RESUMEN
OBJECTIVES: To present long-term results of endoleak/endograft migration treatment by aortomonoiliac (AMI) endografting after failed endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. DESIGN: Post hoc analysis of a prospectively gathered database at a tertiary care university hospital. MATERIALS AND METHODS: From March 1995 to November 2010, 23 patients were identified who underwent modification into AMI configuration after failed elective EVAR. Major causes for modification were type I (with/without endograft migration) or type III endoleaks with aneurysm expansion. An average increase in aneurysm size of 1.6 cm (range: -1.5 to 10.5 cm) since initial aneurysm treatment was observed. Interventional outcomes and long-term results were recorded for analysis. RESULTS: Technical success rate of AMI endografting was 95.65% (n = 22). All except two endoleaks could be successfully sealed with this manoeuvre (94.44%). Median time to modification was 5.3 years (interquartile range Q1-Q3: 1.3-9.3 years). No intra-operative conversion to open surgery was necessary and mortality was 0%. Median follow-up was 44 months (interquartile range Q1-Q3: 17-69 months). CONCLUSIONS: Treatment of graft-related endoleaks/endograft migration by AMI endografting after failed EVAR represents a safe and feasible procedure. This approach broadens the minimal invasive opportunities of aneurysm treatment, and open surgical conversion may be avoided except in selected patients.
Asunto(s)
Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Prótesis Vascular , Endofuga/cirugía , Procedimientos Endovasculares , Arteria Ilíaca/cirugía , Stents , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/métodos , Aneurisma de la Aorta Abdominal/mortalidad , Austria/epidemiología , Endofuga/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Falla de Prótesis , Reoperación , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to investigate whether initial abdominal aortic aneurysm (AAA) diameter influences long-term survival after elective repair. DESIGN: Retrospective analysis of database. MATERIAL AND METHODS: Between March 1995 and December 2006, a consecutive series of 895 patients underwent elective treatment of an AAA either by open surgical or endovascular repair. An AAA diameter of 5.5cm was chosen as threshold to distinguish between small and large aneurysms, according to the definition given by the UK small aneurysm trial. Patient characteristics and distribution of basic risk factors were assessed. Survival estimates (Kaplan-Meier) and Cox proportional hazards regression results are reported. RESULTS: Patients with small aneurysms were more likely to survive the first 6 years after AAA repair, even after adjustment for treatment modality and baseline risk factors. After adjustment for age and sex aneurysms with smaller diameter were related to a lower risk of death (p<0.0016). CONCLUSIONS: Patients with small aneurysms (< or =5.5cm) have an improved long-term survival than patients with larger aneurysms.
Asunto(s)
Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/patología , Implantación de Prótesis Vascular , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Modelos de Riesgos Proporcionales , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
INTRODUCTION: Subclavian to carotid transposition (SCT) is gaining importance as an adjunct for thoracic endovascular aortic repair (TEVAR). Two different anatomical approaches are described. We reviewed our experience with both approaches to evaluate the occurrence of complications and long-term outcome. MATERIALS/METHODS: We report the outcome of 150 SCTs carried between October 1979 and April 200710/79 at 2 university based tertiary care centers. Independent neurologic evaluation was performed. RESULTS: Lateral and medial approaches were used in 83 (55.4%) and 67 (44.6%) cases, respectively. The internal thoracic artery and the thyrocervical trunk were sacrificed more frequently when the lateral approach was used (1.5% vs 39.8%; p=0.0001 and 1.5% vs 49.4%; p=0.0001, respectively). The medial approach was associated with significantly less complications (8, 11.9%, compared to 24, 28.9%, p=0.012). Thirty day mortality was 0.7%. Median follow-up was 36 months (1-227), and no subclavian artery occlusions were identified. CONCLUSIONS: SCT is a durable procedure for the management of occlusive pathologies of the proximal subclavian artery occlusion. The medial approach is associated with significantly fewer complications.