RESUMO
A total of 22 patients with ruptured abdominal aortic aneurysms (rAAAs) after previous endovascular aortic repair (EVAR; rAAAevar) were presented to 7 referral hospitals in Greece, between January 2006 and April 2012. Type Ia endoleak and endograft migration were identified in 72.7% and 50%, respectively. Compliance to follow-up protocol prior to rupture was 31.8%. In-hospital mortality was 36.4% (9.1% for those treated with secondary EVAR and 63.6% for those treated with open surgical repair, P = .02). An increase in the proportion of patients with rAAAevar among the total number of patients with rAAAs from 1.3% in 2007 to 18.2% in 2012 (P for trend = .04) was recorded, corresponding to an annual increase of 2.8% (b = 2.84, P = .04). Rupture after EVAR seemed to be a clinical entity encountered with increasing frequency over the past years. Type I endoleak and endograft migration were most frequently observed, whereas compliance to follow-up was low.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/etiologia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/mortalidade , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Endoleak/etiologia , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Migração de Corpo Estranho/etiologia , Grécia , Mortalidade Hospitalar , Humanos , Masculino , Cooperação do Paciente , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Stents , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Endovascular aortic repair (EVAR) is being used with increasing frequency for the treatment of ruptured abdominal aortic aneurysms (rAAAs), although conflicting results have been reported concerning perioperative mortality. The aim of our study was to evaluate potential difference in mortality rates between EVAR and open surgical repair (OSR) and identify independent risk factors for in-hospital mortality in rAAAs. This study also aimed to evaluate the Glasgow Aneurysm Score (GAS) in predicting in-hospital mortality. A time-trend analysis of EVAR for ruptured AAAs was also performed. METHODS: Prospectively collected data from 7 public hospitals in Greece concerning rAAA repairs between January 2006 and April 2012 were analyzed. Primary outcome was in-hospital mortality. Multivariate logistic regression analysis was used to identify independent risk factors. The receiver-operator characteristic curve was used to determine the value of the GAS in predicting in-hospital death. Time-trend analysis, depicting annual changes (%), concerning EVAR for ruptured AAAs was also conducted. RESULTS: A total of 418 patients (92.3% men, mean age = 74.3 ± 8.8) with rAAAs were recorded during the study period. Among them, 113 patients (27%) underwent EVAR. Overall in-hospital mortality was 45.2%, whereas in-hospital mortality after EVAR and OSR was 20.4% and 54.3%, respectively (P < 0.001). Multivariate analysis evidenced that hemodynamic instability (P < 0.001), OSR (P < 0.001), age ≥80 years (P < 0.001), coronary artery disease (P < 0.001), and renal insufficiency (P = 0.02) independently increased in-hospital mortality. Area under the curve of GAS was 0.80 (95% confidence interval [CI] = 0.75-0.85, P < 0.001) for OSR and 0.64 (95% CI = 0.51-0.77, P = 0.04) for EVAR. Annual increase of proportion (%) of EVAR for rupture was 5% (P = 0.004). CONCLUSIONS: EVAR is being used with increasing frequency for the treatment of rAAAs and it appears to be associated with lower in-hospital mortality compared with OSR, after adjustment for hemodynamic instability and known atherosclerotic risk factors. Preoperative predictors of in-hospital mortality such as GAS should be probably modified in these patients.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/mortalidade , Mortalidade Hospitalar , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/fisiopatologia , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/mortalidade , Ruptura Aórtica/fisiopatologia , Área Sob a Curva , Implante de Prótese Vascular/efeitos adversos , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Técnicas de Apoio para a Decisão , Procedimentos Endovasculares/efeitos adversos , Feminino , Grécia , Hemodinâmica , Hospitais Públicos , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Curva ROC , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Suprarenal endograft fixation is routinely used in the endovascular repair of abdominal aortic aneurysms (EVAR) to enhance proximal endograft attachment but can be associated with an adverse outcome in renal function. This prospective study assessed the effect of suprarenal fixation on serum creatinine concentration and estimated glomerular filtration rate (eGFR), calculated by the Modified Diet in Renal Disease equation, 12 months after elective EVAR. METHODS: Patients undergoing elective EVAR were divided into suprarenal vs infrarenal fixation groups matched for age, sex, smoking, and