RESUMO
BACKGROUND: Early postoperative glycemic variability is associated with worse outcome after cardiac surgery, but the underlying mechanisms remain unknown. This study aimed to describe the relationship between postoperative glycemic variability and endothelial function, as assessed by serum endocan level in cardiac surgery patients. METHODS: We performed a post hoc analysis of patients included in the single-center observational ENDOLUNG study. Adult patients who underwent planned isolated coronary artery bypass graft surgery were eligible. Postoperative glycemic variability was assessed by calculating the coefficient of variability (CV) of blood glucose measured within 24 (CV24) and 48 (CV48) hours after surgery. Serum endocan level was measured at 24 (Endocan24) and 48 (Endocan48) hours after surgery. Pearson's correlation coefficient with 95% confidence interval (95% CI) was calculated between CV24 and Endocan24, and between CV48 and Endocan48. RESULTS: Data from 177 patients were analyzed. Median CV24 and CV48 were 18% (range 7 to 39%) and 20% (range 7 to 35%) respectively. Neither CV48 nor CV24 were significantly correlated to Endocan48 and Endocan24 respectively (r (95% CI) = 0.150 (0.001 to 0.290; and r (95% CI) = 0.080 (-0.070 to 0.220), respectively). CONCLUSIONS: Early postoperative glycemic variability within 48 h after planned cardiac surgery does not appear to be correlated with postoperative serum endocan level. CLINICAL TRIAL REGISTRATION NUMBER: NCT02542423.
Assuntos
Glicemia , Procedimentos Cirúrgicos Cardíacos , Adulto , Humanos , Ponte de Artéria Coronária/efeitos adversosRESUMO
BACKGROUND: The complications of EVAR require compliance to a close follow-up imaging. The purpose of this study was to determine whether home location predicted a poor compliance to imaging follow-up after EVAR. METHODS: We analyzed a cohort of patients treated by EVAR at the Besançon University Hospital between 2007 and 2017. Follow-up imaging followed the French High Health Authority recommendations. Noncompliance with follow-up compliance was defined as a first missed postoperative appointment or 2 consecutive missed appointments after the first control CT-scan, and 2 groups of patients were identified: compliant (group C) or noncompliant (group NC). Univariate and multivariate analyzes were used to investigate compliance risk factors. Collected complications included endoleaks, limb thrombosis, infections, and secondary ruptures. RESULTS: Two hundred and fifty-eight of the 359 patients treated during this period were enrolled, including 233 men (90.3%), with a mean age of 74.0 years (±9.0) and a mean follow-up of 5.0 years (±2.6). The compliance rate was 38.8% and the 1-year mortality rate was 12.0%. Using univariate and multivariate analysis, a place of residence greater located over 60 min away from the hospital had a poor effect on compliance (Odd ratio [OR] = 0.58; P = 0.047). Peripheral arterial occlusive disease (PAD) and an abdominal aortic aneurysm (AAA) diameter greater than 5.0 cm were protective factors (OR = 2.23; P = 0.006 and OR = 1.85, respectively; P = 0.002). Four-year all-cause mortality was 21.0% in group C and 17.0% in the NC group (P = 0.54). Complications were more significant in group C (59.0%) compared to group NC (39.0%) (P = 0.001). Two ruptures occurred in the NC group (1.3%), versus none in the C group (P = 0.25). CONCLUSIONS: In this study, a long distance from the home to the hospital was a detrimental factor for follow up compliance. However, a good compliance did not decrease the 4-year mortality rate. The high rate of noncompliance found should lead to a more personalized follow-up strategy taking into account the anatomical elements but also the comorbidities and some social aspects.
Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Masculino , Humanos , Idoso , Seguimentos , Resultado do Tratamento , Implante de Prótese Vascular/efeitos adversos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/etiologia , Tomografia Computadorizada por Raios X , Fatores de Risco , Procedimentos Endovasculares/efeitos adversos , Estudos Retrospectivos , Complicações Pós-OperatóriasRESUMO
BACKGROUND: The femoral tripod remains technically crucial in vascular surgery, as well for an elective revascularization as for an extensive approach to the arterial tree. The management of septic complications and healing disorders in this area is really challenging. Obturator bypass (OB) represents an alternative sometimes employed in this context, but few recent series were recently published. The objectives of this work were thus to evaluate the results of OB in terms of patency, morbi-mortality, healing evolution and absence of reinfection. METHODS: This was a monocentric retrospective study including all the patients treated by OB, whatever the cause, between January 2010 and December 2020. Primary outcomes were the primary and the secondary patencies. The secondary outcomes were the morbi-mortality, freedom from infection and healing. RESULTS: During this period, 23 OBs were carried out in 22 patients, with a majority of men (77%) whose median age was 70 years [34-87]. The indications were infection in 19 patients (86%), and iterative thrombosis in 3 patients (14%). The substitute was an arterial allograft in 82% of the cases, and the outflow was the deep femoral artery only in 14% of the cases. The median operative time was 224 min [111-391] and median blood losses were 900 mL [300-3,900]. We observed 7 systemic (32%), and 8 local complications (36%). Healing was obtained in 90% of the cases, and freedom from infection was obtained in 100% of the cases. The median duration of follow-up was 594 days [5-2,517]. One-year, 2-year and 3-year primary patency rates were 84%, 78%, and 63%, respectively. One-year, 2-year and 3-year secondary patencies were 94%, 94%, and 80%, respectively. One-month, 1-year, 2-year and 3-year survival rates were 86%, 73%, 67%, and 53%, respectively. CONCLUSIONS: Our study showed that the OB represents a relevant alternative in the event of complex lesions of the femoral tripod, with good patency and healing rates and good infection control. On the other hand, its consequences in terms of morbi-mortality confirm that OB is a major surgery that should be used when a traditional approach is not possible.
Assuntos
Implante de Prótese Vascular , Prótese Vascular , Masculino , Humanos , Idoso , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução Vascular , Fatores de Risco , Salvamento de MembroRESUMO
BACKGROUND: Endovascular abdominal aortic aneurysm repair (EVAR) is a safe and minimally invasive alternative to open surgical repair for infra renal aortic aneuvrysm. EVAR requires lifelong post-procedural surveillance. Endoleaks represent the main complication. Type II endoleaks (EL2) are the most frequent and tend to be indolent. Most practitioners do not treat in EL2 as long as they are associated with stable aneurysm diameter. European guidelines recommend treatment in case of aneurysm growth. Several techniques can be offered, such as transarterial embolization and translumbar embolization. This study reports the experience and results of a single center for EL2 endovascular treatment. The aim of this study was to determine more precisely the efficacity of embolization for type 2 endoleaks treatment. METHODS: A single center cohort of patients treated for EL2 with endovascular technique between 1998 and 2018 was formed to perform a descriptive analysis. Preoperative sizing, risk factors of endoleaks and intraoperative data were collected. Computed topography (CT) scans were regularly performed after EVAR to detect endoleak recurrence. Clinical recurrence was defined as the persistence of aneurysm sac growth and radiological recurrence was defined as the occurrence of EL2 on a post-embolization CT scan. Data related to reintervention, overall mortality and aneurysm related mortality were also collected. Kaplan-Meier survival analyses were used to determine the rates of reoperation-free survival and recurrence-free survival. RESULTS: Six hundred seven patients underwent an endovascular treatment for abdominal aorta aneurysm between 1998 and 2018. One hundred forty-five type 2 endoleaks occurred during this period. Nineteen patients (median age 76 years), underwent endovascular treatment for EL2, with immediate success on 15 patients (8 transarterial embolization, 8 direct sac puncture and 3 combined procedures). During follow-up, 5 patients required a new translumbar embolization and 6 required an open surgery for recurrence of the EL2. Six patients died, 2 of them of causes related to the aneurysm. At 59,6 months median follow-up, 53% of the patients presented a radiologic recurrence, with a sac growth of more than 5 mm since last procedure in 4 patients (24%). CONCLUSIONS: Long term clinical recurrence of type 2 endoleaks treated by endovascular procedures appear to be frequent in our experience, leading to several deaths and requiring open surgical treatment.