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Arterias Carótidas/cirugía , Arteria Subclavia/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Abdominal aortic aneurysms (AAA) are managed by two different treatment options, i.e. open graft replacement (OGR) as open surgical technique or endovascular aneurysm repair (EVAR) as minimally invasive procedure, to avoid fatal rupture. The intention of this review was to show how by offering electively either OGR or EVAR - adjusted to the patient's individual risk profile--a benefit for the individual patient could be obtained and overall mortality rates of elective AAA repair could be significantly reduced. A comparative evaluation of both treatment regimes is offered, latest literature as well as own research is presented. Our own risk adjusted patient selection regime is described as well as its statistically significant impact on overall mortality rates in elective AAA exclusion. As conclusion, the benefit of offering both EVAR and OGR is the capability to select and recommend the optimal AAA management for the individual patient with respect to the individual risk profile. The result is a decrease in the overall mortality rate while simultaneously the number of treated patients increases. Furthermore EVAR offers a treatment option for otherwise incurable high risk patients.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Selección de Paciente , Stents , Aneurisma Roto/mortalidad , Aneurisma Roto/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos , Ajuste de RiesgoRESUMEN
Three case reports are reviewed to illustrate the possibility of treating irradiation-induced lesions of the subclavian-brachial vascular segment (aneurysm and segmental occlusions) 14, 20, and 26 years after radical mastectomy and subsequent radiotherapy. All patients had an extraanatomic vein bypass graft from the carotid to the brachial artery crossing the shoulder near the acromioclavicular joint, with the advantage that the tissue changed by radiotherapy or infected by ulceration could be circumvented. There were no postoperative complications, with adequate function of the grafts (follow-up, 17, 24, and 20 months, respectively).
Asunto(s)
Arteria Axilar/efectos de la radiación , Neoplasias de la Mama/radioterapia , Radioterapia/efectos adversos , Arteria Subclavia/efectos de la radiación , Anciano , Arteria Axilar/diagnóstico por imagen , Arteria Axilar/patología , Arteria Braquial/cirugía , Neoplasias de la Mama/cirugía , Arterias Carótidas/cirugía , Terapia Combinada , Embolización Terapéutica , Femenino , Estudios de Seguimiento , Humanos , Mastectomía , Persona de Mediana Edad , Radiografía , Radioterapia/métodos , Vena Safena/trasplante , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/patologíaRESUMEN
An occlusion of the superior vena cava by a tumor thrombus extending into the right atrium was diagnosed in three patients with a follicular thyroid cancer. All patients showed the typical clinical picture of the superior vena cava syndrome. A right parasternal thoracotomy was performed for preparation of the major vessels. The superior vena cava was opened and the entire intravascular tumor thrombus was removed. The cavotomy was closed directly in two patients. In the third patient the left brachiocephalic trunk was resected and reconstructed with a vascular (polytetrafluoroethylene) graft. This patient had bone and brain metastases and an occlusion of the graft 3 months after surgery after anticoagulation was stopped. The other two patients were clinically symptom free without local recurrence 13 and 50 months after surgery. An aggressive surgical approach is justified in grossly invasive thyroid cancer to decrease local recurrence and death rates, to correct the disturbing clinical symptoms of superior vena caval occlusion, and to prevent tumor embolism and the development of distant metastases. By reducing tumor mass, an even better basis for radioiodine treatment can be prepared.
