twenty-four cases (0.25%) were suspected to have major complications and subsequently received consults. A total of 18 complications were diagnosed, including 8 vascular injuries or perforations, 4 hematomas, 4 radial artery occlusions, 1 case of compartment syndrome, and 1 severe radial artery spasm. Of the complications noted, 3 (16.7%) required operative interventions, but all recovered neurovascular function. CONCLUSIONS: Radial artery access for cardiac procedures has become increasingly common and has been associated with a low rate of major peripheral neurovascular complications. The majority (83.3%) of complications were successfully treated with a nonoperative management algorithm.


Assuntos
Cateterismo Cardíaco/efeitos adversos , Cateterismo Periférico/efeitos adversos , Angiografia Coronária/efeitos adversos , Intervenção Coronária Percutânea/efeitos adversos , Traumatismos dos Nervos Periféricos/epidemiologia , Artéria Radial , Encaminhamento e Consulta , Lesões do Sistema Vascular/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Boston/epidemiologia , Cateterismo Periférico/métodos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Traumatismos dos Nervos Periféricos/diagnóstico , Traumatismos dos Nervos Periféricos/fisiopatologia , Traumatismos dos Nervos Periféricos/terapia , Punções , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/fisiopatologia , Lesões do Sistema Vascular/terapia
9.
J Hand Surg Am ; 44(12): 1060-1065, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31677909

RESUMO

PURPOSE: Arterial calcifications in the lower extremity, chest, and cardiac vessels have been linked to coronary artery disease (CAD). However, the relation between arterial calcifications observed on routine hand and upper-extremity radiographs and atherosclerosis has not been determined. This study examined whether arterial calcifications found on hand radiographs are associated with CAD. METHODS: A record review from a single institution identified 345 patients with both hand radiographs and CAD screening with cardiac stress testing or coronary angiography. Patients with chronic kidney disease, end-stage renal disease, or incomplete hand films were excluded. We reviewed x-rays for findings of arterial calcifications. Cardiac testing results were used to establish a baseline diagnosis of CAD. We made group comparisons and employed multivariable logistic regression to evaluate the association between upper-extremity calcification and CAD. RESULTS: A total of 210 patients met inclusion criteria: 155 with CAD and 55 without it. Mean age was 72 years, body mass index was 28.8, and 54% were male. Patients had comorbidities of hypertension (91%), hyperlipidemia (87%), diabetes (39%), cerebrovascular accident (9%), and a history of tobacco use (53%). Of 155 CAD patients, 67 had arterial calcifications on hand radiographs (43%), compared with 6 of 55 without it (11%). In a multivariable model controlling for sex, hyperlipidemia, and diabetes, the presence of arterial calcifications on hand plain films indicated a 6.2-fold increased odds of CAD. CONCLUSIONS: The current data demonstrate that arterial calcifications on hand radiographs are independently associated with CAD. This may represent an opportunity to the treating physician as a point of referral or investigation for underlying or occult CAD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prevalence III.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Mãos/irrigação sanguínea , Mãos/diagnóstico por imagem , Calcificação Vascular/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Coronária , Teste de Esforço , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
10.
J Craniofac Surg ; 30(2): 400-407, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30570592

RESUMO

Facial defects following Mohs surgery can cause significant functional, cosmetic, and psychologic sequelae. Various techniques for nasal reconstruction after Mohs surgery have been analyzed in the medical literature, yet there has been less attention given to procedures for other crucial facial aesthetic regions. A literature search using PubMed, EMBASE, and ISI Web of Science for studies assessing reconstructive techniques of the forehead, cheek, and perioral regions after Mohs surgery was performed. No limitations on date or language were imposed. Studies meeting inclusion criteria consisted of an entirely post-Mohs population, specified technique for aesthetic unit reconstruction, and detailed complications. The initial search yielded 2177 citations. Application of the author's inclusion and exclusion criteria resulted in 21 relevant studies. Linear closure was highlighted as the predominant technique when possible in all 3 aesthetic zones. Local flaps remained the workhorse option for cheek and forehead defects. Cheek and perioral reconstruction were associated with higher complication rates. Eighty-one percent of studies did not include patient-reported outcomes or standardized outcome measurement assessments. Mohs surgery has become a valuable approach for treatment of skin malignancies of the face. This review has identified significant study heterogeneity in methodology, design, and outcome assessment. Currently, there is no evidence-based literature to support an algorithm to guide surgeon choice of treatment in these 3 central areas. Recommendations are provided to improve the quality of future studies to better inform appropriate surgical technique for each facial unit analyzed.


