RESUMO
OBJECTIVE: Recent randomized controlled trials have shown that age significantly affects the outcome of carotid revascularization procedures. This study used data from the Society for Vascular Surgery Vascular Registry (VR) to report the influence of age on the comparative effectiveness of carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: VR collects provider-reported data on patients using a Web-based database. Patients were stratified by age and symptoms. The primary end point was the composite outcome of death, stroke, or myocardial infarction (MI) at 30 days. RESULTS: As of December 7, 2010, there were 1347 CEA and 861 CAS patients aged < 65 years and 4169 CEA and 2536 CAS patients aged ≥ 65 years. CAS patients in both age groups were more likely to have a disease etiology of radiation or restenosis, be symptomatic, and have more cardiac comorbidities. In patients aged <65 years, the primary end point (5.23% CAS vs 3.56% CEA; P = .065) did not reach statistical significance. Subgroup analyses showed that CAS had a higher combined death/stroke/MI rate (4.44% vs 2.10%; P < .031) in asymptomatic patients but there was no difference in the symptomatic (6.00% vs 5.47%; P = .79) group. In patients aged ≥ 65 years, CEA had lower rates of death (0.91% vs 1.97%; P < .01), stroke (2.52% vs 4.89%; P < .01), and composite death/stroke/MI (4.27% vs 7.14%; P < .01). CEA in patients aged ≥ 65 years was associated with lower rates of the primary end point in symptomatic (5.27% vs 9.52%; P < .01) and asymptomatic (3.31% vs 5.27%; P < .01) subgroups. After risk adjustment, CAS patients aged ≥ 65 years were more likely to reach the primary end point. CONCLUSIONS: Compared with CEA, CAS resulted in inferior 30-day outcomes in symptomatic and asymptomatic patients aged ≥ 65 years. These findings do not support the widespread use of CAS in patients aged ≥ 65 years.
Assuntos
Angioplastia , Doenças das Artérias Carótidas/terapia , Endarterectomia das Carótidas , Medicare , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Angioplastia/instrumentação , Angioplastia/mortalidade , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/mortalidade , Doenças das Artérias Carótidas/cirurgia , Distribuição de Qui-Quadrado , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Medicina Baseada em Evidências , Feminino , Humanos , Modelos Logísticos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Razão de Chances , Seleção de Pacientes , Sistema de Registros , Medição de Risco , Fatores de Risco , Sociedades Médicas , Stents , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: The goal of rehabilitation following lower extremity amputation is to restore the highest level of independent function. As much as possible, this includes the functional use of a prosthetic device fitted to the residual limb. Early prosthetic fit depends, in turn, on rapid healing of the amputation site. METHODS: We hypothesized that compliance with a novel custom-designed amputation protection and compression system (CAPCS) to the residual limb can accelerate and improve the likelihood of successful prosthesis use. We conducted a retrospective study of all patients who were offered CAPCS by certified prosthetists (Hanger Prosthetics and Orthotics, Bethesda, MD) during the period between April 2004 and November 2009. Variables included age, sex, indication for amputation, and compliance with CAPCS. Compliance was defined as consistent observed wearing of the CAPCS as directed. The primary end point was the fitting of a prosthetic device to the amputated limb, with time to prosthetic fit being the secondary outcome. RESULTS: Out of 100 patients who were offered CAPCS (n = 100) during the study period, 76% were considered compliant (n = 76). Sixty five patients (65%) were ultimately fitted with prosthetic limbs. In multivariate analysis, we found that patients who had compliant use of CAPCS were significantly more likely to be successfully fit with prosthesis (72 vs. 42%, p = 0.005). At 100 days post amputation, the cumulative incidence of prosthesis fitting was significantly higher in CAPCS compliant patients (69.7 vs. 22.2%, p = 0.012). CONCLUSIONS: Compliant use of a CAPCS following amputation is associated with earlier and more frequent use of a prosthetic. Based on this limited data set, a conclusion can be drawn that the potential exists to significantly improve functional outcomes after amputation, but well-designed prospective studies are needed to confirm this association.
