RESUMO
INTRODUCTION: Patients with abdominal aortic aneurysms (AAAs) who are deemed unacceptable candidates for open repair (UNFIT) pose a clinical challenge. The EVAR2 Trial randomized UNFIT patients to endovascular aortic repair (EVAR) vs no intervention from 1999 to 2003, concluding that survival was not improved by EVAR. However, outcomes after EVAR over the last 2 decades have dramatically changed. Thus, the purpose of this study was to evaluate outcomes after EVAR in UNFIT patients using more contemporary data and to determine which subsets of UNFIT patients may potentially benefit from EVAR. METHODS: The Vascular Quality Initiative database (2003-2020) was used to identify elective EVARs for AAAs. Patients were categorized as UNFIT or suitable (SUITABLE) for open repair by the operative surgeon. Predicted 1-year mortality of untreated AAAs was calculated via a modified Gagne Index adjusted for AAA size. The primary outcome for the study was 30-day mortality. Secondary outcomes included perioperative major adverse cardiac events (a composite of clinically significant arrhythmia, congestive heart failure, and myocardial infarction), length of stay, and 1-year mortality. RESULTS: A total of 31,471 patients met study criteria with 27,036 (85.9%) deemed SUITABLE and 4435 (14.1%) UNFIT. UNFIT patients were more likely to experience a perioperative major adverse cardiac event (5.1% vs 2.2%, P < .001) and had longer lengths of stay (1 day [interquartile range, 1-3 days] vs 1 day [interquartile range, 1-2 days], P < .001). The 30-day mortality was significantly higher for UNFIT patients (0.8% vs 0.4%, P < .001). UNFIT patients had worse 1-year survival compared with SUITABLE patients. However, UNFIT and SUITABLE patients had significantly improved actual 1-year mortality with EVAR compared with predicted 1-year mortality without EVAR: 9.5% vs 15.6% (P < .001) and 4.0% vs 11.7% (P < .001), respectively. The mortality benefit after EVAR in UNFIT patients was primarily restricted to those with smaller Gagne Indices and larger aneurysm diameters. Patients deemed unsuitable for open repair due to frailty or multiple reasons had significantly higher 30-day mortality rates after EVAR when compared with SUITABLE patients (1.3% vs 1.6% vs 0.4%, P < .001). Those deemed unsuitable for open repair due to frailty or multiple reasons had worse 1-year cumulative survival compared with all other UNFIT patients. CONCLUSIONS: Despite being high risk with higher perioperative morbidity and mortality, UNFIT patients have lower actual 1-year mortality with EVAR than predicted 1-year mortality without EVAR. However, this potential benefit is reserved to those with small Gagne Indices, larger AAA diameters, and lack of frailty.
Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Fragilidade , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Fragilidade/complicações , Humanos , Complicações Pós-Operatórias , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: Patients with descending thoracic aortic aneurysms (dTAA) or thoracoabdominal aortic aneurysms (TAAA) often have a variety of medical comorbidities. Those that are deemed acceptable for intervention undergo complicated repairs with good early outcomes. The purpose of this study was to identify variables that were associated with mortality over time. METHODS: This was a retrospective review of a prospectively maintained database at our institution from 1983 to 2015. Patients were included if they underwent open or endovascular repair for dTAA or TAAA. Patients were excluded if they were intervened on for traumatic transections. The primary outcome for the study was long-term survival. Secondary outcomes included aortic-related mortality. We had mortality and survival data on all patients. RESULTS: A total of 946 patients met our study criteria with a median follow-up of 102.8 months (interquartile range [IQR], 58.9-148.2 months). The median age of the cohort was 71 years (IQR, 63-77 years) with the majority of patients being male (58.1%). The extent of TAAA pathology was as follows: type I (14.2%), type II (21.2%), type III (17.1%), type IV (26.2%), and dTAA (21.2%). A total of 147 patients (15.5%) had a prior dissection. The median diameter of aneurysm was 6.4 cm (IQR, 6.0-7.0 cm). A total of 158 patients (16.7%) underwent endovascular repair over the study period. Variables associated with mortality over time were age, surgical era, acute pathology, dissection, preoperative creatinine, and type IV TAAAs. In addition, experiencing the following complications in the postoperative period was associated with mortality over time: neurological, cardiac, and pulmonary. Aortic-related mortality was 2.1% (n = 20) over the study period. Patients who underwent endovascular repair for acute conditions had better long-term survival when compared with open repair. However, there were no differences in long-term survival between open and endovascular repair for nonacute cases. In addition, repair in the more modern era was associated with improved survival. CONCLUSIONS: TAAAs can be repaired with reasonable perioperative mortality rates. Once patients undergo repair of their aneurysm, aortic-related mortality remains low. The addition of endovascular options has dramatically changed management of patients with dTAA and TAAA. Further, endovascular repair was associated with decreased perioperative mortality and significantly increased long-term survival in acute patients. Patients undergoing TAAA repair are generally considered high risk and therefore require extensive long-term follow-up for management of their comorbidities and complications, because these are the main contributors to mortality over time.