Assuntos
Neoplasias Faciais/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Neoplasias Cutâneas/cirurgia , Retalhos Cirúrgicos , Bochecha/cirurgia , Estética , Testa/cirurgia , Humanos , Cirurgia de Mohs/efeitos adversos , Boca/cirurgia , Procedimentos de Cirurgia Plástica/efeitos adversos
11.
Ann Plast Surg ; 81(2): 156-162, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29846217

RESUMO

OBJECTIVE: Although resident involvement in surgical procedures is critical for training, it may be associated with increased morbidity, particularly early in the academic year-a concept dubbed the "July effect." Assessments of such phenomena within the field of plastic surgery have been both limited and inconclusive. We sought to investigate the impact of resident participation and academic quarter on outcomes for autologous breast reconstruction. METHODS: All autologous breast reconstruction cases after mastectomy were gathered from the 2005-2012 American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression models were constructed to investigate the association between resident involvement and the first academic quarter (Q1 = July-September) with 30-day morbidity (odds ratios [ORs] with 95% confidence intervals). Medical and surgical complications, median operation time, and length of stay (LOS) were also compared. RESULTS: Overall, 2527 cases were identified. Cases with residents (n = 1467) were not associated with increased 30-day morbidity (OR, 1.20; 0.95-1.52) when compared with those without (n = 1060), although complications including transfusion (OR, 2.08; 1.39-3.13) and return to the operating room (OR, 1.46; 1.11-1.93) were more frequently observed in resident cases. Operation time and LOS were greater in cases with resident involvement.In cases with residents, there was decreased morbidity in Q1 (n = 343) when compared with later quarters (n = 1124; OR, 0.67; 0.48-0.92). Specifically, transfusion (OR, 0.52; 0.29-0.95), return to operating room (OR, 0.64; 0.41-0.98), and surgical site infection (OR, 0.37; 0.18-0.75) occurred less often during Q1. No differences in median operation time or LOS were observed within this subgroup. CONCLUSIONS: Our study reveals that resident involvement in autologous breast reconstruction is not associated with increased morbidity and offers no evidence for a July effect. Notably, our results suggest that resident cases performed earlier in the academic year, when surgical attendings may offer more surveillance and oversight, is associated with decreased morbidity.


Assuntos
Internato e Residência , Mamoplastia/educação , Segurança do Paciente/estatística & dados numéricos , Estações do Ano , Cirurgia Plástica/educação , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Mamoplastia/métodos , Mamoplastia/normas , Mastectomia , Pessoa de Meia-Idade , Duração da Cirurgia , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Retalhos Cirúrgicos , Transplante Autólogo/educação , Transplante Autólogo/métodos , Transplante Autólogo/normas , Estados Unidos
12.
Ann Plast Surg ; 80(4 Suppl 4): S182-S188, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29596085

RESUMO

BACKGROUND: Patients with connective tissue diseases (CTD), or collagen vascular diseases, are at risk of potentially higher morbidity after surgical procedures. We aimed to investigate the complication profile in CTD versus non-CTD patients who underwent breast reconstruction on a national scale. METHODS: A retrospective analysis of the Healthcare Cost and Utilization Project NIS Database between 2010 and 2014 was conducted for patients 18 years or older admitted for immediate autologous or implant breast reconstruction. Connective tissue disease was defined as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, scleroderma, Raynaud phenomenon, psoriatic arthritis, or sarcoidosis. Independent t test/Wilcoxon-Mann-Whitney was used to compare continuous variables and Pearson χ/Fischer exact test was used for categorical variables. Outcomes of interest were assessed using multivariable linear regressions for continuous variables and multivariable logistic regressions for categorical variables. RESULTS: There were 19,496 immediate autologous breast reconstruction patients, with 357 CTD and 19,139 non-CTD patients (2010-2014). The CTD patients had higher postoperative complication rates for infection (2.8% vs 0.8%, P < 0.001), wound dehiscence (1.4% vs 0.4%, P = 0.019), and bleeding (hemorrhage and hematoma) (6.7% vs 3.5%, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for bleeding (odds ratio [OR], 1.568; 95% confidence interval [CI], 1.019-2.412). There were a total of 23,048 immediate implant breast reconstruction patients, with 431 CTD and 22,617 non-CTD patients (2010-2014). The CTD patients had a higher postoperative complication rate for wound dehiscence/complication (2.3% vs 0.6%, P < 0.001). They also experienced a longer length of stay (2.31 days vs 2.07 days, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for wound dehiscence (OR, 4.084; 95% CI, 2.101-7.939) and increased length of stay by 0.050 days (95% CI, -0.081 to 0.181). CONCLUSIONS: Connective tissue disease patients who underwent autologous breast reconstruction had significantly higher infection, wound dehiscence, and bleeding rates, and those who underwent implant breast reconstruction had significantly higher wound dehiscence rates. Connective tissue diseases appear to be an independent risk factor for bleeding and wound dehiscence in autologous and implant breast reconstruction, respectively. This information may help clinicians be aware of this increased risk when determining patients for reconstruction.