Asunto(s)
Adenocarcinoma/cirugía , Miocardio/patología , Neoplasias de la Tiroides/cirugía , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/patología , Terapia Combinada , Estudios de Seguimiento , Atrios Cardíacos , Humanos , Invasividad Neoplásica , Estadificación de Neoplasias , Flebografía , Cuidados Posoperatorios , Neoplasias de la Tiroides/diagnóstico por imagen , Neoplasias de la Tiroides/patología , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: A prospective, randomized trial was conducted to compare Dacron with expanded polytetrafluoroethylene (ePTFE) in reconstructive aortoiliac surgery. No comparable trial with a prospective, randomized design with a comparable number of patients or an equal long-term follow-up period can be found in the literature. METHODS: Between 1984 and 1989, 165 patients were randomized for either Dacron or ePTFE on the basis of age, sex, indication for surgery, diabetes, nicotine consumption, runoff, and operative approach. The two groups were well matched for randomization criteria, as well as the incidence of aneurysms. RESULTS: No statistically significant difference was found between the two graft materials in terms of patency rates (corrected 3-year patency rates: Dacron = 95% vs ePTFE = 95%; Breslow, p = 0.83; Mantel-Cox, p = 0.74). Subgroup analysis comparing long-term patency rates of the two graft materials and relating them to poor runoff, good runoff, aneurysms, and arterial occlusive disease also failed to show any significant differences between ePTFE and Dacron. Early graft failure (n = 6; 3.6% of the patient population; p = 0.045) and severe abdominal graft infection (n = 3; 1.8% of the total population) were seen only in ePTFE grafts. However, these did not affect the corrected long-term patency rate of ePTFE grafts. There were five late graft failures with PTFE (3.0%) and four with Dacron (2.4%). CONCLUSIONS: Graft materials currently available for aortoiliac repair were comparable in terms of corrected long-term patency rates. The alleged advantages of PTFE were not confirmed by our data. PTFE grafts were associated with a higher rate of complications, and more redo operations were required to duplicate the results obtained with Dacron.
Asunto(s)
Aorta/cirugía , Prótesis Vascular , Tereftalatos Polietilenos , Politetrafluoroetileno , Prótesis Vascular/mortalidad , Estudios de Seguimiento , Humanos , Infecciones/etiología , Complicaciones Posoperatorias , Estudios Prospectivos , Análisis de Supervivencia , Grado de Desobstrucción VascularRESUMEN
During the years 1970 to 1985, 463 patients with obliterative atherosclerosis at the femoropopliteal level underwent elective surgery. The operation performed was an autologous saphenous vein bypass using the reversed technique. The vascular surgical treatment was documented in reasonable detail (both baseline and follow-up) in accordance with the documentation system of the Austrian Society of Vascular Surgery. On-line data entry with use of SAS data-base management software was used. The patency curves were estimated in accordance with the Kaplan-Meier method; possible differences were checked by means Breslow's and Mantel's tests. The preoperative clinical status (claudicants, n = 200; limb salvage, n = 263) influenced the postoperative results in a statistically significant manner (Breslow p less than 0.01; Mantel p less than 0.03). All the other risk factors analyzed (site of distal anastomosis above versus below the knee, n = 231, and n = 232, respectively; Breslow p less than 0.58, Mantel p less than 0.58. Presence [n = 122] or nonpresence [n = 341], of diabetes mellitus [Breslow p less than 0.77, Mantel p less than 0.68]; smoking habits [nonsmokers, n = 93, smokers n = 370, Breslow p less than 0.68, Mantel p less than 0.69;]) did not reach statistical significance. Anticoagulant treatment (n = 101) had no effect (Breslow p less than 0.93, Mantel p less than 0.72), even when the therapy was restricted to cases with disease at advanced clinical stages (stages III, IV; n = 50; Breslow p less than 0.55, Mantel p less than 0.95). On the basis of these analyses, a prospective trial was initiated in 1979. Eighty-eight patients were studied; those in group I (n = 42) received dicumarol, and those in group II (n = 46) were controls who did not receive anticoagulant treatment. At present, the median follow-up time is at 30 months. Treatment with dicumarol favorably influenced graft patency (Breslow, p less than 0.03, Mantel p less than 0.07; one-tailed tests). The patients' preoperative clinical status affected the results of surgery (Breslow p less than 0.03, Mantel p less than 0.02; one-tailed tests). In relation to the preoperative clinical status, a therapeutic effect was observed in stages III and IV (n = 45; Breslow p less than 0.03, Mantel p less than 0.07; one-tailed tests), while no effect of therapy was demonstrable in claudicants (n = 43; Breslow p less than 0.3, Mantel p less than 0.4; one-tailed tests).(ABSTRACT TRUNCATED AT 400 WORDS)