Assuntos
Implante de Prótese Vascular , Embolização Terapêutica , Humanos , Idoso , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/cirurgia , Implante de Prótese Vascular/efeitos adversos , Resultado do Tratamento , Embolização Terapêutica/métodos , Fatores de RiscoRESUMO
INTRODUCTION: On-pump coronary artery bypass graft (CABG) and surgical valve replacement (SVR) are high-risk procedures. Several studies reported that perioperative blood glucose (BG) variability was independently associated with impaired postoperative outcome. However, the underlying mechanisms contributing to increased perioperative BG variability and to its deleterious impact remain unknown. The hypothesis of the study is that perioperative BG variability could be related to perioperative alteration of the autonomic nervous system (ANS) activity and to preoperative BG variability. METHODS AND ANALYSIS: We designed a prospective observational single-center study. Four groups of 30 patients will be studied: group 1, including insulin-requiring type 2 diabetic patients undergoing on-pump CABG; group 2, including non-insulin-requiring type 2 diabetic patients undergoing on-pump CABG; group 3, including non-diabetic patients undergoing aortic SVR; and group 4, including non-diabetic patient undergoing on-pump CABG. Preoperative (baseline) and postoperative BG variability will be quantified using the Abbott's Freestyle Libre Pro sensor allowing for continuous subcutaneous BG monitoring. Preoperative (baseline) and postoperative ANS activity will be measured using noninvasive continuous heart rate monitoring (Mooky HR memory®). Blood level and urinary concentration of inflammatory and endothelial dysfunction biomarkers will be measured from blood and urinary samples at the end of the surgery and on postoperative day 1 and 2. The primary objective is to describe the relationship between baseline BG variability and postoperative BG variability. The secondary objectives are to describe the relationship: between baseline and postoperative BG variability according to the diabetes phenotype and to the type of surgery; between the ANS activity and the BG variability; and between postoperative BG variability and, urinary and blood biomarkers.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Diabetes Mellitus Tipo 2 , Humanos , Glicemia , Sistema Nervoso Autônomo , Insulina , Diabetes Mellitus Tipo 2/cirurgia , Estudos Observacionais como AssuntoRESUMO
BACKGROUND: Thanks to its well proved long-term patency rates, native radiocephalic arteriovenous fistula remains the most commonly used vascular access type. Many articles had approached the criteria leading to a mature fistula. The aims of this work are to evaluate variables that may affect the maturation of distal fistulas and to determine if wrist fistulas have less risk of maturation failure than the snuff-box fistulas. METHODS: We recorded all distal radiocephalic fistulas that had been created from January 2018 to February 2021. Epidemiological and clinical profile of patients, characteristics of performed fistulas and per and post-operative data were recorded and analyzed. RESULTS: From January 2018 to February 2021, 165 upper limb vascular accesses for hemodialysis had been created including 47 (28.5%) distal radiocephalic fistulas. Among the latter, 39 (83%) fistulas were performed at the wrist and 8 (17%) at snuff-box area. There were 34 men (72.3%). Mean age was 67 years (37-87). Both types of fistulas had approximately an identic frequency of primary maturation failure (50% for radiocephalic versus 47.2% for snuff-box fistulas). Secondary maturation had been achieved in 9 fistulas. Patients with medical history of dyslipidemia, peripheral arterial disease (PAD), central catheter placement, and bad quality of vessels tend to develop an immature fistula. CONCLUSIONS: No significant differences in maturation tend between snuff-box and wrist fistulas had been demonstrated. Thus, it seems reasonable to privilege the creation of the most distal fistulas allowing preservation of wrist fistulas as a second option in case of snuff-box fistulas maturation failure. However, selection of the most suitable cases for snuff-box fistulas creation, based on clinical and duplex ultrasound data, remains primordial.
Assuntos
Fístula Arteriovenosa , Derivação Arteriovenosa Cirúrgica , Tabaco sem Fumaça , Masculino , Humanos , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Grau de Desobstrução Vascular , Punho , Fatores de Risco , Resultado do Tratamento , Estudos Retrospectivos , Diálise Renal , Extremidade Superior/irrigação sanguíneaRESUMO
BACKGROUND: The purpose of our study was to evaluate the analgesic properties of continuous transversus abdominis plane (TAP) infusion with ropivacaine compared to placebo for postoperative analgesia in elective surgery of the abdominal aorta by retroperitoneal exposure. METHODS: We conducted a prospective, single-center, randomized, double-blind study comparing a group of patients with a TAP catheter undoing ropivacaine infusion with a placebo group. Patients received a left retroperitoneal pararectal exposure for abdominal aortic surgery. A continuous infusion catheter was placed under visual control by the surgeon before closure and removed after 48 hr. All patients had postoperative patient-controlled analgesia with morphine. The primary endpoint was morphine consumption during the first 24 hr. RESULTS: The analysis included 25 patients in the placebo group and 24 in the ropivacaine group. The average morphine consumption during the first 24 hr was significantly different, with 31 ± 16 mg in the ropivacaine group and 41 ± 17 mg in the placebo group (P = 0.019). At 48 hr, morphine consumption was still lower in the ropivacaine group (42 ± 26 mg) than in the placebo group (64 ± 25 mg) (P = 0.003). The opioid narcotic-related side effects of opioid infusion (postoperative nausea and vomiting, constipation) and length of hospital stay were similar in both populations. CONCLUSIONS: Our study showed that continuous TAP block with ropivacaine via surgically inserted catheter significantly decreased morphine consumption at 24 and 48 hr after elective abdominal aortic surgery by retroperitoneal exposure.