Assuntos
Doenças do Tecido Conjuntivo/complicações , Mamoplastia , Complicações Pós-Operatórias/etiologia , Adolescente , Adulto , Idoso , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Modelos Lineares , Modelos Logísticos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
14.
J Vasc Surg ; 74(5): 1438-1439, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34022379
16.
J Immunol ; 189(10): 4870-80, 2012 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-23066148

RESUMO

The formation of a dynamic, actin-rich immunological synapse (IS) and the polarization of cytolytic granules toward target cells are essential to the cytotoxic function of NK cells. Following polarization, lytic granules navigate through the pervasive actin network at the IS to degranulate and secrete their toxic contents onto target cells. We examined lytic granule motility and persistence at the cell cortex of activated human NK cells, using high-resolution total internal reflection microscopy and highly quantitative analysis techniques. We illustrate that lytic granules are dynamic and observe substantial motility at the plane of the cell cortex prior to, but not after, degranulation. We also show that there is no significant change in granule motility in the presence of Latrunculin A (which induces actin depolymerization), when added after granule polarization, but that there is a significant decrease in lytic granule persistence subsequent to degranulation. Thus, we show that lytic granules are highly dynamic at the cytolytic human NK cell IS prior to degranulation and that the persistence of granules at the cortex following exocytosis requires the integrity of the synaptic actin network.


Assuntos
Actinas/imunologia , Degranulação Celular/imunologia , Sinapses Imunológicas/imunologia , Células Matadoras Naturais/imunologia , Vesículas Secretórias/imunologia , Actinas/metabolismo , Compostos Bicíclicos Heterocíclicos com Pontes/farmacologia , Degranulação Celular/efeitos dos fármacos , Linhagem Celular , Humanos , Sinapses Imunológicas/metabolismo , Células Matadoras Naturais/citologia , Células Matadoras Naturais/metabolismo , Vesículas Secretórias/metabolismo , Tiazolidinas/farmacologia
17.
Plast Reconstr Surg Glob Open ; 11(2): e4820, 2023 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-36761011

RESUMO

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions limiting residents to 80 hours per week in 2003 and further extended restrictions in 2011 to improve resident and patient well-being. Numerous studies have examined the effects of these restrictions on patient outcomes with inconclusive results. Few efforts have been made to examine the impact of this reform on the safety of common plastic surgery procedures. This study seeks to assess the influence of ACGME duty-hour restrictions on patient outcomes, using bilateral breast reduction mammoplasty as a marker for resident involvement and operative autonomy. Methods: Bilateral breast reductions performed in the 3 years before and after each reform were collected from the National Inpatient Sample database: pre-duty hours (2000-2002), duty hours (2006-2008), and extended duty hours (2012-2014). Multivariable logistic regression models were constructed to investigate the association between ACGME duty hour restrictions on medical and surgical complications. Results: Overall, 19,423 bilateral breast reductions were identified. Medical and surgical complication rates in these patients increased with each successive iteration of duty hour restrictions (P < 0.001). The 2003 duty-hour restriction independently associated with increased surgical (OR = 1.51, P < 0.001) and medical complications (OR = 1.85, P < 0.001). The 2011 extended duty-hour restriction was independently associated with increased surgical complications (OR = 1.39, P < 0.001). Conclusions: ACGME duty-hour restrictions do not seem associated with better patient outcomes for bilateral breast reduction although there are multiple factors involved. These considerations and consequences should be considered in decisions that affect resident quality of life, education, and patient safety.