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: The attempt to repair a ruptured abdominal aortic aneurysm carries a significant risk of perioperative mortality. The relationship between body mass index (BMI) and outcomes after repair of ruptured abdominal aortic aneurysms (AAAs) has not been well defined. We report the association of BMI with outcomes after ruptured AAA repair. METHODS: Patients undergoing ruptured AAA repairs between 2008 and 2017 at 2 tertiary academic centers were included in this retrospective study. Demographics (including BMI), type of repair, length of stay, and admission mortality risk scores were gathered and analyzed using bivariate and multivariate logistic regressions. Adjusted odds ratio (AOR) was reported with 95% CIs and P values from the multivariate analysis. The primary outcome was 30-day mortality. Akaike information criterion (AIC) and c-statistics were used to assess the predictive power of models including physiologic score with or without BMI. RESULTS: A total of 202 patients underwent repair of ruptured AAA. In bivariate relationship, increased BMI was significantly associated with 30-day mortality. With multivariate analysis, adjusting for demographics, type of procedure, and physiologic score, for each kg/m2 increase in BMI, an 8% increase in the likelihood of perioperative mortality (AOR = 1.08, 95% CI: 1.01-1.17; P = .04) was observed. CONCLUSION: When adjusted for admission risk score, type of procedure, and demographics, obesity was associated with increased 30-day mortality. With BMI as an additional data point, the c-statistics and AIC comparisons indicated that we would have a greater ability to preoperatively estimate mortality after ruptured AAA repair. Consideration could be made to include BMI in future mortality risk scoring systems for ruptured AAA.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Índice de Massa Corporal , Obesidade/diagnóstico , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Feminino , Humanos , Indiana , Masculino , Pessoa de Meia-Idade , Obesidade/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , WashingtonRESUMO
Frozen elephant trunk repair is a technique described to simplify total arch repair for Stanford type A aortic dissection. Spinal cord ischemia is a devastating complication after frozen elephant trunk repair. In this report, we describe a case of spinal cord ischemia resulting in paralysis after frozen elephant trunk repair. Our spinal cord ischemia protocol was implemented and rescued patients from paraplegia. We report a dedicated spinal cord ischemia protocol that can rescue patients from paraplegia after hybrid arch repair with frozen elephant trunk.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Isquemia do Cordão Espinal/terapia , Idoso , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Paraplegia/etiologia , Paraplegia/fisiopatologia , Paraplegia/terapia , Recuperação de Função Fisiológica , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: This study investigated the growth and behavior of the ascending aorta in patients with descending thoracic aortic disease. METHODS: We examined 200 patients with descending thoracic aortic disease including acute type B dissection (n = 95), chronic type B dissection (n = 38), intramural hematoma (n = 23), and thoracoabdominal aortic aneurysms (n = 44). Images from computed tomography and magnetic resonance imaging were evaluated after three-dimensional reconstruction to examine the growth rate in those with >1 year of imaging follow-up (n = 108). Survival data were derived from all 200 patients in this study. RESULTS: Average proximal aortic dimensions at the index image were relatively small, measuring 3.65 ± 0.51 cm in the root, 3.67 ± 0.48 cm in the ascending aorta, and 3.50 ± 0.44 cm in the proximal arch. Average growth rate was low for the aortic root, ascending aorta, and proximal arch at 0.36 ± 0.64 mm/y, 0.26 ± 0.44 mm/y, and 0.25 ± 0.44 mm/y, respectively. There was no difference in baseline proximal aortic dimensions and growth rate between the four subgroups. An index aortic diameter ≥4.1 cm grew faster than those <4.1 cm at the ascending aorta (P = .028) and proximal arch (P = .019). There was no difference in aortic growth rates at the aortic root (P = .887). After the index scan, five patients underwent six ascending aortic replacement procedures, leading to a 3% ascending aortic intervention rate. Overall median life expectancy was 86.15 years. CONCLUSIONS: Native ascending aortic growth in patients with descending thoracic aortic disease is slow. We suggest regular follow-up for index ascending aorta ≥4.1 cm because of its larger initial size and more rapid growth.
