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OBJECTIVE: Although observational cohort studies report that interventions to achieve functionality are clinically successful in 85% of patients, the proportion of newly created autologous arteriovenous fistulas that result in functional vascular access typically is only 70 - 80%. To address this discrepancy, the selection and outcomes of interventions to achieve functionality in a multicentre prospective cohort study were analysed. METHODS: The Shunt Simulation Study enrolled 222 patients who needed a first arteriovenous fistula in nine dialysis units in The Netherlands from 2015 to 2018 and followed these patients until one year after access creation. In this observational study, the technical and clinical success rates of interventions to achieve functionality based on lesion and intervention characteristics were analysed and the clinical outcomes of arteriovenous fistulas with assisted and unassisted functionality were compared. RESULTS: For patients who were on dialysis treatment at the end of the study, unassisted fistula functionality was 54% and overall fistula functionality was 78%. Thirty-four per cent of arteriovenous fistulas required an intervention to achieve functionality, 68% of which eventually became functional. Seventy-five per cent of these interventions were percutaneous balloon angioplasties of vascular access stenoses. Patients with clinically successful interventions to achieve functionality had larger pre-operative vein diameters (2.8 ± 1.0 mm vs. 2.3 ± 0.6 mm, p = .036) and less often presented with thrombosed fistulas than patients with unsuccessful interventions (7% vs. 43%, p = .006). Arteriovenous fistulas with assisted functionality had similar secondary patency as fistulas with unassisted functionality (100% and 98% at six months, p = .44), although they required more interventions to maintain function (2.6 vs. 1.7 per year; rate ratio 1.52, 95% CI 1.04 - 2.18, p = .032). CONCLUSION: Interventions to achieve functionality were needed in about a third of newly created arteriovenous fistulas. Most thrombosed fistulas were abandoned, and when selected for thrombectomy rarely reached clinical success. On the other hand, interventions to achieve functionality of patent fistulas had high clinical success rates and therefore can be done repeatedly until the fistula has become functional.
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OBJECTIVE: An arteriovenous fistula (AVF) needs to mature before it becomes suitable to cannulate for haemodialysis treatment. Maturation importantly depends on the post-operative flow increase. Unfortunately, 20-40% of AVFs fail to mature (FTM). A patient specific computational model that predicts immediate post-operative flow was developed, and it was hypothesised that providing information from this model for planning of fistula creation might reduce FTM rates. METHODS: A multicentre, randomised controlled trial in nine Dutch hospitals was conducted in which patients with renal failure who were referred for AVF creation, were recruited. Patients were randomly assigned (1:1) to the control or computer simulation group. Both groups underwent a work up, with physical and duplex ultrasonography (DUS) examination. In the simulation group the data from the DUS examination were used for model simulations, and based on the immediate post-operative flow prediction, the ideal AVF configuration was recommended. The primary endpoint was AVF maturation defined as an AVF flow ≥500 mL/min and a vein inner diameter of ≥4 mm six weeks post-operatively. The secondary endpoint was model performance (i.e. comparisons between measured and predicted flows, and (multivariable) regression analysis for maturation probability with accompanying area under the receiver operator characteristic curve [AUC]). RESULTS: A total of 236 patients were randomly assigned (116 in the control and 120 in the simulation group), of whom 205 (100 and 105 respectively) were analysed for the primary endpoint. There was no difference in FTM rates between the groups (29% and 32% respectively). Immediate post-operative flow prediction had an OR of 1.15 (1.06-1.26; p < .001) per 100 mL/min for maturation, and the accompanying AUC was 0.67 (0.59-0.75). CONCLUSION: Providing pre-operative patient specific flow simulations during surgical planning does not result in improved maturation rates. Further study is needed to improve the predictive power of these simulations in order to render the computational model an adjunct to surgical planning.
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Fístula Arteriovenosa/cirugía , Diálisis Renal/métodos , Remodelación Vascular , Anciano , Circulación Sanguínea , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: Interruption of the hypogastric artery by ligation, embolization, or coverage frequently results in ischemic complications. The aim of this study was to compare the rate and risk factors for the development of ischemic complications after interruption of the hypogastric artery in obstetrics and gynecology (OBG), vascular surgery, oncology, and trauma patients. METHODS: MEDLINE, Ovid, and Scopus were searched for articles containing data of patients who underwent interruption of the hypogastric artery. Based on the indication, details of the procedure, and complications developed, data were categorized and a systematic review was done to evaluate any significant differences. RESULTS: A total of 394 patients (median age, 48.5 years) from 124 papers were included in the study; 31% of the study population was male and 69% was female. Indication for interruption was OBG related in 53.3%, vascular surgery related in 25.1%, oncology related in 17.5%, and trauma related in 4.1% of patients. Overall ischemic complication rate was 22.6%, comprising buttock claudication in 12.2%, buttock necrosis in 4.8%, erectile dysfunction in 2.7%, spinal cord ischemia in 4.0%, colonic ischemia in 2.5%, and bladder necrosis in 0.8%. Complications were fewer in patients younger than the median age of 48.5 years (12.8%) compared with those older than the median age (36.3%; P < .01), women compared with men (13.1% vs 41.7%; P < .01), OBG patients compared with vascular surgery patients (9.5% vs 37.4%; P < .01), patients after ligation compared with embolization (9.4% vs 31.0%; P < .01), and proximal interruption compared with distal interruption (19.6% vs 51.4%; P < .01). No significant difference in complications was seen after bilateral interruption compared with unilateral interruption (20.6% vs 27.1%; P > .05). Similarly, no significant difference in complication rate was seen with the type of embolization material used. Among OBG patients, ligations resulted in fewer complications compared with embolization (4.1% vs 16.7%; P < .01). Among vascular surgery patients, bilateral embolization resulted in a higher rate of complications compared with bilateral ligation (83.3% vs 30.5%; P < .01). Among oncology patients, fewer complications were seen after proximal interruption compared with distal interruption (25.5% vs 75%; P = .01). No significant differences in outcome were seen with regard to gender, laterality, and material used for embolization when patients were compared within each specialty. CONCLUSIONS: Interruption of the hypogastric artery is relatively safe in young and OBG patients compared with vascular surgery and oncology patients. Ligation of the hypogastric arteries is preferred to embolization, and proximal embolization should be preferred to distal embolization to decrease the risk of ischemic complications. Randomized controlled trials with larger sample size are needed to definitively elucidate clear risk factors for development of complications after hypogastric artery interruption.
