RESUMO
OBJECTIVE: To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI). METHODS: Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level. RESULTS: Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R2 = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R2 = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001). CONCLUSIONS: A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals.
Assuntos
Assistência Ambulatorial/tendências , Procedimentos Cirúrgicos Ambulatórios/tendências , Angioplastia/tendências , Aterectomia/tendências , Doença Arterial Periférica/terapia , Padrões de Prática Médica/tendências , Assistência Ambulatorial/economia , Procedimentos Cirúrgicos Ambulatórios/economia , Angioplastia/economia , Angioplastia/instrumentação , Aterectomia/economia , Centers for Medicare and Medicaid Services, U.S./economia , Centers for Medicare and Medicaid Services, U.S./tendências , Bases de Dados Factuais , Custos de Cuidados de Saúde , Disparidades em Assistência à Saúde/tendências , Humanos , Reembolso de Seguro de Saúde/tendências , Medicare/economia , Medicare/tendências , Doença Arterial Periférica/economia , Doença Arterial Periférica/epidemiologia , Padrões de Prática Médica/economia , Estudos Retrospectivos , Stents , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
It is unknown whether endovascular intervention (EVI) is associated with superior outcomes when compared with surgical revascularization in octogenarian. National Inpatient Sample (NIS) database was used to compare the outcomes of limb revascularization in octogenarians who had surgical revascularization versus EVI. The NIS database's information on PAD patients ≥80-year-old who underwent limb revascularization between 2002 and 2014 included 394,504 octogenarian patients, of which 184,926 underwent surgical revascularization (46.9%) and 209,578 underwent EVI (53.1%). Multivariate analysis was performed to examine in-hospital outcomes. Trend over time in limb revascularization utilization was examined using Cochrane-Armitage test. EVI group had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.61 [95% CI: 0.58 to 0.63], myocardial infarction (aOR: 0.84 [95% CI: 0.81 to 0.87]), stroke (aOR: 0.93 [95% CI: 0.89 to 0.96]), acute kidney injury (aOR: 0.79 [95% CI: 0.77 to 0.81]), and limb amputation (aOR: 0.77 [95% CI: 0.74 to 0.79]) compared with surgical group (p < 0.001 for all). EVI group had higher risk of bleeding (aOR: 1.20 [95% CI: 1.18 to 1.23]) and vascular complications (3.2% vs 2.7%, aOR: 1.25 [95% CI: 1.19 to 1.30]) compared with surgical group (p < 0.001 for all). Within study period, EVI utilization increased in octogenarian patients from 2.6% to 8.9% (ptrend < 0.001); whereas use of surgical revascularization decreased from 11.6% to 5.2% (ptrend < 0.001). In conclusion, the utilization of EVI in octogenarians is increasing, and associated with lower risk of in-hospital mortality and adverse cardiovascular and limb outcomes as compared with surgical revascularization.
Assuntos
Procedimentos Endovasculares/tendências , Mortalidade Hospitalar , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Injúria Renal Aguda/epidemiologia , Idoso de 80 Anos ou mais , Amputação Cirúrgica/estatística & dados numéricos , Angioplastia/tendências , Aterectomia/tendências , Endarterectomia/tendências , Feminino , Humanos , Masculino , Infarto do Miocárdio/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Risco , Stents , Acidente Vascular Cerebral/epidemiologia , Enxerto Vascular/tendências , Procedimentos Cirúrgicos Vasculares/tendênciasRESUMO
Budd-Chiari syndrome (BCS) is an uncommon condition, caused by obstruction to hepatic venous outflow. It is largely underdiagnosed, and a high index of suspicion is required for any patient with unexplained portal hypertension. The understanding of its etiology and pathology is improving with advances in diagnostic techniques. Recent studies reported an identifiable etiology in > 80% of cases. Myeloproliferative neoplasm (MPN) is the most common etiology, and genetic studies help in diagnosing latent MPN. Better cross-sectional imaging helps delineate the site of obstruction accurately. The majority of BCS patients are now treated by endovascular intervention and anticoagulation which have improved survival in this disease. Angioplasty of hepatic veins/inferior vena cava remains under-utilized at present. While surgical porto-systemic shunts are no longer done for BCS, liver transplantation is reserved for select indications. Some of the unresolved issues in the current management of BCS are also discussed in this review.
