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BACKGROUND: The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision-making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1-year limb salvage and survival rates. RESULTS: A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One-month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10 days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n = 8, 9.1%), primary major amputation (n = 1, 1.1%) or revascularization (n = 78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One-year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR = 1.81, p = 0.014) and ALI severity (HR = 1.73, p = 0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1-year survival rate significantly below that of a similar matched population. CONCLUSION: Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery.
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Isquemia , Salvamento de Membro , Humanos , Feminino , Masculino , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Isquemia/mortalidade , Isquemia/cirurgia , Salvamento de Membro/métodos , Doença Aguda , Resultado do Tratamento , Amputação Cirúrgica/estatística & dados numéricos , Taxa de SobrevidaRESUMO
OBJECTIVE/BACKGROUND: Our study analyzed the relationship between two polypharmacy scores (addition of chronic prescribed drugs [ACPDs] and Rx-Risk Comorbidity Index) and survival in patients with an intact abdominal aortic and/or common iliac aneurysm (AAA). METHODS: Consecutive retrospective, single-center cohort of patients attended for an intact AAA with indication for repair from 2008 to 2021. Demographic data, Charlson Comorbidity Index, AAA treatment, ACPD, and Rx-Risk polypharmacy scores were recorded at baseline. Main outcomes were the 5-year and long-term survival rates. The statistical analysis included Cox regression, area under the curve, and continuous net reclassification index. RESULTS: A total of 424 patients with AAA were evaluated (median age: 76 years; 92.2% male, median Charlson index 2), of whom 314 (74.1%) underwent intervention (80% endovascular and 20% open) and 110 (25.9%) did not. During follow-up (mean 4.6 years), 245 patients (57.8%) died, with 1-month, 1-year, and 5-year survival rates of 98.1%, 86.3%, and 52.7%, respectively. ACPD and Rx-Risk indices (median [interquartile range]: 6 [4-9] and 3 [0-5], respectively) were significantly and linearly associated (P < .001) with survival, with the best cutoff points at 5 and 0, respectively. An ACPD >5 (patients with >5 chronically prescribed drugs at baseline) and an Rx-Risk >0 were associated with a 45.2% (P = .038) and 102% (P = .002) increase in 5-year mortality, respectively, after adjustment for age, sex, Charlson index, and type of AAA treatment. Both polypharmacy indices improved significantly the discriminative power of the Charlson Comorbidity Index in predicting survival. CONCLUSIONS: Both ACPD and Rx-Risk polypharmacy scores are independently related to survival among patients with an intact AAA and indication for repair. Their behavior is similar, so the simple ACPD >5 appears to be sufficient to identify patients with lower survival rates.
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Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Masculino , Idoso , Feminino , Procedimentos Endovasculares/efeitos adversos , Estudos Retrospectivos , Polimedicação , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/etiologia , Resultado do Tratamento , Fatores de Tempo , Fatores de Risco , Implante de Prótese Vascular/efeitos adversosRESUMO
INTRODUCTION: Our objective is to describe the clinical characteristics and preoperative ultrasound mapping parameters associated with primary and secondary patency of radio-cephalic arteriovenous fistulas (RCF). METHODS: A retrospective, single-center, descriptive study, including patients undergoing a RCF creation between 2015 and 2019. Socio-demographic data and ultrasound parameters were collected and an analysis of primary and secondary patency was performed. RESULTS: Eighty-four patients were included in this study. Mean age was 65.6 (±13.9) years; 76.6% were male. Mean preoperative ultrasound parameters: forearm cephalic vein diameter was 2.8 (±0.57) mm, radial artery diameter was 2.6 (±0.42) mm, radial artery systolic peak velocity was 68 (±14.3) cm/s radial artery resistance index was 0.76 (±0.9). At the end of the 4 years the follow-up, the mean primary and secondary patency were 47.2% and 80% respectively. Only female sex was significantly associated with a decrease in both primary patency (p = 0.043, HR = 0.48) and secondary patency (p = 0.021, HR = 0.023). Furthermore, radial artery systolic peak velocity (p = 0.007, HR = 2.6) showed a significant association with decreased primary patency and forearm cephalic vein diameter showed a borderline significant association with decreased secondary patency (p = 0.046, HR = 8.2). CONCLUSIONS: A standardized evaluation by a vascular surgeon or nephrologist represent a key in the preoperative assessment of AVF candidates. Based on our results, we will consider to avoid distal vascular access in both female patients with lower radial artery systolic peak velocity (less than 68 cm/s) and borderline forearm cephalic vein diameter (less than 2.8 mm) after initial assessment in our clinical practice. Our results could encourage new studies in order to stablish the potential role of these parameters in the RCFs patency rates.