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Implantación de Prótesis Vascular , Embolización Terapéutica , Arteria Ilíaca/cirugía , Pelvis/irrigación sanguínea , Adolescente , Adulto , Factores de Edad , Anciano , Implantación de Prótesis Vascular/efectos adversos , Distribución de Chi-Cuadrado , Embolización Terapéutica/efectos adversos , Femenino , Humanos , Arteria Ilíaca/fisiopatología , Isquemia/etiología , Isquemia/fisiopatología , Ligadura , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Flujo Sanguíneo Regional , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: Open revascularization (OR) has been the treatment of choice for chronic mesenteric ischemia (CMI) for many years, but endovascular revascularization (EV) has been increasingly used with good short-term results. In this study, we evaluated the comparative effectiveness and cost-effectiveness of EV and OR in patients with CMI refractory to conservative management. METHODS: A Markov-state transition model was developed using TreeAge Pro 2012 (TreeAge Inc, Williamstown, Mass) to simulate a hypothetical cohort of 10,000 65-year-old female patients with CMI requiring treatment with either OR or EV. Data for the model, including perioperative and long-term overall mortality risks, disease-specific mortality risks, complications, and reintervention and patency rates, were retrieved from original studies and systematic reviews about CMI. Costs were analyzed with the 2013 Medicare database. Outcomes evaluated were quality-adjusted life-years (QALYs), costs from the health care perspective, and the incremental cost-effectiveness ratio. Extensive sensitivity analyses were performed and different clinical scenarios evaluated. Probabilistic sensitivity analysis was performed to assess robustness of the model. RESULTS: For a reference-case 65-year-old female patient with CMI and an average risk for operation, EV is preferred with 10.03 QALYs (95% credibility interval [CI], 9.76-10.29) vs 9.59 after OR (95% CI, 9.29-9.87). The difference is comparable to 5 months in perfect health: 0.44 QALY (95% CI, 0.13-0.76). For 65-year-old men, this was 8.71 QALYs (95% CI, 8.48-8.94) for EV vs 8.42 (95% CI, 8.14-8.63) for OR. Sensitivity analysis showed that for younger patients, EV results in a higher increase in QALYs compared with older patients. Total expected reinterventions per patient are 1.70 for EV vs 0.30 for OR. Total expected health care costs for the reference-case patient were $39,942 (95% CI, $28,509-$53,380) for OR and $38.217 (95% CI, $29,329-$48,309) for EV. For men, this was $39,375 (95% CI, $28,092-$52,853) for OR and $35,903 (95% CI, $27,685-$45,597) for EV. For patients younger than 60 years, EV is a more expensive treatment strategy compared with OR, but with an incremental cost-effectiveness ratio for EV of less than $60,000/QALY. For patients 60 years and older, EV dominated OR as preferential treatment because effectiveness was higher than for OR and costs were lower. CONCLUSIONS: The results of this decision analysis model suggest that EV is favored over OR for patients with CMI in all age groups. Although EV is associated with more expected reinterventions, EV appears to be cost-effective for all age groups.