Asunto(s)
Arteriosclerosis/cirugía , Dicumarol/uso terapéutico , Arteria Femoral/cirugía , Arteria Poplítea/cirugía , Anciano , Arteriosclerosis/tratamiento farmacológico , Ensayos Clínicos como Asunto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Estudios Prospectivos , Distribución Aleatoria , Recurrencia , RiesgoRESUMEN
The aims of this study were to determine whether diabetes could be ameliorated in dogs by autotransplantation of pancreatic fragments to the spleen and to determine the optimal time of collagenase digestion for pancreatic tissue dispersal. Forty-eight dogs were made diabetic by total pancreatectomy. Fifteen dogs not further treated survived 7.0+/-1.1 (SE) days with a mean plasma glucose of 401+/-5 (SE) mg/100 ml 2 days after pancreatectomy. The pancreases of 33 dogs were distended with Hanks' solution, minced, digested with collagenase (600 microns/ml of tissue), for 0 to 25 minutes, and autotransplanted to the splenic pulp. The incidence of permanent normoglycemia (fasting plasma glucose less than 150 mg/100 ml) and the K value of glucose tolerance tests (GTT) performed 2 and 10 weeks after transplant were determined in experimental groups divided according to the length of collagenase digestion. All five dogs receiving undigested tissue remained hyperglycemic. One of seven dogs receiving tissue digested for 10 minutes became normoglycemic. In contrast, seven of eight, seven of seven, and six of six dogs receiving tissue digested for 15, 20, and 25 minutes, respectively, became normoglycemic (followed for 6 months). K values at 2 weeks were 1.20+/-1.19 (SE)% 1.60+/-0.25 (SE)%, and 0.78+/-0.08 (SE)% in the normolgycemic dogs of the 15, 20, and 25 minute digestion groups, respectively. The K value of normal dogs was 3.30+/-0.27 (SE)%. The glucose tolerance curves of the 20 minute group at 2 and 10 weeks most nearly approximated the curves of normal dogs. K values improved in all recipient dogs. Diabetes recurred immediately and death occurred at a mean of 4.8+/-1.5 days in 12 recipient dogs following splenectomy. We conclude that pancreatic fragments can be successfully autotransplanted to the spleen without separation of endocrine and exocrine tissue and that 20 minutes is the optimal period of collagenase digestion for tissue preparation.
Asunto(s)
Diabetes Mellitus/terapia , Trasplante de Islotes Pancreáticos , Pancreatectomía , Animales , Glucemia/análisis , Perros , Prueba de Tolerancia a la Glucosa , Islotes Pancreáticos/enzimología , Islotes Pancreáticos/metabolismo , Colagenasa Microbiana , Recurrencia , Bazo/metabolismo , Bazo/cirugía , Esplenectomía , Factores de Tiempo , Trasplante AutólogoRESUMEN
BACKGROUND: A prospective randomized multicenter trial was performed to compare knitted gelatin-coated Dacron bifurcation grafts, knitted collagen-coated Dacron grafts, and stretch polytetrafluoroethylene (PTFE) grafts. METHODS: Between 1991 and 1998, 315 elective patients were randomized by age, gender, diabetes, runoff, indication (aneurysm, aortoiliac occlusive disease), and nicotine consumption at 3 centers of vascular surgery in Austria. The patients received gelatin-coated Dacron (GEL-D) grafts (n = 109), collagen-coated Dacron (COL-D) grafts (n = 100), or stretch PTFE grafts (n = 106). RESULTS: No intraoperative deaths occurred. The 30-day mortality was 3%. No difference was found between the 3 graft materials in long-term patency. The primary 5-year patency rates were 92% for GEL-D, 89% for COL-D, and 91% for stretch PTFE (P =.6001). The secondary 5-year patency rates also differed: 97% for GEL-D, 100% for COL-D, and 97% for stretch PTFE (P =.2062). Early occlusions were observed overall in 3% and late occlusions in 5% of patients. When both Dacron grafts were compared collectively with stretch PTFE, a difference was found in infection rate: Dacron 3% (6/209) versus PTFE 0% (0/106); P <.03. CONCLUSIONS: The bifurcation grafts of all 3 materials were comparable in primary and secondary patency rates, incidence of false aneurysms, and rate of perioperative complications. Graft infections were confined to the 2 Dacron grafts and did not occur in stretch PTFE grafts.
