RESUMO
OBJECTIVE: A crucial step in designing fenestrated stent grafts for treatment of complex aortic abdominal aneurysms is the accurate positioning of the fenestrations. The deployment of a fenestrated stent graft prototype in a patient-specific rigid aortic model can be used for design verification in vitro, but is time and human resources consuming. Numerical simulation (NS) of fenestrated stent graft deployment using the finite element analysis has recently been developed; the aim of this study was to compare the accuracy of fenestration positioning by NS and in vitro. METHODS: All consecutive cases of complex aortic abdominal aneurysm treated with the Fenestrated Anaconda (Terumo Aortic) in six European centers were included in a prospective, observational study. To compare fenestration positioning, the distance from the center of the fenestration to the proximal end of the stent graft (L) and the angular distance from the 0° position (C) were measured and compared between in vitro testing (L1, C1) and NS (L2, C2). The primary hypothesis was that ΔL (|L2 - L1|) and ΔC (|C2 - C1|) would be 2.5 or less mm in more than 80% of the cases. The duration of both processes was also compared. RESULTS: Between May 2018 and January 2019, 50 patients with complex aortic abdominal aneurysms received a fenestrated stent graft with a total of 176 fenestrations. The ΔL and ΔC was 2.5 mm or less for 173 (98%) and 174 (99%) fenestrations, respectively. The NS process duration was significantly shorter than the in vitro (2.1 days [range, 1.0-5.2 days] vs 20.6 days [range, 9-82 days]; P < .001). CONCLUSIONS: Positioning of fenestrations using NS is as accurate as in vitro and could significantly decrease delivery time of fenestrated stent grafts.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Modelos Cardiovasculares , Complicações Pós-Operatórias/epidemiologia , Stents/efeitos adversos , Aorta Abdominal/anatomia & histologia , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Simulação por Computador , Humanos , Modelos Anatômicos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Desenho de Prótese , Resultado do TratamentoRESUMO
BACKGROUND: Preoperative decolonization is recommended in Staphylococcus aureus nasal carriers scheduled for cardiac surgery. We aimed to evaluate the effectiveness of and compliance with mupirocin use in nasal S. aureus carriers in a real-life setting. METHODS: Prospective study including consecutive patients scheduled for cardiac surgery screened for S. aureus nasal carriage at preoperative consultation. Carriers were prescribed mupirocin nasal ointment, chlorhexidine shower and mouthwash. Effectiveness of decolonization was evaluated with a postoperative nasal sample. Compliance was evaluated objectively by determination of nasal mupirocin concentration using UPLC-MS/MS and self-reported by questionnaire. RESULTS: Over 10 months, 361 patients were included, 286 had preoperative screening, 75 (26.2%) were S. aureus nasal carriers and 19 of them (25.3%) failed to be effectively decolonized. No resistance to mupirocin was documented. Preoperative and postoperative strains were identical in all cases. Declared good compliance was associated with decolonization success (OR = 24; 95% CI 4-143, P < 0.0001). Mupirocin detection was significantly associated with the level of compliance. Mupirocin was detected in 52.2% (24/46) of patients effectively decolonized and in 12.5% (2/16) of patients with decolonization failure (P < 0.01). In 2/19 patients, failure of decolonization was not associated with a compliance issue. Postoperative carriage was associated with an increased risk of S. aureus infection (OR = 9.8; 95% CI 1.8-53, P < 0.01). CONCLUSIONS: In real life, decolonization is not always effective, hence there is a persisting risk of S. aureus endogenous infection. Mupirocin concentration measurement may help to understand compliance issues and failures in decolonization.