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BACKGROUND: Multiple CT-derived measurements of sarcopenia have been described yet their relationship with survival after abdominal aortic aneurysm (AAA) repair has not been properly assessed. We aimed to define and compare the relationship between several psoas CT-derived measurements and the 5-year survival after AAA repair and to evaluate their potential contribution to survival prediction. METHODS: Preoperative CT area (TPA) and density (MTPD) of the psoas muscle at L3 were measured in 218 consecutive AAA patients electively intervened. Additional measurements were obtained by normalizing TPA by anthropometric data or L3-vertebra surface or by TPAxMTPD multiplication (lean psoas muscle area-LPMA). The association of sarcopenia markers with survival was evaluated with Cox models adjusted by age, sex, type of intervention and the Charlson Comorbidity Index, and their contribution to survival prediction assessed with the C-statistic and the Continuous Net Reclassification Index (c-NRI). RESULTS: Sixty patients (27.5%) died during the first 5 years after surgery. There was a statistically significant and linear (spline analysis) relationship of sarcopenia markers with 5-year survival in all multivariate models, except that including LPMA. Despite this association, the inclusion of sarcopenia markers did not improve the C-statistic and moderately increased the c-NRI. None normalized sarcopenia markers performed better than TPA. CONCLUSION: The majority of CT-derived psoas muscle measurements of sarcopenia showed a significant and independent relationship with survival after elective AAA repair. Despite this association, they did not appear to improve sufficiently our survival prediction ability to become an efficient tool for decision-making.
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Aneurisma da Aorta Abdominal , Sarcopenia , Humanos , Sarcopenia/complicações , Sarcopenia/diagnóstico por imagem , Músculos Psoas/diagnóstico por imagem , Resultado do Tratamento , Fatores de Risco , Estudos Retrospectivos , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: A prolonged operative time (OT) is a well-recognized risk factor of postoperative complications after many open surgical procedures, although little is known about its impact in less-invasive endovascular procedures. We aimed to define the characteristics related to a prolonged OT in the endovascular treatment of aorto-iliac aneurysms (EVAR) and to evaluate the influence of OT on postoperative outcomes. METHODS: Retrospective analysis of 284 consecutive patients (mean age 75 years, 95% male) who underwent an elective EVAR between 2000 and 2019. Operative characteristics related to OT and the impact of OT in postoperative results was studied using multiple lineal and logistic regression analyses, respectively. RESULTS: The mean surgical time was 200 min. OT was associated (regression model) with the implantation of straight endografts (-38 min, P = 0.007), femoral artery surgery (+80 min, P < 0.001), hypogastric preservation procedures (+70 min, P < 0.001), associated peripheral arterial disease (+22 min, P = 0.013), general anesthesia (+34 min, P < 0.001), and aneurysm diameter (+9 min/cm, P = 0.002). During the postoperative period (<30 days or at discharge), 21% presented a complication and 2.8% died. OT was independently associated with a higher incidence of postoperative complications (odds ratio [OR] for each additional 30' of surgery = 1.34, P < 0.001), such as immediate (OR = 1.48, P = 0.003) and 6-month mortality (OR = 1.28, P = 0.025). CONCLUSIONS: A prolonged OT is an independent risk factor for complications and mortality after EVAR. Surgeons must take this factor into consideration when defining the best therapeutic strategy for abdominal aortic aneurysms.