Asunto(s)
Aorta Abdominal/cirugía , Prótesis Vascular , Materiales Biocompatibles Revestidos , Colágeno , Gelatina , Tereftalatos Polietilenos , Politetrafluoroetileno , Femenino , Oclusión de Injerto Vascular/epidemiología , Humanos , Incidencia , Complicaciones Intraoperatorias/epidemiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Infección de la Herida Quirúrgica/epidemiología , Análisis de Supervivencia , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
OBJECTIVE: The choice of material for above-knee femoropopliteal bypass grafting is a matter of continuing controversy for various reasons. The most important argument in favor of alloplastic grafts is to preserve the autologous saphenous vein for a below-knee bypass, which might become indicated at a later date. DESIGN: A consecutive series of above-knee reconstructions were analyzed with regard to long-term behavior. Early graft occlusions were not included, and the median follow-up was 83 months. SETTING: A university hospital with a particular interest in vascular surgery. PATIENTS AND METHODS: Four hundred forty-two patients received either autologous saphenous vein (n = 310) or alloplastic graft (n = 132) material, and were analyzed in a univariate (Kaplan-Meier) and multivariate (Cox) manner. MAIN OUTCOME MEASURES: Analysis as to whether alloplastic graft material provides equal or less favorable results as compared with autologous saphenous vein material, in terms of primary and secondary patency, secondary below-knee bypass grafting, limb salvage, and survival. RESULTS: Although univariate analysis demonstrated a significantly better primary patency rate for autologous saphenous vein material, multivariate analysis did not show any effect of the material in terms of patency, limb salvage, and survival. The frequency of secondary below-knee repair was 7% (31 patients); 56% were performed in the first 2 years postoperatively. This amounted to an estimated probability of 4.4% and 12.3% at 18 years, respectively. CONCLUSION: The small probability of secondary below-knee repair in our series does not support the policy to use alloplastic grafts routinely for a primary above-knee bypass, to spare the saphenous vein. Therefore, patients should be offered the best material for the first operation even at the above-knee level.
Asunto(s)
Prótesis Vascular , Arteria Femoral/cirugía , Isquemia/cirugía , Arteria Poplítea/cirugía , Adulto , Anciano , Análisis de Varianza , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Análisis de Regresión , Reoperación , Estudios Retrospectivos , Vena Safena/trasplante , Análisis de Supervivencia , Trasplante Autólogo , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: To review the value of obturator canal bypass with respect to long-term results. DESIGN: Case series and literature review. SETTING: University of Vienna Medical School in Austria. PATIENTS/METHODS: Personal experience with 34 consecutive patients and 125 cases published since 1982 with respect to patient data, patency, and survival are compared and jointly analyzed retrospectively. INTERVENTIONS: Patients received obturator canal bypass for lesions of the pelvic or common femoral vessels precluding orthotopic reconstruction. MAIN OUTCOME MEASURES: The rates of patient survival, limb salvage, and graft patency were analyzed. RESULTS: The postoperative mortality rate in the present series was 14.7%. The limb salvage rate after 5 years was 76.5%. One- and 5-year secondary patency rates were 75.3% and 54.9%, respectively. All grafts in patients without atherosclerosis were patent at a median of 34 months. For 57 cases documented in the literature, 1- and 5-year patency rates were 70.8% and 59.7%, respectively. Combined analysis of 90 obturator canal bypasses revealed rates of 72.7% and 56.9% of patent grafts at 1- and 5-years, respectively. CONCLUSIONS: The use of obturator canal bypass is recommended in deep groin infections and especially in patients with lesions of the pelvic vessels due to other occlusive vascular disease.