Assuntos
Mupirocina , Infecções Estafilocócicas , Administração Intranasal , Antibacterianos/uso terapêutico , Portador Sadio/tratamento farmacológico , Clorexidina/uso terapêutico , Cromatografia Líquida de Alta Pressão , Cromatografia Líquida , Humanos , Mupirocina/uso terapêutico , Pomadas/uso terapêutico , Estudos Prospectivos , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus aureus , Infecção da Ferida Cirúrgica/tratamento farmacológico , Espectrometria de Massas em TandemRESUMO
OBJECTIVES: With a focus on renal function, the goal of this multicentre study was to assess peri-operative complications and late mortality of open surgical repair (OSR) of juxtarenal abdominal aortic aneurysms (JRAAA). METHODS: From February 2005 to December 2015, 315 consecutive patients undergoing elective OSR of a JRAAA in five French academic centres were evaluated retrospectively. The definition of JRAAA was an aortic aneurysm extending up to but not involving the renal arteries, i.e., a short neck <10 mm. End points included post-operative death; acute kidney injury (AKI) defined by the RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease) criteria; and long term follow-up with freedom from chronic renal decline (CRD) and any graft related complications. Factors predictive of renal insufficiency were determined by multivariable analysis. RESULTS: Of 315 patients, 292 (92.6%) were men (mean age 68 ± 8 years), and 73 (23.2%) had baseline chronic kidney disease (CKD) with an estimated glomerular filtration rate of <60 mL/min/1.73 m2. The level of aortic clamping was supracoeliac (n = 11), suprarenal (n = 235), or inter-renal above one renal artery (n = 69). The mean duration of renal artery clamping was 24 ± 7 min (range 10-55 min). Eleven patients (3.5%) presented with a renal artery stenosis that was treated conservatively. Perfusion of the renal arteries with a chilled Ringer's solution was used selectively in seven patients (2.2%). The overall 30 day mortality was 0.9% (three patients). AKI occurred in 53 patients (16.8%). Nine patients (2.9%) required temporary dialysis and one patient required chronic dialysis. Predictors of AKI were pre-existing CKD (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.13-4.48; p = .021], diabetes (OR 3.15, 95% CI 1.48-6.71; p = .003), hypertension (OR 3.38, 95% CI 1.33-8.57; p = .01), and age (OR 1.05, 95% CI 1.01-1.10; p = .014). The level of aortic clamping and duration of renal artery clamping were not associated with an increased risk of AKI. The Kaplan-Meier survival estimate was 71% ± 5% at five years. Predictors of CRD during follow up were AKI (hazard ratio [HR] 15.81, 95% CI 5.26-47.54; p = .001), diabetes (HR 4.56, 95% CI 1.57-13.17; p = .005), and pre-existing CKD (HR 2.93, 95% CI 1.19-7.20; p = .019), with freedom from CRD of 89% ± 3% at five years. Surveillance imaging was obtained by computed tomography angiography in 290 patients (92.6%) at a mean follow up of 4.3 ± 2.4 years. Renal artery occlusion occurred in two patients (0.7% of imaged renal arteries). One patient (1.9%) had an aneurysm of the visceral aorta and eight patients had a descending thoracic aneurysm. CONCLUSIONS: This multicentre study suggests that in fit patients, open JRAAA repair can be performed with acceptable operative risk with durable results in terms of both graft integrity and preservation of renal function.
Assuntos
Injúria Renal Aguda/epidemiologia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Obstrução da Artéria Renal/epidemiologia , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/fisiopatologia , Fatores Etários , Idoso , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/métodos , Comorbidade , Diabetes Mellitus/epidemiologia , Feminino , Seguimentos , França , Humanos , Hipertensão/epidemiologia , Estimativa de Kaplan-Meier , Rim/irrigação sanguínea , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Artéria Renal/diagnóstico por imagem , Artéria Renal/cirurgia , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/etiologia , Obstrução da Artéria Renal/fisiopatologia , Insuficiência Renal Crônica/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
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: Although autogenous venous grafts are preferable for below-the-knee bypass surgery in patients with critical limb ischemia, some 20% of patients will have no suitable vein for grafting, compelling a resort to artificial graft materials. Retrospective subgroup analyses within published studies comparing heparin-bonded polytetrafluoroethylene (PTFE) with crude PFTE graft in below-the-knee bypass suggest that heparin-bonded graft offers superior long-term patency rates, but this has not been prospectively verified in patients with critical limb ischemia. METHODS: A single-blind randomized controlled trial in 20 French centers has been designed. Patients assessed as having no suitable autologous vein for bypass grafting for critical lower limb ischemia will be randomized to receive either a heparin-bonded PTFE graft or a crude PTFE graft. A literature review suggested expected 1-year patency rates of 53% for the crude ePTFE arm and 74% for the heparin-bonded PTFE arm. On analyzing 1-year patency rate as a binary variable, for a significance level α = 0.05 and a randomization ratio of 1:1, a total of 176 patients (88 in each arm) will be required to obtain approximately 80% power to reject the null hypothesis. Assuming 10% dropout at 1 year and 20% mortality, 228 patients will be randomized (114 patients in each arm). RESULTS: The primary outcome variable will be patency at 1 year assessed by duplex ultrasound color-flow scan. Any intervention to open up or prevent a graft occlusion before 1 year will be classified as loss of patency. Technical success, deaths, complications, major adverse cardiovascular and limb events, length of hospitalization, and quality of life will also be recorded and analyzed as secondary outcome variables. Cost-utility and cost-effectiveness analyses based on standard tariffs in the French health insurance system will be performed. CONCLUSIONS: The REPLACE trial is the first randomized controlled trial designed to determine if heparin-bonded PTFE graft is superior to crude PTFE graft in below-the-knee bypass surgery for critical limb ischemia.
