RESUMO
OBJECTIVE/BACKGROUND: This study aimed to describe an arch morphology protocol in a healthy population, and to assess the impact of age and sex. METHODS: A retrospective morphology evaluation was conducted in a population with no personal history of thoracic aorta surgery or pathology, through computed tomography (CT) imaging analysis, using a standardised protocol. Based on centreline three dimensional coordinates, a single investigator calculated a series of parameters in the arch zones and in the total arch, using Matlab scripts. These were categorized as: (i) morphometric data: diameter, length and aortic angle of each zone, total arch angle, and length; (ii) geometric data: tortuosity index (TI), arch width, assimilated curvature radius (CRi), and attachment zone angles. Student or Mann-Whitney tests were used to compare parameter means. Their variability with age and sex was assessed through univariate and multivariate regression analysis. RESULTS: CT images from 123 subjects (mean ± SD age 53 ± 19 years) were reviewed. Significant correlation between age and morphology was found. The aorta expanded homogeneously and stretched heterogeneously with age because of posterior arch elongation. TI decrease, CRi, and attachment zone angle increase were also observed with aging. Age remained significantly associated with these morphological parameters, independently of body surface area and hypertension. Sex also affected morphology: longer total arch length and higher CRarch in men; lower zone 3 attachment angle in women CONCLUSION: Using mathematical algorithms, and with a view to improving endovascular arch treatment, this study provides a standardised arch morphology protocol and objectively identifies both age related evolution and sex related variation in the different zones.
Assuntos
Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Estudos Transversais , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Interpretação de Imagem Radiográfica Assistida por Computador , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: The present study aimed at quantifying mal-positioning during thoracic endovascular aortic repair and analysing the extent to which anatomical factors influence the exact stent graft positioning. METHODS: A retrospective review was conducted of patients treated between 2007 and 2014 with a stent graft for whom proximal landing zones (LZ) could be precisely located by anatomical fixed landmarks, that is LZ 1, 2, or 3. The study included 66 patients (54 men; mean age 51 years, range 17-83 years) treated for traumatic aortic rupture (n = 27), type B aortic dissection (n = 21), thoracic aortic aneurysm (n = 8), penetrating aortic ulcer (n = 5), intramural hematoma (n = 1), and floating aortic thrombus (n = 4). Pharmacologic hemodynamic control was systematically obtained during stent graft deployment. Pre- and post-operative computed tomographic angiography was reviewed to quantify the distance between planned and achieved LZ and to analyze different anatomical factors: iliac diameter, calcification degree, aortic angulation at the proximal deployment zone, and tortuosity index (TI). RESULTS: Primary endoleak was noted in seven cases (10%): five type I (7%) and two type II (3%). Over a mean 35 month follow up (range 3-95 months), secondary endoleak was detected in two patients (3%), both type I, and stent graft migration was seen in three patients. Mal-positioning varied from 2 to 15 mm. A cutoff value of 11 mm was identified as an adverse event risk. Univariate analysis showed that TI and LZ were significantly associated with mal-positioning (p = .01, p = .04 respectively), and that aortic angulation tends to reach significance (p = .08). No influence of deployment mechanism (p = .50) or stent graft generation (p = .71) or access-related factors was observed. Multivariate analysis identified TI as the unique independent risk factor of mal-positioning (OR 241, 95% CI 1-6,149, p = .05). A TI >1.68 was optimal for inaccurate deployment prediction. CONCLUSION: TI calculation can be useful to anticipate difficulties during stent graft deployment and to reduce mal-positioning.
Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Stents/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/patologia , Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
OBJECTIVES: The aim was to analyze the role played by anatomy and stent graft in the incidence of incomplete apposition to aortic arch. METHODS: Between 2007 and 2014 data including available and suitable computed tomographic angiography (CTA) imaging of patients who had undergone thoracic endovascular aortic repair were reviewed. The study included 80 patients (65 men, 54 ± 21 years) treated for traumatic aortic rupture (n = 27), thoracic aortic aneurysm (n = 15), type B aortic dissection (n = 24), penetrating aortic ulcer (n = 5), intramural hematoma (n = 2), aorto-oesophageal fistula (n = 2), and aortic mural thrombus (n = 5). Pre- and post-operative CTA images were analyzed to characterize bird beak in terms of length and angle, and to calculate aortic angulation within a 30 mm range at the proximal deployment zone. RESULTS: Bird beak configuration was detected in 46 patients (57%): mean stent protrusion length was 16 mm (range: 8-29 mm) and mean bird beak angle was 20° (range: 7-40°). The bird beak effect was significantly more frequent after traumatic aortic rupture treatment (p = .05) and in landing zone 2 (p = .01). No influence of either stent graft type or generation, or degree of oversizing was observed (p = .29, p = .28, p = .81 respectively). However, the mean aortic angle of patients with bird beak was higher in the Pro-form group than that in the Zenith TX2 group (62° vs. 48°, p = .13). Multivariate analysis identified the aortic angle of the deployment zone as the unique independent risk factor of malapposition (HR = 1.05, 95% CI 1-1.10, p = .005). The cutoff value of 51° was found to be predictive of bird beak occurrence with a sensitivity of 58% and a specificity of 85%. CONCLUSIONS: Assessment of proximal landing zone morphology to avoid deployment zones generating an aortic angle of over 50° can be recommended to improve aortic curvature apposition with the current available devices.
Assuntos
Aorta Torácica/anatomia & histologia , Aorta Torácica/cirurgia , Procedimentos Endovasculares , Stents , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Medição de Risco , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
BACKGROUND: Optimal management of aorta mural thrombus (AMT) continues to be controversial. The aim of this study was to describe the management of AMT in the thoracic aorta with either conservative or stent-graft treatment and to analyze the role of morphological characteristics of thrombus in the selection of suitable candidates for intervention. METHODS: A retrospective review was conducted of all patients admitted for thoracic AMT. Clinical data, treatment used, and outcomes were recorded. Patients were divided in two groups according to the treatment used: either conservative or stent-graft. Morphological features of thrombus, including size, sessile or pedunculated aspect and mobility, were compared between the two groups. RESULTS: From January 2006 to March 2013, 13 consecutive patients (nine male, mean age 53, range 37-76) were admitted for symptomatic (n = 8) or asymptomatic AMT (n = 5). All patients received unfractionated heparin. Management of primary aortic thrombus required stent-graft in seven patients, aortic thrombectomy in one, and anticoagulation therapy alone in five. Indications for intervention were recurrent embolism (n = 4), occurrence of embolism under heparin (n = 1), or persistent thrombus (n = 2). Endovascular exclusion of AMT was successful in all cases, with no complications or deaths at 30 days and no recurrence at midterm. Analysis of the morphological features of the thrombus identified solely the high degree mobility as associated with adverse outcome (p = .048). CONCLUSION: In our experience, stent-graft exclusion of AMT is an effective approach. Systematic evaluation of thrombus mobility by a real-time imaging study can be helpful to better define the indications for radical treatment of the aortic lesion.
Assuntos
Aorta Torácica/cirurgia , Stents , Trombose/terapia , Adulto , Idoso , Anticoagulantes/uso terapêutico , Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/complicações , Doenças da Aorta/cirurgia , Embolia/etiologia , Embolia/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Estudos Retrospectivos , Prevenção Secundária , Trombose/complicações , Resultado do TratamentoRESUMO
OBJECTIVE: To assess a practice of claudicant revascularization with either subintimal angioplasty (SIA) plus stenting or femoropopliteal bypass. METHODS: All claudicants related to femoropopliteal occlusions treated either with above-the-knee femoropopliteal (AKFP) bypass (group 1) or SIA and stent (group 2) between 2004 and 2011 were reviewed. The two groups were analyzed with regard to patency and freedom from re-intervention. RESULTS: One hundred and fifty limbs were consecutively treated with AKFP bypass (n = 82), SIA plus stenting (n = 58), or SIA (n = 10). Bypasses were performed with synthetic grafts in 49 limbs (59.7%). Covered stents were used in 34 limbs (63%) and self-expandable stents in the remainder. Mean follow-up was 26 and 36 months, respectively, in group 1 and 2. At 24 months, primary, primary-assisted, and secondary patency for bypass versus SIA + stent groups was, respectively, 66.6 versus 70.1%, 76.5 versus 90.1%, and 88.2 versus 90.1%. Freedom from re-intervention rates at 12 and 36 months were, respectively, 78.8 and 68.4% for group 2 and 86.4% and 65.2% for group 1. CONCLUSION: SIA plus stenting is an effective and useful option for the management of claudicants with femoropopliteal occlusions, and can be considered as complementary to surgical bypass.