Assuntos
Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/diagnóstico , Imageamento Tridimensional , Imageamento por Ressonância Magnética/métodos , Tomografia Computadorizada por Raios X/métodos , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Tamanho do Órgão , Estudos Retrospectivos , Fatores de TempoRESUMO
INTRODUCTION: Despite evidence from prospective trials and meta-analyses supporting laparoscopic pyloromyotomy (LP) over open pyloromyotomy (OP), the open technique is still utilized by some surgeons on the premise that there is minimal clinical benefit to LP over OP. Although the potential cosmetic benefit of LP over OP is often cited in reports, it has never been objectively evaluated. METHODS: After internal review board approval, the parents of patients from a previous prospective trial who had undergone LP (n = 9) and OP (n = 10) were contacted. After consent was obtained, the parents and patients were asked to complete a validated scar scoring questionnaire that was compared between groups. Standardized photos were taken of study subjects and controls with no abdominal procedures. Blinded volunteers were recruited to view the photos, identify if scars were present, and complete questions if a scar(s) was seen. Volunteers were also asked about the degree of satisfaction if their child had similar scars on a four-point scale from happy to unacceptable. RESULTS: Mean age was 7 years in both groups. Parental scar assessment scores were superior in the LP group in every category. Blinded volunteers detected abdominal scars significantly more often in the OP group (98%) vs. the LP group (28%; P < .001). The volunteers detected a scar in 16% of the controls, comparable to the 28% detected in the LP group (P = .17). The degree of satisfaction estimate by volunteers was 1.78 for OP and 1.02 for LP and controls, generating a Cohen's d effect size of 5.1 standard deviation units comparing OP to either LP or controls (very large ≥1.3). CONCLUSIONS: Parents of children scored LP scars superior to OP scars. Surgical scars are almost always identifiable with OP while the surgical scars associated with LP approach invisibility to the observer, appearing similar to patients with no prior abdominal operation.
Assuntos
Cicatriz/etiologia , Laparoscopia/efeitos adversos , Estenose Pilórica Hipertrófica/cirurgia , Criança , Feminino , Humanos , Lactente , Laparoscopia/métodos , Masculino , Pais/psicologia , Satisfação do Paciente , Percepção , Estudos Prospectivos , Método Simples-Cego , Inquéritos e Questionários , Voluntários/psicologiaRESUMO
OBJECTIVE: To study complications from spinal fluid drainage in open thoracic/thoracoabdominal and thoracic endovascular aortic aneurysm repairs to define risks of spinal fluid drainage. DESIGN: Retrospective, prospectively maintained, institutionally approved database. SETTING: Single institution university center. PARTICIPANTS: 724 patients treated from 1987 to 2013 INTERVENTIONS: The authors drained spinal fluid to a pressure≤6 mmHg during thoracic aortic occlusion/reperfusion in open and ≤8 mmHg after stent deployment in endovascular procedures. Low pressure was maintained until leg strength was documented. If bloody fluid appeared, drainage was stopped. Head computed tomography (CT) and, if indicated, spine CT and magnetic resonance imaging (MRI) were performed for bloody spinal fluid or neurologic deficit. MEASUREMENTS AND MAIN RESULTS: Spinal fluid drainage was studied for bloody fluid, CT/MRI-identified intracranial and spinal bleeding, neurologic deficit, and death. Seventy-three patients (10.1%) had bloody fluid; 38 (5.2%) had intracranial blood on CT. One patient had spinal epidural hematoma. Higher volume of fluid drained and higher central venous pressure during proximal clamping were associated with intracranial blood. Most patients with intracranial blood were asymptomatic. Six patients had neurologic deficits: of the 6, 3 died (0.4%), 1 (0.1%) had permanent hemiparesis, and 2 recovered. Three of the six deficits were delayed, associated with heparin anticoagulation. CONCLUSIONS: 10% of patients had bloody spinal fluid; half of these had intracranial bleeding, which was almost always asymptomatic. In these patients, immediately stopping drainage and correcting coagulopathy may decrease the risk of serious complications. Neurologic deficit from spinal fluid drainage is uncommon (0.8%), but has high morbidity and mortality.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Drenagem/efeitos adversos , Complicações Intraoperatórias/diagnóstico , Punção Espinal/efeitos adversos , Adulto , Idoso , Aneurisma da Aorta Abdominal/epidemiologia , Aneurisma da Aorta Torácica/epidemiologia , Pressão do Líquido Cefalorraquidiano , Drenagem/tendências , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Punção Espinal/tendênciasRESUMO
BACKGROUND: In children, severe, life-threatening traumatic injuries of the thoracic aorta can be seen after motor vehicle collisions (MVCs) resulting in a sudden deceleration. Concurrent injuries in the thorax and abdomen can make treatment prioritization difficult and require early recognition and prompt intervention. With the increased utilization of minimally invasive endovascular approaches to traumatic aortic (TA) injuries, patients are often spared the increased surgical morbidity (spinal cord ischemia and renal insults) that can be seen with an open technique. The aim of this study was to evaluate a single American College of Surgeons level 1 pediatric trauma center's 22-y experience with TA injuries in children. METHODS: After the Institutional Review Board approval, a 22-y (January 1990-April 2013) retrospective review of all pediatric trauma patients admitted with TA injuries was performed. Patient demographics including age, injury detail, treatment, and outcomes were recorded for analysis. RESULTS: 17 children (<21-y old) were identified with ages ranging from 13-20 y old. The most common mechanism of injury was MVC with all 17 children sustaining TA injuries. The traumatic injuries included aortic transection (9), intimal flap (5), pseudoaneurysm (2), and contained thoracic rupture (1). All children were managed operatively with those before 2008 using an open technique. The endovascular approach was used in 7/17 (41%) cases with the median length of hospitalization 12 d versus 22.5 d using the open approach (P < 0.05). No child required conversion from an endovascular to an open technique for treatment of the aortic injury. There were no operative deaths, no procedure-related paraplegia and all children were discharged home from the hospital. Two children had mild mental deficits as a result of head trauma. CONCLUSIONS: TA injuries are an uncommon injury in children and can result from MVCs or other sudden deceleration mechanisms. Surgical intervention is required in most of the cases and can be performed safely and effectively with low morbidity using an endovascular approach, which is the evolving approach of choice for thoracic aortic injuries. Lengthy follow-up care is recommended in children treated with an endovascular device to monitor for endoleaks and device complications.