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Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Masculino , Idoso , Feminino , Duração da Cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/complicações , Fatores de Risco , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgiaRESUMO
INTRODUCTION: Duplex ultrasound (DUS) is increasingly used before vascular access (VA) surgery for haemodialysis. However, the cost-effectiveness of this approach is unknown. Our objective was to assess whether the introduction of a specialised consultation with DUS assessment modifies the cost and the time delay to achieve a first VA valid for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA (June 2014-July 2017) after a specialised consultation with DUS (ECO group). They were compared with a historical cohort (January 2012-May 2014) where VA was indicated exclusively by clinical evaluation (CLN group). We analysed the cost related to visits, DUS assessments, interventions, hospital admissions and graft materials to achieve a first VA valid for haemodialysis at least during 1 month. RESULTS: 86 patients in the CLN group were compared with 92 in the ECO group. Patients in the ECO group were younger (68.4 vs. 64.0 years; P=.038) but no other differences were seen among groups. The average cost to achieve a first AV valid for haemodialysis was significantly lower in the ECO group (2707 vs. 3347; P=.024). There was a higher cost associated with DUS assessments in the ECO group yet the CLN group had a higher cost related to follow-up visits, successive surgical interventions, prosthetic material, days of hospital admission and catheters. The mean time needed to achieve a first AV valid for haemodialysis was also shorter in the ECO group (49.9 vs. 82.9 days, P=.002). CONCLUSION: The introduction of a specialised vascular access consultation with DUS prior to VA surgery has reduced the cost necessary to achieve a first VA valid for haemodialysis. From the patient's point of view this has meant less interventions and hospital admissions and a shortening of the time delay.
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Derivação Arteriovenosa Cirúrgica , Análise Custo-Benefício , Humanos , Estudos Prospectivos , Encaminhamento e Consulta , Diálise RenalRESUMO
BACKGROUND: As a result of the increasing life expectancy of the western population, the number of older patients with chronic limb-threatening ischemia (CLTI) seeking medical care is growing. Our objective was to describe the characteristics of a consecutive series of nonagenarian patients with CLTI and evaluate the outcomes of their management. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with CLTI attended at our institution between 2005 and 2019. Primary endpoints were 1-year limb salvage and survival rates. RESULTS: A total of 171 patients were included (mean age 92.7, 51.5% women), of which in 59 (34.5%) primary major amputation (n = 10) or palliative care (n = 49) was indicated at presentation because of severe dementia (n = 30, 50.8%), knee retraction (n = 17, 28.8%), terminal condition (n = 13, 22%) or a non-salvageable foot (n = 28, 47.4%). In the remaining 112 (65.5%), the need for a revascularization was further assessed finally performing A) conservative treatment/minor amputation (n = 57, 50.9%), B) revascularization (n = 50, 44.6%) or C) direct major amputation (n = 5, 4.4%), with 1-year limb salvage and survival rates of 93.1 and 57.4%, respectively. Predictive factors for lower survival included age >92 years (HR = 1,59, p = 0.041), hemoglobin <10.5 mg/dL (HR 2,34, p < 0.001), congestive heart failure (HR = 1.65, p = 0.036), non-severe dementia (HR 3,11, p < 0.001) and current mobility with wheelchair (HR 1,74, p = 0.014). CONCLUSION: Nearly one-third of nonagenarian patients with CLTI have a direct indication for amputation or palliative care at presentation. In the remaining, a judicious approach with conservative treatment, minor amputation or revascularization procedures yields excellent limb salvage rates. Survival is, however, the cornerstone of these patients. It can be predicted with certain clinical factors which may help decision-making.