Assuntos
Analgésicos Opioides , Dor Pós-Operatória , Humanos , Ropivacaina/efeitos adversos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Estudos Prospectivos , Medição da Dor , Resultado do Tratamento , Músculos Abdominais , Analgesia Controlada pelo Paciente/efeitos adversos , Morfina/efeitos adversos , Método Duplo-Cego , Catéteres , Anestésicos Locais/efeitos adversosAssuntos
Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Humanos , Alta do Paciente , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Estudos Retrospectivos , Doença Aguda , Resultado do Tratamento , Implante de Prótese Vascular/efeitos adversosRESUMO
BACKGROUND: Conventional open surgery is still important beside endovascular surgery in the management of abdominal aortic aneurysms, with less reinterventions in the long-term follow-up. Incisional hernias are the major complication open surgery in the mid- and long term. The occurrence of this late complication could be due to the choice of the incision, median or transverse. The objectives of our retrospective and bicentric study were to characterize the long-term risk factors for incisional hernias after open surgery for abdominal aortic aneurysms, in particular by comparing the 2 types of laparotomy, and to determine the prevalence of the operated and not operated incisional hernias. MATERIALS AND METHODS: Between January 2009 and December 2011, all the patients having elective open surgery for abdominal aortic aneurysm (AAA) by midline laparotomy at the University hospital of Besancon or by transversal laparotomy at the University Hospital of Strasbourg were included retrospectively. The demographic data, the time of diagnosis of the incisional hernia and the parietal reinterventions were collected during a 5-year postoperative follow-up. A univariate and multivariate Cox model was used for the statistical analysis to determine the long-term risk factors for the appearance of an incisional hernia. RESULTS: During the study period, 223 patients presenting with AAA were included, 112 of them were operated by a midline laparotomy and 111 by a transverse laparotomy. The mean age of the patients was 69 ± 8,4years and 208 (93.3%) were men. The 5-year prevalence of incisional hernias was 14.3% (32), and 20 of these hernias (9%) had to be operated. Eighteen hernias (16.1%) occurred after a midline laparotomy and 14 (12.6%) after a transverse incision (P = 0.30). In univariate analysis, obstructive chronic pulmonary disease was the only significant risk factor for incisional hernia (P = 0.01) and an age over 65 years appeared to protect against this risk (P = 0.049). These results were confirmed by multivariate analysis, which showed that obstructive chronic pulmonary disease was an independent risk factor for incisional hernia (HR = 2.35, 95% CI 1.16-4.75), and that an age over 65 years was a protective factor (HR = 0.49 95% IC 0.00-0.99). CONCLUSIONS: The type of laparotomy did not modify the rate of incisional hernias. We showed that only 9% of the patients had to be operated to treat an incisional hernia during the first 5 years after surgery for AAA in our bicentric study. Chronic obstructive pulmonary disease was the only independent risk factor for the occurrence of an incisional hernia.