Assuntos
Síndrome de Budd-Chiari/diagnóstico por imagem , Síndrome de Budd-Chiari/terapia , Gerenciamento Clínico , Angioplastia/tendências , Síndrome de Budd-Chiari/fisiopatologia , Procedimentos Endovasculares/tendências , Humanos , Transplante de Fígado/tendências , Terapia Trombolítica/tendênciasRESUMO
INTRODUCTION: Management approaches for intracranial atherosclerosis include medical, surgical, or endovascular treatment. Among endovascular treatments, recent studies have stated that submaximal angioplasty (SA) may offer considerable benefits and be a promising alternative to aggressive medical therapyand/or stenting in the treatment of intracranial atherosclerotic disease (ICAD). OBJECTIVE: To investigate the rates of periprocedural and long-term cerebrovascular accidents, mortality, and restenosis in patients with symptomatic ICAD who were treated with SA. METHODS: An electronic database search was performed for relevant studies that reported clinical outcomes of patients with ICAD following SA. Outcomes of interest were incidence of transient ischemic attack, intracerebral hemorrhage, stroke, and mortality in the periprocedural period and at 1 year. The periprocedural period was defined as the time from SA until 30 days after the procedure. Technical success and restenosis rates after the procedure were also analyzed. RESULTS: A total of 19 studies with 777 patients were identified. The technical success rate was 93% (95% CI 85% to 98%). The incidence of 30-day and 1-year stroke (all types) was 3% (95% CI 1% to 5%) and 5% (95% CI 4% to 8%), respectively. Thirty-day and 1-year mortality was found to be 1% (95% CI 0% to 2%) and 2% (95% CI 0% to 4%), respectively. The combined incidence of stroke or death was 5% (95% CI 3% to 8%) at 30 days, and 9% (95% CI 7% to 12%) at 1 year. CONCLUSION: The findings suggest that SA might be a promising alternative treatment in the treatment of symptomatic ICAD due to its favorable technical profile, periprocedural safety, and long-term efficacy. A randomized clinical trial is warranted to compare the safety and efficacy of SA with 'gold standard' medical treatment.
Assuntos
Angioplastia/métodos , Angioplastia/tendências , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/cirurgia , Angioplastia/efeitos adversos , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/cirurgia , Humanos , Arteriosclerose Intracraniana/epidemiologia , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/cirurgia , Stents/efeitos adversos , Stents/tendências , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The STICH trial showed superiority of coronary artery bypass plus medical treatment (CABG) over medical treatment alone (MED) in patients with left ventricular ejection fraction (LVEF) ≤35%. In previous publications, percutaneous coronary intervention (PCI) prior to CABG was associated with worse prognosis. OBJECTIVES: The main purpose of this study was to analyse if prior PCI influenced outcomes in STICH. METHODS AND RESULTS: Patients in the STICH trial (nâ¯=â¯1212), followed for a median time of 9.8â¯years, were included in the present analyses. In the total population, 156 had a prior PCI (74 and 82, respectively, in the MED and CABG groups). In those with vs. without prior PCI, the adjusted hazard-ratios (aHRs) were 0.92 (95% CIâ¯=â¯0.74-1.15) for all-cause mortality, 0.85 (95% CIâ¯=â¯0.64-1.11) for CV mortality, and 1.43 (95% CIâ¯=â¯1.15-1.77) for CV hospitalization. In the group randomized to CABG without prior PCI, the aHRs were 0.82 (95% CIâ¯=â¯0.70-0.95) for all-cause mortality, 0.75 (95% CIâ¯=â¯0.62-0.90) for CV mortality and 0.67 (95% CIâ¯=â¯0.56-0.80) for CV hospitalization. In the group randomized to CABG with prior PCI, the aHRs were 0.76 (95% CIâ¯=â¯0.50-1.15) for all-cause mortality, 0.81 (95% CIâ¯=â¯0.49-1.36) for CV mortality and 0.61 (95% CIâ¯=â¯0.41-0.90) for CV hospitalization. There was no evidence of interaction between randomized treatment and prior PCI for any endpoint (all adjusted pâ¯>â¯0.05). CONCLUSION: In the STICH trial, prior PCI did not affect the outcomes of patients whether they were treated medically or surgically, and the superiority of CABG over MED remained unchanged regardless of prior PCI. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov; Identifier: NCT00023595.
Assuntos
Angioplastia/tendências , Ponte de Artéria Coronária/tendências , Doença da Artéria Coronariana/cirurgia , Revascularização Miocárdica/tendências , Intervenção Coronária Percutânea/tendências , Disfunção Ventricular Esquerda/cirurgia , Idoso , Angioplastia/mortalidade , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Revascularização Miocárdica/mortalidade , Intervenção Coronária Percutânea/mortalidade , Estudos Prospectivos , Volume Sistólico/fisiologia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidadeRESUMO
The prevalence rate and the incidence rate of hemodialysis and functioning kidney transplant recipients have continuously increased; on the contrary, those of peritoneal dialysis have continuously decreased since 2006. Dialysis patients have been getting older and have been maintained on dialysis longer. Diabetic nephropathy was the leading cause of end stage renal disease. The type of hemodialysis vascular access has been stable during the last 5 years (arteriovenous fistulas 76%, arteriovenous grafts 16%, central venous catheters 8% at 2016). Peritoneal dialysis catheter was mostly inserted surgically (67%), and swan neck straight tip peritoneal dialysis catheter was the most commonly used (48%). Vascular access was managed by radiologists and surgeons, and the management was fragmented among them in the past. However, since the nephrologists became interested in and knowledgeable about the vascular access, they began to play roles in vascular access management. Vascular access has been mostly created by vascular surgeons (≈60%); tunneled central venous hemodialysis catheter insertion and endovascular intervention such as percutaneous transluminal angioplasty (PTA) and thrombectomy have been mostly performed by radiologists (≈70%). Tunneled hemodialysis catheter insertion and endovascular intervention by nephrologists have slowly but consistently increased. Recently, the number of central venous hemodialysis catheter insertion has decreased, and tunneled hemodialysis catheter has been inserted more than non-tunneled hemodialysis catheter, indicating that vascular access has been created timely and the vascular access team has been educated about and following international guidelines.