Assuntos
Amputação Cirúrgica , Membros Artificiais , Bandagens , Extremidade Inferior/cirurgia , Ajuste de Prótese , Idoso , Amputação Cirúrgica/efeitos adversos , Distribuição de Qui-Quadrado , Desenho de Equipamento , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Missouri , Análise Multivariada , Razão de Chances , Cooperação do Paciente , Projetos Piloto , Pressão , Modelos de Riscos Proporcionais , Desenho de Prótese , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , CicatrizaçãoRESUMO
OBJECTIVE: The Society for Vascular Surgery (SVS) Vascular Registry (VR) collects data on outcomes of carotid endarterectomy and carotid artery stenting (CAS). The purpose of this study was to evaluate the impact of open vs closed cell stent design on the in-hospital and 30-day outcome of CAS. METHODS: The VR collects provider-reported data on patients using a Web-based database. Data were analyzed both in-hospital and at 30 days postprocedure. The primary outcome is combined death/stroke/myocardial infarction (MI). RESULTS: As of October 14, 2009, there were 4337 CAS with discharge data and 2397 with 30-day data. Open cell stents (OPEN) were used in 3451 patients (79.6%), and closed cell stents (CLOSED) were used in 866 patients (20.4%). Baseline demographics showed no differences in age, gender, race, and ethnicity. However, the OPEN group had more patients with atherosclerosis (74.5% vs 67.4%; P = .0003) as the etiology of carotid artery disease. The OPEN group also had a higher prevalence of preprocedural stroke (25.8% vs 21.4%; P = .0079), chronic obstructive pulmonary disease (COPD; 21.0% vs 17.6%; P = .0277), cardiac arrhythmia (14.7% vs 11.4%; P = .0108), valvular heart disease (7.4% vs 3.7%; P < .0001), peripheral vascular disease (PVD; 40.0% vs 35.3%; P = .0109), and smoking history (59.0% vs 54.1%; P = .0085). There are no statistically significant differences in the in-hospital or 30-day outcomes between the OPEN and CLOSED patients. Further subgroup analyses demonstrated symptomatic patients had a higher event rate than the asymptomatic cohort in both the OPEN and CLOSED groups. Among symptomatic patients, the OPEN patients had a lower (0.43% vs 1.41%; P = .0349) rate of in-hospital mortality with no difference in stroke or transient ischemic attack (TIA). There were no differences in 30-day event rates. In asymptomatic patients, there were also no statistically significant differences between the OPEN and CLOSED groups. After risk adjustment, there remained no statistically significant differences between groups of the primary endpoint (death/stroke/MI) during in-hospital or 30 days. CONCLUSION: In-hospital and 30-day outcomes after CAS were not significantly influenced by stent cell design. Symptomatic patients had higher adverse event rates compared to the asymptomatic cohort. As there is no current evidence of differential outcome between the use of open and closed cell stents, physicians should continue to use approved stent platforms based on criteria other than stent cell design.
Assuntos
Angioplastia/instrumentação , Doenças das Artérias Carótidas/terapia , Sociedades Médicas , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Doenças das Artérias Carótidas/mortalidade , Distribuição de Qui-Quadrado , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Razão de Chances , Seleção de Pacientes , Desenho de Prótese , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Traditional open repair of distal arch aortic aneurysms requires a two-stage procedure associated with significant morbidity and mortality. The introduction of thoracic endovascular aneurysm repair has created a less invasive option to complete the second stage of the repair after proximal elephant trunk creation. The present study reports a series of patients treated with a combined open proximal and endovascular distal repair of distal arch aortic aneurysms. METHODS: A retrospective review was undertaken at a university medical center. All patients treated with the hybrid approach were identified. The patients were evaluated for demographics, preoperative imaging, technical success, postoperative complications, length of hospital stay, need for secondary intervention, and overall survival. RESULTS: A total of 10 patients (3 men, mean age: 67.5 years) were identified during a 4-year period between August 2005 and July 2009. All patients were treated electively and the mean maximum aneurysm diameter was 70.8 mm. Of the 10 patients, four had undergone previous thoracotomy (three aortic repair, one pulmonary resection for malignancy) and all were deemed at prohibitive risk for open second-stage surgery. The first three patients had staged reconstruction with delayed endovascular intervention through retrograde arterial access. The more recent seven patients underwent single-stage repair with endograft delivery through an antegrade ascending aortic access. Technical success was achieved in all cases. No perioperative paraplegias or strokes were reported. One patient had successful endovascular treatment of a type IB endoleak at 38 months. Another had an enlarging thoracoabdominal aneurysm resulting in a type IB endoleak which was detected at 43 months. There was one death within 30 days after the procedure. The remaining nine patients are all alive, with a mean survival of 35.1 months (range: 8-53) after surgery. CONCLUSIONS: The hybrid approach to treatment of distal arch aortic aneurysms is safe and serves as a viable alternative to conventional open repair. Less technically challenging, avoidance of a second surgery as well as elimination of the possibility of becoming lost to follow-up, or interval mortality have led us to consider a single-stage repair using an antegrade approach as the preferred option.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Centros Médicos Acadêmicos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Terapia Combinada , Procedimentos Cirúrgicos Eletivos , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Tempo de Internação , Masculino , Missouri , Desenho de Prótese , Reoperação , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
