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INTRODUCTION: Endovascular aneurysm repair has improved outcomes for ruptured abdominal aortic aneurysms (rAAA) compared with open repair. We examined the impact of aorto-uni-iliac (AUI) vs standard bifurcated endograft configuration on outcomes in rAAA. METHODS: Patients 18 years or older in the Vascular Quality Initiative database who underwent endovascular aneurysm repair for rAAA from January 2011 to April 2020 were included. Patient characteristics were analyzed by graft configuration: AUI or standard bifurcated. Primary and secondary outcomes included 30-day mortality, postoperative major adverse events (myocardial infarction, stroke, heart failure, mesenteric ischemia, lower extremity embolization, dialysis requirement, reoperation, pneumonia, or reintubation), and 1-year mortality. A subset propensity-score matched cohort was also analyzed. RESULTS: We included 2717 patients: 151 had AUI and 2566 had standard bifurcated repair. There was no significant difference between the groups in terms of age, major medical comorbidities, anatomic aortic neck characteristics, or rates of conversion to open repair. Patients who underwent AUI were more commonly female (30% vs 22%, P = .011) and had a history of congestive heart failure (19% vs 12%, P = .013). Perioperatively, patients who underwent AUI had a significantly higher incidence of cardiac arrest (15% vs 7%, P < .001), greater intraoperative blood loss (1.3 L vs 0.6 L, P < .001), longer operative duration (218 minutes vs 138 minutes, P < .0001), higher incidence of major adverse events (46.3% vs 33.3%, P = .001), and prolonged intensive care unit (7 vs 4.7 days, P = .0006) and overall hospital length of stay (11.4 vs 8.1 days, P = .0003). Kaplan-Meier survival analyses demonstrated significant differences in 30-day (31.1% vs 20.2%, log-rank P = .001) and 1-year mortality (41.7% vs 27.7%, log-rank P = .001). The propensity-score matched cohort demonstrated similar results. CONCLUSIONS: The AUI configuration for rAAA appears to be implemented in a sicker cohort of patients and is associated with worse perioperative and 1-year outcomes compared with a bifurcated graft configuration, which was also seen on propensity-matched analysis. Standard bifurcated graft configuration may be the preferred approach in the management of rAAA unless AUI configuration is mandated by patient anatomy or other extenuating circumstances.
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Aneurisma de la Aorta Abdominal , Rotura de la Aorta , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Femenino , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Complicaciones Posoperatorias , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/cirugía , Rotura de la Aorta/etiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: Type II endoleaks (T2Es), often identified after endovascular aneurysm repair (EVAR), have been associated with late endograft failure and secondary rupture. The number and size of the patent aortic aneurysm sac outflow vessels (ie, the inferior mesenteric, lumbar, and accessory renal arteries) have been implicated as known risk factors for persistent T2Es. Given the technical challenges associated with post-EVAR embolization, prophylactic embolization of aortic aneurysm sac outflow vessels has been advocated to prevent T2Es; however, the evidence available at present is limited. We sought to examine the effects of concomitant prophylactic aortic aneurysm sac outflow vessel embolization in patients undergoing EVAR. METHODS: Patients aged ≥18 years included in the Society for Vascular Surgery Vascular Quality Initiative database who had undergone elective EVAR for intact aneurysms between January 2009 and November 2020 were included in the present study. Patients with a history of prior aortic repair and those without available follow-up data were excluded. The patient demographics, operative characteristics, and outcomes were analyzed by group: EVAR alone vs EVAR with prophylactic sac outflow vessel embolization (emboEVAR). The outcomes of interest were the in-hospital postoperative complication rates, incidence of aneurysmal sac regression (≥5 mm) and T2Es, and reintervention rates during follow-up. RESULTS: A total of 15,060 patients were included. Of these patients, 272 had undergone emboEVAR and 14,788 had undergone EVAR alone. No significant differences were found between the two groups in age, comorbidities, or anatomic characteristics, including the mean maximum preoperative aortic diameter (5.5 vs 5.6 cm; P = .48). emboEVAR was associated with significantly longer procedural times (148 vs 124 minutes; P < .0001), prolonged fluoroscopy times (32 vs 23 minutes; P < .0001), increased contrast use (105 vs 91 mL; P < .0001), without a significant reduction in T2Es at case completion (17.7% vs 16.3%; P = .54). The incidence of postoperative complications (3.7% vs 4.6%; P = .56), index hospitalization reintervention rates (0.7% vs 1.3%; P = .59), length of stay (1.8 vs 2 days; P = .75), and 30-day mortality (0% vs 0%; P = 1.00) were similar between the two groups. At mid-term follow-up (14.6 ± 6.2 months), the emboEVAR group had a significantly greater mean reduction in the maximum aortic diameter (0.69 vs 0.54 cm; P = .006), with a greater proportion experiencing sac regression of ≥5 mm (53.5% vs 48.7%). The reintervention rates were similar between the two groups. On multivariable analysis, prophylactic aortic aneurysm sac outflow vessel embolization (odds ratio, 1.34; 95% confidence interval, 1.04-1.74; P = .024) was a significant independent predictor of sac regression. CONCLUSIONS: Prophylactic sac outflow vessel embolization can be performed safely for patients with intact aortic aneurysms undergoing elective EVAR without significant associated perioperative morbidity or mortality. emboEVAR was associated with significant sac regression compared with EVAR alone at mid-term follow-up. Although no decrease was found in the incidence of T2Es, this technique shows promise, and future efforts should focus on identifying a subset of aneurysm and outflow branch characteristics that will benefit from concomitant selective vs complete prophylactic sac outflow vessel embolization.