Assuntos
Angioplastia com Balão/métodos , Implante de Prótese Vascular , Artéria Femoral/cirurgia , Claudicação Intermitente/cirurgia , Artéria Poplítea/cirurgia , Stents , Idoso , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Claudicação Intermitente/diagnóstico por imagem , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/diagnóstico por imagem , Estudos Retrospectivos , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Grau de Desobstrução VascularRESUMO
OBJECTIVE: To report the long-term results of stenting for chronic ilio-caval obstructive lesions. MATERIAL AND METHODS: From January 1996 to January 2008, 89 patients (72 women, 17 men; median age 43 years) were admitted for endovascular treatment of chronic disabling non-malignant obstructive ilio-caval lesions. Patients were classified as C2 in 15 cases, C3 in 59, C4 in seven, C5 in two and C6 in six. Median preoperative venous disability score (VDS) and venous clinical severity score (VCSS) were 2 and 9, respectively. Aetiology was primary in 52 patients, secondary in 35 and congenital in two. Lesions were bilateral in seven cases, eight patients had inferior vena cava (IVC) involvement and 18 had common femoral vein (CFV) obstructive lesions. Complete occlusion was found in 30 cases. RESULTS: Technical success was achieved in 98%. The median hospital stay was 2 days. During a median follow-up of 38 months (range: 1-144 months), one patient died and five cases of thromboses occurred. Iterative stenting was performed for restenosis in six cases. Primary, assisted-primary and secondary patency rates, in terms of intention to treat, were 83%, 89% and 93%, respectively, at 3 and 10 years, with a median VDS of 1. Univariate analysis found that significant factors affecting patency were CFV involvement for primary patency and history of deep venous thrombosis (DVT) and CFV involvement for secondary patency. The last 46 patients had statistically more severe lesions than the first 43 (higher VDS, more secondary lesions, more occlusions, more stented segments, higher length of stented vein), and in spite of which patency rates are not different. CONCLUSION: Endovenous angioplasty, combined with stenting, is a sure, safe, effective and very minimally invasive technique which provides good long-term patency rates. Currently, it is recognised as the technique of choice for the treatment of ilio-caval obstructive lesions. Surgery should be proposed only in case of failure.
Assuntos
Implante de Prótese Vascular/instrumentação , Veia Ilíaca/cirurgia , Stents , Veia Cava Inferior/cirurgia , Adolescente , Adulto , Idoso , Doença Crônica , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/cirurgia , Feminino , Seguimentos , Humanos , Veia Ilíaca/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Flebografia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Adulto JovemRESUMO
OBJECTIVES: A feasibility study. METHODS: Eight pigs (all females; mean weight: 29 kg) underwent a conventional transperitoneal aortic approach with implantation of an aorto-prosthetic end-to-side anastomosis using a Clampless device and deployment of a 5-mm polytetrafluoroethylene (PTFE) graft. After proximal ligature, a conventional end-to-end anastomosis was then performed between the graft and the left iliac artery. RESULTS: The first pig died during the procedure due to graft misplacement. The seven other procedures were successful with a mean operative and anastomosis time of 101 min (range: 81-115 min) and 3.35 min (range: 2.25-4.25 min), respectively; mean blood loss was 152 ml (range: 30-235 ml). Another pig with a patent graft died at day 4 as a result of a severe unrelated pneumonopathy. The angiogram performed during the procedure and before sacrifice, at 2 (n=2), 4 (n=2) and 6 weeks (n=2), showed no graft stenosis or thrombosis. Microscopic examination revealed a tissue covering the intraluminal stent, which evolved over time, with no visible endothelial proliferation or inflammation. CONCLUSION: An aorto-prosthetic anastomosis can be performed safely and efficiently with our new clampless and sutureless device. The next step will be a laparoscopic Clampless implantation.