aneurysm diameter. Serum creatinine and eGFR were measured at baseline, 6, and 12 months. RESULTS: Included were 92 patients (two women) with a mean age of 71 ± 7 years, with 46 in each group. No device-related complications were noted. Serum creatinine did not differ significantly between groups at 6 (P = .24) or 12 (P = .08) months but significantly increased in the suprarenal group at 12 months (1.08 ± 0.36 to 1.16 ± 0.36 mg/dL; P < .001) vs baseline. The eGFR (mL/min/1.73 m(2)) did not differ significantly at baseline between the suprarenal (85 ± 27) and infrarenal (80 ± 28; P = .33) groups or at 6 months (88 ± 29 vs 77 ± 24, respectively; P = .07). At 12 months, the suprarenal group had a lower eGFR (73 ± 23) than the infrarenal group (84 ± 26; P = .027). The eGFR at 12 months showed a significant decrease in the suprarenal (80 ± 28 to 73 ± 23; P < .001) but not in the infrarenal group (85 ± 27 to 84 ± 26; P = .48). The drop in eGFR differed significantly at 12 months in the infrarenal vs the suprarenal (0.82 vs -6.94; P < .001) group. No patient progressed to end-stage renal disease or disclosed a drop in eGFR > 30%. CONCLUSIONS: In contrast to previous studies, this study suggests that suprarenal endograft fixation in elective EVAR is associated with a drop in eGFR at 12 months.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Rim/fisiopatologia , Idoso , Biomarcadores/sangue , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Estudos de Casos e Controles , Creatinina/sangue , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/instrumentação , Inglaterra , Feminino , Taxa de Filtração Glomerular , Humanos , Rim/metabolismo , Nefropatias/sangue , Nefropatias/etiologia , Nefropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Desenho de Prótese , Medição de Risco , Fatores de Risco , Stents , Fatores de Tempo , Resultado do TratamentoRESUMO
Despite significant progress in the management of hepatocellular carcinoma (HCC), patients with large HCC (defined as >10 cm) continue to present a significant challenge. The goal of this paper is to review the existing literature regarding large HCC, with emphasis on identifying the issues and challenges involved in approaching these tumours surgically. A computerized search was made of the Medline database from January 1992 to December 2010. The MESH heading 'large' or 'huge' in combination with the keyword 'hepatocellular carcinoma' was used. After excluding further studies that identified 'large' HCC as less than 10 cm and/or sequential publications with overlapping patient populations, the search produced a study population of 22 non-duplicated papers, reporting on a total of 5223 patients with HCC tumours >10 cm. Regarding resection for large HCC, the overall 5-year survival in these studies ranged from 25% to 45%, with few outliers on both sides, whereas in most studies, the 5-year disease-free survival ranged between 15% and 35%, with the only exception being studies with patients with single lesions and no cirrhosis showing disease-free survival of 41% and 56%, respectively. Risk factors identified included vascular invasion, cirrhosis, high level of alpha-fetoprotein and the presence of multiple lesions. Finally, liver transplantation, although an attractive concept, did not appear to offer a survival benefit in any of the studies. In conclusion, identifying the risk factors that affect the outcome in patients undergoing surgery for large HCC is critical. The reason is that surgical resection can have excellent outcomes in carefully selected patients.
Assuntos
Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/cirurgia , Hepatectomia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Carga Tumoral , Humanos , Fatores de RiscoRESUMO
AIM: The aim of this study was to compare midterm mortality between anemic and nonanemic patients undergoing endovascular repair of abdominal aortic aneurysm and to assess a correlation with markers of inflammation. METHODS: Anemia was defined as hemoglobin <13 (men) and <12 g/dL (women). The impact of anemia and inflammatory markers on mortality was assessed using Kaplan-Meier curves and Cox regression. RESULTS: A total of 224 patients (12 females [5.36%]; age: 69.73 ± 8.72 years) were included; 102 (45.53%) were anemic. Median follow-up was 17 months (interquartile range: 7-25 months). Nine patients died (1.79%; 8 anemic vs 1 nonanemic). Survival was lower for patients with anemia (log-rank, P = .01). White blood cell count and C-reactive protein (CRP) differed significantly (P < .001 and P = .01). Anemia and CRP were associated with decreased survival (Cox regression, P = .01, hazard ratio [HR]: 0.35, 95% confidence interval: 0.14-0.84 and P = .002, HR: 1.18, 95% CI: 1.06-1.31). CONCLUSION: Patients with anemia had decreased survival over the midterm; inflammatory markers were higher among this group.