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Aneurisma de la Aorta Abdominal , Aneurisma de la Aorta , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Adolescente , Adulto , Aneurisma de la Aorta/cirugía , Aneurisma de la Aorta Abdominal/complicaciones , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/prevención & control , Procedimientos Endovasculares/efectos adversos , Humanos , Complicaciones Posoperatorias/cirugía , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Patients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR) and/or complex EVAR. Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI). However, these results were largely based on single-center experiences with limited multi-institutional and national data that had assessed the clinical outcomes for these patients. The objective of the present study was to evaluate the effect of prior infrarenal aortic surgery on the occurrence of SCI. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was retrospectively reviewed to identify all patients aged ≥18 years who had undergone TEVAR and/or complex EVAR from January 2012 to June 2020. Patients with previous thoracic or suprarenal aortic repair were excluded. The baseline and procedural characteristics and postoperative outcomes were compared between TEVAR and/or complex EVAR with and without previous infrarenal aortic repair. The primary outcome was postoperative SCI. The secondary outcomes included postoperative hospital length of stay, bowel ischemia, renal ischemia, and 30-day mortality. Multivariate regression was used to determine the independent predictors of postoperative SCI. Additional analysis was performed of the patients who had undergone isolated TEVAR. RESULTS: A total of 9506 patients met the inclusion criteria: 8691 (91.4%) had not undergone prior infrarenal aortic repair and 815 (8.6%) had undergone previous infrarenal aortic repair. Patients with previous infrarenal repair were older with an increased prevalence of chronic kidney disease (P = .001) and cardiovascular risk factors, including hypertension, chronic obstructive pulmonary disease, and positive smoking history (P < .001). These patients also presented with a larger maximal aortic diameter (6.06 ± 1.47 cm vs 5.15 ± 1.76 cm; P < .001) and required more stent-grafts (P < .001) with increased intraoperative blood transfusion requirements (P < .001), and longer procedure times (P < .001). Univariate analysis demonstrated no differences in postoperative SCI, postoperative hospital length of stay, bowel ischemia, or renal ischemia between the two groups. The 30-day mortality was significantly higher in patients with prior infrarenal repair (P = .001). On multivariate regression, prior infrarenal aortic repair was not a predictor of postoperative SCI. In contrast, aortic dissection (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.26-2.16; P < .001), number of stent-grafts deployed (OR, 1.45; 95% CI, 1.30-1.62; P < .001), and units of packed red blood cells transfused intraoperatively (OR, 1.33; 95% CI, 1.03-1.73; P = .032) were independent predictors of postoperative SCI. CONCLUSIONS: Although the patients in the TEVAR and/or complex EVAR group with prior infrarenal aortic repair constituted a sicker cohort with higher 30-day mortality, the rate of SCI was comparable to that of the patients without prior repair. Previous infrarenal repair was not associated with the risk of SCI.