OBJECTIVE: The Vascular Registry (VR) on carotid procedures collects long-term outcomes on carotid artery stenting (CAS) and carotid endarterectomy (CEA) patients. The purpose of this report is to describe in-hospital and 30-day CAS outcomes in patients with atherosclerotic carotid artery disease (CAD; atherosclerosis [ATH]) compared to recurrent carotid stenosis (RES) and radiation-induced stenosis (RAD). METHODS: The VR collects provider-reported data on CAS using a Web-based data management system. For this report, data were analyzed at the preprocedure, procedure, predischarge, and 30-day intervals. RESULTS: As of November 20, 2008, there were 4017 patients with CAS with discharge data, of which 72% were due to ATH. A total of 2321 patients were available for 30-day outcomes analysis (1623 ATH, 529 restenosis, 119 radiation, 17 dissection, 3 trauma, and 30 other). Baseline demographics showed that ATH occurred in older patients (72-years-old), had the greatest history of coronary artery disease (CAD; 62%), myocardial infarction (MI; 24%), valvular heart disease (8%), arrhythmia (16%), congestive heart failure (CHF; 16%), diabetes mellitus (DM; 35%), and chronic obstructive pulmonary disease (COPD; 20%). RES had a higher degree of baseline stenosis (87.0 vs 85.8 ATH; P = .010), were less likely to be symptomatic (35.5% vs 46.3% ATH; P < .001), but had a greater history of hypertension, peripheral vascular disease (PVD), and smoking. RAD was seen in younger patients (66.6 vs 71.7 ATH; P < .001), were more likely to be male (78.2% vs 60.9% ATH; P < .001), and had less comorbidities overall, with the exception of amaurosis fugax, smoking, and cancer. The only statistically significant difference in perioperative rates was in transient ischemic attack (TIA; 2.7% ATH vs 0.9% RES; P = .02). There were no statistically significant differences in in-hospital death/stroke/MI (ATH 5.4%, RES 3.8%, RAD 4.2%) or at 30 days (ATH 7.1%, RES 5.1%, RAD 5.0%). Even after adjusting for age, gender, symptomatology, CHF, and renal failure, the only statistically significant difference at 30 days was amaurosis fugax between ATH and RAD (odds ratio [OR] 0.13; P = .01). CONCLUSION: Although patients with ATH have statistically significant comorbidities, they did not have statistically significant increased rates of death/stroke/MI during hospitalization or within 30 days after discharge when compared to RES or RAD. The CAS event rates for ATH vs RES and RAD are similar, despite prior published reports. Symptomatic ATH have statistically significant higher rates of death/stroke/MI compared to asymptomatic cohort. Finally, consistent and accurate entry of long-term data beyond initial hospitalization is essential to fully assess CAS outcomes since a significant number of adverse events occur in the interval from hospital discharge to 30 days.
Assuntos
Angioplastia/instrumentação , Aterosclerose/patologia , Estenose das Carótidas/patologia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/métodos , Stents , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Angioplastia/métodos , Angioplastia/mortalidade , Aterosclerose/diagnóstico por imagem , Aterosclerose/cirurgia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Estudos de Coortes , Endarterectomia das Carótidas/efeitos adversos , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Probabilidade , Falha de Prótese , Sistema de Registros , Medição de Risco , Índice de Gravidade de Doença , Sociedades Médicas , Análise de Sobrevida , Ultrassonografia Doppler DuplaRESUMO
OBJECTIVE: Proximal attachment failure, often leading to graft migration, is a severe complication of endovascular aneurysm repair (EVAR). Aortic cuffs have been used to treat proximal attachment failure with mixed results. The Zenith Renu AAA Ancillary Graft (Cook Inc, Bloomington, Ind) is available in two configurations: converter and main body extension. Both provide proximal extension with active fixation for the treatment of pre-existing endovascular grafts with failed or failing proximal fixation or seal in patients who are not surgical candidates. We prospectively compared the outcomes of patient treatment with these two device configurations. METHODS: From September 2005 to May 2008, a prospective, nonrandomized, postmarket registry was conducted to collect data from 151 patients treated at 95 institutions for proximal aortic endovascular graft failure using the Renu graft. Treatment indications included inadequate proximal fixation or seal, for example, migration, and type I and III endoleak. A total of 136 patients (90%) had migration, 111 (74%) had endoleak, and 94 (62%) had endoleaks and graft migration. AneuRx grafts were present in 126 patients (83%), of which 89 (59%) were treated with a converter and 62 (41%) with a main body extension. Outcomes using converters vs main body extensions for endoleak rates, changes in aneurysm size, and ruptures were compared. RESULTS: Preprocedural demographics between the two groups did not differ significantly. Procedural success rates were 98% for the converter group and 100% for the main body extension group. At a mean follow-up of 12.8 +/- 7.5 months, no type III endoleaks (0%)were identified in the converter group, and five (8%) were identified in the main body extension group. There were no aneurysm ruptures in patients treated with converters (0%) and three ruptures (5%) in patients treated with main body extensions. Each patient with aneurysm rupture had been treated with a Renu main body extension, developed a type III endoleak, and underwent surgical conversion. Two of the three patients died postoperatively. CONCLUSIONS: Proximal attachment failure and graft migration are potentially lethal complications of EVAR. Proximal graft extension using an aortic cuff is the easiest technique for salvaging an endovascular graft. Unfortunately, it has a predictable failure mode (development of a type III endoleak due to component separation) and is associated with a significantly higher failure rate than with the use of a converter. EVAR salvage with a converter and a femorofemoral bypass is a more complex but superior option for endovascular graft salvage.