Assuntos
Anemia/mortalidade , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/mortalidade , Idoso , Anemia/sangue , Aneurisma da Aorta Abdominal/sangue , Aneurisma da Aorta Abdominal/mortalidade , Biomarcadores/sangue , Implante de Prótese Vascular/efeitos adversos , Proteína C-Reativa/metabolismo , Comorbidade , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Mediadores da Inflamação/sangue , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Reino Unido/epidemiologia , Regulação para CimaRESUMO
OBJECTIVE: This study evaluated the contribution of Aptus EndoStaples (Aptus Endosystems, Sunnyvale, Calif) in the proximal fixation of eight endografts used in the endovascular repair of abdominal aortic aneurysms (EVAR). METHODS: Nine human cadaveric aortas were exposed, left in situ, and transected to serve as fixation zones. The Zenith (Cook, Bloomington, Ind), Anaconda (Vascutek, Inchinnan, Scotland, UK), Endurant (Medtronic, Minneapolis, Minn), Excluder (W. L. Gore and Associates, Flagstaff, Ariz), Aptus (Aptus Endosystems), Aorfix (Lombard Medical, Didcot, UK), Talent (Medtronic), and AneuRx (Medtronic) stent grafts were proximally deployed and caudal displacement force (DF) was applied via a force gauge, recording the DF required to dislocate each device ≥20 mm from the infrarenal neck. Measurements were repeated after four and six EndoStaples were applied at the proximal fixation zone, as well as after a Dacron graft was sutured at the proximal neck in standard fashion. Finally, a silicone tube was used as a control fixation zone to test the DF of grafts with EndoStaples in a material that exceeded the integrity of a typical human cadaveric aorta and provided a consistent substrate to examine the differential effect of variable degrees of EndoStaple implantation using zero, two, four, and six EndoStaples. RESULTS: In the cadaveric model, the mean DF required to dislocate the endografts without the application of EndoStaples was 19.73 ± 12.52 N; this increased to 49.72 ± 12.53 N (P < .0001) when four EndoStaples where applied and to 79.77 ± 28.04 N when six EndoStaples were applied (P = .003). The DF necessary to separate the conventionally hand-sutured Dacron graft from the aorta was 56 N. In the silicone tube model, the Aptus endograft without EndoStaples withstood 3.2 N of DF. The DF increased to 39 ± 3 N when two EndoStaples were added, to 71 ± 6 N when four were added, and to 98 ± 5 N when six were added. In eight of the 13 cadaver experiments conducted with four and six EndoStaples, the displacement occurred as a result of complete aortic transection proximal to the fixation site, indicating that aortic tissue integrity was the limiting factor in these experiments. CONCLUSIONS: The fixation of eight different endografts was increased by a mean of 30 N with four Aptus EndoStaples and by a mean of 57 N with six EndoStaples in this model. Endostaples can increase endograft fixation to levels equivalent or superior to that of a hand-sewn anastomosis. The application of six EndoStaples results in aortic tissue failure above the fixation zone, demonstrating fixation strength that exceeds inherent aortic integrity in these cadavers.
Assuntos
Aorta/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Stents , Técnicas de Sutura/instrumentação , Suturas , Idoso , Idoso de 80 Anos ou mais , Implante de Prótese Vascular/métodos , Cadáver , Desenho de Equipamento , Falha de Equipamento , Humanos , Masculino , Teste de Materiais , Pessoa de Meia-Idade , Desenho de Prótese , Falha de Prótese , Estresse MecânicoRESUMO
BACKGROUND: To present an unusual case of blunt aortic injury in a 30-year-old male patient with an aberrant right subclavian artery. METHODS AND RESULTS: Driven by the complicated and challenging nature of the case, we decided to treat the patient by a combined approach-right subclavian artery transposition and endograft implantation at the isthmus level. During the 24-month follow-up (clinical examination, angiogram, computed tomographic scan), we registered no complaints; normal perfusion of the right arm; and adequate sealing of the aortic tear. CONCLUSIONS: We believe that the hybrid management of such trauma is a feasible, effective, and less-invasive option.