Assuntos
Aorta/lesões , Procedimentos Endovasculares/tendências , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adolescente , Feminino , Humanos , Masculino , Estudos Retrospectivos , Resultado do Tratamento , Lesões do Sistema Vascular/complicações , Lesões do Sistema Vascular/diagnóstico , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Adulto JovemRESUMO
Arterial stiffness may be associated with cognitive function. In this study, pulse wave velocity (PWV) was measured from the carotid to femoral (CF-PWV) and from the carotid to radial (CR-PWV) with the Complior SP System. Cognitive function was measured by 6 tests of executive function, psychomotor speed, memory, and language fluency. A total of 1433 participants were included (mean age 75 y, 43% men). Adjusting for age, sex, education, pulse rate, hemoglobin A1C, high-density lipoprotein cholesterol, hypertension, cardiovascular disease history, smoking, drinking, and depression symptoms, a CF-PWV>12 m/s was associated with a lower Mini-Mental State Examination score (coefficient: -0.31, SE: 0.11, P=0.005), fewer words recalled on Auditory Verbal Learning Test (coefficient: -1.10, SE: 0.43, P=0.01), and lower score on the composite cognition score (coefficient: -0.10, SE: 0.05, P=0.04) and marginally significantly associated with longer time to complete Trail Making Test-part B (coefficient: 6.30, SE: 3.41, P=0.06), CF-PWV was not associated with Trail Making Test-part A, Digit Symbol Substation Test, or Verbal Fluency Test. No associations were found between CR-PWV and cognitive performance measures. Higher large artery stiffness was associated with worse cognitive function, and longitudinal studies are needed to confirm these associations.
Assuntos
Cognição/fisiologia , Rigidez Vascular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Testes Neuropsicológicos , Análise de Componente Principal , Análise de Onda de Pulso , Fatores de RiscoRESUMO
OBJECTIVE: Perioperative outcomes after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) have been rigorously studied; however, inpatient and postdischarge outcomes have not been separately analyzed. The objective of this study was to examine postdischarge 30-day outcomes after elective EVAR. METHODS: Patients who underwent an elective EVAR for AAA (n = 11,229) were identified from the American College of Surgeons 2005-2010 National Surgical Quality Improvement Project database. Univariable and multivariable logistic regression analyses were performed. RESULTS: The median length of hospital stay was 2 days (interquartile range, 1-3 days). Overall 30-day mortality was 1.0% (n = 117), with 31% (n = 36) of the patients dying after discharge. Overall 30-day morbidity was 10.7% (n = 1204), with 40% (n = 500) of the morbidities being postdischarge. The median time of death and complication was 9 and 3 days, respectively, after surgery. Eighty-eight percent of the wound infections (n = 205 of 234), 33% of pneumonia (n = 44 of 133), and 55% of venous thromboembolism (n = 36 of 65) were postdischarge. Multivariable analyses showed age, congestive heart failure, admission from nursing facility, postoperative pneumonia, myocardial infarction, and renal failure were independently associated with postdischarge mortality, and peripheral arterial disease, female gender, previous cardiac surgery, age, smoking, and diabetes with postdischarge morbidity (P < .05 for all). CONCLUSIONS: Patient characteristics associated with a higher risk for postdischarge adverse events after EVAR were identified. Whether improved predischarge surveillance and close postdischarge follow-up of identified high-risk patients will further improve 30-day outcomes after EVAR needs to be prospectively studied.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares , Alta do Paciente , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Carotid atherosclerosis has been suggested to be involved in cognitive decline. METHODS: The Epidemiology of Hearing Loss Study is a longitudinal study of aging among Beaver Dam residents, WI. In 1998-2000, carotid intima-media thickness (IMT) and plaque were measured by ultrasound; cognitive function was measured by the Mini-Mental State Examination (MMSE). Follow-up examinations were conducted in 2003-2005 and 2009-2010. Incidence of cognitive impairment was defined as an MMSE score <24 or reported physician-diagnosed dementia during the follow-up. In the last examination, five additional cognitive tests were added. The associations of carotid atherosclerosis with incident cognitive impairment and cognitive test performance ten years later were evaluated. RESULTS: A total of 1651 participants (mean age 66.8 years, 41% men) without cognitive impairment at baseline were included in the incidence analysis. IMT was associated with incidence of cognitive impairment after multiple adjustments (hazard ratio: 1.09, p = 0.02 for each 0.1 mm increase in IMT). A total of 1311 participants with atherosclerosis data at baseline had the additional cognitive tests 10 years later. Larger IMT was associated with longer time to complete the Trail-Making Test-part B after multiple adjustments (0.1 mm IMT: 2.3 s longer, p = 0.02). Plaque was not associated with incident cognitive impairment or cognitive test performance 10 years later. CONCLUSIONS: In this population-based longitudinal study, carotid IMT was associated with a higher risk of developing cognitive impairment during the 10-year follow-up, and was associated with poorer performance in a test of executive function 10 years later.