Assuntos
Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Migração de Corpo Estranho/cirurgia , Falha de Prótese , Aneurisma Aórtico/mortalidade , Ruptura Aórtica/etiologia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Migração de Corpo Estranho/etiologia , Migração de Corpo Estranho/mortalidade , Humanos , Estimativa de Kaplan-Meier , Vigilância de Produtos Comercializados , Estudos Prospectivos , Desenho de Prótese , Sistema de Registros , Reoperação , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Although endovascular aneurysm repair has been shown to be an effective way to treat abdominal aortic aneurysm (AAA), certain anatomic characteristics such as a short aortic neck, limit its applicability. Initially, commercially available devices were approved only for the treatment of AAA with an aortic neck length ≥ 15 mm. The purpose of this study was to evaluate the outcomes of the recently approved Talent endograft for AAAs with a short aortic neck length (10-15 mm). METHOD: Data were obtained from the prospective, nonrandomized, multicenter Talent enhanced Low Profile Stent Graft System trial which enrolled patients between February 2002 and April 2003. A total of 154 patients with adequate preoperative imaging were identified for this study. Subgroup analyses were performed for AAA with 10-15 mm aortic neck and those with >15 mm neck. Safety and effectiveness endpoints were evaluated at 30 days, 1 year, and 5 years postprocedure. RESULTS: Patients treated with aortic neck lengths of 10-15 mm (n = 35) and those with >15 mm (n = 102) had similar age, gender, and risk factor profile. Both groups had similar preoperative aneurysm morphology in terms of maximum aneurysm size, degree of neck angulation, or proximal neck diameter. There were no statistically significant differences in freedom from major adverse events and mortality rates at 30 and 365 days. Similarly, there was no difference in the effectiveness endpoints at 12 months. At 5 years, there was no difference in migration rate, endoleaks, or change in aneurysm diameter from baseline. In addition, there is no difference in freedom from aneurysm-related mortality (94% vs. 99%). CONCLUSIONS: AAAs with short aortic necks (10-15 mm) and otherwise suitable anatomy for endovascular repair can be safely and effectively treated with the Talent endograft with excellent 1 and 5 year outcomes.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Distribuição de Qui-Quadrado , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Prospectivos , Desenho de Prótese , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Popliteal artery aneurysms have traditionally been repaired with an open surgical approach. However, endovascular popliteal artery repair (EVPAR) has been used in selected patients because of its less invasive nature. In this report, we present our long-term outcomes for EVPAR. METHODS: Retrospective review of all patients who underwent EVPAR at a single academic institution between September 2002 and March 2006. These patients were evaluated for patency, need for secondary intervention, amputation-free survival, and overall survival. RESULTS: A total of 15 limbs in 13 patients were treated with EVPAR during the study period. All EVPAR were performed using the Viabahn(®) endoprostheses, with an average of 1.67 stents per limb. The mean age of the patients was 74.6 years (range, 66-84). Technical success was achieved in 100% and all limbs had initial postoperative ankle-arm indices of ≥ 1.0. Mean duration of follow-up was 54 months (range, 42-70). Two patients died of unrelated causes at 3 and 38 months with intact limbs, and one patient was lost to follow-up. Two limbs developed type I or III endoleaks, and were successfully treated with additional endovascular stent placement, resulting in a primary patency rate of 84.6% and secondary patency rate of 100%. There were no instances of limb loss during the follow-up period, yielding both amputation-free survival and overall survival rates of 85.7%. CONCLUSIONS: Long-term follow-up of this cohort of EVPAR patients suggests that in selected patients, this is a durable technique, capable of achieving excellent patency rates and limb preservation. Further large-scale clinical trials are warranted to help define optimal candidates for this technique.