Assuntos
Derivação Arteriovenosa Cirúrgica/tendências , Implante de Prótese Vascular/tendências , Cateterismo Venoso Central/tendências , Nefropatias/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Diálise Peritoneal/tendências , Padrões de Prática Médica/tendências , Diálise Renal/tendências , Idoso , Angioplastia/tendências , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Obstrução do Cateter , Cateterismo Venoso Central/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/epidemiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/cirurgia , Humanos , Nefropatias/diagnóstico , Nefropatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Nefrologistas/tendências , Radiologistas/tendências , República da Coreia/epidemiologia , Cirurgiões/tendências , Trombectomia/tendências , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: Bypass surgery (BS) remains the gold standard revascularization strategy in patients with chronic limb-threatening ischemia (CLTI) owing to infrainguinal disease. The Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL)-1 trial showed that, in patients with CLTI who survived for 2 years or more, BS resulted in better clinical outcomes. Despite this finding, there has been an increasing trend toward an endovascular-first approach to infrainguinal CLTI. Our aim was to investigate whether changes in practice have impacted the clinical outcomes of BS in our unit 10 years after BASIL-1. METHODS: Data for patients who underwent femoropopliteal (FP) BS in BASIL-1 (1999-2004) were retrieved from trial case record forms. The comparator contemporary series (CS) comprised all patients undergoing FP BS for CLTI in our unit between 2009 and 2014. Demographic and clinical outcome data on patients in the CS were collected from the prospectively collected hospital electronic notes. Anatomic patterns of disease in the BASIL-1 and CS cohorts were scored using the Bollinger and GLASS criteria. Statistical analysis was performed in SAS v9.4. RESULTS: There were 128 patients from BASIL-1 and 50 patients in the CS. Baseline age, gender, affected limb, and diabetes prevalence were similar, as were days spent in hospital out to 12 months and length of follow-up. BASIL-1 patients were more likely to be current smokers (P = .000) and had a higher creatinine (P = .04). The 30-day morbidity and mortality were higher in BASIL-1 (45.3% vs 22%; P = .004). There was no significant difference between BASIL-1 and CS with regard to run-off Bollinger (37.7 vs 32.1; P = .167) and IP GLASS (0 vs 0; P = .390) scores, with both groups having a median of two runoff vessels. Amputation-free survival (62% vs 28%; hazard ratio [HR], 1.86; 95% confidence interval [CI], 1.18-2.93; P = .007), limb salvage (85% vs 69%; HR, 2.31; 95% CI, 1.14-4.68; P = .02), overall survival (69% vs 35%; HR, 1.66; 95% CI, 1.00-2.74; P = .05) and major adverse limb events (67% vs 47%; HR, 1.93; 95% CI, 1.15-3.22; P = .01) were all significantly better in BASIL-1. CONCLUSIONS: Although 30-day mortality and morbidity were significantly lower, all of the examined longer term clinical outcomes after FP BS were significantly worse in the CS group a decade on from BASIL-1. Further research in the form of prospective cohort studies and randomized controlled trials is urgently required to determine if the CS data reported herein are generalizable to current vascular surgical practice and, if so, to determine the reasons for these unexpected outcomes.
Assuntos
Angioplastia/tendências , Artéria Femoral/cirurgia , Isquemia/cirurgia , Doença Arterial Periférica/cirurgia , Artéria Poplítea/cirurgia , Enxerto Vascular/tendências , Amputação Cirúrgica/tendências , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Doença Crônica , Humanos , Isquemia/mortalidade , Salvamento de Membro/tendências , Doença Arterial Periférica/mortalidade , Intervalo Livre de Progressão , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Reino Unido/epidemiologia , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidadeRESUMO
Carotid Artery Stenosis (CAS) is a marker of systemic atherosclerosis and patients with CAS are at high risk of vascular events in multiple vascular locations, including ipsilateral ischemic stroke. Both medical and surgical therapies have been demonstrated effective in reducing this risk. The optimal management for patients with asymptomatic carotid artery stenosis remains controversial. In patients with symptomatic CAS ≥70%, CEA has been demonstrated to reduce the risk of stroke. With the risk of recurrent stroke being particularly high in the first 2 weeks after the first event, Carotid Endarterectomy (CEA) or carotid angioplasty with stenting provides maximal benefits to patients with symptomatic CAS ≥70% if performed within this «2-week¼ target. Several large ongoing trials are currently comparing the risks and benefits of carotid revascularization versus medical therapy alone.