Assuntos
Aneurisma da Aorta Abdominal , Hérnia Incisional , Pneumopatias , Idoso , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Feminino , Hérnia/complicações , Humanos , Hérnia Incisional/epidemiologia , Hérnia Incisional/etiologia , Masculino , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: Nutcracker syndrome can cause disabling chronic pain requiring surgical intervention. At present, data describing a straightforward management approach are lacking. Transposition of the left gonadal vein is one of the surgical therapeutic alternatives. The aim of the present study was to describe our clinical results with gonadal vein transposition. METHODS: All 11 patients from three centers who had undergone left gonadal vein transposition for nutcracker syndrome from 2016 to 2019 were retrospectively included. The surgical cases were mainly selected according to the morphologic criteria of the left gonadal vein. The diameter and length dictated the type of approach (laparotomy or retroperitoneal) and the transposition level. A minimally invasive retroperitoneal approach was preferred. Pain was assessed using a numeric rating scale. RESULTS: We included 11 patients (10 women) with a median age of 35 years (range, 25-69). Preoperative computed tomography angiography showed anterior nutcracker syndrome in 10 patients (91%). All 11 patients had experienced lower back and/or pelvic pain, which was associated with pelvic congestion syndrome in 6 patients (55%) and hematuria in 5 patients (45%). The median preoperative numeric rating scale score for pain was 7.0 (range, 3.5-10.0) and 6.0 (range, 3.5-8.0) for lower back pain and pelvic pain, respectively. At the level of the iliac vein crossing (external or common), the median diameter of the left gonadal vein was 7.87 mm (range, 6.45-11.28). The left gonadal vein was transposed to the inferior vena cava in one case (9%), the left external iliac vein in five (45%), and the left common iliac vein in five cases (45%). The median in-hospital stay was 4 days (range, 2-20 days). Two early complications (18%) requiring surgical revision occurred: one of active bleeding and one hematoma. The median follow-up was 15 months (range, 6-44 months). The median postoperative pain score was 1.0 (range, 0.0-4.0) and 0.0 (range, 0.0-6.0) for lower back and pelvic pain, respectively. Incisional and/or neuropathic pain was noted, with a median score of 3.5 (range, 1.0-6.0) in seven patients (64%). Two late complications (18%) were observed: one case of thrombosis and one case of anastomotic stenosis. The hematuria had disappeared in all patients who had presented with it initially. CONCLUSIONS: Left gonadal vein transposition can be proposed as a first approach if the diameter of the left gonadal vein is sufficient to perform the anastomosis. It is an easily achievable, minimally invasive alternative that achieves satisfactory results without the use of foreign material.
Assuntos
Síndrome do Quebra-Nozes/cirurgia , Veias/cirurgia , Adulto , Idoso , Feminino , Gônadas/irrigação sanguínea , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos VascularesRESUMO
BACKGROUND: Long-term outcomes of accessory renal artery (ARA) coverage after endovascular aneurysm repair (EVAR) are unknown. We analyzed the impact of ARA coverage on renal function long-term. METHODS: This retrospective, monocentric study included patients treated by EVAR between 2008 and 2016. Patients with at least one ARA covered with EVAR (ARA group) were compared with patients with no covered ARA (control group). Renal function was determined by estimating the glomerular filtration rate (eGFR) and graded according to chronic kidney disease (CKD) classification stages. RESULTS: A total of 184 patients were included (ARA group, n = 25; control group, n = 159). Renal risk factors were similar in the 2 groups. Mean (±standard deviation) duration of follow-up was 41.6 ± 25.8 months. Preoperative eGFR (mL/min/1.73 m2) was 68.9 ± 17.8 in the ARA group and 72.5 ± 17.4 in the control group (P = 0.33), with a similar decline in the 2 groups during follow-up (-6.52 ± 11.6 ARA group vs. -6.43 ± 13.8 control group; P = 0.97). At the end of the study, 8 ARA patients and 56 controls had deteriorated by one CKD stage (32% vs. 35.2%, respectively; P = 0.75). Rate of renal infarction was significantly higher in the ARA group (96% vs. 1.9%; P < 0.0001). In multivariate analysis, suprarenal fixation was identified as a risk factor for a decline in renal function (odds ratio = 2.01 [95% confidence interval: 1.05-3.84]; P = 0.04). CONCLUSIONS: ARA coverage after EVAR does not appear to affect renal function long-term. Suprarenal fixation led to a greater decline in renal function.