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Técnicas de Apoyo para la Decisión , Procedimientos Endovasculares , Isquemia/cirugía , Enfermedades Vasculares/cirugía , Procedimientos Quirúrgicos Vasculares , Factores de Edad , Anciano , Anciano de 80 o más Años , Investigación sobre la Eficacia Comparativa , Simulación por Computador , Análisis Costo-Beneficio , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/mortalidad , Femenino , Costos de la Atención en Salud , Humanos , Isquemia/diagnóstico , Isquemia/economía , Isquemia/mortalidad , Isquemia/fisiopatología , Masculino , Cadenas de Markov , Isquemia Mesentérica , Persona de Mediana Edad , Selección de Paciente , Valor Predictivo de las Pruebas , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Reoperación , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Resultado del Tratamiento , Enfermedades Vasculares/diagnóstico , Enfermedades Vasculares/economía , Enfermedades Vasculares/mortalidad , Enfermedades Vasculares/fisiopatología , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/economía , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
OBJECTIVE: The optimal treatment for patients with uncomplicated chronic Stanford type B aortic dissections (chTBADs) is still matter of debate. The purpose of this study was to design a decision tool to guide the surgeon in determining the preferred treatment option. METHODS: A Markov decision-analysis model compared chTBAD patients treated with initial open surgical repair (OSR), thoracic endovascular aortic repair (TEVAR), and optimal medical therapy (OMT), followed during follow-up by OSR (OMT-OSR) or TEVAR (OMT-TEVAR), if indicated. Procedural risks, aortic growth and rupture rates, outcomes, and quality of life values were derived from the best available evidence in the literature. A chTBAD treatment strategy decision tool was developed, including the four key variables of age, sex, surgical risk, and maximum initial aortic diameter. Primary outcome was quality-adjusted life-years (QALYs). RESULTS: For the reference patient cohort, 55-year-old men with chTBAD with a maximum aortic diameter of 5.0 cm, medium risk for surgery, and a threshold for surgery of 6.0 cm during follow-up, OSR yielded higher QALYs, with 10.06 QALYs (95% credibility interval [CI], 9.52-10.56 QALYs) vs 9.92 QALYs (95% CI, 9.23-10.58 QALYs) after TEVAR and 9.64 QALYs (95% CI, 9.38-9.88 QALYs) and 9.40 QALYs (95% CI, 9.11-9.69 QALYs) for OMT-OSR and OMT-TEVAR. The difference between OSR and OMT-OSR was 0.42 QALYs (95% CI, 0.01-0.81 QALYs) and between TEVAR and OMT-TEVAR was 0.52 QALYs (95% CI, 0.04-0.68 QALYs). This showed that intervention is preferred over OMT. A change of the four variables resulted in a change of preferred treatment. In general, OSR was the preferred treatment in younger patients with a larger aortic diameter and in low-risk patients. TEVAR was preferred in elderly patients with large aortic diameter and if the aortic diameter threshold for repair decreased. OMT was the optimal therapy in high-risk patients, elderly patients, or in patients with small aortic diameters. CONCLUSIONS: This decision-analysis model shows that there is no "one-size-fits-all" treatment for uncomplicated chTBADs. For the reference patient cohort, intervention is preferred over OMT. Age is the most important deciding factor, followed by initial aortic diameter. Immediate OSR is the preferred treatment option in younger patients with a large initial aortic diameter and in low-risk patients. Immediate TEVAR is preferred in elderly patients with a large initial aortic diameter and in patients with a lower threshold for OSR. OMT should be considered in high-risk patients, in patients with small initial aortic diameters, and in patients aged >80 years, unless their initial aortic diameter is >5.5 cm. However, the differences in some patient groups are clinically insignificant, allowing a major role for patient preferences and hospital-specific considerations. This clinical decision model may guide chTBAD treatment.
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Aneurisma de la Aorta Torácica/terapia , Disección Aórtica/terapia , Técnicas de Apoyo para la Decisión , Años de Vida Ajustados por Calidad de Vida , Factores de Edad , Anciano , Disección Aórtica/patología , Disección Aórtica/cirugía , Angioplastia/efectos adversos , Aorta Torácica/patología , Aneurisma de la Aorta Torácica/patología , Aneurisma de la Aorta Torácica/cirugía , Simulación por Computador , Femenino , Humanos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Injerto Vascular/efectos adversosRESUMEN
OBJECTIVE: Repair is indicated of asymptomatic popliteal artery aneurysms (aPAAs) that are >2 cm. Endovascular PAA repair with covered stents (stenting) is increasingly used. It is, however, unclear when an endovascular approach is preferred to traditional open repair with great saphenous vein bypass (GSVB). The goal of this study was to assess the treatment options for aPAAs using decision analysis. METHODS: A Markov model was developed and a hypothetic cohort of patients with aPAAs was analyzed. GSVB, stenting, and nonoperative management with optimal medical treatment (OMT) were compared. Operative mortality, patency rates, quality-of-life values, and costs were determined by comprehensive review of the best available evidence. The main outcome was quality-adjusted life-years (QALYs). Secondary outcomes were cost-effectiveness and number of reinterventions. RESULTS: For a 65-year-old male patient with a 2.0-cm aPAA and without significant comorbidities, probabilistic sensitivity analysis shows that intervention is preferred over OMT (5.77 QALYs, 95% credibility interval [CI], 5.43-6.11; OMT). GSVB treatment for this patient results in slightly higher QALYs than stent placement, with a predicted 8.43 QALYs (GSVB: 95% CI, 8.21-8.64) vs 8.07 QALYs (stenting: 95% CI, 7.84-8.29), a difference of 0.36 QALYs (95% CI, 0.14-0.58). Furthermore, costs are higher for stenting ($40,464; 95% CI, $34,814-$46,242) vs GSVB ($21,618; 95% CI, $15,932-$28,070), and more reinterventions are required after stenting (1.03 per patient) vs GSVB (0.52 per patient), making GSVB the preferred strategy for all outcomes considered. Stenting is preferred in patients who are at high risk for open repair (>6% 30-day mortality) or if the 5-year primary patency rates of stenting increase to 80%. For very old patients (>95 years) and patients with a very short life expectancy (<1.5 years), OMT yields higher QALYs. CONCLUSIONS: GSVB is the preferred treatment in 65-year-old patients with aPAAs for all outcomes considered. However, patients at high risk for open repair or without suitable vein should be considered as candidates for endovascular repair. Very elderly patients and patients with a short life expectancy are best treated with OMT. Further improvement of endovascular techniques that increase patency rates of endovascular stents could make this the preferred therapy for more patients in the future.