Assuntos
Aorta/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Stents , Anastomose Cirúrgica , Animais , Aorta/patologia , Aortografia , Perda Sanguínea Cirúrgica , Implante de Prótese Vascular/efeitos adversos , Estudos de Viabilidade , Feminino , Artéria Ilíaca/cirurgia , Ligadura , Teste de Materiais , Modelos Animais , Politetrafluoretileno , Desenho de Prótese , Suínos , Fatores de TempoRESUMO
UNLABELLED: The objective of this systematic review of the literature is to evaluate whether a laparoscopic operation can be performed on patients with occlusive or abdominal aortic aneurysm as a minimally invasive and durable alternative. For this purpose, the literature was reviewed and laparoscopic surgery results were compared with those of conventional and endovascular surgery. All series were included, even when containing also one case. Operative and clamping times, mortality and morbidity and hospital stay were evaluated. Thirty-five studies were identified about conventional (4), minilaparotomy (4), endovascular (4), total (12) and video-assisted (11) laparoscopic surgery. Operative and clamping times were shorter for video-assisted procedures than total-laparoscopic procedures. The mortality rate ranged from 3% to 4.5% for conventional surgery, from 0% to 3% for endovascular surgery, from 0% to 6% for total-laparoscopic surgery and from 0% to 4.2% for video-assisted laparoscopic surgery. A variable morbidity was described for all techniques, with a higher incidence in total-laparoscopic surgery. Mean hospital stay was similar for laparoscopic surgery procedures. The learning curve of a surgical team performing laparoscopic surgery improves the RESULTS: Laparoscopic abdominal aortic surgery is feasible and may offer good postoperative recovery with excellent mid-term patency. Shorter hospital stay and simple mid-term follow-up allow more comfort for the patient and probably monetary savings for the community. A steep learning curve is needed. For these reasons laparoscopic video-assisted technique can be considered a third means of treating severe occlusive and aortic aneurysm, but only new instruments for performing aortoprosthetic anastomoses can diffuse the total laparoscopic technique as a routine approach.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Arteriopatias Oclusivas/cirurgia , Laparoscopia/métodos , Cirurgia Vídeoassistida/instrumentação , Cirurgia Vídeoassistida/métodos , Constrição , Desenho de Equipamento , Medicina Baseada em Evidências , Estudos de Viabilidade , Humanos , Incidência , Tempo de Internação , Medição de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
PURPOSE: To evaluate superficial femoral artery (SFA) occlusive disease treatment by means of covered stents. STUDY DESIGN: retrospective. METHOD: From 2000 to 2005, a Hemobahn/Viabahn endoprosthesis was implanted in 102 limbs (95 patients; mean age: 72.1 years, 52-94) for intermittent claudication (group I, n=50 limbs), critical (group II, n=32) or acute ischemia (group III, n=20). Lesions treated were Trans-Atlantic Inter-Society Consensus (TASC) A (n=9) B (n=42), C (n=28) or D (n=23), associated with a good (2 or 3 leg arteries, n=60) or a poor (1 or 0 artery, n=42) runoff. RESULTS: The endograft was placed successfully in all cases, but 3 early deaths (3.2%) (1 in group II and 2 in group III), and 4 acute thromboses (4%) occurred. Primary and secondary actuarial patency rates were 97+/-1.7%, and 99+/-1% at 1 month, 74+/-4.8% & 84+/-4.1% at 1 year,and 71+/-9.5% & 79+/-8.5% at 3 years, after a mean follow-up of 30.2 months (1-60). Long-term primary and secondary patencies were significantly different between TASC Cand TASC D lesions (P<.004 & .001). CONCLUSION: Severity of lesions, rather than preoperative symptoms or runoff, is mainly to be considered before using Hemobahn/Viabahn endoprosthesis in severe SFA occlusive lesions.
Assuntos
Arteriopatias Oclusivas/cirurgia , Prótese Vascular , Artéria Femoral , Isquemia/cirurgia , Stents , Grau de Desobstrução Vascular , Idoso , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/epidemiologia , Feminino , Humanos , Claudicação Intermitente/cirurgia , Estimativa de Kaplan-Meier , Perna (Membro)/irrigação sanguínea , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to assess the feasibility and efficacy of a new laparoscopic vascular suturing device. METHODS: Animal study: six pigs underwent surgery using a retroperitoneal laparoscopic approach. Aorto-prosthetic side-to-end and end-to-end anastomoses were performed laparoscopically on each pig using SuDyn. Clamping and anastomosis times, as well as the properties of the anastomoses, were recorded. Study on cadavers: four aorto-prosthetic end-to-end anastomoses were performed using the direct transperitoneal laparoscopic approach to assess the feasibility of the SuDyn device on atherosclerotic aortas. RESULTS: Animal study: No pigs died and 12 patent and impermeable anastomoses were obtained. Mean anastomosis time was 38(+/-8)min for end-to-side anastomoses and 37(+/-5)min for end-to-end anastomoses. Study on cadavers: Totally laparoscopic anastomoses were performed in 4 human cadavers with a mean anastomosis time of 37(+/-3)min. CONCLUSIONS: SuDyn makes laparoscopic aorto-prosthetic anastomoses easier to perform, produces good results and does not require a learning curve.