Assuntos
Aneurisma/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Poplítea/cirurgia , Centros Médicos Acadêmicos , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Aneurisma/mortalidade , Aneurisma/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Salvamento de Membro , Masculino , Missouri , Artéria Poplítea/fisiopatologia , Desenho de Prótese , Reoperação , Estudos Retrospectivos , Stents , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: Endovascular repair of thoracic aortic disease continues to evolve since FDA approval of the first thoracic endograft in the United States in March 2005. Certain anatomic characteristics, including adequacy of arterial access, remain a significant limiting factor in thoracic endovascular repair. In clinical trials evaluating thoracic endografts, vascular access complications occurred in >20% of cases. The purpose of this study is to evaluate the arterial access and the selective use of the ascending aorta for thoracic endograft placement. METHOD: A retrospective review was performed for patients who underwent thoracic endograft placement between May 2005 and April 2009 (4 years since FDA approval of the first thoracic endograft). Patient records were reviewed for the indication for the procedure, type of arterial access, technical success, and access-related complications. RESULTS: Seventy-nine thoracic endografts were placed during the study period. The indications for endograft placement included 53 aneurysms, 10 traumatic lesions, 6 endoleaks, 4 dissections, 3 penetrating ulcers, 2 bleeding aortic fistulas, and 1 thoracic diverticulum. Retrograde access was used in 70 cases (89%): 60 femoral (76%) and 10 aortoiliac (13%). Antegrade access through a 10-mm polyester graft anastomosed to the ascending aorta was used in nine cases (11%). These procedures included endograft placement with proximal elephant trunk creation in six cases, endograft-alone in two cases, and combination with proximal arch reconstruction/debranching in one case. There was 100% technical success for all cases. The overall access-related complication rate was 6%. There were no complications with antegrade access through the ascending aorta or with aortoiliac access. There were five complications in the femoral access group (three iliac artery dissection, one iliac artery injury, and one femoral artery injury). CONCLUSIONS: Access selection is an important part of the preoperative planning of endovascular procedures. Choosing the most appropriate access for a patient will decrease the access-associated complication rate. In addition, selected patients with poor aortoiliac access and those that require debranching or elephant trunk procedures may benefit from antegrade access.
Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/métodos , Cateterismo Periférico , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Cateterismo Periférico/efeitos adversos , Feminino , Artéria Femoral , Humanos , Artéria Ilíaca , Masculino , Missouri , Seleção de Pacientes , Desenho de Prótese , Medição de Risco , Resultado do TratamentoRESUMO
BACKGROUND: We report the outcomes of a single-center experience with endovascular aneurysm repair (EVAR) in nonagenarians. METHODS: Via a retrospective medical records review, we identified all patients > or = 90 years old who underwent EVAR at a single university teaching hospital during a 5-year period (January 2004 to December 2008). Patients were evaluated for surgical risk factor profile, preoperative imaging, technical success, postoperative complications, length of hospital stay, and need for secondary intervention. In addition, mortality rates were evaluated at 30 days, 365 days, and 2 years. RESULTS: There were 18 nonagenarians (12 male, 67%) with a mean age of 91.2 years (range 90-95). Each patient averaged 3.5 risk factors, and the mean preoperative maximal aneurysm size was 68.3mm (range 50-105). Sixteen (89%) patients were treated on an elective basis, and two patients were emergently treated for aneurysm rupture, with one undergoing aortouni-iliac stenting with femoral-femoral bypass. All other patients in the study had bifurcated stent grafts. There was 100% technical success with no need for open conversion. The mean length of hospital stay was 4.3 days with a mean intensive care unit stay of 0.6 days. Systemic complications occurred in three patients (17%) including one death within 30 days. Secondary interventions were required in two patients (11%). One had endovascular treatment of a type I endoleak at 4 months, and a second patient underwent femoral-femoral bypass at 25 months for severe flow-limiting limb angulation. Mortality rates were 5.6% at 30 days, 41.2% at 365 days, and 58.3% at 2 years. Mean survival of the 11 patients who expired beyond the first 30 days was 17.5 months (range 4-50). Of these, mean survival of the nine patients treated electively was 20.2 months (range 7-50). Mean survival of the six patients still alive is 25.6 months (range 8-65). CONCLUSION: EVAR is safe in nonagenarians despite their advanced age and significant surgical risk factor profile. The procedure can be performed with excellent technical success and a low rate of perioperative complications. However, mortality rates after 30 days are significant. The substantial long-term mortality raises the question of possible treatment futility in this unique population. While age should not be a contraindication for EVAR, recommendations for the procedure should be based on individual patient selection.