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Aneurisma/cirugía , Técnicas de Apoyo para la Decisión , Procedimientos Endovasculares , Arteria Poplítea/cirugía , Vena Safena/trasplante , Anciano , Anciano de 80 o más Años , Aneurisma/diagnóstico , Aneurisma/economía , Aneurisma/mortalidad , Aneurisma/fisiopatología , Animales , Enfermedades Asintomáticas , Fármacos Cardiovasculares/uso terapéutico , Gatos , Simulación por Computador , Análisis Costo-Beneficio , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Costos de Hospital , Humanos , Masculino , Cadenas de Markov , Método de Montecarlo , Selección de Paciente , Arteria Poplítea/fisiopatología , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Factores de Riesgo , Stents , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Purpose : To assess the comparative effectiveness of thoracic endovascular aortic repair (TEVAR) vs. open surgical repair (OSR) of complicated acute type B aortic dissections (cABAD) using decision analysis. Methods : A decision analysis comparing TEVAR and OSR for cABAD included variables extracted from the best-available evidence. Main outcomes were quality-adjusted life years (QALYs), presented with the 95% credibility intervals (CI), and number of reinterventions over the remaining lifetime. Different clinical scenarios, including age, gender, and risk profile were analyzed. Parameter uncertainty was analyzed using probabilistic sensitivity analysis. Results : In the reference case, a cohort of 55-year-old men, TEVAR was preferred over OSR: 7.07 QALYs (95% CI 6.77 to 7.38) vs. 6.34 QALYs (95% CI 6.04 to 6.66) for OSR. The difference of 0.73 QALYs (95% CI 0.29 to 1.17) is equal to 8.5 months in perfect health. TEVAR was more effective in all analyzed cases and age groups. Perioperative mortality was the most important variable affecting the difference between OSR and TEVAR, followed by the relative risk and percentage of aortic-related complications. Total expected reinterventions were 0.43/patient (TEVAR) and 0.35/patient (OSR). Conclusion : The results of this decision model for the treatment of cABAD suggest that TEVAR is preferred over OSR. Although a higher number of reinterventions is expected, the total effectiveness of TEVAR is higher for all age groups. OSR should be reserved for patients whose aortic anatomy is unsuitable for endovascular repair.
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Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Procedimientos Endovasculares , Procedimientos Quirúrgicos Vasculares , Enfermedad Aguda , Disección Aórtica/diagnóstico , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/mortalidad , Investigación sobre la Eficacia Comparativa , Simulación por Computador , Técnicas de Apoyo para la Decisión , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Medicina Basada en la Evidencia , Humanos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Selección de Paciente , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Años de Vida Ajustados por Calidad de Vida , Reoperación , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
We report the use of Aptus HeliFX EndoAnchors for endovascular treatment of a proximal type I endoleak after previous endovascular aneurysm repair (EVAR) of a ruptured abdominal aortic aneurysm. An 81-year-old man had been treated with EVAR after a ruptured 12 × 11 cm abdominal aortic aneurysm. Standard computed tomographic angiography follow-up demonstrated a proximal type I endoleak. Because of the highly angulated neck and close position of the endograft to the renal arteries, placement of a proximal extension cuff was prohibited; therefore, the endoleak was treated with an alternative approach using the Aptus HeliFX EndoAnchors. Nine EndoAnchors were successfully placed circumferentially on the proximal site of the endograft. This successfully treated the endoleak by excluding the aneurysm sac from the circulation. Computed tomographic angiography follow-up after 3 months showed no residual type I endoleak. This case shows that placement of EndoAnchors can serve as a viable treatment option for proximal type I endoleaks after failed EVAR.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Grapado Quirúrgico/instrumentación , Suturas , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico , Rotura de la Aorta/diagnóstico , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Endofuga/diagnóstico , Endofuga/etiología , Procedimientos Endovasculares/instrumentación , Humanos , Masculino , Reoperación , Stents , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: Ruptured descending thoracic aortic aneurysm (rDTAA) is a life-threatening disease. In the last decade, thoracic endovascular aortic repair (TEVAR) has evolved as a viable option and is now considered the preferred treatment for rDTAAs. New opportunities as well as new challenges are faced by both the surgeon and the anesthesiologist. This review describes the impact of current developments and new modalities for the surgical and anesthetic management of rDTAAs. RECENT FINDINGS: A collaborative approach between the anesthesiologist and surgeon during critical moments such as induction, moment of aortic occlusion and placement of the aortic stent-graft is mandatory. Important issues to consider on preoperative imaging evaluation are correct sizing of the aortic stent-graft and localization of the artery of Adamkiewicz. Emergency TEVAR should preferentially be started under local anesthesia and could be switched to general anesthesia after stent placement. Patients should be kept in permissive hypotension preoperatively and during the intervention before stent-graft deployment and relative hypertension after deployment. The use of a proactive spinal cord protection protocol could decrease the risk of spinal cord ischemia and/or paraplegia and consists of permissive hypertension after stent deployment, cerebrospinal fluid drainage to maintain adequate spinal cord perfusion, relative hypothermia and possibly use of mannitol. SUMMARY: In order to improve outcomes of TEVAR for rDTAA, a close communication between the anesthesiologist and the surgeon and a thorough understanding of the events during the procedure is mandatory. The use of a proactive spinal cord protection protocol may decrease the rates of devastating spinal cord ischemia.