Assuntos
Estenose das Carótidas/diagnóstico , Estenose das Carótidas/terapia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/prevenção & controle , Angioplastia/métodos , Angioplastia/tendências , Endarterectomia das Carótidas/métodos , Endarterectomia das Carótidas/tendências , Humanos , Inibidores da Agregação Plaquetária/administração & dosagem , Acidente Vascular Cerebral/terapia , Resultado do TratamentoRESUMO
BACKGROUND: As patient care is being increasingly transitioned out of the hospital and into the outpatient setting, there is a growing interest in developing office-based angiography suites, that is, office-based laboratories. Office-based care has been associated with increased efficiency and greater patient satisfaction, with substantially higher reimbursement directly to the physicians providing care. Prior studies have demonstrated a shift of revascularization procedures to office-based laboratories with a concomitant increase in atherectomy use, a procedure with disproportionately high reimbursement in comparison to other peripheral revascularization techniques. We sought to determine provider trends in endovascular procedure volume, settings, and shifts in practice over time, specific to atherectomy. METHODS: Using Centers for Medicare & Medicaid Services Provider Utilization and Payment Data Public Use Files from 2013 to 2015, we identified providers who performed diagnostic angiography (DA), percutaneous transluminal angioplasty (PTA), stent placement (stent), and atherectomy, and procedures were aggregated at the provider level. Trends in procedures performed in office-based laboratory and facility-based settings were analyzed. Atherectomy was specifically analyzed using the total number and proportion of office-based laboratory procedures, and providers were stratified into quintiles by case volume. RESULTS: Between 2013 and 2015, 5,298 providers were identified. Over this time period, the number of providers performing atherectomy increased 25.7%, with the highest quintile of atherectomy providers performing an average of 263 cases (range 109-1,455). The proportion of physicians who performed atherectomy only in the office increased from 39.8% to 50.7% from 2013 to 2015, whereas only 20.8% of physicians who performed DA, PTA, or stent in 2015 did so only in an office-based laboratory. Of the physicians with the highest atherectomy volume, 77.8% operated only in the office in 2015, and these physicians increased their atherectomy volume to 114.1% during the study period. Of those physicians who transitioned to a solely office-based laboratory practice over the study period, atherectomy volume increased 63.4%, which was disproportionate compared with the growth of their DA, PTA, and stent volume. CONCLUSIONS: Over this short study period, a rapid shift into the office setting for peripheral intervention occurred, with a concomitant increase in atherectomy volume that was disproportionate to the increase in other peripheral interventions. This increase in office-based laboratory atherectomy occurred in the setting of increased reimbursement for the procedure and despite a lack of data supporting superiority over PTA/stent.
Assuntos
Instituições de Assistência Ambulatorial/tendências , Procedimentos Cirúrgicos Ambulatórios/tendências , Aterectomia/tendências , Visita a Consultório Médico/tendências , Padrões de Prática Médica/tendências , Idoso , Instituições de Assistência Ambulatorial/economia , Procedimentos Cirúrgicos Ambulatórios/economia , Angiografia/tendências , Angioplastia/instrumentação , Angioplastia/tendências , Aterectomia/economia , Centers for Medicare and Medicaid Services, U.S./tendências , Planos de Pagamento por Serviço Prestado/tendências , Feminino , Humanos , Masculino , Visita a Consultório Médico/economia , Padrões de Prática Médica/economia , Stents/tendências , Fatores de Tempo , Estados UnidosRESUMO
This observational retrospective study assessed the antiplatelet response and clinical events after clopidogrel treatment in patients who underwent percutaneous neurointervention, related to CYP2C19 metabolizer status (normal (NM), intermediate/poor (IM-PM), and ultrarapid (UM); inferred from *2, *3, and *17 allele determination). From 123 patients, IM-PM had a higher aggregation value (201.1 vs. 137.6 NM, 149.4 UM, P < 0.05) and lower response rate (37.5% vs. 69.8% NM, 61.1% UM), along with higher treatment change rate (25% vs. 5.7% NM, 10.5% UM). The highest ischemic events incidence occurred in NM (11.3% vs. 6.3% IM, 10.5% UM) and hemorrhagic events in UM (13.2% vs. 0% IM and 3.8% NM). No differences were found regarding ischemic event onset time, while hemorrhagic event frequency in UM was higher with shorter onset time (P = 0.047). CYP2C19 no-function and increased function alleles defined the clopidogrel response. UM patients had increased bleeding risk. Therapeutic recommendations should include dose reduction or treatment change in UM.