Assuntos
Aorta/cirurgia , Implante de Prótese Vascular/instrumentação , Laparoscópios , Laparoscopia , Técnicas de Sutura/instrumentação , Anastomose Cirúrgica/instrumentação , Animais , Aorta/patologia , Aorta/fisiopatologia , Aortografia , Implante de Prótese Vascular/métodos , Cadáver , Desenho de Equipamento , Estudos de Viabilidade , Humanos , Suínos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
OBJECTIVE: To determine whether access to extra-corporal circulation (ECC) is necessary to treat acute descending thoracic aorta disease. METHOD: From January 2004 to May 2006, 16 patients underwent endovascular stent-graft repair of the descending thoracic aorta, among them 13 (81%) were treated in an emergency setting (nine men, mean age: 75.4 years, range 30-94 years). The indication was traumatic aortic rupture (n=3, 23%), complicated acute type B dissection (n=4; 31%), symptomatic or ruptured thoracic aortic aneurysm (n=4; 31%), aorto-esophageal fistula (n=1; 7,5%) and aortic intramural haematoma (n=1; 7,5%). Computed tomography showed hemomediastin and/or hemothorax in five patients (38%). Transesophageal echocardiography and angiography were performed in two (15%) and one patients respectively. Cerebrospinal fluid drainage was performed for two patients (15%). RESULTS: Endovascular repair was successfully completed in 92.3% of cases. The 30-day mortality was 7.5% (n=1). There was one case (7.5%) of delayed paraplegia. Follow-up ranged between two and 24 months (mean 10.2), no rupture occurred. Three type I endoleaks were detected and only two were treated. Two none related additional mortalities were observed. None of these patients has needed ECC. CONCLUSION: The unavailability of ECC does not seem to be a compromising factor in the management of thoracic aorta disease, however a good experience in endovascular techniques is required.
Assuntos
Aorta Torácica , Doenças da Aorta/cirurgia , Circulação Extracorpórea , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Tratamento de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , StentsRESUMO
Forty-four patients undergoing abdominal aortic surgery and twenty-eight patients undergoing carotid surgery were randomly treated with different anticoagulant regimens. During surgery, an unfractionated heparin (UFH) intravenous bolus of 50 IU/kg was compared with a low molecular weight heparin (LMWH) bolus of either 120 IU/kg, 80 IU/kg, 40 IU/kg or 20 IU/kg. Six hours after surgery and for 48 hours, an UFH infusion was compared with an LMWH infusion of either 10,000 IU/day or 6,000 IU/day and then, a single LMWH subcutaneous injection of 3,075 IU was administered. Heparin activity was measured by factor Xa inhibitor and by prolongation of APTT which were studied 15, 30 and 60 minutes after cross-clamping, at the end of surgery and six hours later, and on days 1, 2, 3 and 6. After a descriptive analysis of clinical and pharmacokinetic profiles of each regimen, optimal LMWH treatment is proposed.