Assuntos
Aneurisma/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Anormalidades Cardiovasculares/cirurgia , Transtornos de Deglutição/cirurgia , Procedimentos Endovasculares , Lesões do Sistema Vascular/complicações , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Aneurisma/complicações , Aneurisma/diagnóstico por imagem , Angiografia Digital , Ruptura Aórtica/complicações , Ruptura Aórtica/diagnóstico por imagem , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Anormalidades Cardiovasculares/complicações , Anormalidades Cardiovasculares/diagnóstico por imagem , Transtornos de Deglutição/complicações , Transtornos de Deglutição/diagnóstico por imagem , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Desenho de Prótese , Stents , Artéria Subclávia/anormalidades , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgia , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagemRESUMO
PURPOSE: To report a case in which a persistent high-flow type II endoleak after endovascular aneurysm repair (EVAR) of a leaking abdominal aortic aneurysm (AAA) complicated by an aortocaval fistula was repaired with a stent-graft in the inferior vena cava (IVC). CASE REPORT: A 76-year-old man underwent emergent EVAR with an aortomonoiliac device to exclude a leaking 9-cm AAA. The 30-day computed tomography (CT) scan showed 2-mm sac expansion and a type II endoleak arising from a lumbar artery; the outflow vessel was the inferior vena cava (IVC) via a fistula that was not depicted on the non-contrast preoperative CT or the intraoperative angiogram. No intervention was deemed necessary at the time. Six months after EVAR, the AAA had not expanded further, but the fistula between the sac and the IVC was larger in diameter. A tubular stent-graft was implanted in the IVC to seal the defect. No complications have been noted up to 36 months after the IVC stent-graft procedure. CONCLUSION: Aortocaval fistulae should be excluded in the case of persistent type II endoleaks after EVAR for ruptured AAAs. IVC endografting is a minimally invasive alternative to treat such a complication, with promising midterm results in this patient.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Stents , Fístula Vascular/cirurgia , Veia Cava Inferior/cirurgia , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/etiologia , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Humanos , Masculino , Reoperação , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Fístula Vascular/diagnóstico por imagem , Fístula Vascular/etiologia , Veia Cava Inferior/diagnóstico por imagemRESUMO
We are presenting a case of giant internal carotid artery aneurysm (ICAA) managed by a new exposure technique. Following double mandibular osteotomy, the exposure of the entire aneurysm was achieved by mandible mobilization. The aneurysm repair was performed by resection and graft interposition. Mandible bone reconstruction was succeeded via mini plate osteosynthesis. No adverse events were noticed during the 24-month follow-up period. The surgical ICAA management is necessary to prevent severe complications. In cases of aneurysm extension to the skull base, double mandibular osteotomy is a safe technique that facilitates aneurysm exposure and control.
Assuntos
Aneurisma/cirurgia , Implante de Prótese Vascular , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Interna/cirurgia , Endarterectomia das Carótidas , Mandíbula/cirurgia , Osteotomia , Adulto , Aneurisma/diagnóstico por imagem , Angiografia Digital , Placas Ósseas , Doenças das Artérias Carótidas/diagnóstico por imagem , Artéria Carótida Interna/diagnóstico por imagem , Feminino , Humanos , Osteotomia/instrumentação , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: The optimal management of the patients requiring cardiac surgery with concomitant severe carotid disease remains a controversy. The traditional approach involves staged or combined carotid endarterectomy and cardiac surgery. This study evaluated the feasibility and safety of angioplasty and stenting for the treatment of carotid stenoses concomitantly to cardiac operations to reduce the risk of perioperative stroke. METHODS: All patients scheduled for cardiac surgery were screened preoperatively by color duplex ultrasonography for carotid disease. Carotid stenoses ≥60% in symptomatic patients and ≥70% in asymptomatic patients were treated using carotid artery stenting (CAS) under local anesthesia immediately before the open heart surgery. Cerebral protection devices were used in all cases. Patients did not receive aspirin or clopidogrel before the procedure. In a prospective, nonrandomized study, we analyzed 90 consecutive patients requiring cardiac surgery with concomitant severe carotid artery disease who underwent one stage CAS and cardiac surgery. RESULTS: Despite the high baseline risk profile, our results were encouraging. Carotid stenting was successful in all patients. No neurologic complications occurred during the carotid stenting procedures. The 30-day death/stroke rate was 2.2% (one death, one contralateral stroke). No myocardial infarction occurred. The carotid restenosis rate was zero during the intermediate-term follow-up. CONCLUSIONS: In our experience, CAS followed immediately by cardiac surgery is safe and represents a reasonable option for selected patients presenting with severe carotid and coronary disease.