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Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Isquemia Mesentérica , Insuficiencia Renal Crónica , Isquemia de la Médula Espinal , Adolescente , Adulto , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Femenino , Humanos , Isquemia/cirugía , Masculino , Isquemia Mesentérica/cirugía , Insuficiencia Renal Crónica/complicaciones , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Isquemia de la Médula Espinal/diagnóstico , Isquemia de la Médula Espinal/etiología , Resultado del TratamientoRESUMEN
OBJECTIVES: Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a major source of morbidity, mortality, and healthcare utilization. Given the prevalence of venous thromboembolism and its associated mortality, our study sought to identify factors associated with loss to follow-up in venous thromboembolism patients. METHODS: This is a single-center retrospective study of all consecutive admitted (inpatient) and emergency department patients diagnosed with acute venous thromboembolism via venous duplex examination and/or chest computed tomography from January 2018 to March 2019. Patients with chronic deep venous thrombosis and those diagnosed in the outpatient setting were excluded. Lost to venous thromboembolism-specific follow-up (LTFU) was defined as patients who did not follow up with vascular, cardiology, hematology, oncology, pulmonology, or primary care clinic for venous thromboembolism management at our institution within three months of initial discharge. Patients discharged to hospice or dead within 30 days of initial discharge were excluded from LTFU analysis. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC) with a p-value of <0.05 set for significance. RESULTS: During the study period, 291 isolated deep venous thrombosis, 25 isolated pulmonary embolism, and 54 pulmonary embolism with associated deep venous thrombosis were identified in 370 patients. Of these patients, 129 (35%) were diagnosed in the emergency department and 241 (65%) in the inpatient setting. At discharge, 289 (78%) were on anticoagulation, 66 (18%) were not, and 15 (4%) were deceased. At the conclusion of the study, 120 patients (38%) had been LTFU, 85% of whom were discharged on anticoagulation. There was no statistically significant difference between those LTFU and those with follow-up with respect to age, gender, diagnosis time of day, venous thromboembolism anatomic location, discharge unit location, or anticoagulation choice at discharge. There was a non-significant trend toward longer inpatient length of stay among patients LTFU (16.2 days vs. 12.3 days, p = 0.07), and a significant increase in the proportion of LTFU patients discharged to a facility rather than home (p = 0.02). On multivariate analysis, we found a 95% increase in the odds of being lost to venous thromboembolism-specific follow-up if discharged to a facility (OR 1.95, CI 1.1-3.6, p = 0.03) as opposed to home. CONCLUSIONS: Our study demonstrates that over one-third of patients diagnosed with venous thromboembolism at our institution are lost to venous thromboembolism-specific follow-up, particularly those discharged to a facility. Our work suggests that significant improvement could be achieved by establishing a pathway for the targeted transition of care to a venous thromboembolism-specific follow-up clinic.
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Embolia Pulmonar , Tromboembolia Venosa , Trombosis de la Vena , Anticoagulantes/uso terapéutico , Humanos , Incidencia , Perdida de Seguimiento , Transferencia de Pacientes , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Tromboembolia Venosa/diagnóstico por imagen , Tromboembolia Venosa/epidemiología , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/epidemiología , Trombosis de la Vena/terapiaRESUMEN
OBJECTIVE: Current guidelines recommend dual antiplatelet therapy (DAPT) in patients undergoing carotid artery stenting. The most common DAPT regimen is aspirin and clopidogrel, a P2Y12 receptor antagonist; however, the prevalence of clopidogrel resistance (CR) in patients undergoing percutaneous coronary interventions may exceed 60%. Few studies have investigated the prevalence and impact of CR in patients undergoing extracranial carotid artery stenting, particularly transcarotid artery revascularization (TCAR). METHODS: Consecutive high-risk patients ≥ 18 years who underwent TCAR for high grade (≥70%) and/or symptomatic (≥50%) carotid stenosis with preoperative P2Y12 testing between August 2019 and December 2021 were identified across five institutions. Preoperative platelet reactivity was measured with the VerifyNow P2Y12 Reaction Unit (PRU) Test (Instrumentation Laboratory, Bedford, MA), with CR defined as PRU ≥ 194 and hyper-response as PRU <70. Patients without preoperative P2Y12 testing within 30 days prior to TCAR or those on a non-clopidogrel P2Y12 inhibitor preoperatively were excluded. The primary outcome of interest was prevalence of CR. Secondary outcomes of interest included the incidence of ischemic and hemorrhagic complications. RESULTS: Of 92 patients identified, the majority were male (59%) and Caucasian (75%) with a mean age of 75 years (±8, range 56-92). Preoperatively, 93% of patients were on aspirin, 100% on clopidogrel, and 13% on therapeutic anticoagulation. At presentation, 36% were symptomatic. The mean preoperative P2Y12 was 156 PRU (±76, range 6-349). In total, 30 (33%) patients met criteria for CR (mean PRU 240 ± 37; range 197-349), and 15 (16%) met criteria for hyper-responder (mean PRU 38 ± 20; range 6-68). There was no significant difference by clopidogrel response phenotype in terms of sex (p = 0.246), race (p = 0.384), or symptomatic presentation (p = 0.956). Postoperatively, the cumulative incidence of stroke and MI was 2.1%, with no statistically significant difference in the incidence of in-hospital stroke (PRU 238, p = 0.489) or MI (PRU 168, p = 1) between clopidogrel phenotypes. Three (3.3%) patients, one CR (PRU 240) and two responders (PRU 119 and PRU 189), experienced postoperative access site hematomas that required no subsequent intervention. No other index hospitalization hemorrhagic complications occurred. CONCLUSIONS: Using preoperative P2Y12 testing with a threshold PRU ≥ 194 to define CR, we identified a high prevalence of CR in patients undergoing TCAR similar to that in the pre-existing coronary literature. We found no significant differences in postoperative ischemic or hemorrhagic complications by clopidogrel response phenotype, although complication rates in the overall study cohort were low. CR may be a spectrum from responder to partial responder to complete non-responder, and this may account for the differences in our CR cohort compared to the ROADSTER 2 protocol deviation cohort. Further investigation is warranted to determine if a quantitative assessment of CR is sufficient to identify patients at risk of developing secondary cerebrovascular ischemic events in this patient population.