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Anestesia , Anestésicos , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Procedimientos Endovasculares/métodos , Aneurisma Roto/cirugía , Aneurisma de la Aorta Torácica/diagnóstico , Delirio/prevención & control , Humanos , Monitoreo Intraoperatorio , Cuidados Posoperatorios , Complicaciones Posoperatorias/psicología , Complicaciones Posoperatorias/terapia , Cuidados Preoperatorios , StentsRESUMEN
OBJECTIVE: This study was conducted to provide insight into the safety, applicability, and outcomes of thoracic endovascular aortic repair (TEVAR) with the chimney graft technique. METHODS: Original data regarding the chimney technique in TEVAR in the emergent and elective setting were collected from MEDLINE, Embase, and Scopus databases. All variables were systematically extracted and included in a database. Patient and procedural characteristics, details, and outcomes were analyzed. RESULTS: In total, 94 patients with 101 chimney-stented aortic arch branches were analyzed, consisting of the brachiocephalic artery in 20, the left common carotid artery in 48, and the left subclavian artery in 33. Balloon-expandable stents were used in 36% and self-expandable stents in 64% for the aortic side branch. The interventions were elective in 72% and emergent in 28%. Technical success was achieved in 98% in elective and emergent settings combined. Endoleaks were described in 18%; with type Ia being most frequently reported in 6.4% overall and in 6.5% in the elective setting. Stroke was reported in 5.3% of the patients, of which 40% were fatal. The overall perioperative mortality was 3.2%. Median follow-up time was 11 months, and chimney stents remained patent in all patients. CONCLUSIONS: TEVAR with the chimney technique is a viable treatment option and may expand treatment strategies for patients with challenging thoracic aortic pathology and anatomy in the emergent and elective setting. Patency of the thoracic chimney stents appears to be good during short-term follow-up. Other complications, such as endoleak and stroke, deserve attention by future research to further improve treatment strategies and the prognosis of these patients.
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Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aorta Torácica/fisiopatología , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Niño , Procedimientos Quirúrgicos Electivos , Urgencias Médicas , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Stents , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Adulto JovenRESUMEN
OBJECTIVE: Clinical guidelines provide recommendations on the minimal blood vessel diameters required for arteriovenous fistula creation but the evidence for these recommendations is limited. We compared vascular access outcomes of fistulas created in agreement with the ESVS Clinical Practice Guidelines (i.e. arteries and veins >2 mm for forearm fistulas and >3 mm for upper arm fistulas) with fistulas created outside these recommendations. METHODS: The multicenter Shunt Simulation Study cohort contains 211 hemodialysis patients who received a first radiocephalic, brachiocephalic, or brachiobasilic fistula before publication of the ESVS Clinical Practice Guidelines. All patients had preoperative duplex ultrasound measurements according to a standardized protocol. Outcomes included duplex ultrasound findings at 6 weeks after surgery, vascular access function, and intervention rates until 1 year after surgery. RESULTS: In 55% of patients, fistulas were created in agreement with the ESVS Clinical Practice Guidelines recommendations on minimal blood vessel diameters. Concordance with the guideline recommendations was more frequent for forearm fistulas than for upper arm fistulas (65% vs 46%, p = 0.01). In the entire cohort, agreement with the guideline recommendations was not associated with an increased proportion of functional vascular accesses (70% vs 66% for fistulas created within and outside guideline recommendations, respectively; p = 0.61) or with decreased access-related intervention rates (1.45 vs 1.68 per patient-year, p = 0.20). In forearm fistulas, however, only 52% of arteriovenous fistulas created outside these recommendations developed into a timely functional vascular access. CONCLUSIONS: Whereas upper arm arteriovenous fistulas with preoperative blood vessel diameters <3 mm had similar vascular access function as fistulas created with larger blood vessels, forearm arteriovenous fistulas with preoperative blood vessel diameters <2 mm had poor clinical outcomes. These results support that clinical decision-making should be guided by an individual approach.
