RESUMEN
We report the case of a 62-year-old male who underwent urgent cardiac surgery due to the incidental finding of a huge and asymptomatic coronary button pseudoaneurysm at an 18-month outpatients clinic follow-up requiring a very complex preoperative planning.
Asunto(s)
Aneurisma Falso , Procedimientos Quirúrgicos Cardíacos , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aneurisma Falso/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Humanos , Hallazgos Incidentales , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugíaRESUMEN
BACKGROUND: The incidence of coronary artery disease (CAD) is high in patients with an aortic aneurysm but preoperative routine coronary angiography and preventive coronary revascularization are not recommended to reduce cardiac events in patients with severe CAD. AIM: This study evaluated the safeness and efficacy of preventive percutaneous coronary intervention (PCI) in patients with severe CAD scheduled for endovascular aneurysm repair (EVAR). METHODS: All patients with descending thoracic aneurysm (DTA) or abdominal aortic aneurysm (AAA) scheduled for EVAR underwent preliminary coronary angiography. Based on coronary angiography results, 917 patients (40.7%) had significant CAD and were treated by percutaneous coronary intervention (PCI; CAD group) and 1337 patients (59.3%) were without or with mild/moderate CAD and were considered as controls (no-CAD group). To evaluate the safeness and efficacy of preventive PCI in patients with severe CAD undergoing EVAR, groups were compared for hospital and 12-month cardiac adverse events. RESULTS: CAD was present in 1210 patients (53.6%): significant in 917 patients (38%) and mild to moderate in 293 patients (5.3%). Hospital and 12-month cardiac events occurred in 15 (1.6%) and 13 (1.4%) CAD group patients and in 9 (0.7%) and 8 (0.4%) no-CAD group patients (p = .05 and p = .08), respectively. Hospital and 12-month cardiac deaths occurred in 3 (0.3%) and 2 (0.2%) CAD group patients and in 3 (0.2%) and 2 (0.2%) no-CAD group patients (p = .9 and p = .9), respectively. CONCLUSION: The strategy to treat severe CAD preoperatively by PCI and early subsequent EVAR brings a similar outcome to that in patients without or with mild/moderate CAD.
Asunto(s)
Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Enfermedad de la Arteria Coronaria , Procedimientos Endovasculares , Intervención Coronaria Percutánea , Aneurisma de la Aorta Abdominal/cirugía , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Guidelines advice against dual antiplatelet therapy (DAPT) discontinuation less than 12 months after percutaneous coronary intervention with drug-eluting stents (DES-PCI). However, any delay of necessary surgery in patients with descending thoracic (DTA) or abdominal aortic aneurysm (AAA), treated by DES-PCI, increases the risk of aneurysm rupture/dissection. We evaluated the safety of 8-week waiting time between DES-PCI and endovascular aortic repair (EVAR). 1152 consecutive patients with coronary artery disease (CAD) needing elective DTA or AAA repair were enrolled and divided into two groups. Group A included 830 patients treated by DES-PCI for significant CAD who underwent surgery 8 weeks after implantation. Group B included 322 patients treated by DES-PCI at least 6 months before with no residual significant CAD and treated by elective EVAR. Groups were compared according to a composite of death, myocardial infarction, stent thrombosis, cerebrovascular events and bleeding. No aneurysm rupture/dissection occurred while waiting for surgery. Hospital averse events occurred in 6.2% (52/830) group A patients versus 6.5% (21/322) group B patients (p = 0.8). Mortality was 0.7% (6/830) in group A and 0.9% (3/322) in group B (p = 0.7). Multivariate predictors of events were triple vessel DES-PCI (p < 0.001), > 3 stents implanted (p < 0.001), early-generation stents (p < 0.001), diabetes insulin requiring (p = 0.01), stent diameter < 3.0 mm (p = 0.009) and total stented length > 30 mm (p = 0.02). Eight weeks of waiting after DES-PCI in addition to an adequate management of DAPT were safe in terms of cardiac morbidity and bleeding complications. No aneurysm rupture occurred in the interval before surgery.