Asunto(s)
Arteriopatías Oclusivas/cirugía , Arteria Femoral/cirugía , Anciano , Arteriopatías Oclusivas/mortalidad , Prótesis Vascular , Femenino , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Reoperación , Estudios Retrospectivos , Terapia Recuperativa , Tasa de Supervivencia , Factores de Tiempo , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
To determine whether long-term oral anticoagulant treatment was effective in improving graft performance and preventing major amputation following vein bypass surgery for femoropopliteal atherosclerosis, a clinical trial was conducted in one single center and continued during 10 years. After 130 patients had electively received a femoropopliteal vein graft, they were randomly assigned to a therapy group (treatment with phenprocoumon [n = 66]) or to a control group (n = 64) that remained without any anticoagulant treatment. Primary end points of the study were graft reocclusion and limb loss. The median durations of primary patency and limb salvage were significantly longer for treated patients than that for controls. In addition, survival in the therapy group was longer. Following autologous vein bypass surgery in the treated group, the results were superior in terms of graft patency, limb salvage, and survival.
Asunto(s)
Arteriosclerosis/cirugía , Arteria Femoral/cirugía , Fenprocumón/uso terapéutico , Arteria Poplítea/cirugía , Vena Safena/trasplante , Administración Oral , Anciano , Pruebas de Coagulación Sanguínea , Femenino , Estudios de Seguimiento , Gangrena/cirugía , Oclusión de Injerto Vascular/etiología , Humanos , Claudicación Intermitente/cirugía , Masculino , Persona de Mediana Edad , Fenprocumón/administración & dosificación , Pulso Arterial , Tasa de Supervivencia , Comprimidos , Grado de Desobstrucción VascularRESUMEN
Common carotid artery occlusion is not necessarily associated with thrombosis of the ipsilateral internal carotid artery. Noninvasive imaging of the carotid bifurcation with colour-coded Doppler sonography demonstrated patency of the external and internal carotid arteries distal to a common carotid occlusion in 4 patients which could be proven surgically. Identification of internal carotid artery patency could be demonstrated by angiography in two of the patients while in the other two cases angiography was inconclusive. Thus, CCDS provided a correct diagnosis of the internal carotid patency in these patients with common carotid occlusion.
Asunto(s)
Arteriopatías Oclusivas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Grado de Desobstrucción Vascular , Adulto , Anciano , Angiografía de Substracción Digital , Arteria Carótida Externa , Arteria Carótida Interna , Humanos , Masculino , UltrasonografíaRESUMEN
A clinical series has been analysed to determine which of two similar, extrathoracic "extraanatomic" methods of treating proximal blocks of the subclavian artery is the superior option. From 1975 until 1988 direct carotid-subclavian anastomosis was used in 32 patients and carotid-subclavian bypass in 19. There were no statistically significant differences for the probability of postoperative survival (p less than 0.877 Breslow; p less than 0.774 Mantel), intraoperative blood loss or the duration of anaesthesia. Those patients who had undergone subclavian artery repair had a significantly longer survival than those following carotid bifurcation endarterectomy (p less than 0.002 Breslow, p less than 0.0002 Mantel). As patients with subclavian lesions have a reasonable life-expectancy, they may possibly experience late complications of their vascular repair. Therefore it seems important to select the most durable operation, and direct carotid subclavian anastomosis has a significantly greater patency rate than bypass (p less than 0.006 Breslow, p less than 0.006 Mantel). Patients with preoperative symptoms of cerebrovascular insufficiency had a lower probability of survival than those with upper extremity claudication, although this did not reach statistical significance (p less than 0.205 Breslow; p less than 0.198 Mantel).