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Feminino , Hospitais Universitários , Humanos , Tempo de Internação , Masculino , Futilidade Médica , Missouri , Seleção de Pacientes , Desenho de Prótese , Falha de Prótese , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: As the first operational societal registry of carotid procedures, the Outcomes Committee of the Society for Vascular Surgery (SVS) developed the Vascular Registry (VR) in response to the Centers for Medicare and Medicaid Services' (CMS) National Coverage Decision on carotid artery stenting (CAS). Although CMS requires data submission only on CAS, the VR collects similar data on carotid endarterectomy (CEA) to allow comparison of outcomes, as well as potential for expansion to other procedures. METHODS: SVS-VR on-line provider-reported data include baseline through follow-up visits to better understand long-term risks and benefits associated with CAS and CEA. The primary outcomes are combined death, stroke, and myocardial infarction (MI). An independent data coordinating center maintains the database, which is Health Insurance Portability and Accountability Act (HIPAA)-compliant and auditable. RESULTS: As of December 26, 2007, 6403 procedures with discharge data were entered by 287 providers at 56 centers on 2763 CAS patients (1450 with 30-day outcomes, 52.5%) and 3259 CEA patients (1368 with 30-day outcomes, 42%). Of the total cohort, 98% of CEA and 70.7% of CAS (P < .001) were performed for atherosclerotic disease. Restenosis accounted for 22.3% and post-radiation induced stenosis in 4.5% of CAS patients. Preprocedure lateralizing neurologic symptoms were present in a greater proportion of CAS patients (49.2%) than CEA patients (42.4%, P < .001). CAS patients also had higher preprocedure prevalence of coronary artery disease (CAD), MI, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and cardiac arrhythmia. For CAS, death/stroke/MI at 30 days was 7.13% for symptomatic patients and 4.60% for asymptomatic patients (P = .04). For CEA, death/stroke/MI at 30 days was 3.75% in symptomatic patients and 1.97% in asymptomatic patients (P = .05). After risk-adjustment for age, history of stroke, diabetes, and American Society of Anesthesiologists (ASA) grade (ie, factors found to be significant confounders in outcomes using backwards elimination), logistic regression analysis suggested better outcomes following CEA. There were no statistically significant differences when examining CAS outcomes based on center volume. CAS in atherosclerotic disease had significantly worse outcomes than in nonatherosclerotic stenosis. When CAS and CEA were compared in the treatment of atherosclerotic disease only, the difference in outcomes between the two procedures was more pronounced, with death/stroke/MI 6.42% after CAS vs 2.62% following CEA, P < .0001. CONCLUSION: Following best possible risk adjustment of these unmatched groups, symptomatic and asymptomatic CAS patients had significantly higher 30-day postprocedure incidence of death/stroke/MI when compared with CEA patients. The initial 1.5 years of data collection provide proof of concept that a specialty society based VR can succeed in meeting regulatory and scientific goals. With continued enrollment and follow-up, analysis of SVS-VR will supplement randomized trials by providing real-world comparisons of CAS and CEA with sufficient numbers to serve as an outcome assessment tool of important patient subsets and across the spectrum of peripheral vascular procedures.
Assuntos
Angioplastia/instrumentação , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Estudos de Viabilidade , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Razão de Chances , Recidiva , Sistema de Registros , Medição de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECT: The aim of this study was to determine the efficacy of venous ultrasonography in screening for deep venous thrombosis (DVT) after subarachnoid hemorrhage (SAH). A large cohort of patients who had suffered SAH was evaluated with the primary end points of ascertaining the incidence of asymptomatic DVT with venous Doppler ultrasonography screening and of identifying risk factors for the development of DVT and subsequent pulmonary embolism. METHODS: Data from patients with aneurysmal SAH who had been admitted to the neurosurgical intensive care unit (ICU) between December 2002 and October 2006 were retrospectively evaluated. Patients who had undergone surgical or endovascular treatment of an aneurysm following SAH and survived > or = 15 days were included in the study. RESULTS: The overall incidence of DVT among the entire study cohort was 18%. A subgroup analysis identified all patients, with or without symptoms for DVT, who had undergone venous Doppler ultrasonography screening. The incidence of asymptomatic DVT was 24%. Univariate analysis of all patients revealed a significant correlation between the risk of DVT and Hunt and Hess grade (r = 0.38, p < 0.0001), Fisher grade (r = 0.31, p < 0.0001), total hospital stay (r = 0.49, p < 0.0001), and number of days in the ICU (r = 0.48, p < 0.0001). Multivariate analysis demonstrated that the total hospital stay and number of days in the ICU were significant predictors of DVT in all patients (p < 0.0001 and p < 0.0002, respectively). In the subgroup of screened patients, Hunt and Hess grade, total hospital stay, and number of days in the ICU were significant predictors of DVT. Although screened patients were more likely to have DVT (chi(2) = 6.0976, p < 0.02), there was no significant difference in the incidence of DVT or pulmonary embolism between patients who did and those who did not undergo routine lower-extremity Doppler ultrasonography screening. CONCLUSIONS: Routine compressive venous Doppler ultrasonography is an efficient, noninvasive means of identifying DVT as a screening modality in both symptomatic and asymptomatic patients following aneurysmal SAH. The ability to confirm or deny the presence of DVT in this patient population allows one to better identify the indications for chemoprophylaxis. Prophylaxis for venous thromboembolism in neurosurgical patients is common. Emerging literature and anecdotal experience have exposed risks of complications with prophylactic anticoagulation protocols. The identification of patients at high risk-for example, those with asymptomatic DVT-will allow physicians to better assess the role of prophylactic anticoagulation.