Assuntos
Angioplastia/instrumentação , Estenose das Carótidas/terapia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Stents , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Feminino , Grécia , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/prevenção & controle , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/prevenção & controle , Seleção de Pacientes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler em CoresRESUMO
BACKGROUND: Carotid artery stenosis (CAS) is a well-known risk factor for perioperative stroke in cardiac surgery. It is unclear whether preoperative carotid screening should be applied to all patients. Carotid intervention concomitantly with cardiac operations is also controversial. Our objective was to identify the prevalence of significant CAS and its related risk factors by applying a protocol of preoperative carotid screening to all patients undergoing cardiac surgery. METHODS: We studied 307 patients who were primarily screened preoperatively by duplex Doppler ultrasonography. Catheter carotid angiography or transcranial Doppler was performed on equivocal cases. Univariate and multivariate analyses were applied across selected parameters to identify risk factors for significant CAS (> 70%). The prevalence of CAS and perioperative stroke rates were determined. RESULTS: Twenty-two patients with severe and 18 with moderate carotid stenosis were identified. Further radiological evaluation with catheter carotid angiography and transcranial Doppler confirmed the presence of significant CAS in 20 patients who underwent carotid stenting or endarterectomy before the open heart surgery. The cardiac surgeon was free to modify the surgical technique according to the preoperative assessment. No patient had major stroke perioperatively, while two minor strokes with complete neurologic recovery have been documented. The history of stroke and the presence of bruit on clinical examination were the only significant predictors of severe carotid disease. CONCLUSION: Careful clinical examination together with detailed previous history taking can identify the majority of patients with CAS. Further data are required for the construction of a scientifically valid policy as a guideline.
Assuntos
Estenose das Carótidas/diagnóstico , Estenose das Carótidas/cirurgia , Programas de Rastreamento , Período Pré-Operatório , Idoso , Angiografia , Estenose das Carótidas/epidemiologia , Ponte de Artéria Coronária/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Guias de Prática Clínica como Assunto , Prevalência , Prognóstico , Fatores de Risco , Stents , Acidente Vascular Cerebral/etiologia , Ultrassonografia Doppler TranscranianaRESUMO
PURPOSE: This study evaluated the feasibility, efficacy, and durability of a specific aortomonoiliac endograft for the treatment of abdominal aortic aneurysm (AAA) during a midterm follow-up. METHODS: From January 2002 until November 2008, 106 patients (6 women; mean age, 73.37 +/- 7.39 years) were treated for an AAA using an EndoFit aortomonoiliac graft (LeMaitre Vascular, Burlington, Mass). All procedures were elective. RESULTS: Mean follow-up was 34.9 months (SD, 20.08; range, 2-81 months). Long-term data (follow-up >60 months) were available for nine patients, none of which reported any vascular or procedure related complications. Three of the 106 patients (2.83%) died during early follow-up (<30 days); eight died during late follow-up (7.54%). Endograft infection developed in two patients (1.88%), and an aortoduodenal fistula developed in two (1.88%). Also observed were 15 type II (14.15%) and three type I (2.83%) endoleaks. Femorofemoral bypass thrombosis was detected in two patients (1.88%). CONCLUSION: In this retrospective analysis, the aortomonoiliac configuration for elective AAA repair was proven to be safe and efficacious. Midterm and long-term follow-up results in this series compare well with previously reported results for AAA endografting using both bifurcated and aortomonoiliac endoprostheses.
Assuntos
Aorta/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Artéria Ilíaca/cirurgia , Idoso , Idoso de 80 Anos ou mais , Prótese Vascular , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: We report mid-term results from the endovascular treatment of acute thoracic aortic pathologies in a single center. METHODS: We retrospectively interrogated our clinical database and identified the following patients who were treated for an acute thoracic aortic pathology during a 3-year period (January 2003 to February 2006) with the deployment of a thoracic endograft: 8 male patients diagnosed with a thoracic aortic pseudoaneurysm and/or a thoracic aortic disruption following blunt chest trauma; 1 male patient with a large mobile mural thrombus of the descending thoracic aorta; 1 patient with an aortobronchial fistula; and 8 patients with a symptomatic descending thoracic aortic aneurysm. RESULTS: Complete exclusion of the lesion was achieved in all patients. No procedure-related deaths occurred. Postoperative complications included one case of a distal type 1 endoleak, repaired with re-intervention and deployment of an extension graft, and 1 case of moderate graft kinking without further complications. CONCLUSION: The endovascular treatment of acute thoracic aortic pathologies is technically feasible and safe. Early and intermediate results are promising.