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Demência , Procedimentos Endovasculares , Doença Arterial Periférica , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Isquemia Crônica Crítica de Membro , Demência/etiologia , Feminino , Humanos , Isquemia/etiologia , Isquemia/cirurgia , Salvamento de Membro , Masculino , Nonagenários , Doença Arterial Periférica/complicações , Doença Arterial Periférica/cirurgia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Duplex ultrasound (DUS) is increasingly used before vascular access (VA) surgery for haemodialysis. However, the cost-effectiveness of this approach is unknown. Our objective was to assess whether the introduction of a specialised consultation with DUS assessment modifies the cost and the time delay to achieve a first VA valid for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA (June 2014-July 2017) after a specialised consultation with DUS (ECO group). They were compared with a historical cohort (January 2012-May 2014) where VA was indicated exclusively by clinical evaluation (CLN group). We analysed the cost related to visits, DUS assessments, interventions, hospital admissions and graft materials to achieve a first VA valid for haemodialysis at least during 1 month. RESULTS: Eighty-six patients in the CLN group were compared with 92 in the ECO group. Patients in the ECO group were younger (68.4 vs. 64.0 years; P=.038) but no other differences were seen among groups. The average cost to achieve a first AV valid for haemodialysis was significantly lower in the ECO group (2707 vs. 3347; P=.024). There was a higher cost associated with DUS assessments in the ECO group yet the CLN group had a higher cost related to follow-up visits, successive surgical interventions, prosthetic material, days of hospital admission and catheters. The mean time needed to achieve a first AV valid for haemodialysis was also shorter in the ECO group (49.9 vs. 82.9 days, P=.002). CONCLUSION: The introduction of a specialised vascular access consultation with DUS prior to VA surgery has reduced the cost necessary to achieve a first VA valid for haemodialysis. From the patient's point of view this has meant less interventions and hospital admissions and a shortening of the time delay.
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AIM: The need to adjust the indications of elective abdominal aortic aneurysm (AAA) repair among patients with a limited life-span deserves a specific evaluation for octogenarians. The aim of this study was to compare the postoperative results and the long-term survival after endovascular repair of abdominal aortic and/or iliac aneurysms (EVAR) in octogenarians compared with patients under 80 years of age. METHODS: Retrospective analysis of 241 consecutive patients who underwent an elective EVAR between 2000 and 2017. EVAR was not considered among patients with clear life-limiting conditions. Patients receiving other than commercially standard infra-renal endoprostheses were excluded. RESULTS: Seventy patients (29.0%) were octogenarians. They had a lower rate of active smoking (10.0% vs. 30.4%, P < 0.001) and a higher prevalence of previous cerebrovascular disease (21.4% vs. 11.7%, P = 0.055) than younger patients. Thirty-day/in-hospital complication and mortality rates were not significantly higher among octogenarians when compared with younger patients (24.3% vs. 16.9% and 2.9% vs. 2.4%, respectively). Octogenarians had a lower long-term survival at 1, 3 and 5 years (92.6% vs. 93.3%, 67.7% vs. 78.0% and 39.3% vs. 60.6%, P = 0.039) in the bivariate analysis. However, an age ≥ 80 years per se was not an independent predictor of survival after adjustment for confounding factors. CONCLUSION: An age above 80 years was not associated with an increased risk of postoperative complications or long-term mortality. Our results suggest that EVAR can be considered in elderly patients without a clear life-limiting condition and with a suitable aneurysm anatomy. Geriatr Gerontol Int 2021; 21: 392-397.
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Aneurisma da Aorta Abdominal , Procedimentos Endovasculares , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/cirurgia , Humanos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: This study sought to evaluate the natural history of patients undergoing below-knee amputation (BKA) and compare their evolution over 2 decades, as well as survival predictors, prosthetic fitting, and contralateral amputation. METHODS: Retrospective study of 209 consecutive patients (mean age 72.9 years; 68% males) who underwent BKA in 2 periods: 1996-2005 and 2006-2015. The fitting of prostheses, risk of contralateral amputation and survival, as well as their predictive factors, were assessed by survival analysis. RESULTS: 133 BKA were performed from 1996-2005 and 106 from 2006-2015. The etiology that motivated the BKA was acute ischemia (4.3%), chronic ischemia (34.0%), infection (9.1%) or mixed (chronic+infection, 52.6%), with no differences found between periods. Survival: mortality within one month=9.2%, one year=31.9%, 2 years=43.8% and 5 years=63.9%, with no significant differences between the 2 periods. Prosthetic: the fitting rate was 44.5% throughout the follow-up, with no significant differences between the two periods. 41.1% patients managed to walk. Contralateral amputation: 20.1% of the patients later required a major contralateral amputation, with no significant differences between the two periods. CONCLUSIONS: In the last decade, fewer BKA have been performed probably, due to higher previous interventional revascularization. Despite this, the results of fitting, contralateral amputation or survival were not modified. In any case, the number of patients who are able to achieve ambulation is modest, so it emphasizes the need for an optimal selection of patients with BKA with the goal of prosthetic fitting.