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PURPOSE OF REVIEW: To review the current state of diagnosis, treatment, and outcomes of the different types of endoleaks after endovascular abdominal aortic aneurysm repair (endovascular aneurysm repair, EVAR). RECENT FINDINGS: Endoleaks are the most frequent complication after EVAR, the most common indication for secondary interventions, and the most common cause of rupture after EVAR. Imaging is critical for detecting endoleaks. Type I and III endoleaks require urgent intervention to prevent aneurysm rupture. Intervention for other endoleaks or endotension is indicated if the aneurysm sac continues to grow during follow-up. The majority of endoleaks can be treated with endovascular techniques. Open surgical conversion may be considered if the risk of aneurysm rupture is high and if no endovascular options are available or if they have failed. SUMMARY: Endoleaks continue to be a challenge and this article discusses the different treatment options for endoleaks after EVAR. Long-term follow-up after EVAR is required to diagnose and treat endoleaks before they result in aneurysm rupture. The majority of endoleaks can be treated with endovascular techniques, although open surgical interventions may be required in selected patients.
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Aneurisma de la Aorta Abdominal/cirugía , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Supervivencia de Injerto , Complicaciones Posoperatorias/epidemiología , Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/patología , Humanos , Factores de RiesgoRESUMEN
OBJECTIVE: Diabetic peripheral neuropathy is a major complication of diabetes mellitus (DM) and is the leading cause of foot ulceration and lower extremity amputations (LEAs). The purpose of this systematic review is to evaluate current evidence regarding the prognostic value of the Semmes Weinstein monofilament examination (SWME) in predicting foot ulceration and LEA in patients with DM. METHODS: The MEDLINE/PubMed database was searched through November 2009 for articles pertaining to diabetic foot and SWME with no language or publication date restrictions. Prognostic studies with original data assessing the predictive value of SWME for foot ulceration or LEA in patients with DM were included in the selection. Data were systematically extracted and analyzed by two independent investigators. Absolute risks and relative risks were determined for each study. RESULTS: Of the 863 studies identified, nine articles were relevant, involving 11,007 patients with DM. Six studies were identified that assessed the prognostic value of SWME regarding diabetic foot ulceration. The relative risk for patients with a positive SWME result versus those with a negative result ranged from 2.5 (95% confidence interval [CI], 2.0 to 3.2) to 7.9 (95% CI, 4.4 to 14.3) in the identified studies with follow up between 1 and 4 years. Three of the studies assessed the risk of LEA with a positive SWME result. The relative risk for LEA ranged from 1.7 (95% CI, 1.1 to 2.6) to 15.1 (95% CI, 4.3 to 52.6) with follow-up between 1.5 and 3.3 years. CONCLUSIONS: All nine studies found SWME to be a significant and independent predictor of future foot ulceration or likely of future LEA as well in patients with DM. Therefore, SWME is an important evidence-based tool for predicting the prognosis of patients with diabetic foot, thus enabling improved patient selection for early intervention and management. More research should be conducted to elucidate the relationship between SWME and LEA.
Asunto(s)
Amputación Quirúrgica/estadística & datos numéricos , Pie Diabético/epidemiología , Pie/inervación , Examen Físico/métodos , Medición de Riesgo/métodos , Pie Diabético/patología , Pie Diabético/fisiopatología , Pie Diabético/prevención & control , Pie Diabético/cirugía , Humanos , Pronóstico , Trastornos Somatosensoriales/diagnósticoRESUMEN
A 79-year-old woman presented with a ruptured saccular thoracoabdominal aortic aneurysm involving the celiac and mesenteric artery. The patient was unfit for open surgical repair. A "chimney" procedure was performed, which involved placement of stents in the aortic side branches alongside the endograft. The patient underwent another chimney procedure 2 weeks later for a type I endoleak. Computed tomography angiography (CTA) at 1 and 6 months showed a good result with no endoleaks or graft migration. The chimney procedure provides an alternative for emergency patients unfit for open repair and has the advantage that stents can be used that are already available in most institutions.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares , Anciano , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Rotura de la Aorta/diagnóstico por imagen , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Arteria Celíaca/diagnóstico por imagen , Endofuga/etiología , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Arterias Mesentéricas/diagnóstico por imagen , Diseño de Prótesis , Reoperación , Stents , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
PURPOSE: To investigate the thoracic aortic pulsatility during hypovolemic shock in an experimental porcine model. METHODS: The circulating blood volume of 7 healthy Yorkshire pigs was gradually lowered until the subjects had lost 40% of their normal blood volume. Intravascular ultrasound was used to assess the aortic pulsatility in normovolemic and hypovolemic state at the level of the ascending and descending thoracic aorta. RESULTS: The mean aortic pulsatility at the level of the ascending aorta decreased from 15.9% ± 7.2% (range 6.3%-25.7%) in normovolemia to 6.2% ± 2.8% (range 2.9%-10.7%, p = 0.018) in hypovolemia. At the level of the descending thoracic aorta, the mean aortic pulsatility decreased from 8.7% ± 2.8% (range 4.4%-12.2%) at baseline to 5.6% ± 2.5% (range 1.5%-9.5%, p = 0.028) in hypovolemia. The maximum mean aortic diameter, obtained in cardiac systole, was significantly smaller as well at both evaluated levels during hypovolemic shock compared with the mean diameter in normovolemia. CONCLUSION: The thoracic aortic diameter and pulsatility decreased significantly during hypovolemic shock in this porcine model, most impressively at the level of the ascending aorta. Electrocardiographically-gated imaging may not be necessary for hypovolemic patients with acute aortic disease requiring endovascular repair because of the minimal aortic pulsatility.