Assuntos
Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Rim/fisiopatologia , Artéria Renal/cirurgia , Insuficiência Renal Crônica/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Aneurisma Aórtico/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Progressão da Doença , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Artéria Renal/anormalidades , Artéria Renal/diagnóstico por imagem , Insuficiência Renal Crônica/diagnóstico , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The aging of the population leads us to treat older patients, in particular presenting with acute limb ischemia (ALI). However, there has been little evaluation of this pathology in the nonagenarians. The objectives of this work are thus to evaluate the 1-month and 1-year mortality of the nonagenarians treated for ALI, which made possible to determine the 1-year survival and to highlight the factors influencing the mortality. METHODS: This is a monocentric retrospective study including all the patients aged 90 years old or more surgically treated for ALI between January 2012 and December 2016. In all the patients, we recorded the 1-month mortality and the 1-year survival and the demographic, clinical, and paraclinical data. RESULTS: We operated 83 nonagenarians, with a majority of women (59, 71.1%), using general anesthesia in 20 patients (16.6%), including 10 cases of upper limb acute ischemia (12.0%). The overall mortality rate at 1 month was 22.9%, and the 1-year survival rate was 43.4%. Major amputation rate was 9.6% at 1 year. The survival of the patients operated for upper or lower limb ischemia was similar (P = 0.82). Univariate analysis showed that the 1-year survival was lower in patients having a history of cerebrovascular problems (P = 0.0003), heart failure (P = 0.0027), dementia (P = 0.0452), or in patients that were institutionalized (P = 0.0125), invalid (P = 0.0001), or presented with a complete acute ischemia (P = 0.0002). In multivariate analysis, 3 risk factors remained statistically significant: a previous history of cerebrovascular accident (hazard ratio [HR] = 3.05 [1.54-6.02]; P = 0.0014), cardiac failure (HR = 2.21 [1.23-3.97]; P = 0.0083), and complete ALI (HR = 3.07 [1.64-5.75]; P = 0.0005). CONCLUSIONS: Our study showed that a history of cerebrovascular accident, cardiac failure, or complete ALI is a poor prognostic factor for the 1-year survival of nonagenarians dealt operated for ALI. These elements should be taken into account when deciding either to operate or not in this precise context.
Assuntos
Procedimentos Endovasculares , Isquemia/cirurgia , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares , Doença Aguda , Fatores Etários , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Comorbidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Isquemia/mortalidade , Salvamento de Membro , Masculino , Doença Arterial Periférica/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidadeRESUMO
BACKGROUND: Current decision about when to operate abdominal aortic aneurysms (AAAs) is based only on the maximum aneurysm diameter (MAD). However, small aneurysms still rupture and we can observe very large AAA without any symptom. A simple morphologic analysis could be a tool to assess the risk of rupture. The main objective of this study was to assess the relevance of ratios between MAD and healthy aorta on computed tomography (CT) as a risk factor of AAA rupture. The secondary objective was to evaluate CT signs as risk factors of AAA rupture. METHODS: Retrospective observational bicentric study comparing CT scans of a ruptured AAA group and a control group treated electively was conducted. Appariement 1:1 based on MAD was applied. Ratios between healthy aorta diameters at several levels, celiac trunk (CTR), superior mesenteric artery (SMA), highest renal artery (RA), and the MAD were calculated. The presence of blebs, crescent signs, ruptures of calcifications of the aneurysm sack, and draped aorta were notified. RESULTS: From 2010 to 2016, 38 ruptured AAA and 38 controls were included. Ratios were superior in the rupture group, respectively: MAD/CTR [2.77 (±0.5) versus 2.58 (±0.4) P < 0.095], MAD/SMA [2.92 (±0.7) versus 2.74 (±0.5) P < 0.194], and MAD/RA [3.02 (±0.70) versus 2.76 (±0.5) P < 0.054] but not significatively. Receiver operating characteristic curve analysis demonstrated optimal threshold to detect rupture at 2.8 for the ratio MAD/CTR (area under the curve (AUC) 0.593, sensitivity 47.4%, specificity 78.9%), at 3.3 for the ratio MAD/SMA (AUC 0.564, sensitivity 31.6%, specificity 92.1%), and at 3.3 for the ratio MAD/RA (AUC 0.591, sensitivity 31.6%, specificity 94.7%). Bivariate analysis for rupture risk factor showed significance for the three ratios (MAD/CTR > 2.8 [OR = 11 (1.42; 85.20) P < 0.0217], MAD/SMA > 3.3 [OR = 10 (1.28; 78.12) P < 0.0281], and MAD/RA >3.3 [OR = 11.00 (1.42; 85.20) P < 0.0217]). One scannographic sign was more present in the rupture group: crescent sign 36.8% versus 5.3%, P = 0.0007, as well in bivariate analysis [OR = 7 (1.59; 30.80) P < 0.0326]. CONCLUSIONS: In our experience, specific ratios when they exceed calculated threshold, seem to be more prone to rupture. We could consider that these measures, easy to apply in clinical practice, would be complementary keys for rupture risk individual assessment.