Asunto(s)
Aneurisma de la Aorta/cirugía , Enfermedad de la Arteria Coronaria/cirugía , Procedimientos Quirúrgicos Electivos/métodos , Procedimientos Endovasculares/métodos , Intervención Coronaria Percutánea/métodos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Espera Vigilante/métodos , Anciano , Anciano de 80 o más Años , Aneurisma Roto/prevención & control , Aneurisma de la Aorta/complicaciones , Estudios de Cohortes , Enfermedad de la Arteria Coronaria/complicaciones , Stents Liberadores de Fármacos , Femenino , Hemorragia/epidemiología , Hemorragia/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Seguridad , Factores de Tiempo , Resultado del TratamientoRESUMEN
Late aneurysm formation in the proximal aorta or distal aortic arch is a recognized sequela of untreated stenosis of the aortic isthmus and is associated with substantial risk of aortic rupture. We describe the case of a 44-year-old man with untreated coarctation of the aorta who presented with a prestenotic dissecting thoracic aortic aneurysm. He declined surgery because he was a Jehovah's Witness. Instead, we performed emergency endovascular aortic repair in which 2 stent-grafts were placed in the descending aorta. Our experience suggests that this procedure is a useful and safe alternative to open surgery in patients who have aneurysms associated with coarctation of the aorta.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Coartación Aórtica/complicaciones , Disección Aórtica/cirugía , Prótesis Vascular , Procedimientos Endovasculares/métodos , Testigos de Jehová , Adulto , Disección Aórtica/diagnóstico , Disección Aórtica/etiología , Angiografía , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/etiología , Coartación Aórtica/diagnóstico , Coartación Aórtica/cirugía , Humanos , Imagenología Tridimensional , Masculino , Diseño de Prótesis , Tomografía Computarizada por Rayos XRESUMEN
AIMS: Mortality and left ventricular mass (LVM) recovery/regression after aortic valve replacement in patients with prosthesis-patient mismatch (PPM) is controversial. This study evaluated the impact of different values of indexed effective orifice area (EOAi) in male patients on mortality and indexed LVM (ILVM) recovery/regression. METHOD: The study recruited 376 male patients with and without PPM after aortic valve replacement with different EOAi cut-off values. RESULTS: At EOAi 0.85âcm/m or less, 295 patients had PPM (78.5%). ILVM recovery occurred in 60.5% of no-PPM patients versus 46.1% of patients with PPM (Pâ=â0.003), and ILVM regression was 35 versus 25% (Pâ<â0.001). Time for ILVM regression was shorter in no-PPM group. At EOAi 0.75âcm/m or less, 201 patients had PPM (53.4%). ILVM recovery occurred in 55.4% of no-PPM patients versus 45.2% of patients with PPM (Pâ=â0.06), regression was 32 versus 29% (Pâ=â0.09). Time for ILVM regression was similar between groups. Regardless the cut-off value for PPM definition, mortality was similar. CONCLUSION: LVM recovery/regression, but not mortality, was different at different EOAi. The cut-off value at EOAi 0.75âcm/m or less guaranteed a more balanced patient distribution between groups and the best compromise between specificity and sensitivity.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Hipertrofia Ventricular Izquierda/fisiopatología , Diseño de Prótesis , Función Ventricular Izquierda , Remodelación Ventricular , Anciano , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Bases de Datos Factuales , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/etiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: This study was undertaken to determine the impact of a strategy of systematic coronary angiography on immediate- and long-term outcome of patients at medium-high risk who were undergoing surgical treatment of peripheral arterial disease. BACKGROUND: Despite pre-operative risk stratification according to the current guidelines, vascular surgery patients still represent a high-risk population, as 30-day cardiovascular complications and mortality rates still remain as high as 15% to 20% and 3% to 5%, respectively. METHODS: In all, 208 consecutive patients scheduled for elective surgical treatment of major vascular disease and with a revised cardiac risk index > or =2 were randomly allocated to either a "selective strategy" group (group A, n = 103), in whom coronary angiography was performed based on the results of noninvasive tests, or to a "systematic strategy" group (group B, n = 105), consisting of patients who systematically underwent pre-operative coronary angiography. RESULTS: The 2 groups were similar with respect to baseline clinical characteristics, revised cardiac risk index, and type of vascular surgery performed. The myocardial revascularization rate in group B was higher than in group A (58.1% vs. 40.1%; p = 0.01). In-hospital major adverse cardiovascular event rate was not significantly lower in group B (p = 0.07). At 58 +/- 17 months of follow-up, group B showed significantly better survival (p = 0.01) and freedom from death/cardiovascular events (p = 0.003). CONCLUSIONS: In this study, a strategy of routine coronary angiography positively impacted long-term outcome of peripheral arterial disease surgical patients at medium-high risk. This is the first such demonstration in a randomized, prospective trial. Multicenter trials to confirm this finding in a larger population are warranted.