RESUMEN
BACKGROUND: The natural history of penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs) of the aorta has not been well described. Although repair is warranted for rupture, unremitting chest pain, or growth, no threshold has been established for treating those found incidentally. Thoracic endovascular aortic repair (TEVAR) offers an attractive approach for treating these pathologic entities. However, the periprocedural and postoperative outcomes have not been well defined. METHODS: Patients aged ≥18 years identified in the Vascular Quality Initiative database who had undergone TEVAR for PAUs and/or IMHs from January 2011 to February 2020 were included. We identified 1042 patients, of whom 809 had follow-up data available. The patient demographics and comorbidities were analyzed to identify the risk factors for major adverse events (MAEs) and postoperative and late mortality. RESULTS: The cohort was 54.8% female, and 69.9% were former smokers, with a mean age of 71.1 years. Comorbidities were prevalent, with 57.8% classified as having American Society of Anesthesiologists class 4. Of the 1042 patients, 89.8% had hypertension, 28.3% chronic obstructive pulmonary disease, 17.9% coronary artery disease, and 12.2% congestive heart failure. Patients were predominately symptomatic (74%), and 44.5% had undergone nonelective repair. The MAE incidence was 17%. The independent predictors of MAEs were a history of coronary artery disease, nonwhite race, emergent procedural indication, ruptured presentation, and deployment of two or more endografts. In-hospital mortality was 4.3%. Of the index hospitalization mortalities, 73% were treatment related. For the 809 patients with follow-up (mean, 25.1 ± 19 months), the all-cause mortality was 10.6%. The predictors of late mortality during follow-up included age >70 years, ruptured presentation, and a history of chronic obstructive pulmonary disease and end-stage renal disease. A subset analysis comparing symptomatic (74%) vs asymptomatic (26%) patients demonstrated that the former were frequently women (58.2% vs 45.3%; P < .001), with a greater incidence of MAEs (20.6% vs 6.9%; P < .001), including higher in-hospital reintervention rates (5.9% vs 1.5%; P = .002) and mortality (5.6% vs 0.7%; log-rank P = .015), and a prolonged length of stay (6.9 vs 3.7 days; P < .0001), despite similar procedural risks. During follow-up, late mortality was greater in the symptomatic cohort (12.2% vs 6.5%; log-rank P = .025), with all treatment-related mortalities limited to the symptomatic group. CONCLUSIONS: We found significantly greater morbidity and mortality in symptomatic patients undergoing repair compared with asymptomatic patients, despite similar baseline characteristics. Asymptomatic patients treated with TEVAR had no treatment-related mortality during follow-up, with the overall prognosis largely dependent on preexisting comorbidities. These findings, in conjunction with increasing evidence highlighting the risk of disease progression and attendant morbidity associated with these aortic entities, suggest a need for natural history studies and definitive guidelines on the elective repair of IMHs and PAUs.