Assuntos
Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/etiologia , Aortografia , Angiografia por Tomografia Computadorizada , Idoso , Idoso de 80 Anos ou mais , Pontos de Referência Anatômicos , Aneurisma da Aorta Abdominal/complicações , Ruptura Aórtica/diagnóstico por imagem , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoAssuntos
Aneurisma da Aorta Abdominal/cirurgia , Endoleak/diagnóstico , Procedimentos Endovasculares/efeitos adversos , Cooperação do Paciente , Fístula Traqueoesofágica/diagnóstico , Idoso , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/patologia , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/diagnóstico , Diagnóstico Tardio , Endoleak/etiologia , Endoleak/cirurgia , Evolução Fatal , Humanos , Perda de Seguimento , Masculino , Tomografia Computadorizada por Raios X , Fístula Traqueoesofágica/etiologiaRESUMO
OBJECTIVE: The aim of this study was to define whether rapidly reallocating health care workers not experienced with PP for performing PP in ICU is feasible and safe. SUMMARY BACKGROUND DATA: In the setting of severe acute respiratory distress syndrome (ARDS), the use of prone and supine positioning procedures (PP) has been associated with improved oxygenation resulting in decreased mortality. Nevertheless, applying PP is time consuming for ICU staffs that are at risk of mental of physical exhaustion, especially with the constant surge of admitted COVID-19 patients with severe ARDS. METHODS: This prospective cohort study conducted at a single regional university hospital between March 27 and April 15, 2020. Among 117 patients admitted to ICU, 67 patients (57.3%) presented with proven SARS-CoV-2 infection with severe ARDS requiring PP. After accelerated simulation training, 109 volunteers including surgeons, physicians, nurses and physiotherapists, multiple dedicated teams performed daily multiple PP following a systematic checklist. Patient demographics and PP data were collected. Patient safety and health care workers safety were assessed. RESULTS: Among 117 patients admitted to ICU, 67 patients (57.3%) required PP. Overall, 53 (79%) were male, with a median age of 68.5 years and median body mass index of 29.3âkg/m. A total of 384 PP were performed. Overall, complication occurred in 34 PP (8.8%) and led to PP cancelation in 4 patients (1%). Regarding health care workers safety, four health care workers presented with potential COVID-19 related symptoms and none was positive. CONCLUSIONS: To overcome the surge of critically ill COVID-19 patients, reallocating health care workers to targeted medical tasks beyond their respective expertise such as PP was safe.
Assuntos
COVID-19/complicações , Mão de Obra em Saúde/organização & administração , Posicionamento do Paciente/métodos , Decúbito Ventral , SARS-CoV-2 , Síndrome Respiratória Aguda Grave/terapia , Síndrome Respiratória Aguda Grave/virologia , Procedimentos Cirúrgicos Operatórios , Idoso , COVID-19/epidemiologia , Lista de Checagem , Surtos de Doenças , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Alocação de Recursos/métodos , Alocação de Recursos/organização & administraçãoRESUMO
INTRODUCTION: The treatment of abdominal aortic aneurysm (AAA) is increasingly performed via endovascular aneurysm repair (EVAR). Different types of fixation are possible with EVAR, i.e., below (infrarenal fixation) or above (suprarenal fixation) the renal arteries. Hemodynamic alterations in renal arterial flow with suprarenal (SR) fixation remain to be demonstrated. The IFIXEAR (Impact of Supra-renal Fixation of EVAR on Hemodynamics of Renal Arteries) study is designed to assess the hemodynamic effects at the ostia of at least 1 renal artery, generated immediately post-surgery by the implantation of an aortic stent with SR fixation. METHODS: IFIXEAR is a prospective, 2 center study. Every patient undergoing elective EVAR with SR fixation is eligible for inclusion. Patients with previous hemodynamic disturbances to the ostia of 1 of the renal arteries are not eligible. All patients undergo echocardiography and renal arteries duplex ultrasound within a month before surgery, and at 1 and 12 months after surgery. The primary endpoint is hemodynamic disturbance, defined as a peak systolic velocity greater than 120âcm/second, at the ostia of 1 of the renal arteries in the immediate postoperative period. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee "Comité de Protection des Personnes Ouest V" under the number 18/019-2 on April 20, 2018. All patients provide written informed consent before inclusion. The University Hospital of Besancon is the trial sponsor. Results of the study will be submitted for publication in a peer-reviewed international medical journal. REGISTRATION: The trial is registered with ClinicalTrials.gov (Identifier: NCT03594786, principal investigator: Dr Patricia Costa, Registered on April 24, 2018).