Asunto(s)
Aorta Torácica/fisiopatología , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Flujo Pulsátil , Choque/fisiopatología , Stents , Animales , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Volumen Sanguíneo , Modelos Animales de Enfermedad , Elasticidad , Masculino , Diseño de Prótesis , Choque/diagnóstico por imagen , Porcinos , Ultrasonografía IntervencionalRESUMEN
OBJECTIVE: Purpose of this study is to provide detailed age- and gender-specific mortality risks of patients hospitalized for elective AAA repair. SUMMARY BACKGROUND DATA: Whether to perform elective abdominal aortic aneurysm (AAA) surgery is balancing the risks of natural history against the risks of surgical intervention. Literature is lacking mortality risks after elective AAA repair with stratification by both age and gender. METHODS: Mortality risks for 28 days, 1 year, and 5 years were derived from a nationwide cohort of patients hospitalized for elective AAA repair in 1997 or 2000. This cohort was formed through linkage of the Hospital Discharge Register with the Dutch Population Register. The relations between demographics, medical history and mortality were studied by Cox regression. RESULTS: A total of 3457 patients were identified; 86% males, mean age 72 +/- 8.0 years. Mortality risks after elective AAA repair increased with age: 28-day mortality ranged from 3.3% to 27.1% in men and 3.8% to 54.3% in women, 5-year mortality from 12.9% to 78.1% in men and 24.3% to 91.3% in women. Higher age, congestive heart failure, cerebrovascular disease and diabetes mellitus were independent risk factors for 5-years mortality. CONCLUSIONS: Mortality risks after elective AAA repair are strongly age-related. Age, gender, and comorbidities should be taken into account when deciding on surgery. A general threshold of 55 mm for surgery might not be justified for all patients.
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Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/cirugía , Factores de Edad , Anciano , Aneurisma de la Aorta Abdominal/complicaciones , Causas de Muerte , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
PURPOSE: To provide insight into the causes, timing, and optimal management of endograft collapse after thoracic endovascular aortic repair (TEVAR). METHODS: A comprehensive review was conducted of all published cases of endograft collapse after TEVAR identified using Medline, Cochrane Library Central, and EMBASE. In total, 32 articles describing 60 patients (45 men; mean age 40.6 ± 17.2 years, range 17-78) with endograft collapse were included. All data were extracted from the articles and systematically entered into a database for meta-analysis. RESULTS: In the 60 cases of endograft collapse, TEVAR had most commonly been applied to repair traumatic thoracic aortic injuries (39, 65%), followed by acute and chronic type B aortic dissections (9, 15%). The median time interval between TEVAR and diagnosis of endograft collapse was 15 days (range 1 day to 79 months). On average, the collapsed endografts were oversized by 26.7% ± 12.0% (range 8.3%-60.0%). Excessive oversizing was reported as the primary cause of endograft collapse in 20%, and a small radius of curvature of the aortic arch was responsible for 48% of the cases. The 30-day mortality was 8.3%, and the freedom from procedure-related death at 3 years after diagnosis of stent-graft collapse was 83.1% for asymptomatic patients compared with 72.7% for patients who had symptoms at diagnosis (p=0.029). CONCLUSION: Endograft collapse typically occurs shortly after TEVAR, most frequently after endovascular repair of traumatic aortic injury. A high level of suspicion for endograft collapse in the first month after TEVAR, as well as further improvement of current endovascular devices, may be required to improve the long-term outcomes of patients after TEVAR.
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Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Complicaciones Posoperatorias/etiología , Falla de Prótesis , Stents , Adolescente , Adulto , Anciano , Disección Aórtica/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/lesiones , Aneurisma de la Aorta Torácica/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Aortografía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Diseño de Prótesis , Reoperación , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: The purpose of this study is to quantify age- and gender-specific mortality risks for patients hospitalized for ruptured abdominal aortic aneurysm (rAAA). METHODS: The mortality risks for 28-day, 1-year, and 5-year were derived from a retrospective nation-wide cohort study of patients who were first hospitalized for rAAA in 1997 or 2000, formed through linkage of the Hospital Discharge Register with the Dutch population register. The Hospital Discharge Register contains a record for each hospital admission, giving information about patient demographics and diagnosis. The population register contains information on patient demographics and the mortality status of all registered persons in The Netherlands. Relations between gender and mortality within specific age groups were assessed with chi-square tests. Associations between age, gender, comorbidities, and mortality were studied in multivariate analysis with Cox regression. RESULTS: A total of 1,463 patients hospitalized for rAAA were identified (86% males). Mean age was higher in women than in men (79 vs. 72 years; 95% CI of difference: 5.0-7.4). Mortality risks at 28-day, 1-year, and 5-year increased significantly with age (28-day: from 36 to 91% in men and 59 to 92% in women; 5-year: from 51 to 97% in men and 79 to 96% in women). In patients aged <80 years, mortality risks were significantly higher in women than in men. Age (HR: 1.04; 95% CI: 1.03-1.05), previous hospitalization for congestive heart failure (HR: 1.55; 95% CI: 1.06-2.26), and cerebrovascular disease (HR: 1.60; 95% CI: 1.16-2.21) were significant predictors of short- and long-term mortality. CONCLUSIONS: Mortality risks after hospitalization for rAAA clearly increase by age and are higher in women than in men in patients aged <80 years. Because of the major effect of age and gender, future studies should consider reporting absolute mortality risks stratified by age and gender, instead of simply presenting overall mortality risks.