Assuntos
Doenças das Artérias Carótidas/epidemiologia , Transtornos Cognitivos/epidemiologia , Cognição , Adulto , Idoso , Idoso de 80 Anos ou mais , Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/psicologia , Espessura Intima-Media Carotídea , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/psicologia , Feminino , Humanos , Incidência , Modelos Lineares , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Testes Neuropsicológicos , Razão de Chances , Placa Aterosclerótica , Valor Preditivo dos Testes , Escalas de Graduação Psiquiátrica , Medição de Risco , Fatores de Risco , Fatores de Tempo , Wisconsin/epidemiologiaRESUMO
OBJECTIVE: Effective implementation of infection control programs and adherence to standard precautions are challenging in resource-limited settings. The objective of this study was to describe infection control knowledge, attitudes, and practices among healthcare workers (HCWs) in Uganda. DESIGN: We conducted a survey of hospital employees who had direct contact with patients or their immediate environment. We also performed an environmental assessment of resource availability and utilization within hospital wards. SETTING: Surgical, medicine, and obstetrics wards at a national referral hospital in Kampala, Uganda. PARTICIPANTS: One hundred eighty-three randomly selected HCWs. RESULTS: Almost all HCWs knew to wash their hands, although nursing and support staff were less likely to perceive that HCWs' hands can be a vector of disease transmission. Hand washing was valued more as a means of self-protection than as a means to prevent patient-to-patient transmission, consistent with the prevailing belief that infection control was important for occupational safety. Sinks were not readily accessible, and soap at sinks was uncommon throughout the medicine and obstetrics wards but more commonly available in the surgery wards. Alcohol gel was rarely available. CONCLUSIONS: Changing infection control practices in developing countries will require a multifaceted approach that addresses resource availability, occupational safety, and local understanding and attitudes about infection control.
Assuntos
Atitude do Pessoal de Saúde , Competência Clínica/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Controle de Infecções , Recursos Humanos em Hospital , Adulto , Países em Desenvolvimento , Transmissão de Doença Infecciosa/prevenção & controle , Feminino , Pesquisas sobre Atenção à Saúde , Recursos em Saúde/estatística & dados numéricos , Recursos em Saúde/provisão & distribuição , Unidades Hospitalares , Humanos , Controle de Infecções/métodos , Controle de Infecções/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Saúde Ocupacional , UgandaRESUMO
OBJECTIVE: This study investigated the long-term effects of socioeconomic status (SES) on atherosclerosis. METHODS: Data from the Epidemiology of Hearing Loss Study and the Beaver Dam Eye Study (Beaver Dam, WI, 1998-2000), were used to examine adult SES (education, household income, and longest-held job) and childhood SES (household density and parental home ownership at age 13) associations with carotid intima-media thickness (IMT) and carotid plaque in a cohort of 2042 men and women aged 53 to 94 years. RESULTS: For education, income, and occupation (women), those in the lowest SES group had statistically larger age-sex-adjusted IMT than those in the highest SES group (<12 vs. >12 years education: 0.92 vs. 0.86 mm respectively, P<0.0001), (<$10,000 vs. >$45,000: 0.97 vs. 0.87 mm, P<0.0001), (operator/fabricator/labor vs. manager/professional: 0.89 vs. 0.82 mm, P<0.001). Associations were similar using carotid plaque as the outcome. Participants with low levels of both adult and childhood SES measures had age-sex-adjusted IMT greater than those with persistently high levels of SES (0.93 vs. 0.84 mm, P<0.0001). CONCLUSIONS: Measures of SES at two points in the life-span were associated with subclinical atherosclerosis.