Assuntos
Aneurisma Roto/cirurgia , Angioscopia/métodos , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Emergências , Adulto , Idoso , Aneurisma Roto/complicações , Aneurisma Roto/diagnóstico por imagem , Angiografia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/diagnóstico por imagem , Fístula Brônquica/diagnóstico por imagem , Fístula Brônquica/etiologia , Fístula Brônquica/cirurgia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ruptura Espontânea , Tomografia Computadorizada por Raios X , Fístula Vascular/diagnóstico por imagem , Fístula Vascular/etiologia , Fístula Vascular/cirurgia , Adulto JovemRESUMO
PURPOSE: To report a single-center experience with aortoduodenal fistula (ADF) after successful endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA). METHODS: Five patients (all men; mean age 68.4 years, range 60-75) developed an ADF between 18 days to 1 year after successful EVAR using 3 types of commercially available endografts: 1 bifurcated Anaconda, 1 unibody Powerlink, and 3 EndoFit stent-grafts in a tubular (n=1) or aortomonoiliac configuration (n=2). The internal iliac artery was not occluded in any of the cases. RESULTS: Hematemesis and diffuse abdominal pain constituted the main symptoms leading to the diagnosis of ADF, which was confirmed on computed tomography. Infection was the etiology of the ADF in 3 patients; all underwent emergency surgical exploration, but 1 died in hospital; the other 2 have survived from 1 to 3 years after an emergency procedure. The other 2 ADFs developed in patients with large type I endoleaks; 1 patient died before surgery could be performed and the other one 18 hours after laparotomy. All stent-grafts were removed; none displayed any defects. CONCLUSION: ADF is a rare but dangerous complication of EVAR. The sequela may be primarily attributed to graft infection, as seen in this series. However, the exact pathogenesis of the pathology remains largely unknown. Prompt diagnosis and intervention are crucial to avoid a fatal outcome.
Assuntos
Aneurisma da Aorta Abdominal/terapia , Doenças da Aorta/etiologia , Implante de Prótese Vascular/efeitos adversos , Duodenopatias/etiologia , Fístula Intestinal/etiologia , Stents/efeitos adversos , Fístula Vascular/etiologia , Idoso , Angiografia , Doenças da Aorta/diagnóstico por imagem , Duodenopatias/diagnóstico por imagem , Feminino , Humanos , Fístula Intestinal/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Falha de Prótese , Tomografia Computadorizada por Raios X , Fístula Vascular/diagnóstico por imagemRESUMO
PURPOSE: To report a retrospective evaluation of the efficacy and midterm clinical results of the Anaconda stent-graft in the endovascular repair of infrarenal abdominal aortic aneurysms. METHODS: Fifty-one patients (48 men; mean age 71+/-8 years, range 62-89) were treated with the Anaconda stent-graft from January 2006 to September 2007. Six patients were considered at high risk for open repair (defined as ASA grade 3) and 10 had undergone previous laparotomy. The mean neck diameter and length were 26 mm (range 22-30) and 18.5 mm (range 14-35), respectively. Mean proximal neck angulation was 30 degrees (range 5-60). Severe iliac artery tortuosity (>60 degrees ) was seen in 20 (39%) patients; 3 (6%) had a proximal aneurysm neck angle >45 degrees. RESULTS: The technical success rate was 100%; intraprocedurally, 7 (14%) stent-grafts were repositioned to address renal artery occlusion by the graft (n = 1) or type I endoleak. This maneuver resolved 6 of the 7 situations; a remaining endoleak required a proximal cuff to seal it. The procedural success rate (no major complication at 30 days) was 94%. The mean follow-up was 16 months (range 1-21). Five (10%) endoleaks (1 type I, 4 type II) and 1 (2%) graft migration occurred. The overall reintervention rate was 6%. Two (4%) patients died in late follow-up. CONCLUSION: The Anaconda stent-graft appears both safe and effective in terms of midterm clinical outcome and compares favorably with previously reported EVAR results. The ability to reposition the stent-graft is a particular advantage.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Prótese Vascular , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Reoperação , Estudos Retrospectivos , Estatísticas não Paramétricas , Análise de Sobrevida , Resultado do TratamentoRESUMO