Assuntos
Anticoagulantes/uso terapêutico , Aorta Abdominal/cirurgia , Artérias Carótidas/cirurgia , Heparina de Baixo Peso Molecular/uso terapêutico , Idoso , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
OBJECTIVE: --To evaluate mechanical strength of new potential systems of vascular prostheses anastomosis versus usual suture (4.0 yarn), --To advance objective quantified data in order to establish the specifications of a new quick and reliable mechanical anastomosis device for laparoscopic surgery. MATERIAL AND METHODS: Two experimental studies were conducted in order to quantify the mechanical resistance of anastomoses between two Dacron vascular prostheses and anastomoses between one Dacron vascular prosthesis and one cadaver abdominal aorta segment. Existing materials, which have generally used for other types of surgery, were applied for these studies (clips, staples, stents). These systems of anastomosis were compared to usual suture, used as reference. RESULTS: The mechanical strength of an anastomosis between two Dacron vascular prostheses performed with staples or the same number of stitches is of equivalent magnitude. Anastomoses made with clips or stent are ten to fifteen times weaker than those made with stitches. We did not succeed in performing an anastomosis with staples on cadaver aorta segments because aorta segments tear when staples are applied. In the experiments with a hand-sewn graft, the aorta always tor before the suture, without breakage of the suture. CONCLUSION: From these in vitro trials, we can advance that a continuous suture is probably far too resistant in relation to the aorta own resistance. As we do not know accurately the physiologic strength applied to a vascular prosthesis in vivo, one acceptance criterion from a safety point of view for a new anastomosis system must be that its strength will be equal to the well-proven continuous suture (greater than 150 N) or to the aorta breaking point (between 100 and 160 N). From that point of view, anastomoses performed with clips or a stent are not convenient, unless special clips or stents can be developed for this application. The mechanical strength is of staples sufficient but their design has to be adapted to this particular type of anastomosis.
Assuntos
Anastomose Cirúrgica/instrumentação , Prótese Vascular , Aorta Abdominal/cirurgia , Humanos , Laparoscopia , Teste de Materiais , Stents , Instrumentos Cirúrgicos , Suturas , Resistência à TraçãoRESUMO
The goal of this study was to evaluate per and postoperative use of nadroparin during carotid surgery with mortality and neurologic morbidity as primary end points. From January 1995 to December 1999, 237 procedures were performed on 215 patients for isolated carotid surgery; 57% were symptomatic. Surgery was performed under general anesthesia. Before clamping, patients received an intravenous bolus of 70 UI/kg of nadroparin. Shunting was used in 40% of patients. Postoperatively, from the 6(th) hour, nadroparin was given subcutaneously, 2,850 UI or 3,800 UI every 12 hours depending on the patient weight (less or more than 70 kg). The only biologic surveillance was platelet count twice a week. Antiplatelet drugs were given at day 2. Completion Duplex scan was performed before day 30. Seven postoperative ischemic strokes (3 non disabling) occurred including one fatal stroke. Another patient died at day 25 from inaugural duodenal bleeding due to pancreas cancer. The 30 days stroke or death rate was 3.37% (5.92% in symptomatic; 0% in asymptomatic). No hemorrhagic stroke occurred. Four patients were reoperated for cervical hematoma (1.68%). No thrombocytopenia occurred. Duplex scan, performed on 235 operated carotid arteries, showed 2 asymptomatic carotid thromboses. No other cardiovascular complication was found on clinical data. These results are comparable to published literature data in prospective as well as retrospective studies. Per and postoperative use of nadroparin in carotid surgery gave results similar to previously published reports in terms of mortality, neurologic morbidity and hematoma. Its easy use, needing only 2 injections a day and platelet count, with a reduction of the risk of heparin-induced thrombocytopenia make the use of nadroparin very attractive during the perioperative period.
Assuntos
Anticoagulantes/uso terapêutico , Implante de Prótese Vascular , Isquemia Encefálica/prevenção & controle , Trombose das Artérias Carótidas/prevenção & controle , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Nadroparina/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Trombose das Artérias Carótidas/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Constrição , Avaliação de Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nadroparina/efeitos adversos , Inibidores da Agregação Plaquetária/uso terapêutico , Cuidados Pós-Operatórios , Pré-Medicação , Recidiva , Estudos Retrospectivos , Resultado do Tratamento , UltrassonografiaRESUMO