Assuntos
Angioplastia/tendências , Clopidogrel/administração & dosagem , Citocromo P-450 CYP2C19/genética , Fenótipo , Inibidores da Agregação Plaquetária/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Clopidogrel/efeitos adversos , Citocromo P-450 CYP2C19/metabolismo , Feminino , Hemorragia/induzido quimicamente , Hemorragia/etiologia , Hemorragia/genética , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/efeitos adversos , Estudos RetrospectivosRESUMO
OBJECTIVE: Verify whether Percutaneous Transluminal Angioplasty (PTA) may affect neural conduction properties in Multiple Sclerosis (MS) patients, thereby modifying patients' disability, with prospective neurophysiological, urodynamic, clinical and subjective well-being evaluations. METHODS: In 55 out of 72 consecutively screened MS patients, the following procedures were carried out before (T0), at 2-6â¯months (T1) and at 6-15â¯months (T2) after a diagnostic phlebography, eventually followed by the PTA intervention if chronic cerebrospinal venous insufficiency (CCSVI) was diagnosed: clinical/objective evaluation (Expanded Disability Status Scale, EDSS), ratings of subjective well-being, evaluation of urodynamic functions and multimodal EPs (visual, acoustic, upper and lower limbs somatosensory and motor evoked potentials). RESULTS: The number of dropouts was relatively high, and a complete set of neurophysiological and clinical data remained available for 37 patients (19 for urological investigations). The subjective well-being score significantly increased at T1 and returned close to basal values at T2, but their degree of objective disability did not change. Nevertheless, global EP-scores (indexing the impairment in conductivity of central pathways in multiple functional domains) significantly increased from T0 (7.9⯱â¯6.0) to T1 (9.2⯱â¯6.3) and from T0 to T2 (9.8⯱â¯6.3), but not from T1 and T2 (pâ¯>â¯0.05). Neurogenic urological lower tract dysfunctions slightly increased throughout the study. CONCLUSIONS: The PTA intervention did not induce significant changes in disability in the present cohort of MS patients, in line with recent evidence of clinical inefficacy of this procedure. SIGNIFICANCE: Absence of multimodal neurophysiological and functional testing changes in the first 15â¯months following PTA suggests that conduction properties of neural pathways are unaffected by PTA. Current findings suggest that the short-lived (2-6â¯months), post-PTA, beneficial effect on subjective well-being measures experienced by MS patients is likely related to a placebo effect.
Assuntos
Angioplastia/métodos , Esclerose Múltipla/fisiopatologia , Esclerose Múltipla/terapia , Condução Nervosa/fisiologia , Sistema Urinário/fisiopatologia , Adolescente , Adulto , Idoso , Angioplastia/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/diagnóstico , Estudos Prospectivos , Sistema Urinário/inervação , Adulto JovemAssuntos
Angioplastia/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Management of chronic deep vein disease focuses on the alleviation of reflux and obstruction. For the suprainguinal veins, the main underlying pathologic process is obstruction, which has been recognized as a significant contributor to chronic venous insufficiency. This is currently being addressed with venous stenting and the development of dedicated stents designed for this segment of the venous system. Treatment of the femoropopliteal vein (FPV) is far more challenging because of the idiosyncratic anatomy, the hemodynamic physiology, and the technical aspects of size mismatch and valve flow dynamics in managing deep venous reflux. This review article discusses traditional and emerging technologies to treat infrainguinal disease. METHODS: Previous and current articles addressing this issue were reviewed. Emphasis was placed on emerging techniques and technologies. RESULTS: Significant bench work, in vitro and in vivo studies, have been conducted over the last 40 years addressing the issue of infrainguinal reflux and obstruction. Historically, open procedures to address FPV reflux and obstruction have had variable success in a few centers around the world. The significant increase of emerging endovascular therapies may allow more appropriate, reproducible, widespread treatment of infrainguinal deep venous disease. CONCLUSIONS: Adequate and durable therapies for infrainguinal venous disease represent one of the greatest challenges for a vein specialist. Recently, a cluster of interest and techniques/technologies have been developed. The endovascular management of arterial disease is mature. The endovenous management of infrainguinal disease is on the cusp of meaningful innovation. The purpose of this evidence summary is to describe the options for the management of chronic FPV disease, with emphasis on emerging technologies and techniques.
Assuntos
Canal Inguinal/irrigação sanguínea , Procedimentos Cirúrgicos Vasculares/tendências , Insuficiência Venosa/cirurgia , Angioplastia/tendências , Procedimentos Endovasculares/tendências , Previsões , Humanos , Stents/tendências , Terapia Trombolítica/tendências , Insuficiência Venosa/terapiaRESUMO
Innovation in medicine is often driven by the observations of imaginative physicians who are blessed with insatiable curiosity, coupled with the inability to accept technical boundaries, the status quo of patient care, or the acceptance of procedural morbidity. Few examples illustrate this truism better than the physician-originated clinical research that transformed the safety of carotid stent angioplasty over the last 2 decades. Initial clinical application of carotid stenting suggested that proximal protection may be a better approach to prevent embolic stroke during the angioplasty procedure. The history of how this innovation was developed is particularly relevant as vascular surgeons adopt new endovascular therapies. It has been more than 15 years since Dr Juan Parodi put together a multidisciplinary team of scientists and clinicians to test the "proximal protection" hypothesis. The goal of this overview was to provide Dr Parodi team's perspective on the development of the proximal protection and flow reversal concept to minimize plaque embolization during carotid stent angioplasty procedures.