The aim of this prospective study was to compare the outcome of the Talent bifurcated endograft versus the Endofit aorto-uni-iliac endograft in the short-term and mid-term. Between March 2000 and December 2003, 86 patients were treated with the Talent bifurcated endograft (group A) and 21 with the Endofit aorto-uni-iliac endograft (group B) in the same institute by the same surgical team. All patients followed a prospective protocol of preoperative evaluation and postoperative follow-up. We compared groups A and B in terms of perioperative mortality and morbidity, mid-term endoleak rate, mid-term success rate, and mid-term survival. The perioperative mortality for group A was 1.63%, while that for group B was 0% (P = 0.62). The endoleak rate for group A was 4.65%, and that for group B was 14.29% (P = 0.135). The mid-term success rate was 96.5% for group A and 100% for group B (P = 0.386). There was no significant difference in outcome between the patients treated with the Talent and those treated with the Endofit endoprosthesis. Treating abdominal aortic aneurysms with aorto-uni-iliac endoprosthesis is as safe and effective as treating them with bifurcated endografts.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Aneurisma Ilíaco/cirurgia , Idoso , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Feminino , Artéria Femoral/cirurgia , Seguimentos , Grécia , Humanos , Aneurisma Ilíaco/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Desenho de Prótese , Reoperação , Stents , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the feasibility and efficacy of repairing isolated iliac artery aneurysms with short proximal necks (<10 mm) by implanting the EndoFit stent-graft. METHODS: Seven patients (6 men; median age 73 years, range 70-78) were diagnosed with an isolated common iliac artery (CIA) aneurysm that featured a short proximal landing zone, complicating endovascular treatment. The median aneurysm diameter was 4.4 cm (range 3.5-7.0), and the median proximal neck length was 7 mm (range 5-9).The aneurysms were treated using the EndoFit stent-graft, which can be deployed in a short proximal landing zone. The modified technique involves the deployment of the graft directly above the aneurysm sac without obstructing the contralateral iliac axis, thus affixing the bare proximal stent in the terminal aorta. Follow-up was performed by clinical evaluation and computed tomography at 1, 6, and 12 months postoperatively. RESULTS: The EndoFit stent-graft was successfully deployed in all cases, with complete aneurysm exclusion. In 1 case, the deployment of a second cuff was necessary to secure complete aneurysm exclusion. The median follow-up was 18 months, during which no deaths occurred, and no endoleak or stent-graft migration was observed. Endograft thrombosis occurred in 1 case due to graft angulation caused by external iliac artery stenosis and kinking. None of the aneurysms has ruptured, and there have been no serious complications. CONCLUSION: Direct endoluminal repair of isolated CIA aneurysms with short proximal necks is feasible using this technique. Efficacy and long-term results are to be confirmed by larger scale series over a long time period.
Assuntos
Aneurisma Ilíaco/patologia , Aneurisma Ilíaco/cirurgia , Stents , Idoso , Implante de Prótese Vascular , Estudos de Viabilidade , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/patologia , Artéria Femoral/fisiopatologia , Artéria Femoral/cirurgia , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/cirurgia , Humanos , Aneurisma Ilíaco/fisiopatologia , Masculino , Desenho de Prótese/instrumentação , Reoperação , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND AND AIMS: Cervical paragangliomas are highly vascular neoplasms and should be considered in the evaluation of all lateral neck masses. The aim of this study is to review an institutional experience in the management of these tumors. MATERIALS AND METHODS: Thirteen patients with 14 paragangliomas were treated in our institution during a period of 15 years. There were eight women (61.5%) and five men (38.5%) with a mean age of 41.3+/-15 years. A painless lateral neck mass was the main finding in 69.2% of patients. There was no evidence of a functional tumor. Carotid angiography was performed in all patients to define the vascular anatomy of the lesion. The 78.6% of paragangliomas underwent selective embolization of the major feeding arteries. Surgical resection followed within the next 48 h. RESULTS: The majority of the lesions were paragangliomas of the carotid bifurcation (85.7%), while one patient was diagnosed with a jugular and one with a vagal paraganglioma. In one patient, bilateral paragangliomas in the carotid bifurcation were detected. There was no evidence of malignancy in any case. Preoperative embolization has proven successful in reducing tumor vascularity. Vascular reconstruction was necessary in one patient. The main postoperative complication was transient cranial nerve deficit in seven (53.8%) patients, and a permanent Horner's syndrome was documented in one patient. No stroke occurred. The jugular paraganglioma was treated with irradiation due to skull base extension with significant symptomatic relief. CONCLUSION: Combined therapeutic approach with preoperative selective embolization followed by surgical resection by an experienced team offers a safe and effective method for complete excision of the tumors with a reduced morbidity rate.