Asunto(s)
Arteriopatías Oclusivas/cirugía , Arterias Carótidas/cirugía , Arteria Subclavia/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Adulto , Anciano , Anastomosis Quirúrgica , Brazo/irrigación sanguínea , Arteriopatías Oclusivas/complicaciones , Femenino , Humanos , Claudicación Intermitente/etiología , Claudicación Intermitente/cirugía , Masculino , Persona de Mediana Edad , Síndrome del Robo de la Subclavia/etiología , Síndrome del Robo de la Subclavia/cirugía , Tasa de Supervivencia , Grado de Desobstrucción VascularRESUMEN
21 patients had aortoiliac reconstructions for aortic aneurysms or occlusive disease with the new PTFE Y-graft during the past 12 months. 2 patients in the aneurysm group with additional renal artery reconstruction suffered postoperative myocardial infarction and subsequently died. 2 patients older than 80 years died after aneurysm repair in cause of graft infection, respectively respiratory insufficiency. All grafts (n=17) are functioning well or did so until death of the patient (n=4). The obvious advantage of the PTFE Y-graft is the fact, that there is no need of preclotting. Suture line--even using 4-0 material at the proximal anastomosis--and graft body is absolutely tight and no blood loss has to be expected from this site. However positioning of the left limb of the y-graft can be difficult in patients with right sided extraperitoneal approach and proximal side end anastomosis. Performing an end-end anastomosis can overcome this problem. For occlusion of the prosthesis limbs two vascular clamps on each side are needed to control blood flow within the rather stiff graft. Immediate and short term function is excellent. There was no material specific complication noted until now. Further longterm experience is necessary to evaluate the definitive quality of this new prosthetic material after some years.
Asunto(s)
Aneurisma de la Aorta/cirugía , Enfermedades de la Aorta/cirugía , Prótesis Vascular , Politetrafluoroetileno , Anciano , Femenino , Humanos , Arteria Ilíaca/cirugía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Técnicas de SuturaRESUMEN
OBJECTIVE: Infection of the retroperitoneum after implantation of an abdomino-femoral aortic graft remains one of the main problems in vascular surgery. On basis of a critical review of own experiences we evaluated the management of this difficult clinical situation. PATIENTS: From 1970-1996 1500 aortofemoral graft operations (aneurysmal disease: 512, aortoiliacal occlusive disease: 988) were performed. Abdominal infection occurred in 12 patients (0.8%) (12 men, median age 60.5 [48-80] years). RESULTS: The median interval between operation and infection was 17.7 (0.5-108) months. The port of infection was in 50% the groin, 25% suffered from abdominal infection, in 3 cases it was not to identify. Clinical manifestation of infection was aortoduodenal fistula in 2 patients, false aneurysms in 2 cases, and a paraprosthetic abscess in another 4 patients. Operative therapy comprised (partial) removal of infected material in 10 patients with consecutive extraanatomical reconstruction in 8 of these. Mortality of graft infection was 50%. Causes of death were untreatable sepsis in 4 patients, another 2 died from hemorrhagic shock. 3 out of 6 surviving patients finally lost their limbs following multiple vascular procedures. CONCLUSION: Adequate surgical therapy of infected aortofemoral grafts remains an unsolved problem. Lack of knowledge of suitable parameters for the best treatment leaves the outcome of prosthetic infection unpredictable. Removal of the infected graft with extraanatomic reconstruction seems to be the standard of surgical treatment, which is recommended in these cases.