Assuntos
Angioplastia/instrumentação , Doenças das Artérias Carótidas/terapia , Circulação Cerebrovascular , Dispositivos de Proteção Embólica , Embolia Intracraniana/prevenção & controle , Stents , Acidente Vascular Cerebral/prevenção & controle , Angioplastia/efeitos adversos , Angioplastia/tendências , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/fisiopatologia , Difusão de Inovações , Dispositivos de Proteção Embólica/tendências , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Embolia Intracraniana/fisiopatologia , Desenho de Prótese , Fatores de Proteção , Fluxo Sanguíneo Regional , Fatores de Risco , Stents/tendências , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/fisiopatologia , Resultado do TratamentoRESUMO
BACKGROUND: The availability and diversity of lower limb revascularization procedures have increased in England in the past decade. We investigated whether these developments in care have translated to improvements in patient pathways and outcomes. METHODS: Individual-patient records from Hospital Episode Statistics were used to identify 103 934 patients who underwent endovascular (angioplasty) or surgical (endarterectomy, profundaplasty, or bypass) lower limb revascularization for infrainguinal peripheral artery disease in England between January 2006 and December 2015. Major lower limb amputations and deaths within 1 year after revascularization were ascertained from Hospital Episode Statistics and Office for National Statistics mortality records. Competing risks regression was used to estimate the cumulative incidence of major amputation and death, adjusted for patient age, sex, comorbidity score, indication for the intervention (intermittent claudication, severe limb ischemia without record of tissue loss, severe limb ischemia with a record of ulceration, severe limb ischemia with a record of gangrene/osteomyelitis), and comorbid diabetes mellitus. RESULTS: The estimated 1-year risk of major amputation decreased from 5.7% (in 2006-2007) to 3.9% (in 2014-2015) following endovascular revascularization, and from 11.2% (2006-2007) to 6.6% (2014-2015) following surgical procedures. The risk of death after both types of revascularization also decreased. These trends were observed for all indication categories, with the largest reductions found in patients with severe limb ischemia with ulceration or gangrene. Overall, morbidity increased over the study period, and a larger proportion of patients was treated for the severe end of the peripheral artery disease spectrum using less invasive procedures. CONCLUSIONS: Our findings show that from 2006 to 2015, the overall survival increased and the risk of major lower limb amputation decreased following revascularization. These observations suggest that patient outcomes after lower limb revascularization have improved during a period of centralization and specialization of vascular services in the United Kingdom.
Assuntos
Angioplastia/tendências , Endarterectomia/tendências , Extremidade Inferior/irrigação sanguínea , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Doença Arterial Periférica/cirurgia , Enxerto Vascular/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica/tendências , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Endarterectomia/efeitos adversos , Endarterectomia/mortalidade , Inglaterra/epidemiologia , Feminino , Humanos , Salvamento de Membro/tendências , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Melhoria de Qualidade , Fatores de Risco , Medicina Estatal , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidadeRESUMO
BACKGROUND: Hyperperfusion syndrome after carotid interventions has a low incidence but it can lead to morbidity and mortality. OBJECTIVE: To evaluate the usefulness of quantitative DSA for predicting hyperperfusion phenomenon (HPP) after carotid artery stenting and angioplasty. METHODS: Thirty-three consecutive patients with carotid stenosis treated with carotid artery stenting or angioplasty between February 2014 and August 2016 were included. Color-coded digital subtraction angiograms showing the time to maximum contrast intensity of each image pixel were obtained from conventional DSA before and after procedures. The cerebral circulation time (CCT) was defined as the difference in the relative time to maximum intensity between arterial and venous regions of interest set on the angiograms. HPP was diagnosed straight after the procedure with qualitative 123I-IMP single-photon emission CT (SPECT). Cut-off points for detecting HPP for preprocedural CCT and periprocedural change of CCT were assessed by receiver operating characteristic analysis using 123I-IMP SPECT as reference standard. RESULTS: 123I-IMP SPECT showed HPP in 4 of 33 patients. In these 4 patients, preprocedural prolongation of CCT (13.0±6.1 vs 7.2±1.3 s; p<0.001) was seen compared with patients without HPP as well as larger periprocedural changes of CCT (5.9±5.7 vs 0.5±1.3 s; p<0.001). The optimal cut-off points of preprocedural CCT and change of CCT for predicting HPP were 8.0 s (100% sensitivity, 69% specificity) and 3.2 s (75% sensitivity, 100% specificity), respectively. CONCLUSIONS: Preprocedural prolongation and greater periprocedural change of CCT are associated with the occurrence of HPP. Periprocedural evaluation of CCT may be useful for predicting HPP.