Assuntos
Aterosclerose/economia , Artérias Carótidas/diagnóstico por imagem , Classe Social , Idoso , Idoso de 80 Anos ou mais , Aterosclerose/epidemiologia , Aterosclerose/patologia , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , UltrassonografiaRESUMO
PURPOSE: To evaluate the use of time-resolved magnetic resonance (MR) angiography in the presurgical localization of the artery of Adamkiewicz prior to reimplantation of the feeding intercostal artery, lumbar artery, or both during aortic aneurysm repair. MATERIALS AND METHODS: This institutional review board-approved retrospective study included 68 patients (36 men, 32 women) who underwent time-resolved spinal MR angiography (0.2 mmol per kilogram of body weight gadobenate dimeglumine administered at a rate of 2.0 mL per second) performed with a 3.0-T imager with a dedicated eight-element spine coil. Images were reviewed at a three-dimensional workstation by two experienced radiologists in consensus. The artery of Adamkiewicz was identified, and the location of the feeding intercostal and/or lumbar artery was ascertained by using a five-point confidence index (scores ranged from 1 to 5). The phases in which the artery of Adamkiewicz, aorta, and great anterior radiculomedullary vein (GARV) demonstrated peak enhancement were also recorded. RESULTS: The artery of Adamkiewicz and the location of the feeding intercostal and/or lumbar artery were identified with high confidence in 60 (88%) of the 68 patients. Origins of the artery of Adamkiewicz were on the left side of the body in 65% of patients and on the right side in 35%. The level of origin ranged from the T6 neuroforamina to the L1 neuroforamina. The arrival of contrast material was highly variable in this patient population, which had substantial aortic disease. The highest signal intensity in the aorta, artery of Adamkiewicz, and GARV occurred a mean of 55 seconds (range, 27-99 seconds; 95% confidence interval [CI] 51, 58), 72 seconds (range, 38-110 seconds; 95% CI: 68, 76), and 95 seconds (range, 46-156 seconds; 95% CI: 89, 101) after contrast material administration, respectively. CONCLUSION: The artery of Adamkiewicz and the anterior spinal artery can be identified and differentiated from the GARV even in patients with substantially altered hemodynamics by using time-resolved 3.0-T MR angiography.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Artérias/anatomia & histologia , Angiografia por Ressonância Magnética/métodos , Medula Espinal/irrigação sanguínea , Adulto , Idoso , Idoso de 80 Anos ou mais , Meios de Contraste , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Imageamento Tridimensional , Masculino , Meglumina/análogos & derivados , Pessoa de Meia-Idade , Compostos Organometálicos , Estudos RetrospectivosRESUMO
BACKGROUND: The ratio of red blood cell (PRBC) transfusion to plasma (FFP) transfusion (PRBC:FFP ratio) has been shown to impact survival in trauma patients with massive hemorrhage. The purpose of this study was to determine the effect of the PRBC:FFP ratio on mortality for patients with massive hemorrhage after ruptured abdominal aortic aneurysm (RAAA). METHODS: A retrospective review was performed of patients undergoing emergent open RAAA repair from January 1987 to December 2007. Patients with massive hemorrhage (≥10 units of blood products transfused prior to conclusion of the operation) were included. The effects of patient demographics, admission vital signs, laboratory values, peri-operative variables, amount of blood products transfused, and the PRBC:FFP ratio on 30-day mortality were analyzed by multivariate analysis. RESULTS: One hundred and twenty-eight of the 168 (76%) patients undergoing repair for RAAA received at least 10 units of blood products within the peri-operative period. Mean age was 73.1 ± 9.1 years, and 109 (85%) were men. Thirty-day mortality was 22.6% (29/128), including 11 intra-operative deaths. By multivariate analysis, 30-day mortality was markedly lower (15% vs 39%; P < .03) for patients transfused at a PRBC:FFP ratio ≤2:1 (HIGH FFP group) compared with those transfused at a ratio of >2:1 (LOW FFP), and the likelihood of death was more than 4-fold greater in the LOW FFP group (odds ratio 4.23; 95% confidence interval, 1.2-14.49). Patients in the HIGH FFP group had a significantly lower incidence of colon ischemia than those in the LOW FFP group (22.4% vs 41.1%; P = .004). CONCLUSION: For RAAA patients requiring massive transfusion, more equivalent transfusion of PRBC to FFP (HIGH FFP) was independently associated with lower 30-day mortality. The lower incidence of colonic ischemia in the HIGH FFP group may suggest an additional benefit of early plasma transfusion that could translate into further mortality reduction. Analysis from this study suggests the potential feasibility for a more standardized protocol of initial resuscitation for these patients, and prospective studies are warranted to determine the optimum PRBC:FFP ratio in RAAA patients.