Asunto(s)
Implantación de Prótesis Vascular/efectos adversos , Infecciones/etiología , Infecciones/cirugía , Anciano , Anciano de 80 o más Años , Arteria Femoral/cirugía , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The outcome of 532 femoro-popliteal vein grafts performed electively during the years 1970 to 1985 for obliterative arterial disease, was analyzed using the documentation-system of the Austrian Society for Vascular Surgery, as well as SAS and BMDP-software on an IBM 4381 computer of the Medical Faculty. The probability of function was estimated according to the Kaplan-Meier method, statistical differences were checked with Breslow's and Mantel's test, the proportional hazards regression model (Cox) was used to elucidate the influence of different risk factors on each own and in combination of each other. In the univariate analysis, the preoperative clinical status was found to be of prognostic significance, but technical details such as intraoperative as well as postoperative arteriography or site of the distal anastomosis were not important. A postoperative coumarine treatment had no demonstrable impact on graft function, but positively influenced the probability of patient survival. Taking into account the factors found to be of significance in the univariate analysis (e.g. set of factors: site of distal anastomosis, diabetic state and smoking habits) were analyzed using the proportional hazards regression model but were found of no major influence. The factors preoperative clinical status, patients age, and coumarine therapy significantly influenced the probability of patient survival, but diabetes mellitus and smoking were found to be not important.
Asunto(s)
Arteriopatías Oclusivas/cirugía , Arteria Femoral/cirugía , Arteria Poplítea/cirugía , Vena Safena/trasplante , Anciano , Angiopatías Diabéticas/cirugía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Riesgo , FumarRESUMEN
Eighty-eight patients underwent a classical reversed saphenous vein graft for femoro-popliteal occlusive disease and were enrolled in a controlled clinical trial. During the second postoperative week the patients were allocated randomly into one of two groups: group I consisted of 42 patients who received dicumarol and group II (46 patients) served as a control group without any anticoagulant treatment. The mean follow-up time was 24 months. After 12 months the cumulative patency rate was 82%, after 18 months 76% and after 24 months 76%; for patients receiving dicumarol treatment the respective figures were 92%, 86% and 86% and for those with no treatment 70%, 67% and 67%, the difference being significant. When the bypass operation was performed for limb salvage (clinical stages III and IV) the overall results were worse (12 months: 72%, 18 months: 68%, 24 months: 68%) than in stages II, II-III (12 months: 90%, 18 months: 85%, 24 months: 85%). In limb salvage surgery the positive effects of anticoagulant treatment were significant (with treatment: 12 months 87%, 18 months 86%, 24 months 86%; without treatment: 12 months 58%, 18 months 54%, 24 months 54%).
Asunto(s)
Dicumarol/uso terapéutico , Oclusión de Injerto Vascular/cirugía , Isquemia/cirugía , Pierna/irrigación sanguínea , Complicaciones Posoperatorias/prevención & control , Tromboflebitis/prevención & control , Anciano , Ensayos Clínicos como Asunto , Arteria Femoral/cirugía , Estudios de Seguimiento , Humanos , Arteria Poplítea/cirugía , Vena Safena/trasplanteRESUMEN
The diversity of clinical manifestations of Boeck's sarcoidosis may also include endocrine disorders. One year after diagnosis of sarcoidosis in a 29 year-old female patient, endocrinological complications became manifest with amenorrhoea. The course of the disease was additionally complicated by hypoglycaemic episodes. Thorough clinical investigation of the patient revealed sarcoid involvement of the skin, lungs, liver and lymph nodes and an extensive retroperitoneal surgically-verified lymph tumour. After tolbutamide and in reaction to an intravenous glucose tolerance test the blood glucose was found to be very low, whilst the immunoreactive insulin was normal. Further investigation of the endocrine functions of the patient revealed normal functioning of the thyroid gland, subnormal values for the follicle stimulating hormone and extremely low serum ACTH and serum cortisol values, without any diurnal changes in these parameters. The clinical symptoms of the patient and the biochemical findings were regarded as manifestations of secondary adrenal failure due to sarcoid involvement of the hypothalamus and pituitary. Hence, treatment with corticosteroids was started. Hypoglycaemia has not since been observed in this patient and the other clinical features of (secondary) adrenal failure have disappeared slowly.