Assuntos
Angiografia Digital/métodos , Angioplastia/métodos , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/terapia , Circulação Cerebrovascular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Angioplastia/tendências , Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/fisiopatologia , Artéria Carótida Primitiva/fisiopatologia , Estenose das Carótidas/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Stents/efeitos adversos , Tomografia Computadorizada de Emissão de Fóton Único/métodosRESUMO
OBJECTIVE: Although endovascular therapy has been widely adopted for the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH), its effect on clinical outcomes remains incompletely understood. The aims of this retrospective cohort study are to evaluate the outcomes of endovascular intervention for post-aSAH vasospasm and identify predictors of functional independence at discharge and repeat endovascular vasospasm treatment. METHODS: We assessed the baseline and outcomes data for patients with aSAH who underwent endovascular vasospasm treatment at our institution, including intra-arterial (IA) vasodilator infusion and angioplasty. Statistical analyses were performed to determine factors associated with good outcome at discharge (modified Rankin Scale 0-2) and repeat endovascular vasospasm treatment. RESULTS: The study cohort comprised 159 patients with a mean age of 52 years. Good outcome was achieved in 17% of patients at discharge (26/150 patients), with an in-hospital mortality rate of 22% (33/150 patients). In the multivariate analysis, age (OR 0.895; p=0.009) and positive smoking status (OR 0.206; p=0.040) were negative independent predictors of good outcome. Endovascular retreatment was performed in 34% (53/156 patients). In the multivariate analysis, older age (OR 0.950; p=0.004), symptomatic vasospasm (OR 0.441; p=0.046), initial treatment with angioplasty alone (OR 0.096; p=0.039), and initial treatment with combined IA vasodilator infusion and angioplasty (OR 0.342; p=0.026) were negative independent predictors of retreatment. CONCLUSION: We found a modest rate of functional independence at discharge in patients with aSAH who underwent endovascular vasospasm treatment. Older patients and smokers had worse functional outcomes at discharge. Initial use of angioplasty appears to decrease the need for subsequent retreatment.
Assuntos
Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/tendências , Hemorragia Subaracnóidea/cirurgia , Vasoespasmo Intracraniano/cirurgia , Adulto , Idoso , Angioplastia/métodos , Angioplastia/mortalidade , Angioplastia/tendências , Estudos de Coortes , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Infusões Intra-Arteriais , Masculino , Pessoa de Meia-Idade , Alta do Paciente/tendências , Retratamento/métodos , Retratamento/mortalidade , Retratamento/tendências , Estudos Retrospectivos , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/mortalidade , Resultado do Tratamento , Vasodilatadores/administração & dosagem , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/mortalidadeRESUMO
OBJECTIVES: To assess and compare predictive factors for persistent hemodynamic depression (PHD) after carotid artery angioplasty and stenting (CAS) using artificial neural network (ANN) and multiple logistic regression (MLR) or support vector machines (SVM) models. PATIENTS AND METHODS: A retrospective data set of patients (n=76) who underwent CAS from 2007 to 2014 was used as input (training cohort) to a back-propagation ANN using TensorFlow platform. PHD was defined when systolic blood pressure was less than 90mmHg or heart rate was less 50 beats/min that lasted for more than one hour. The resulting ANN was prospectively tested in 33 patients (test cohort) and compared with MLR or SVM models according to accuracy and receiver operating characteristics (ROC) curve analysis. RESULTS: No significant difference in baseline characteristics between the training cohort and the test cohort was observed. PHD was observed in 21 (27.6%) patients in the training cohort and 10 (30.3%) patients in the test cohort. In the training cohort, the accuracy of ANN for the prediction of PHD was 98.7% and the area under the ROC curve (AUROC) was 0.961. In the test cohort, the number of correctly classified instances was 32 (97.0%) using the ANN model. In contrast, the accuracy rate of MLR or SVM model was both 75.8%. ANN (AUROC: 0.950; 95% CI [confidence interval]: 0.813-0.996) showed superior predictive performance compared to MLR model (AUROC: 0.796; 95% CI: 0.620-0.915, p<0.001) or SVM model (AUROC: 0.885; 95% CI: 0.725-0.969, p<0.001). CONCLUSIONS: The ANN model seems to have more powerful prediction capabilities than MLR or SVM model for persistent hemodynamic depression after CAS. External validation with a large cohort is needed to confirm our results.