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Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Hematoma/cirugía , Complicaciones Posoperatorias/etiología , Úlcera/cirugía , Anciano , Anciano de 80 o más Años , Aorta Torácica/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Implantación de Prótesis Vascular/mortalidad , Comorbilidad , Bases de Datos Factuales , Procedimientos Endovasculares/mortalidad , Femenino , Hematoma/diagnóstico por imagen , Hematoma/mortalidad , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Úlcera/diagnóstico por imagen , Úlcera/mortalidad , Estados UnidosRESUMEN
OBJECTIVE: During the past two decades, the treatment of popliteal artery aneurysms (PAAs) has undergone a transformation. Although open surgical repair (OR) has remained the reference standard for treatment, endovascular repair (ER) has become an attractive alternative for select patient populations. The objective of the present study was to compare the outcomes of OR vs ER of PAAs at a single institution. METHODS: We performed a retrospective review of the medical records for all patients who had undergone repair for PAAs from 1998 to 2017. The baseline patient, anatomic, and operative characteristics and outcomes were compared between the OR and ER cohorts. Intervention and treatment were at the discretion of the surgeon. RESULTS: From 1998 to 2017, 64 patients had undergone repair of 73 PAAs at our tertiary care center. Of the 69 patients (73 PAAs), 29 (33 PAAs) had undergone OR and 35 (40 PAAs) had undergone ER. When comparing the two cohorts, no statistically significant differences were found in the demographic characteristics such as age, gender, or number of runoff vessels. Significantly more patients in the ER group (n = 21; 53%) than in the OR group (n = 7; 21%) had had hyperlipidemia (P = .008) and a previous carotid intervention (6% vs 0%; P = .029). Overall, the presence of symptoms was similar between the two groups. However, the OR group had a significantly higher number of patients who had presented with acute ischemia (P = .01). The length of stay was significantly shorter for the ER cohort (mean, 1.8 days; range, 1-11 days) than for the OR group (mean, 5.4 days; range, 2-13 days; P < .0001). No significant difference was found in the primary or secondary patency rates between the two groups. In the ER group, good runoff (two or more vessels) was a positive predictor for primary patency at 1 year (odds ratio, 3.36; 95% confidence interval, 1.0-11.25). However, it was not in the OR group. Postoperative single and/or dual antiplatelet therapy did not affect primary patency in either cohort. CONCLUSIONS: The results of our study have demonstrated that ER of PAAs is a safe and durable option with patency rates comparable to those with OR and a decreased length of stay, with good runoff a positive predictor for primary patency in the ER cohort.
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Aneurisma/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Tiempo de Internación , Arteria Poplítea/cirugía , Anciano , Anciano de 80 o más Años , Aneurisma/diagnóstico por imagen , Aneurisma/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: Adjunctive false lumen embolization (FLE) with thoracic endovascular aortic repair (TEVAR) in patients with chronic aortic dissection is thought to induce FL thrombosis and favorable aortic remodeling. However, these data are derived from small single-institution experiences and the potential benefit of FLE remains unproven. In this study, we examined perioperative and midterm outcomes of patients with aortic dissection undergoing concomitant TEVAR and FLE.* METHODS: : Patients 18 or older who underwent TEVAR for chronic aortic dissection with known FLE status in the Society for Vascular Surgery Vascular Quality Initiative database between January 2010 and February 2020 were included. Ruptured patients and emergent procedures were excluded. Patient characteristics, operative details and outcomes were analyzed by group: TEVAR with or without FLE. Primary outcomes were in-hospital post-operative complications and all-cause mortality. Secondary outcomes included follow-up mean maximum aortic diameter change, rates of false lumen thrombosis, re-intervention rates, and mortality. RESULTS: 884 patients were included: 46 had TEVAR/FLE and 838 had TEVAR alone. There was no significant difference between groups in terms of age, gender, comorbidities, prior aortic interventions, mean maximum pre-operative aortic diameter (5.1cm vs. 5.0cm, P=0.43), presentation symptomatology, or intervention indication. FLE was associated with significantly longer procedural times (178min vs. 146min, P=0.0002), increased contrast use (134mL vs. 113mL, P=0.02), and prolonged fluoroscopy time (34min vs. 21min, P<0.0001). However, FLE was not associated with a significant difference in post-operative complications (17.4% vs. 13.8%, P=0.51), length of stay (6.5 vs. 5.7 days, P=0.18), or in-hospital all-cause mortality (0% vs. 1.3%, P=1). In mid-term follow-up (median 15.5months, IQR 2.2-36.2 months), all-cause mortality trended lower, but was not significant (2.2% vs. 7.8%); and Kaplan-Meier analysis demonstrated no difference in overall survival between groups (P=0.23). By Cox regression analysis, post-operative complications had the strongest independent association with all-cause mortality (HR 2.65, 95% CI 1.56-4.5, P<0.001). In patients with available follow-up imaging and re-intervention status, mean aortic diameter change (n=337, -0.71cm vs. -0.69cm, P=0.64) and re-intervention rates (n=487, 10% vs. 11.4%, P=1) were similar. CONCLUSIONS: Adjunctive FLE, despite increased procedural times, can be performed safely for patients with chronic dissection without significantly higher overall perioperative morbidity or mortality. TEVAR/FLE demonstrates trends for improved survival and increased rates of FL thrombosis in the treated thoracic segment; however, given the lack of evidence to suggest a significant reduction in re-intervention rates or induction of more favorable aortic remodeling compared to TEVAR alone, the overall utility of this technique in practice remains unclear. Further investigation is needed to determine the most appropriate role for FLE in managing chronic aortic dissections.