Assuntos
Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/mortalidade , Transfusão de Componentes Sanguíneos , Transfusão de Eritrócitos , Plasma , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Ruptura Aórtica/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Time to revascularization is speculated to be a major determinant of limb salvage for traumatic popliteal injuries. The purpose of this study was to determine whether location of diagnostic arteriography affected outcome. METHODS: From 1996 to 2006, patients with popliteal injuries were identified from our trauma database. Additional data were extracted from chart review. Amputation rates for those undergoing arteriography performed in radiology (ARAD) versus the operating room (AOR) were compared. RESULTS: In 35 patients 36 limbs were treated, with 94% resulting from blunt mechanisms. The mean age was 37 years (11-69 years), 81% were men, and the mean Injury Severity Score was 15. The average mangled extremity severity scores (MESS) was 6 +/- 2. Follow-up was available in 97% patients with a median of 14 months. Overall amputation rate was 16.7% (6 of 36). Extremities with MESS <8 had 93% limb salvage, and MESS > or =8 had 55% limb salvage. ARAD (n = 10) and AOR (n = 15) groups were equivalent with regard to age, mechanism, Injury Severity Score, MESS, time to presentation, associated injuries, and fasciotomy rate. The median time from emergency room arrival to operating room was shorter (125 minutes vs. 214 minutes; p < 0.05) and salvage rate was higher (100% vs. 70%; p = 0.05) in the AOR group compared with the ARAD group. CONCLUSION: For popliteal artery injuries, diagnostic arteriography in the operating room reduces the likelihood of amputation by decreasing time to initiating repair and thereby limiting limb ischemia. Salvage is possible in the most severely injured extremities with rapid transport to the operating room.
Assuntos
Cuidados Intraoperatórios/métodos , Salvamento de Membro , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/lesões , Adolescente , Adulto , Idoso , Amputação Cirúrgica , Angiografia/métodos , Criança , Feminino , Seguimentos , Hemorragia/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao Leito , Artéria Poplítea/cirurgia , Estudos Retrospectivos , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVE: To demonstrate that a modern theory of paraplegia prevention in thoracoabdominal aortic (TAAA) surgery is primarily non-anatomic and derives from experimentally validated interventions that prolong the ischemic tolerance, reduce reperfusion injury, and enhance the collateral perfusion of the spinal cord with or without assisted circulation. METHODS: Using an accurate predictive model (r(2) > 0.95) for paraplegia risk we studied the effects of protective strategies in 82 clinical series reporting more than 15,000 patients treated from 1985 to 2008. The observed/expected (O/E) ratios were calculated for each series and the results were grouped by technique. The effect of interventions such as spinal fluid drainage (SFD), systemic hypothermia, epidural cooling, and naloxone on O/E ratios were studied. We analyzed changes in O/E ratios from Era 1 (1985 to 1997) to Era 2 (1997 to 2008) and within treatment techniques over time. RESULTS: The mean O/E ratio for paraplegia for all patients declined from 1.13 in Era 1 to 0.26 in Era 2. Adding SFD to patients treated with assisted circulation (AC) decreased the O/E ratio from 1.03 to 0.24 (P < .0001). Adding SFD to patients treated with aortic clamping without AC (XCL) decreased O/E from 0.91 to 0.23 (P = .0013). O/E for hypothermic arrest (HA) declined from 0.42 to 0.14 with SFD. The addition of SFD to AC, XCL, and HA accounted for most of the decline in O/E between Eras. Other factors which played a less defined but important role in the decline in O/E ratios were attention to higher mean arterial pressures (MAPs), more hypothermia, and neurochemical protection. CONCLUSION: Paraplegia causation is anatomic but paraplegia prevention is physiologic (non-anatomic). We demonstrate that by using hypothermia, SFD, and increasing MAP, clinicians had similar improvements in paraplegia, reducing O/E deficit ratios from 1.03 to as low as 0.16, with or without intercostal reimplantation, and whether or not assisted circulation was used. Understanding the fundamental principles of paraplegia prevention and how to apply protective strategies leads to a reduction in paralysis in clinical series with or without the use of assisted circulation. This modern theory of paraplegia has significant implications for the rapidly advancing field of TAAA repair with branched endografts where the same principles apply.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Paraplegia/prevenção & controle , Traumatismo por Reperfusão/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Circulação Assistida , Pressão Sanguínea , Circulação Colateral , Constrição , Drenagem/métodos , Humanos , Hipotermia Induzida , Modelos Logísticos , Modelos Biológicos , Naloxona/uso terapêutico , Fármacos Neuroprotetores/uso terapêutico , Paraplegia/etiologia , Paraplegia/fisiopatologia , Traumatismo por Reperfusão/etiologia , Traumatismo por Reperfusão/fisiopatologia , Medição de Risco , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Spinal fluid drainage reduces paraplegia risk in thoracic (TAA) and thoracoabdominal (TAAA) aortic aneurysm repair. There has not been a comprehensive study of the risks of spinal fluid drainage and how these risks can be reduced. Here we report complications of spinal fluid drainage in patients undergoing TAA/TAAA repair. METHODS: The study comprised 648 patients who had TAA or TAAA repair from 1987 to 2008. Spinal drains were used in 486 patients. Spinal fluid pressure was measured continuously, except when draining fluid, and was reduced to <6 mm Hg during thoracic aortic occlusion and reperfusion. After surgery, spinal fluid pressure was kept <10 mm Hg until patients were awake with normal leg lift. Drains were removed 48 hours after surgery. Spinal and head computed tomography (CT) scans were performed in patients with bloody spinal fluid or neurologic deficit. We studied the incidence of headache treated with epidural blood patch, infection, bloody spinal fluid, intracranial and spinal bleeding on CT, as well as the clinical consequences. RESULTS: Twenty-four patients (5%) had bloody spinal fluid. CT exams showed seven had no evidence of intracranial hemorrhage, 14 (2.9%) had intracranial blood without neurologic deficit, and three with intracranial bleeding and cerebral atrophy had neurologic deficits (1 died, 1 had permanent hemiparesis, and 1 with transient ataxia recovered fully). Two patients without bloody spinal fluid or neurologic deficit after surgery presented with neurologic deficits 5 days postoperatively and died from acute on chronic subdural hematoma. Neurologic deficits occurred after spinal fluid drainage in 5 of 482 patients (1%), and 3 died. The mortality from spinal fluid drainage complications was 0.6% (3 of 482). By univariate and multivariate analysis, larger volume of spinal fluid drainage (mean, 178 mL vs 124 mL, P < .0001) and higher central venous pressure before thoracic aortic occlusion (mean, 16 mm Hg vs 13 mm Hg, P < .0012) correlated with bloody spinal fluid. CONCLUSION: Strategies that reduce the volume of spinal fluid drainage but still control spinal fluid pressure are helpful in reducing serious complications. Patients with cerebral atrophy are at increased risk for complications of spinal fluid drainage.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Cateterismo/efeitos adversos , Drenagem/efeitos adversos , Paraplegia/prevenção & controle , Punção Espinal/efeitos adversos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Atrofia , Encefalopatias/complicações , Encefalopatias/patologia , Cateterismo/mortalidade , Pressão Venosa Central , Pressão do Líquido Cefalorraquidiano , Drenagem/métodos , Drenagem/mortalidade , Feminino , Cefaleia/etiologia , Hematoma Subdural/etiologia , Humanos , Hemorragias Intracranianas/etiologia , Masculino , Paraplegia/diagnóstico por imagem , Paraplegia/etiologia , Paraplegia/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Punção Espinal/mortalidade , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Vascular rings are a rare cause of symptoms in adult patients. We report the case of a 48-year-old woman presenting with dysphagia lusoria due to an uncommon vascular ring: right aortic arch with mirror-image branching and a left ligamentum arteriosum. No previous reports exist of adult-onset dysphagia lusoria attributable to this anatomy. The patient underwent a limited muscle-sparing thoracotomy with division of the ligamentum. The division interrupted the vascular ring and relieved her esophageal compression. The presentation, evaluation, pathophysiology, and treatment of this condition are discussed.
Assuntos
Aorta Torácica/anormalidades , Doenças da Aorta/complicações , Transtornos de Deglutição/etiologia , Estenose Esofágica/etiologia , Aorta Torácica/patologia , Doenças da Aorta/congênito , Doenças da Aorta/patologia , Doenças da Aorta/cirurgia , Transtornos de Deglutição/patologia , Transtornos de Deglutição/cirurgia , Estenose Esofágica/patologia , Estenose Esofágica/cirurgia , Esofagoscopia , Feminino , Gastroscopia , Humanos , Angiografia por Ressonância Magnética , Pessoa de Meia-Idade , Toracotomia , Resultado do Tratamento , Procedimentos Cirúrgicos VascularesRESUMO
OBJECTIVE: The purpose of this study is to describe a new approach for addressing the intraoperative management of intercostal arteries during thoracoabdominal aortic aneurysm (TAAA) repair, using preoperative spinal MRA for detection of intercostal arteries supplying the anterior spinal artery. METHODS: Patients undergoing TAAA repair from August 2005 to September 2007 were included. Spinal artery MRA was performed to identify the anterior spinal artery, the artery of Adamkiewicz, and its major intercostal source artery (SA-AAK). Intraoperative spinal cord protection was carried out using standard techniques. Important intercostal arteries were either preserved or reimplanted as a button patch after removing aortic clamps. Demographic and perioperative data were collected for review. Analysis was performed with Fisher's exact test or Student's t-test, where applicable, using SAS ver. 8.0 (Cary, NC). RESULTS: Spinal artery MRA was performed in 27 patients. The SA-AAK was identified in 85% of preoperative studies. Open or endovascular repair was performed in 74% and 26% of patients, respectively. The SA-AAK was preserved or reimplanted in 13 (65%) of patients who underwent open repair. A mean of 1.67 (range 1-3) intercostal arteries were reimplanted. All patients undergoing endovascular repair necessitated coverage of the SA-AAK. No patient developed immediate or delayed paraplegia. Longer mean operative times in the reimplanted cohort were not statistically significant (330 versus 245 min, P = 0.1). CONCLUSION: The SA-AAK identified by MRA can be preserved or safely reimplanted after TAAA repair. Further study is warranted to determine if selective intercostal reimplantation can reduce the risk of immediate or delayed paraplegia.