Assuntos
Angioplastia/tendências , Doenças das Artérias Carótidas/cirurgia , Monitorização Hemodinâmica/tendências , Hemodinâmica/fisiologia , Redes Neurais de Computação , Stents/tendências , Idoso , Angioplastia/efeitos adversos , Doenças das Artérias Carótidas/diagnóstico , Doenças das Artérias Carótidas/fisiopatologia , Feminino , Seguimentos , Monitorização Hemodinâmica/métodos , Humanos , Aprendizado de Máquina/tendências , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Estudos Retrospectivos , Stents/efeitos adversosRESUMO
OBJECTIVE: Diabetes mellitus is associated with an increased risk for cardiovascular morbidity and mortality. The vascular burden in terms of incidence of cardiovascular events (CVE) and vascular interventions is however poorly quantified. In this study we evaluated the incidence rates of CVE and vascular interventions in patients with type 2 diabetes (T2DM) with and without cardiovascular disease (CVD) in comparison to patients without type 2 diabetes. RESEARCH DESIGN AND METHODS: In a cohort of 9.808 high-risk patients with and without cardiovascular disease and type 2 diabetes originated from the ongoing, single-center prospective SMART (Second Manifestations of ARTerial disease) cohort, the number and incidence rates of CVE and interventions were calculated. The incidence rates were adjusted for confounders using Poisson regression models. CVE were defined as vascular death, stroke and myocardial infarction (MI). Interventions were defined as percutaneous coronary intervention, coronary artery bypass grafting, percutaneous transluminal angioplasty or stenting of the peripheral arteries and amputation. RESULTS: Patients with T2DM and CVD had a 4-fold higher incidence rate of CVE and a 8-fold higher incidence rate of vascular interventions compared to high-risk patients without T2DM and CVD after adjusting for confounders. The incidence rate for the composite of non-fatal MI, non-fatal stroke and vascular death was 5.8 per 1000person-years in patients without T2DM or CVD at baseline, 15.2 per 1000person-years in patients with T2DM but without CVD at baseline, 26.0 per 1000person-years in patients without T2DM but with CVD and 40.7 per 1000person-years in patients with both T2DM and CVD at baseline. A similar increasing incidence rate was seen for all vascular interventions from patients without T2DM or CVD to patients with both T2DM and CVD. CONCLUSIONS: Patients with type 2 diabetes or CVD are subject to an increased incidence of cardiovascular events and interventions compared to high-risk patients without type 2 diabetes or vascular disease. Patients with type 2 diabetes and CVD have the highest incidence of new cardiovascular diseases and vascular interventions when compared to patients without type 2 diabetes and CVD. These results underline the need for optimal risk factor treatment as well as the need for new prevention and treatment strategies in this very high risk population.
Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/cirurgia , Ponte de Artéria Coronária/tendências , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/cirurgia , Intervenção Coronária Percutânea/tendências , Adulto , Idoso , Angioplastia/tendências , Doenças Cardiovasculares/diagnóstico , Estudos de Coortes , Diabetes Mellitus Tipo 2/diagnóstico , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Estudos Prospectivos , Stents/tendênciasRESUMO
BACKGROUND: Several concerns have emerged about the higher risk of very late stent thrombosis (ST) with first generation drug-eluting stent (DES) especially among STEMI patients. Newer generation DES has demonstrated to reduce ST at mid-term follow-up. Therefore, the aim of the present study is to perform an individual patient's data meta-analysis of trials comparing 1st generation DES vs. 2nd generation DES (everolimus-eluting stent, EES) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI. METHODS: We performed a formal search of electronic databases (MEDLINE and CENTRAL) and scientific session presentations from January 2010 to June 2016. We included all completed randomized trials comparing 1st vs. EES for patient presenting with STEMI. RESULTS: Individual patients data were obtained from 3 trials, including a total of 1581 patients (686 or 43.4% randomized to 1st generation DES and 895 or 56.4% randomized to EES). At long-term follow-up (1584±588days), EES did not significantly reduce mortality (7.8.% vs 11.7%, HR [95%CI]=0.77 [0.52, 1.13], p=0.18, pheterogeneity=0.93), cardiac mortality (6.2% vs 7.6%, HR [95%CI]=0.90 [0.56, 1.44], p=0.65, pheterogeneity=0.85), and reinfarction (8.1% versus 11.2%, respectively; HR [95%CI]=0.74 [0.51, 1.07], p=0.11, pheterogeneity=0.52). However, EES significantly reduced the occurrence of ST (3.4% versus 6.1% respectively, HR [95%CI]=0.56 [0.32, 0.97], p=0.04, pheterogeneity=0.42) and target vessel revascularization (TVR) (14.2% versus 20.1%; HR [95%CI]=0.63 [0.42, 0.96], p=0.03, pheterogeneity=0.55). Landmark analysis showed more consistent benefits in ST with EES within 1year, whereas benefits in TVR were mostly observed later than 1year. CONCLUSIONS: The present pooled patient-level meta-analysis demonstrates that among STEMI patients undergoing primary PCI, EES as compared to 1st generation DES is associated with a significant reduction in ST and TVR at long-term follow-up.