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Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Embolización Terapéutica , Procedimientos Endovasculares , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Disección Aórtica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Enfermedad Crónica , Bases de Datos Factuales , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Remodelación VascularRESUMEN
BACKGROUND: Upper extremity deep venous thrombosis (UEDVT) and its associated complications are increasing in incidence, but management strategies are largely derived from experience treating lower extremity deep venous thrombosis (LEDVT). The purpose of this study is to examine our single institution's experience with in-hospital venous thromboembolism (VTE), specifically the characteristics and outcomes of the UEDVT population as it compares to LEDVT. METHODS: This is a single tertiary care center retrospective cohort study of all consecutive inpatients diagnosed with acute VTE from June 2015 to December 2015. During this period, 4,495 patients underwent venous duplex examination (622 UE and 3,873 LE), identifying 83 inpatient DVTs. Chronic DVT and those diagnosed in the outpatient population were excluded. DVTs were classified as either provoked or unprovoked. Provoked DVT were defined as the presence of any of the following factors within 30 days prior to diagnosis: major surgery, immobilization (greater than 3 days of bedrest), trauma, infection requiring antibiotics, central venous access, pregnancy, and/or hormonal medication use. Inpatient pulmonary embolisms (PE) detected on chest computed tomography (CT) were also evaluated during this time frame. Patient data were collected, including age, gender, race, lifestyle factors, comorbidities, VTE risk factors, symptomatology at presentation, management including anticoagulation choice and filter placement if applicable, as well as discharge disposition. Statistical analysis was performed using GraphPad Prism 8.0 (GraphPad Software, San Diego, California), and a threshold P-value of <0.05 set for significance. RESULTS: During the study period, 83 DVTs (48 LEDVT, 35 UEDVT) and 24 PE were identified in 96 inpatients. Of these DVTs, 77.1% of these were defined as provoked. Eleven patients had simultaneous DVT and PE, and thirteen patients had PE with presumed occult pelvic or LEDVT. UEDVT patients had a higher proportion of comorbidities than LEDVT patients: coronary artery disease (25.7% vs. 13.1%, P = 0.16), congestive heart failure (20% vs. 6.6%, P = 0.09), as well as a trend toward higher incidence of malignancy (60% vs. 42.6%, P = 0.13). Of provoked VTE, UEDVT correlated more significantly with central venous catheters (88.4% vs. 12.5%, P=<0.0001), but was less commonly associated with prolonged bed rest (19.2% vs. 39.5%, P = 0.11). PE was diagnosed in 24/96 (25%) of the study population. Patients with LEDVT were found to have a significantly higher incidence of PE compared to those with UEDVT (34.4% vs. 8.6%, P = 0.006). Same-admission mortality for patients with VTE was 13/96 (13.5%). Of these, patients with UEDVT had significantly higher all-cause mortality than patients with LEDVT (28.5% vs. 4.9%, P = 0.004). When catheter-related UEDVT was excluded, there remained a significant difference in mortality between non-catheter-related UEDVT and LEDVT (33.3% vs. 4.9% P = 0.0119). CONCLUSIONS: This study demonstrates a high prevalence of UEDVT in hospitalized patients who experience VTE. Despite a lower incidence of synchronous PE, patients with UEDVT had a higher prevalence of significant medical comorbidities and higher all-cause mortality on the index hospital admission.
Asunto(s)
Extremidad Inferior/irrigación sanguínea , Admisión del Paciente , Centros de Atención Terciaria , Trombosis Venosa Profunda de la Extremidad Superior/mortalidad , Extremidad Superior/irrigación sanguínea , Tromboembolia Venosa/mortalidad , Trombosis de la Vena/mortalidad , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Ciudad de Nueva York/epidemiología , Prevalencia , Pronóstico , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Ultrasonografía Doppler Dúplex , Trombosis Venosa Profunda de la Extremidad Superior/diagnóstico por imagen , Trombosis Venosa Profunda de la Extremidad Superior/terapia , Tromboembolia Venosa/diagnóstico por imagen , Tromboembolia Venosa/terapia , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/terapiaRESUMEN
