RESUMO
INTRODUCTION: The quality improvement framework for major amputation was developed with the aim of improving outcomes and reducing the perioperartive mortality to less than 5% by 2015. The aim of the study was to assess our compliance with the framework guidelines and look for the reasons for non-compliance. METHOD: All major amputations performed between 2008 and 2010 were included. The following data were collected: presence of infection ± tissue loss, status of arterial supply, revascularisation attempts, time to surgery, type of amputation, morbidity and mortality. RESULTS: A total of 81 patients were included (42 BKAs, 39 AKAs). Ninety percentage had formal preoperative arterial investigations and 84% had an attempted revascularisation procedure. Patients who were transferred late from non-vascular units (n = 12) had a 30-day mortality of 50% whereas patients who presented directly to our unit had a 30-day mortality of 7.2%. The number of amputations has decreased over the last 3 years from 34 to 21 per year, coinciding with the doubling of crural revascularisation procedures performed (from 60 to 120 per year). Ten patients underwent a revision from BKA to AKA because of an inadequate profunda femoris artery (PFA), whereas all those with a healed BKA stump either had a good PFA or a named crural vessel. CONCLUSION: The overall number of amputations is decreasing from year to year. By doubling our crural revascularisation procedures we are saving more limbs. Thirty-day mortality is higher than expected, particularly in patients who present late. Expeditious referral may potentially improve the mortality rate among this group of patients.
Assuntos
Amputação Cirúrgica/normas , Melhoria de Qualidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Reperfusão/estatística & dados numéricos , Infecção da Ferida Cirúrgica/etiologia , Tempo para o Tratamento , Resultado do TratamentoRESUMO
BACKGROUND: Endoluminal repair of thoracic aortic pathology has become established in clinical practice, but is associated with significant neurological complications. The aim of this study was to identify factors that were predictive of stroke and paraplegia. METHODS: Prospective data was collected for a cohort of 293 consecutive patients having thoracic aortic endovascular repair between August 1997 and September 2009. Patient and procedural characteristics were related to the incidence of stroke and paraplegia using multivariate logistic regression analysis. RESULTS: The median age was 68 years (18-87), there were 191 men and 102 women. Mortality was 5.1% for 195 elective and 13.4% for 98 urgent patients. Stroke affected 16 (5.5%) patients: 11 affected the anterior and 5 the posterior circulation. Coverage of the left subclavian artery with no revascularisation was the only significant factor predictive of stroke (OR 5.34 (1.42-20.40) P = 0.01). Paraplegia affected 16 patients (5.5%) but no independent risk factor was identified: 12 were identified perioperatively and 4 were delayed by up to 6 months. CONCLUSION: Covering the left subclavian artery without revascularisation increases the risk of stroke following endoluminal repair of thoracic pathology. Paraplegia appears to be more complex and no independent precipitating factor was identified.
Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Procedimentos Endovasculares/efeitos adversos , Paraplegia/etiologia , Acidente Vascular Cerebral/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Modelos Logísticos , Londres , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Artéria Subclávia/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: There is a common perception that a large number of secondary interventions are needed following endovascular aortic aneurysm repair. METHODS: Prospective data were collected for a cohort of 417 consecutive elective patients undergoing infrarenal aortic endograft repair between April 2000 and May 2008. The rate of secondary interventions, associated morbidity and need for reintervention following surveillance imaging were analysed. RESULTS: The male : female ratio was 11 : 1, median age 76 (range 40-93) years and median aneurysm diameter 6.1 (5.3-11) cm. The overall 30-day mortality rate was 1.7 per cent (seven of 417). Secondary interventions were performed in 31 patients (7.4 per cent), of which six (1.4 per cent) were detected by surveillance. Endoleaks requiring reintervention occurred in 12 patients (2.9 per cent; ten type I and two type III endoleaks). Limb ischaemia secondary to graft occlusion occurred in 17 patients (4.1 per cent); extra-anatomical bypass was needed in 15 patients (3.6 per cent) and the remaining two had an amputation. Graft explantation following late infection was required in two patients (0.5 per cent). CONCLUSION: Endoluminal repair of infrarenal aortic aneurysms can be performed with a low reintervention rate. The value of prolonged surveillance seems limited and current surveillance protocols may require revision.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia/métodos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular , Feminino , Humanos , Isquemia/etiologia , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese , Stents , Deiscência da Ferida Operatória/etiologia , Tomografia Computadorizada por Raios XRESUMO
Open surgery for thoracic aortic disease is associated with significant morbidity and the reported rates for paraplegia and stroke are 3%-19% and 6%-11%, respectively. Spinal cord ischemia and stroke have also been reported following endoluminal repair. This study reviews the incidence of paraplegia and stroke in a series of 186 patients treated with thoracic stent grafts. From July 1997 to September 2006, 186 patients (125 men) underwent endoluminal repair of thoracic aortic pathology. Mean age was 71 years (range, 17-90 years). One hundred twenty-eight patients were treated electively and 58 patients had urgent procedures. Anesthesia was epidural in 131, general in 50, and local in 5 patients. Seven patients developed paraplegia (3.8%; two urgent and five elective). All occurred in-hospital apart from one associated with severe hypotension after a myocardial infarction at 3 weeks. Four of these recovered with cerebrospinal fluid (CSF) drainage. One patient with paraplegia died and two had permanent neurological deficit. The rate of permanent paraplegia and death was 1.6%. There were seven strokes (3.8%; four urgent and three elective). Three patients made a complete recovery, one had permanent expressive dysphasia, and three died. The rate of permanent stroke and death was 2.1%. Endoluminal treatment of thoracic aortic disease is an attractive alternative to open surgery; however, there is still a risk of paraplegia and stroke. Permanent neurological deficits and death occurred in 3.7% of the patients in this series. We conclude that prompt recognition of paraplegia and immediate insertion of a CSF drain can be an effective way of recovering spinal cord function and improving the prognosis.
Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/efeitos adversos , Paraplegia/etiologia , Isquemia do Cordão Espinal/etiologia , Acidente Vascular Cerebral/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças da Aorta/epidemiologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Drenagem/métodos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Paraplegia/mortalidade , Paraplegia/patologia , Paraplegia/fisiopatologia , Paraplegia/cirurgia , Recuperação de Função Fisiológica , Isquemia do Cordão Espinal/mortalidade , Isquemia do Cordão Espinal/patologia , Isquemia do Cordão Espinal/fisiopatologia , Isquemia do Cordão Espinal/cirurgia , Stents , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/patologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Endovascular therapy has revolutionised vascular surgery. Complex open surgical procedures may be replaced with a combination of extra-anatomical reconstruction and endovascular treatment. This minimally invasive approach is associated with a lower peri-operative morbidity and mortality than open repair. We describe a novel 2-stage treatment in a patient with Type B thoracic aortic dissection with subsequent aneurysmal dilatation and the added difficulty of a concomitant aneurysmal aberrant right subclavian artery (Kommerell's diverticulum).
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Divertículo/cirurgia , Artéria Subclávia/cirurgia , Procedimentos Cirúrgicos Vasculares , Idoso , Dissecção Aórtica/diagnóstico , Aneurisma da Aorta Torácica/diagnóstico , Prótese Vascular , Divertículo/diagnóstico , Humanos , Masculino , Stents , Artéria Subclávia/anormalidadesRESUMO
Endovascular aneurysm repair (EVAR) has become an established alternative to open repair (OR). We present a consecutive series of 486 elective patients with large infra-renal aortic abdominal aneurysm, comparing OR with EVAR. Prospective data collected during an 8-year period from January 1997 to October 2005 was reviewed. Statistical analysis performed using SPSS data editor with chi(2) tests and Mann-Whitney U-tests. There were 486 patients with 329 OR (293 males, 36 females) with median age of 72 years with median diameter 6.3 cm and 157 EVAR (148 males, 9 females) with median age 75 years with median diameter 6.1 cm. Mortality was 13 (4%) for OR and 5 (3.2%) for EVAR (three of whom were in the UK EVAR 2 trial). Blood loss was significantly less for EVAR 500 ml vs. 1500 ml for OR. Sixty-five (19.8%) patients with OR had significantly more peri-operative complications compared with 14 (8.9%) with EVAR. The length of stay in hospital was significantly less for EVAR. This non-randomised study shows that although EVAR does not have a statistically significantly lower mortality, it does have statistically significantly lower complication rates compared with OR. EVAR can be achieved with good primary success, but long-term follow-up is essential to assess durability.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Complicações Intraoperatórias/etiologia , Artéria Renal/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular , Estudos de Coortes , Feminino , Humanos , Tempo de Internação , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/mortalidadeRESUMO
The combination of critical limb ischemia and end-stage renal failure (ESRF, ie, dialysis- dependent) represents severe systemic atherosclerosis and is associated with a very poor medium-term survival. Many nephrologists and surgeons advocate primary amputation. We examined the recent experience in this unit to determine whether infrainguinal bypass in these patients can be justified. Retrospective study of all patients with critical limb ischemia and ESRF undergoing surgery in a regional vascular and renal unit between January 1996 and May 2003. Forty-two patients with ESRF (median age 65 years) were referred with critical limb ischemia. Seventeen patients underwent 24 (7 bilateral) infrainguinal bypasses (17 autologous vein, 7 polytetrafluoroethylene [PTFE] conduit; tissue loss in 21/24, 88%), and 25 patients had primary major amputations of 32 limbs. Early occlusion occurred in 5 grafts (21%, all 5/5 PTFE). In-hospital mortality was 13% in the bypass group, 24% in the amputation group. Median in-hospital stay was 59 days in the bypass group, 46 days in the amputation group. Thirty-day, 1- and 2-year survival was 88%, 50%, and 33% in the bypass group; 83%, 39%, and 35% in the amputation group. The limb salvage rate was 66% at 1 year. Seventy-five percent (18/24) of operated on limbs (15/17 of vein grafts) avoided major amputation at follow-up (median 18 months) or death. The combination of critical limb ischemia and end- stage renal failure carries a poor medium-term survival independent of primary amputation or surgical revascularization. Infrainguinal bypass in selected cases with vein conduit can, however, allow the majority of these patients to avoid major limb amputation.