Assuntos
Hemorragia Subaracnóidea/complicações , Ultrassonografia Doppler , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/etiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: The purpose of this study was to evaluate the clinical significance of endoleaks detected on combined arterial and delayed contrast-enhanced follow-up CT examinations of patients who have undergone endovascular aneurysm repair of abdominal aortic aneurysm. MATERIALS AND METHODS: One hundred forty-four patients underwent periodic follow-up CT examinations 12-72 months after abdominal aortic aneurysm repair. The CT protocol consisted of an unenhanced scan and contrast-enhanced scans in the arterial and 90-second delayed phases. The endoleaks detected on dual-phase CT scans were evaluated in association with the outcome (therapeutic intervention or endoleak resolution). RESULTS: The 144 patients underwent 728 CT examinations with a mean follow-up period of 35.5 +/- 14.5 months. Fifty endoleaks were detected in 50 (34.7%) of the patients. Eight endoleaks were detected in the arterial phase only, eight in the delayed phase only, and 34 in both phases. Intervention was performed to manage 16 endoleaks detected in both phases. CT showed that three endoleaks were stable (two in the arterial phase only and one in both phases) and that 31 had resolved completely (six in the arterial phase only, eight in the delayed phase only, and 17 in both phases). This finding represents a higher frequency of resolution of endoleaks detected in one phase only than in both phases (Fisher's exact test, p = 0.006). CONCLUSION: Endoleaks detected only in the delayed phase of CT had resolved spontaneously without intervention. Therefore, we can consider eliminating the delayed phase of acquisition to minimize radiation exposure.
Assuntos
Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos de Cirurgia Plástica/efeitos adversos , Hemorragia Pós-Operatória/diagnóstico por imagem , Hemorragia Pós-Operatória/etiologia , Tomografia Computadorizada por Raios X/métodos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Procedure-related complications with carotid artery stenting must be minimized for it to be a valid treatment for carotid stenosis. Failure analysis was done for 207 carotid stent procedures. All complications were reviewed and technical errors were identified. The procedure-related stroke rate was 2.9%, technical failure rate was 1.9%, and no patients died. Two strokes resulted from protocol deviations. A third stroke occurred while crossing a long, irregular lesion with a protection device instead of establishing flow reversal. Excessive instrumentation of the aortic arch resulted in 2 strokes. Distal embolization occurred after open-cell stenting a friable lesion in 1 patient. The majority of neurologic events and technical complications that occur during carotid stenting are preventable. By adhering to technical protocols, avoiding excessive instrumentation in the aortic arch, using flow reversal in selected lesions, and matching the appropriate anatomy and stent, results of carotid artery stenting can be exceptional.
Assuntos
Angioplastia/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Stents , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Artéria Carótida Primitiva/diagnóstico por imagem , Artéria Carótida Interna/diagnóstico por imagem , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Radiografia , Sistema de Registros , Acidente Vascular Cerebral/epidemiologiaRESUMO
Primary aortic neoplasms are rare. Aortic sarcoma arising after endovascular aneurysm repair (EVAR) is a scarce subset of primary aortic malignancies, reports of which are infrequent in the published literature. The diagnosis of aortic sarcoma is challenging due to its non-specific clinical presentation, and the prognosis is poor due to delayed diagnosis, rapid proliferation, and propensity for metastasis. Post-EVAR, aortic sarcomas may mimic other more common aortic processes on surveillance imaging. Radiologists are rarely knowledgeable about this rare entity for which multimodality imaging and awareness are invaluable in early diagnosis. A series of three pathologically confirmed cases are presented to display the multimodality imaging features and clinical presentations of aortic sarcoma arising after EVAR.