BACKGROUND: Penetrating ulcers of the abdominal aorta (PUAA) are an increasingly common finding on abdominal imaging studies; however, their significance and natural history are not well described. This study's objective was to analyze the demographics, presentation, and outcomes of patients with a radiographic diagnosis of PUAA. MATERIALS AND METHODS: Patients at our tertiary referral center were identified for inclusion based on a search for the term "penetrating ulcer" in abdominal computed tomography and magnetic resonance imaging reports between January 2014 and December 2017. Patients' electronic medical records were retrospectively reviewed to determine baseline medical characteristics, imaging indication, and subsequent clinical course, interventions, and outcomes. Aortic diameters and ulcer depths were measured by a single observer on initial and follow-up imaging to assess for association with concomitant aortic pathology, evolving aortic disease, and ulcer progression, defined as increase in depth of ≥ 1 mm. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC), and a threshold P-value of <0.05 was set for significance. RESULTS: Ninety-two patients with PUAA were identified; 57 (62%) were male. The mean age at diagnosis was 79.3 years, and comorbidities included hypertension (74%), hyperlipidemia (65%), and malignancy (34%). The most common indication for imaging was chest, back, or abdominal pain (19%). On initial imaging, the mean ulcer depth was 1 cm (range from 0.2 cm to 3.4 cm). Concomitant abdominal aortic dilation ≥ 3 cm was found in 34 (37%) patients. Thirty-six (39%) patients had a vascular surgery consultation immediately after radiographic diagnosis. Follow-up axial imaging was performed on 27 (29%) untreated patients. The overall sample's mean ulcer depth remained essentially unchanged from initial measurement (P = 0.99); however, 14 (52%) patients with follow-up imaging were found to have increased overall aortic diameter. Of the total 92 patients, 9 (10%) underwent an endovascular abdominal aortic intervention during the review period: 2 for symptomatic PUAA and the remainder for progression of concomitant aneurysmal disease. All-cause mortality was 5% during the mean follow-up period of 21.9 months (range 0 to 72.5 months). Of the patients lost to follow-up, 61% did not receive vascular referral after initial diagnosis. CONCLUSIONS: PUAA are typically incidental findings identified in elderly, comorbid patients undergoing imaging for an unrelated indication. Although isolated findings of asymptomatic PUAA rarely require surgical intervention, these patients we argue would benefit from vascular surgery referral for long-term follow-up and interval imaging to assess for disease progression and concomitant aortic degeneration, which may necessitate repair. In addition, we observed that most of those patients lost to follow-up did not receive vascular consultation, suggesting that lack of involvement of vascular specialists at the time of diagnosis is a missed opportunity to secure appropriate follow-up and management.
Asunto(s)
Aorta Abdominal/cirugía , Enfermedades de la Aorta/cirugía , Procedimientos Endovasculares , Derivación y Consulta , Úlcera/cirugía , Anciano , Anciano de 80 o más Años , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/patología , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/patología , Bases de Datos Factuales , Progresión de la Enfermedad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Úlcera/diagnóstico por imagen , Úlcera/mortalidad , Úlcera/patologíaRESUMEN
Con A hepatitis is regarded as a T cell-mediated model of acute liver injury. Mincle is a C-type lectin receptor that is critical in the immune response to mycobacteria and fungi but does not have a well-defined role in preclinical models of non-pathogen-mediated inflammation. Because Mincle can ligate the cell death ligand SAP130, we postulated that Mincle signaling drives intrahepatic inflammation and liver injury in Con A hepatitis. Acute liver injury was assessed in the murine Con A hepatitis model using C57BL/6, Mincle(-/-), and Dectin-1(-/-) mice. The role of C/EBPß and hypoxia-inducible factor-1α (HIF-1α) signaling was assessed using selective inhibitors. We found that Mincle was highly expressed in hepatic innate inflammatory cells and endothelial cells in both mice and humans. Furthermore, sterile Mincle ligands and Mincle signaling intermediates were increased in the murine liver in Con A hepatitis. Most significantly, Mincle deletion or blockade protected against Con A hepatitis, whereas Mincle ligation exacerbated disease. Bone marrow chimeric and adoptive transfer experiments suggested that Mincle signaling in infiltrating myeloid cells dictates disease phenotype. Conversely, signaling via other C-type lectin receptors did not alter disease course. Mechanistically, we found that Mincle blockade decreased the NF-κß-related signaling intermediates C/EBPß and HIF-1α, both of which are necessary in macrophage-mediated inflammatory responses. Accordingly, Mincle deletion lowered production of nitrites in Con A hepatitis and inhibition of both C/EBPß and HIF-1α reduced the severity of liver disease. Our work implicates a novel innate immune driver of Con A hepatitis and, more broadly, suggests a potential role for Mincle in diseases governed by sterile inflammation.