OBJECTIVE: To study the feasibility and the tolerance of a combined laparoscopic transperitoneal aortic and renal restoration performed on animals. METHODS: Six pigs (mean weight: 79.5 kg, range 73-86) underwent laparoscopic replacement of the abdominal aorta using a 6-mm Dacron(R) graft, with direct reimplantation of the left renal artery. The study protocol was approved by the Advisory committee of Animal Ethics. The animal was placed supine on the operative table with a pillow under the lumbar region in order to raise the aortic area. A first midline, 10-mm diameter trocar was placed under direct vision, 5 cm above the pubis and allowed the insufflation of a 12-mm Hg pneumoperitoneum. One 30 degrees optic was used during the intervention. The pig was then tilted to a 30 degrees Trendelenbourg's position and two other 10-mm trocars were introduced 5 cm medially to the right and left antero-superior iliac spines ). Four other 10-mm incisions were necessary for introduction of an intestinal retractor, a suction-irrigation device and two laparoscopic aortic clamps. RESULTS: The procedure was performed in all animals in a mean operative time of 320 min (292-366), including ): - a time for aortic and renal artery dissection of 104 min (90-120), - a supra-renal aortic clamping time of 221 min (180-276), - a time for confection of proximal and distal aorto-prosthetic anastomosis of respectively 59 min (40-75) and 64 min (50-80), - a time for the left renal artery reimplantation of 72 min (40-140). Average blood loss was 525 ml (250-1050), and the mean pre and postoperative hemoglobin and pH values were 9.9 g/dl (8.9-10.7) versus 9.4 g/dl (8.5-11.3) and 7.36 (7.31-7.38) versus 7.30 (7.21-7.43) respectively. An angiogram ) performed before the sacrifice of animals showed a wide patent anastomosis in 18 (56%) cases, a<50% stenosis in 4 cases (22%), a > 50% stenosis in 1 case (5%) and a thrombosis of the first three renal artery restorations (17%) probably due to insufficient intraoperative heparinization. CONCLUSION: This experimental study shows the feasibility of laparoscopic transperitoneal abdominal aortic restoration with re-implantation of the left renal artery (fig. et ). The techniques of arterial sutures must be improved in order to decrease aortic and renal clamping times.
Assuntos
Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Laparoscopia , Artéria Renal/cirurgia , Anastomose Cirúrgica , Animais , Perda Sanguínea Cirúrgica , Estudos de Viabilidade , Masculino , Polietilenotereftalatos , Complicações Pós-Operatórias , Obstrução da Artéria Renal/etiologia , Suínos , Trombose/etiologiaRESUMO
OBJECTIVE: Descending thoracic aorta to femoral artery bypass (DTAFB) has demonstrated usefulness in the treatment of aorto-iliac occlusive disease but related morbidity and mortality are not negligible. We wanted to determine the feasibility of thoracoscopic DTAFB and to report our clinical experience. MATERIAL AND METHODS: An experimental study was performed on 8 pigs in helicoidal position under general anesthesia with right selective ventilation ). Three trocars were inserted and the descending aorta was dissected ). After tunnelisation of a 6 mm graft, a lateral aortic anastomosis was thoracoscopically performed ) then femoral anastomoses were made. At the end of the procedure, an angiogram and then an autopsy were performed ). Subsequently, three patients were operated, two for thrombosis of a previous aortobifémoral bypass and one for infrarenal aortic hypoplasia. Dissection and graft tunnelisation were performed thoracoscopically ). Then, the aortic anastomosis ) was constructed through a left lateral minithoracotomy (10 cm). RESULTS: One pig died during surgery of acute lung oedema due to the difficulties of selective ventilation. Excluding this case, the average times of surgery and of dissection were respectively 246 (205-325) and 68 minutes (50-90). The average aortic clamping and anastomosing times were 135 (105-220) and 120 minutes (80-210) ). Three aortic tears were noted; one was repaired. Angiogram was normal 5 times; one pig had a minor stenosis and a leak, and another one had a leak. All the anastomoses were patent without stenosis at autopsy; no organ lesion was found. In humans, the procedure was performed with simple postoperative course in 2 patients and a conversion (20 cm long thoracotomy) was necessary for the third due to poorly supported selective ventilation. CONCLUSION: Totally thoracoscopic DTAFB can be performed in pigs. In clinical practice, we recommend the use of a mini thoracotomy. This way, the aortic anastomosis can be performed with aortic clamping time under 30 minutes, reducing the risk of spinal cord ischemia. These results allow to propose mini invasive thoracoscopically assisted DTAFB for the patients for whom laparoscopic access of the abdominal aorta appears to be difficult (calcified aorta, hostile belly.).