Assuntos
Neoplasias de Cabeça e Pescoço/cirurgia , Paraganglioma Extrassuprarrenal/cirurgia , Adulto , Idoso , Angiografia , Angiografia Digital , Tumor do Corpo Carotídeo/irrigação sanguínea , Tumor do Corpo Carotídeo/diagnóstico , Tumor do Corpo Carotídeo/cirurgia , Diagnóstico por Imagem , Embolização Terapêutica , Feminino , Tumor do Glomo Jugular/irrigação sanguínea , Tumor do Glomo Jugular/diagnóstico , Tumor do Glomo Jugular/cirurgia , Neoplasias de Cabeça e Pescoço/irrigação sanguínea , Neoplasias de Cabeça e Pescoço/diagnóstico , Síndrome de Horner/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Neoplasias Primárias Múltiplas/irrigação sanguínea , Neoplasias Primárias Múltiplas/diagnóstico , Neoplasias Primárias Múltiplas/cirurgia , Paraganglioma Extrassuprarrenal/irrigação sanguínea , Paraganglioma Extrassuprarrenal/diagnóstico , Complicações Pós-Operatórias/etiologia , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler em Cores , Nervo Vago/irrigação sanguínea , Nervo Vago/patologia , Nervo Vago/cirurgiaRESUMO
PURPOSE: To evaluate the feasibility and efficacy of a specific aortomonoiliac endograft and the durability of the femorofemoral bypass for treatment of abdominal aortic aneurysm (AAA). METHODS: From 2002 to 2004, 39 high-risk (ASA III/IV) patients (36 men; median age 74 years, range 63-84) with AAA (n = 33) or AAA and common iliac artery aneurysm (n = 6) were treated with an EndoFit aortomonoiliac endograft and femorofemoral crossover bypass. The contralateral iliac axis was obstructed with an endoluminal occluder. Patients were followed with contrast-enhanced computed tomography at 1, 6, 12, and 24 months. RESULTS: EndoFit AMI stent-grafts were implanted successfully in all patients. Perioperative mortality was zero. Endoleak occurred in 3 (7.7%) cases. A proximal type I endoleak was identified at 1 month and was treated with a proximal cuff. Two type II endoleaks are under surveillance because the aneurysm sac shows no enlargement. Thrombosis of the femorofemoral graft occurred in 1 case during the immediate postoperative period due to insufficient inflow from a residual stenosis of the endograft (primary patency 97.5%). The deficit was treated successfully (secondary patency 100%). Two (5.1%) tunnel hematomas were treated conventionally. Median follow-up was 14 months (range 6-30). All patients are alive. None of the aneurysms has ruptured or been converted to an open procedure. Graft migration, serious infection, paraplegia, distal embolization, or any other serious complication has not been observed. CONCLUSIONS: In high surgical risk patients with complex iliac anatomy, aortomonoiliac endograft with femorofemoral crossover bypass is feasible and efficacious. Moreover, the midterm patency of the extra-anatomic bypass appears quite satisfactory.
Assuntos
Angioscopia/métodos , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Artéria Femoral/cirurgia , Artéria Ilíaca/cirurgia , Stents , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/instrumentação , Angiografia , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Estudos Retrospectivos , Resultado do TratamentoRESUMO
We report a case of malignant fibrous histiocytoma (MFH) metastatic to the spine. A 41-yr-old male was admitted to our hospital for radiation treatment of MFH of the spine. He began to show signs suggestive of partial small bowel obstruction. Computed tomography demonstrated jejuno-jejunal intussusception. The patient was taken to the operating room, where the diagnosis was confirmed. Partial jejunal resection was performed. The lead point of the intussusception was histologically diagnosed to be a high-grade malignant fibrous histiocytoma. We believe that the spinal lesion was the metastatic lesion and that metastasis occurred via the vessels of Adamciewicz. To our knowledge this is the first case thus reported.