Asunto(s)
Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/mortalidad , Admisión del Paciente/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/complicaciones , Rotura de la Aorta/etiología , Distribución de Chi-Cuadrado , Comorbilidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Pronóstico , Modelos de Riesgos Proporcionales , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de TiempoRESUMEN
OBJECTIVE: The purpose of this systematic review is to evaluate current evidence in the literature on the efficacy of Semmes Weinstein monofilament examination (SWME) in diagnosing diabetic peripheral neuropathy (DPN). METHODS: The PubMed database was searched through August 2008 for articles pertaining to DPN and SWME with no language or publication date restrictions. Studies with original data comparing the diagnostic value of SWME with that of one or more other modalities for DPN in patients with diabetes mellitus were analyzed. Data were extracted by two independent investigators. Diagnostic values were calculated after classifying data by reference test, SWME methodology, and diagnostic threshold. RESULTS: Of the 764 studies identified, 30 articles were selected, involving 8365 patients. There was great variation in both the reference test and the methodology of SWME. However, current literature suggests that nerve conduction study (NCS) is the gold standard for diagnosing DPN. Four studies were identified which directly compared SWME with NCS and encompassed 1065 patients with, and 52 patients without diabetes mellitus. SWME had a sensitivity ranging from 57% (95% confidence interval [CI], 44% to 68%) to 93% (95% CI, 77% to 99%), specificity ranging from 75% (95% CI, 64% to 84%) to 100% (95% CI, 63% to 100%), positive predictive value (PPV) ranging from 84% (95% CI, 74% to 90%) to 100% (95% CI, 87% to 100%), and negative predictive value (NPV) ranging from 36% (95% CI, 29% to 43%) to 94% (95% CI, 91% to 96%). CONCLUSIONS: There is great variation in the current literature regarding the diagnostic value of SWME as a result of different methodologies. To maximize the diagnostic value of SWME, a three site test involving the plantar aspects of the great toe, the third metatarsal, and the fifth metatarsals should be used. Screening is vital in identifying DPN early, enabling earlier intervention and management to reduce the risk of ulceration and lower extremity amputation.
Asunto(s)
Neuropatías Diabéticas/diagnóstico , Pie/inervación , Tamizaje Masivo/métodos , Conducción Nerviosa , Examen Neurológico , Tacto , Neuropatías Diabéticas/fisiopatología , Diagnóstico Precoz , Medicina Basada en la Evidencia , Humanos , Valor Predictivo de las Pruebas , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: Evidence regarding the impact of prior abdominal aortic aneurysm (AAA) repair on the risk of neurological deficit after thoracic endovascular aortic aneurysm repair (TEVAR) is lacking. The purpose of this study was to characterize the risk of TEVAR-related neurological deficit in patients who previously underwent infrarenal AAA surgery. METHODS: Prospective maintained databases of patients undergoing TEVAR in the participating institutions were searched for patients with a history of prior AAA surgery before TEVAR. Patient and procedural characteristics and postoperative mortality and morbidity were subsequently centrally collected and systematically entered in a database. Univariate and multivariate logistic regression were performed associating variables with postoperative spinal cord ischemia (SCI). RESULTS: Seventy-two patients were identified that underwent TEVAR after prior AAA repair. The risk of SCI was 12.5% (n = 9) and significantly higher than the 1.7% risk of SCI in patients without prior AAA repair (relative risk [RR] 7.2, 95% confidence interval [CI] 2.6 to 19.6, P < .0001). Symptoms of SCI completely resolved in 4 patients with prior AAA repair. Univariate analysis demonstrated that the following variables were significant predictors of SCI in patients with prior AAA repair: preoperative renal insufficiency (odds ratio [OR] 29.5; 95% CI 5.3-164, P < .001), increased length of aorta coverage by TEVAR (OR 1.1; 95% CI 1.0-1.2, P .039) and a lengthened time interval between prior AAA repair and TEVAR (OR 1.2; 95% CI 1.0-1.4, P .026). Preoperative renal insufficiency was also significantly associated with the risk of SCI in multivariate analysis (P .011). CONCLUSION: Prior infrarenal AAA repair is associated with dramatic increased risk of SCI after TEVAR compared to patients without prior AAA surgery. Preoperative renal insufficiency appears to be an important predictor of SCI after TEVAR in patients with prior AAA repair. A thorough understanding of the risk profile in patients requiring TEVAR following prior AAA surgery is essential when determining appropriate surgical recommendations. If the diameter and rupture risk are large and TEVAR is indicated, the best available care should be offered for maximal protection of the spinal cord in these patients.