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1.
Eur J Vasc Endovasc Surg ; 58(1S): S1-S109.e33, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31182334

RESUMO

GUIDELINE SUMMARY: Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.


Assuntos
Procedimentos Endovasculares/normas , Isquemia/cirurgia , Salvamento de Membro/normas , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/complicações , Guias de Prática Clínica como Assunto , Procedimentos Endovasculares/métodos , Carga Global da Doença , Humanos , Cooperação Internacional , Isquemia/diagnóstico , Isquemia/epidemiologia , Isquemia/etiologia , Salvamento de Membro/métodos , Extremidade Inferior/cirurgia , Doença Arterial Periférica/cirurgia , Prevalência , Qualidade de Vida , Índice de Gravidade de Doença , Sociedades Médicas/normas , Especialidades Cirúrgicas/normas , Resultado do Tratamento
2.
Surg Today ; 42(2): 121-6, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-22072152

RESUMO

PURPOSE: We conducted this study to compare the cost of open surgical repair (OR) with that of endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm (AAA). METHODS: Between January 2007 and November 2008, 70 patients underwent open repair and 57 patients underwent EVAR. We evaluated the total cost, including that of the Diagnosis Procedure Combination (DPC), that of the surgical procedure, that of materials such as grafts and guide wires, and that of the anesthesia. RESULTS: The mean costs for OR versus EVAR were as follows: DPC, ¥632,370 versus ¥490,050, respectively, which was significant; anesthesia, ¥123,540 versus ¥86,220, respectively (P < 0.05); and materials, ¥257,770 versus ¥2,113,280, respectively (P < 0.05). Thus, the mean total cost was ¥1,825,830 versus ¥3,159,270 for open repair and EVAR, respectively (P < 0.05). CONCLUSIONS: New technologies should not only be clinically effective, but also cost effective. EVAR is less invasive clinically, but the cost of endovascular prostheses and other materials remains high.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/economia , Procedimentos Endovasculares/economia , Custos Hospitalares/estatística & dados numéricos , Laparotomia/economia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/economia , Implante de Prótese Vascular/métodos , Análise Custo-Benefício , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Humanos , Laparotomia/métodos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
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