18.
J Vasc Surg Cases Innov Tech ; 6(1): 121-125, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32095671

RESUMO

Nutcracker syndrome is a rare vascular disorder that involves compression of the left renal vein (LRV), most often at the level of the aortomesenteric angle. In some cases, this compression syndrome arises in the setting of unusual vascular anatomic variants. We describe the case of a 43-year-old woman with a duplicated inferior vena cava who was found to have LRV compression on magnetic resonance angiography and venography with intravascular ultrasound. The patient was successfully treated with concurrent transposition of the LRV and left-sided inferior vena cava, with complete resolution of symptoms.

19.
J Exp Med ; 217(5)2020 05 04.
Artigo em Inglês | MEDLINE | ID: mdl-32150623

RESUMO

In chronic infections, the immune response fails to control virus, leading to persistent antigen stimulation and the progressive development of T cell exhaustion. T cell effector differentiation is poorly understood in the context of exhaustion, but targeting effector programs may provide new strategies for reinvigorating T cell function. We identified Tribbles pseudokinase 1 (Trib1) as a central regulator of antiviral T cell immunity, where loss of Trib1 led to a sustained enrichment of effector-like KLRG1+ T cells, enhanced function, and improved viral control. Single-cell profiling revealed that Trib1 restrains a population of KLRG1+ effector CD8 T cells that is transcriptionally distinct from exhausted cells. Mechanistically, we identified an interaction between Trib1 and the T cell receptor (TCR) signaling activator, MALT1, which disrupted MALT1 signaling complexes. These data identify Trib1 as a negative regulator of TCR signaling and downstream function, and reveal a link between Trib1 and effector versus exhausted T cell differentiation that can be targeted to improve antiviral immunity.


Assuntos
Diferenciação Celular , Peptídeos e Proteínas de Sinalização Intracelular/metabolismo , Coriomeningite Linfocítica/imunologia , Coriomeningite Linfocítica/virologia , Proteínas Serina-Treonina Quinases/antagonistas & inibidores , Sequência de Aminoácidos , Animais , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD8-Positivos/imunologia , Linhagem Celular , Doença Crônica , Humanos , Imunidade , Peptídeos e Proteínas de Sinalização Intracelular/química , Peptídeos e Proteínas de Sinalização Intracelular/deficiência , Ativação Linfocitária/imunologia , Subpopulações de Linfócitos/imunologia , Vírus da Coriomeningite Linfocítica/imunologia , Camundongos Endogâmicos C57BL , Camundongos Knockout , Proteína de Translocação 1 do Linfoma de Tecido Linfoide Associado à Mucosa/metabolismo , Fenótipo , Ligação Proteica , Proteínas Serina-Treonina Quinases/química , Proteínas Serina-Treonina Quinases/deficiência , Proteínas Serina-Treonina Quinases/metabolismo , Linfócitos T/citologia , Linfócitos T/imunologia , Transcrição Gênica , Carga Viral
20.
J Cardiovasc Surg (Torino) ; 60(3): 345-353, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30845790

RESUMO

Transfemoral carotid stenting has struggled to become a suitable alternative to carotid endarterectomy for the treatment of carotid disease because of higher perioperative stroke risks, even with use of embolic protection devices. To reduce the perioperative stroke rates associated with carotid stenting, several advancements in stent design, embolic protection systems, and technical approaches have been developed. Transcarotid artery revascularization (TCAR) was also recently introduced as a novel carotid artery stenting option which circumvents several of the high embolic-risk maneuvers found in transfemoral carotid stenting and employs a flow reversal system that provides continuous embolic protection throughout the procedure. Early results from this technique have shown low stroke/death rates comparable to carotid endarterectomy while maintaining the minimally invasive benefits of carotid stenting. TCAR has a strong potential to become the preferred method of carotid stenting in the near future and may challenge carotid endarterectomy as the preferred carotid artery revascularization method.


Assuntos
Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas , Procedimentos Endovasculares , Acidente Vascular Cerebral/prevenção & controle , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/mortalidade , Tomada de Decisão Clínica , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Humanos , Medição de Risco , Fatores de Risco , Stents , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento
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