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Amputação Cirúrgica/métodos , Perna (Membro)/cirurgia , Extremidade Inferior/cirurgia , Ajuste de Prótese/métodos , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica/mortalidade , Amputação Cirúrgica/reabilitação , Membros Artificiais/efeitos adversos , Feminino , Humanos , Infecções/complicações , Infecções/epidemiologia , Isquemia/complicações , Isquemia/epidemiologia , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Ajuste de Prótese/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Análise de Sobrevida , Caminhada/fisiologiaRESUMO
BACKGROUND: Aorto-enteric fistula is a rare and potentially lethal entity. Its presentation may be as an enteric-paraprosthetic fistula, due to injury in the gut caused by direct contact with the vascular prosthesis. OBJECTIVE: We report a case of enteric-paraprosthetic fistulae with the unusual finding of Candida parapsilosis as the only isolated pathogen. CLINICAL CASE: A 65-year-old male, smoker, with aortobifemoral revascularisation with dacron due to aortoiliac occlusive disease, and re-intervention for thrombosis of left arm at 6 months. Hospitalisation at 22 months was required due to a toxic syndrome, which was diagnosed as enteric-paraprosthetic fistulae after complementary studies. The graft was removed and an extra-anatomic revascularisation was performed. Microbiology specimens taken from the duodenal segment in contact with the prosthesis showed the prosthetic segment and peri-prosthetic fluid were positive to C. parapsilosis. DISCUSSION: The finding of C. parapsilosis in all cultures taken during surgery, along with negative blood cultures and no other known sources of infection, is of interest. It is an unusual pathogen with low virulence and limited as regards other Candida species. Our patient had no clinical data common to cases of infection with C. parapsilosis, and the mechanism of graft infection is unknown. CONCLUSION: Graft infection by C. parapsilosis may be anecdotal. However, its consequences can also be severe. Microbiological tests can be useful to adjust antimicrobial therapy in the post-operative period, but their usefulness for determining the aetiology is doubtful, as it may be just an incidental finding.
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Doenças da Aorta/etiologia , Prótese Vascular/efeitos adversos , Candida parapsilosis/isolamento & purificação , Candidíase/etiologia , Duodenopatias/etiologia , Fístula/etiologia , Fístula Intestinal/etiologia , Complicações Pós-Operatórias/etiologia , Infecções Relacionadas à Prótese/etiologia , Idoso , Aorta Abdominal/cirurgia , Doenças da Aorta/microbiologia , Candidíase/microbiologia , Remoção de Dispositivo , Duodenopatias/microbiologia , Fístula/microbiologia , Humanos , Fístula Intestinal/microbiologia , Masculino , Complicações Pós-Operatórias/microbiologia , Infecções Relacionadas à Prótese/microbiologia , Reoperação , Trombose/cirurgiaRESUMO
BACKGROUND: The objective is to study the medium-term results of angioplasty and stenting in the femoro-popliteal sector in patients with critical limb ischemia (CLI), and identify angiographic predictive factors of primary patency. PATIENTS AND METHODS: Retrospective review of 98 patients with critical ischemia and angiographic lesions characterized as TASC A=13 (14%), B=38 (40%), C=24 (25%) or D=20 (21%). A total of 106 angioplasties and primary self-expanding stents (mean length of stent coverage of 19cm) were performed between January 2006 and January 2011. RESULTS: The immediate results of patency, limb salvage and survival were 95, 96 and 96%, respectively. Primary patency at 1 and 2 years was 54 and 38%, respectively. Twenty-seven cases (25%) required endovascular iterative procedures, providing an assisted patency at 1 and 2 years of 72 and 60%, and a secondary patency of 80 and 67%. A lower primary patency was observed (log rank) when stent length was >20cm (P<.001), popliteal artery was invloved (P=.004), and in TASC C and D lesions (P=.04). In multivariate analysis (Cox), only stent length>20cm was an independent negative predictor for primary patency (HR=5.7, P<.001). The limb salvage at 1 and 2 years was 83 and 81%, respectively. CONCLUSIONS: Angioplasty with stent in the femoro-popliteal sector is a safe technique, but with significantly lower permeability results in injuries that require stent coverage of more than 20cm. In these cases, vein bypass surgery should be the procedure of choice.