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Artéria Renal/fisiologia , Feminino , Hemodinâmica , Humanos , MasculinoRESUMO
BACKGROUND: Common femoral artery (CFA) stenting appears as a promising alternative treatment to the open surgery for de novo CFA stenosis. The stenting of lesions just located at the CFA is simple, whereas stenting of CFA bifurcation lesions is more complex, and outcomes are still matter of debate. The aim of this study was to describe and to compare clinical outcomes of techniques used to treat simple over complex lesions for the stenting of CFA lesions. MATERIALS/METHODS: From the French randomized controlled trial, TECCO, a total of 54 patients underwent stenting intervention and were enrolled in this study. Patients were excluded if they had CFA thrombosis, restenosis, and nonatheromatous lesions. Patients were classified by simple and complex lesions based on the type of lesion. The primary end point was the primary sustained clinical improvement. RESULTS: Eighteen patients were included in the simple lesion group, and 36 patients, in the complex lesion group. Baseline characteristics of patients were comparable between the 2 groups. The technical success was 100% in the simple lesion group and 91.7% in the complex lesion group. There was no significant difference between the 2 groups, regarding the primary sustained clinical improvement. The primary patency rates at 24 months for simple and complex lesion groups were 86.3% and 79%, respectively (P = 0.66). Freedom from target lesion revascularization was of 93.3% and 82% in the simple and complex lesion group, respectively (P = 0.34). CONCLUSIONS: The stenting technique for CFA bifurcation lesions is a safe and effective technique. More trials with a large number of patients are needed to define the optimal stenting technique.
Assuntos
Procedimentos Endovasculares/instrumentação , Artéria Femoral , Doença Arterial Periférica/terapia , Stents , Idoso , Constrição Patológica , Procedimentos Endovasculares/efeitos adversos , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , França , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: Patients suffering from chronic mesenteric ischemia are at risk of malnutrition due to the fear of food and weight loss. However, the impact of malnutrition on the morbidity and mortality at the time of surgery is not studied extensively, just as its prevalence. The main objective of this study was to evaluate the influence of malnutrition on the survival of the patients operated for chronic mesenteric ischemia. The secondary objectives were to evaluate the prevalence of malnutrition in this population and to evaluate the early complications after surgery according to the nutritional condition of the patients. METHODS: We conducted a monocentric retrospective observational study including consecutively all the patients operated for chronic mesenteric ischemia between 2005 and 2016. The nutritional status was determined a posteriori according to the criteria of the French High Health Authority using body mass index, the percentage of weight loss, and albumin. We thus divided the patients into 2 groups, "malnourished" and "non-malnourished." We compared the survival of the patients of the 2 groups with a log-rank test. RESULTS: We enrolled 54 patients including 35 men (65%), with a mean age of 68.1 years (±12.3). The prevalence of malnutrition was 70% (38 patients), including 9 severely malnourished patients (23.6%). Twenty-nine patients (53.7%) were treated by endovascular technique, and twenty-five had conventional surgery (46.3%). The type of management was not different between the 2 groups: 20 patients of the malnourished group (52.6%) and 9 patients of the non-malnourished group (56.3%) were treated by endovascular technique (P = 0.8). The 30-day mortality was null in the non-malnourished group, whereas ten patients (26.3%) died in the malnourished group (P = 0.02). The short-term complications were not significantly different between the malnourished and the non-malnourished groups (37% vs. 19%, P = 0.32). The mean duration of follow-up was 639 days (±660). The 3-year survival was not different between the endovascular group and the open surgery group (43% vs. 52%, P = 0.7). The 3-year survival was statistically higher in the non-malnourished group (87%) than in the malnourished group (49.6%) (P = 0.01). CONCLUSIONS: In our experience, preoperative malnutrition is a factor significantly decreasing the survival of the patients treated with open surgery or with endovascular technique for chronic mesenteric ischemia. A more optimal preoperative management of this malnutrition could improve the results of these procedures.