Assuntos
Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Doenças da Aorta/diagnóstico por imagem , Implante de Prótese Vascular , Procedimentos Endovasculares , Hemangiossarcoma/diagnóstico por imagem , Leiomiossarcoma/diagnóstico por imagem , Imagem Multimodal , Complicações Pós-Operatórias/diagnóstico , Neoplasias Vasculares/diagnóstico por imagem , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia , Angiografia por Tomografia Computadorizada , Diagnóstico Diferencial , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Venous thromboembolism (VTE) and atherosclerosis may be associated and may share common risk factors. We conducted a retrospective case-control study to investigate the association between VTE and coronary atherosclerotic disease (CAD) by means of measuring coronary artery calcification and evaluating clinical risk factors. METHODS: From 385 consecutive patients suspected of VTE, we randomly selected 89 cases with idiopathic VTE and 89 controls without VTE, frequency matched on gender and age. Risk factors for atherosclerosis were noted for both groups. Coronary artery calcification was quantified on pulmonary computed tomography (CT) angiographic images. The coronary artery calcification and risk factors were compared between the case and control groups. The associations between VTE and the presence of coronary artery calcium and risk factors were assessed with logistic regression analysis. RESULTS: A higher prevalence of coronary artery calcium was found in the case group (51.7%) than in the control group (28.1%) (p=0.001). The presence of coronary artery calcium was significantly associated with VTE with an odds ratio of 4.3 (95% confidence interval, 1.9-10.1) in a multivariable model. Diabetes mellitus and hypertension were also significantly associated with VTE. CONCLUSION: A significant association between VTE and CAD suggests that CAD is an independent risk factor for VTE. Diabetes and hypertension are also independent risk factors for VTE.
Assuntos
Calcinose/epidemiologia , Cálcio/análise , Doença da Artéria Coronariana/epidemiologia , Vasos Coronários/química , Tromboembolia/epidemiologia , Tomografia Computadorizada por Raios X , Trombose Venosa/epidemiologia , Adulto , Idoso , Calcinose/diagnóstico por imagem , Estudos de Casos e Controles , Comorbidade , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Hiperlipidemias/epidemiologia , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Estudos de Amostragem , Trombofilia/epidemiologia , Tomografia Computadorizada EspiralRESUMO
BACKGROUND: The functional results of cryopreserved heterotopic parathyroid autotransplantation (CHPA) are not well defined. The authors evaluated the outcomes of delayed CHPA for the treatment of surgically induced hypoparathyroidism. METHODS: Since November 1991, 448 parathyroid samples from 436 patients were cryopreserved at our institution. Of these, 29 patients underwent 34 CHPA procedures, with placement of 20 to 25 pieces of parathyroid tissue (approximately 50 to 75 mg) into the forearm. Outcomes were determined based on peripheral parathyroid hormone (PTH) levels and, where available, PTH gradients between grafted and nongrafted arms. Graft function results were defined as completely functional (patients with normal PTH and calcium levels off all calcium/vitamin D supplementation), partially functional (normal PTH levels and mild hypocalcemia on calcium supplementation), or nonfunctional (low PTH levels and dependent on calcium/vitamin D supplementation). RESULTS: Of the 29 patients with CHPA, prospective data were available for 26 patients undergoing 30 CHPA procedures (9 patients with MEN 1, 4 with MEN 2A, 1 with MEN 2B, and 12 with sporadic hyperparathyroidism). The mean follow-up interval was 2 years. Twelve of 26 patients (46%) had completely functional grafts, 6 patients (23%) had partially functional grafts, and the remaining 8 patients (31%) had nonfunctional grafts. No patient with CHPA had graft-dependent recurrent hyperparathyroidism. Of the 14 patients (15 autografts) with MEN, 7 patients (50%) had fully functional grafts, and 2 patients (14%) had partially functional grafts. The mean cryopreservation period was 7.9 months (range, 1 week to 22 months) for functional autografts and 15.3 months (range, 2 weeks to 106 months) for nonfunctional autografts (P < .01). CONCLUSIONS: Based on these data and those in previous studies, approximately 60% of delayed, cryopreserved parathyroid autografts are functional. In this study 40% autografts (46% of patients) achieved full competency off supplements. Some patients have evidence of graft function with normal PTH levels but are not normocalcemic. Results were similar for patients with MEN and nonhereditary hyperparathyroidism. The duration of cryopreservation was a significant indicator of graft failure, and no functional autograft was observed beyond 22 months of preservation. CHPA is a useful treatment modality for patients with postoperative hypocalcemia after thyroid or parathyroid surgery, who do not respond to immediate parathyroid autotransplantation.