Assuntos
Aorta Torácica/cirurgia , Artéria Femoral/cirurgia , Toracoscopia/métodos , Idoso , Anastomose Cirúrgica/métodos , Animais , Aorta Torácica/anormalidades , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/cirurgia , Suínos , Trombose/cirurgiaRESUMO
OBJECTIVES: There is no consensus on heart explorations required before infra-renal reconstruction surgery of the aorta. We proposed a selective approach in 81 consecutive patients undergoing elective surgery. METHODS: Four clinical criteria were recorded: age over 70 years, diabetes mellitus and a clinical history of coronary artery disease or heart failure. RESULTS: For 23 patients (group 1), none of the criteria were positive. Surgery was performed in all without prior exploration. There was one death (4.8%) and one post-operative cardiac event (4.8%) in this group. The 58 other patients (group 2) had at least one of the criteria and had complementary heart explorations before surgery. There were 2 deaths (3.4%) and 5 cases of cardiac morbidity (8.6%) in this group. CONCLUSION: The lack of any statistical difference between the two groups with and without risk criteria has led us to propose selective indications for preoperative explorations based on specific clinical criteria.
Assuntos
Doenças da Aorta/cirurgia , Cardiopatias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/cirurgia , Doenças da Aorta/mortalidade , Arteriopatias Oclusivas/mortalidade , Arteriopatias Oclusivas/cirurgia , Eletrocardiografia , Feminino , Coração/diagnóstico por imagem , Hemodinâmica , Humanos , Artéria Ilíaca , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Cintilografia , Fatores de RiscoRESUMO
PURPOSE: To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease. METHOD: From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001). RESULTS: Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3+/-10.6% in group I and 88.6+/-9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5+/-8.9 and 100% in group I and 87.5+/-8.93 and 94.45+/-6.71% in group II. CONCLUSION: Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed.
Assuntos
Arteriopatias Oclusivas/cirurgia , Implante de Prótese Vascular/instrumentação , Artéria Femoral , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Prótese Vascular , Feminino , Humanos , Claudicação Intermitente/etiologia , Claudicação Intermitente/cirurgia , Isquemia/complicações , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , StentsRESUMO
Considerable advances have been made in reconstructive venous surgery in the past two decades because of an increased recognition of venous disease and because of extensive experimental work. Meaningful evaluation of longterm patency of bypass grafts and midterm patency of stent placement are now available and seem appropriate to provide guidelines. Based on our experience and on the literature, this article highlights the techniques and the respective indications of surgical and endovascular treatment of large vein reconstructions.
Assuntos
Veia Ilíaca/cirurgia , Procedimentos Cirúrgicos Vasculares , Veia Cava Inferior/cirurgia , Trombose Venosa/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Feminino , Seguimentos , Humanos , Veia Ilíaca/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Flebografia , Síndrome da Veia Cava Superior/diagnóstico por imagem , Síndrome da Veia Cava Superior/cirurgia , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagemRESUMO
PURPOSE: Little data are available concerning the relation between the muscular pumping mechanism and the variation of superficial and deep venous pressure during normal action of the calf pump; therefore we undertook this study to determine the pressure values in three compartments of the calf and in the deep and the superficial venous system and to establish correlation between muscular and venous pressure. METHODS: Nine healthy young women with a mean age of 23 years (range 19 to 28 years) were examined. In the same calf, a muscular catheter was placed in the deep posterior compartment (DPC), in the superficial posterior compartment (SPC), and in the anterior tibial compartment (ATC), and a vascular catheter was placed in the popliteal vein and in the greater saphenous vein (GSV). The five lines of pressure were simultaneously recorded in the following situations: at rest, during Valsalva maneuver, foot flexion, and foot extension. The situation was studied with the patient in the following positions: decubitus, sitting, standing, and squatting. A final continuous recording was carried out after the patient had been walking for 5 minutes. RESULTS: Mean values with standard errors of muscular and venous pressure were established in each situation. At rest and during Valsalva maneuver, the muscular pressures did not vary, whereas venous pressures increased significantly when the patient was sitting and standing. On the other hand, squatting was associated with a rise in the muscular and vein pressures. Foot flexion entailed a significant increase in the ATC pressure and a rise in the GSV pressure, whereas foot extension caused the DPC pressure to rise without venous pressure modifications. Walking was associated with an alternating increase in the DPC, SPC, GSV and popliteal vein pressures when the foot was compressed to floor followed by a significant decrease when the foot pressure was released. CONCLUSIONS: The variations in the deep and superficial venous pressures when the patient is sitting and standing both at rest and during Valsalva maneuver are not associated with an increase in the muscular pressure. On the contrary, during foot movements, the ATC and the DPC are responsible for superficial vein pressure variations without modifications of the SPC pressure.