Asunto(s)
Concanavalina A/inmunología , Hepatitis/inmunología , Lectinas Tipo C/inmunología , Proteínas de la Membrana/inmunología , Transducción de Señal/inmunología , Animales , Modelos Animales de Enfermedad , Hepatitis/metabolismo , Humanos , Inflamación/inmunología , Lectinas Tipo C/deficiencia , Leucocitos Mononucleares , Masculino , Proteínas de la Membrana/deficiencia , Ratones , Ratones Endogámicos BALB C , Ratones Endogámicos C57BL , Ratones Noqueados , Nitritos/metabolismoAsunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/normas , Procedimientos Endovasculares/normas , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Reglas de Decisión Clínica , Consenso , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Humanos , Medición de Riesgo , Factores de Riesgo , Sociedades Médicas , Tiempo de Tratamiento/normas , Resultado del TratamientoAsunto(s)
Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aortografía/normas , Angiografía por Tomografía Computarizada/normas , Angiografía por Resonancia Magnética/normas , Ultrasonografía/normas , Aneurisma de la Aorta Abdominal/complicaciones , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/prevención & control , Enfermedades Asintomáticas , Toma de Decisiones Clínicas , Consenso , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Pronóstico , Medición de Riesgo , Factores de Riesgo , Sociedades MédicasAsunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aortografía/normas , Implantación de Prótesis Vascular , Angiografía por Tomografía Computarizada/normas , Procedimientos Endovasculares , Complicaciones Posoperatorias/diagnóstico por imagen , Falla de Prótesis , Ultrasonografía Doppler en Color/normas , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Toma de Decisiones Clínicas , Consenso , Árboles de Decisión , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/etiología , Migración de Cuerpo Extraño/mortalidad , Humanos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Sociedades Médicas , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Endofuga/diagnóstico por imagen , Endofuga/etiología , Humanos , Sociedades Médicas , Resultado del TratamientoRESUMEN
Anticoagulant therapeutics are a mainstay of modern surgery and of clotting disorder management such as venous thrombosis, yet performance and supply limitations exist for the most widely used agent - heparin. Herein we report the first synthesis, characterization, and performance of sulfated poly-amido-saccharides (sulPASs) as heparin mimetics. sulPASs inhibit the intrinsic pathway of coagulation, specifically FXa and FXIa, as revealed by ex vivo human plasma clotting assays and serine protease inhibition assays. sulPASs activity positively correlates with molecular weight and degree of sulfation. Importantly, sulPASs are not degraded by heparanases and are non-hemolytic. In addition, their activity is reversed by protamine sulfate, unlike small molecule anticoagulants. In an in vivo murine model, sulPASs extend clotting time in a dose dependent manner with bleeding risk comparable to heparin. These findings support continued development of synthetic anticoagulants to address the clinical risks and shortages associated with heparin.
RESUMEN
OBJECTIVE: Lymphedema is associated with significant morbidity and healthcare resource usage. Conventional therapy efficacy has been limited, with poor surgical salvage options. Preliminary studies have demonstrated that the use of advanced pneumatic compression devices (APCDs) improves clinical outcomes. However, limited evidence regarding their role in healthcare cost mitigation or health-related quality of life (QOL) is available. METHODS: The present postmarket, multicenter, single-arm, observational clinical trial conducted in the Veterans Affairs Healthcare System evaluated patients with a diagnosis of primary or secondary edema of unilateral or bilateral lower extremities treated with the Flexitouch APCD (Tactile Medical, Minneapolis, Minn) from February 2016 to March 2019. The patients were assessed at baseline and 12, 24, and 52 weeks from enrollment by limb circumference, QOL assessments (short form-36 and Lymphedema Quality of Life), device compliance, cellulitis episodes, and lymphedema-related healthcare use since the previous visit. The primary endpoints of interest were the QOL at baseline compared with at 12 weeks, unscheduled lymphedema-related clinic visits, and hospital admissions at 52 weeks. The secondary endpoints included the change in limb girth and QOL at 52 weeks compared with baseline. RESULTS: A total of 178 patients with lower extremity lymphedema were prospectively enrolled. The present study reports the interim data for the first 74 subjects to complete 52 weeks of APCD treatment. The cohort was predominately male (94.6%), elderly (mean age, 67 years), obese (median body mass index, 32 kg/m2), and most commonly enrolled for the treatment of phlebolymphedema (71.6%) with largely bilateral lower extremity involvement (91.9%). No significant difference was seen in QOL at 12 weeks. However, at 52 weeks, the Lymphedema Quality of Life scores had significantly improved from baseline (6.3 vs 7.4; P < .0001) and the short form-36 had demonstrated significant improvement from baseline in the physical component (38.6 vs 40.8; P = .035), with an effect toward overall improvement in the mental component (49.9 vs 51.3; P = .549). The limb circumference had decreased significantly at 12 weeks compared with baseline (28.5 cm vs 27.7 cm; P = .0005) in the most affected lower extremity, and this reduction had remained stable for the study duration. APCD treatment was associated with a significant reduction in cellulitis episodes (24.3% vs 8.1%; P = .005), lymphedema-related clinic visits (2.2 vs 0.7; P = .02), urgent care visits (1.2 vs 0.3; P = .004), and hospital admissions (0.5 vs 0.1; P = .047) per patient. CONCLUSIONS: The Flexitouch APCD resulted in initial significant limb girth reduction as early as 12 weeks and a steady and sustained improvement in health-related QOL for ≤1 year. The latter was likely reflective of a decrease in cellulitis episodes and fewer associated lymphedema-related clinic and urgent care visits and hospital admissions.