Assuntos
Anticoagulantes/administração & dosagem , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Materiais Revestidos Biocompatíveis , Heparina/administração & dosagem , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Politetrafluoretileno , Anticoagulantes/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , França , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Heparina/efeitos adversos , Humanos , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Estudos Multicêntricos como Assunto , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: The purpose of this study was to report our experience of treatment of aortic aneurysms using combination of renal and visceral arteries bypasses and fenestrated/branched stent graft in various complex anatomical situations. METHODS: Between November 2005 and March 2017, 10 patients underwent a hybrid strategy combining bypasses for renal and/or visceral arteries and custom-made fenestrated/branched stent grafts. Two patients had abdominal aortic aneurysm (1 juxtarenal and 1 suprarenal), and 8 patients had thoracoabdominal aortic aneurysm (1 type I, 2 type II including one dissection, 2 type III, 1 type IV, and 2 type V). In total, 37 renal and visceral arteries were targeted, of which 23 were treated using fenestrated or branched stent graft and 14 were treated by bypass (11 to renal artery and 3 to celiac trunk). RESULTS: Technical success was 100%, and no patient died during a mean follow-up of 24.3 ± 21 months. Six patients had 7 postoperative complications after bypass surgery, and 3 patients had 3 complications after fenestrated or branched endovascular aneurysm repair (FEVAR/BEVAR) procedure. Seven reinterventions were performed in 3 patients. No occlusion of target vessels occurred. Renal function was stable during follow-up in all patients except one who developed end-stage renal failure requiring permanent dialysis. On the last follow-up computed tomography scan, aneurysm diameter decreased for 6 patients, was stable for 3 patients, and increased for one patient, in which persistent type II endoleak was observed. Aneurysm exclusion was complete in the remaining 9 patients. CONCLUSIONS: Combination of FEVAR/BEVAR procedures with renal and/or visceral artery bypass in patients with complex aortic aneurysms is feasible with acceptable results. Morbidity associated with bypass surgery has to be carefully balanced with the risk of catheterization difficulties in the setting of adverse anatomical features of the visceral/renal arteries or the aorta.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Artéria Renal/cirurgia , Stents , Vísceras/irrigação sanguínea , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , França , Humanos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Desenho de Prótese , Artéria Renal/diagnóstico por imagem , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: The objective of this study was to evaluate the early and long-term outcome of cryopreserved arterial allografts (CAAs) used for in situ reconstruction of abdominal aortic native or secondary graft infection and to identify predictors of mortality. METHODS: We retrospectively included 71 patients (mean age, 65.2 years [range, 41-84 years]; men, 91.5%) treated for abdominal aortic native or secondary graft infection (65 prosthetic graft infections; 16 of them had secondary aortoenteric fistula, 2 venous graft infections, and 4 mycotic aneurysms) by in situ reconstruction with CAA in the university hospitals of Clermont-Ferrand and Saint-Etienne from 2000 to 2016. The cryopreservation protocol was identical in both centers (-140°C). Early (<30 days) and late (>30 days) mortality and morbidity, reinfection, and CAA patency were assessed. Computed tomography was performed in all survivors. Survival was analyzed with the Kaplan-Meier method. Univariate analyses were performed with the log-rank test and multivariate analysis with the Cox regression model. RESULTS: Mean follow-up was 45 months (0-196 months). Early postoperative mortality rate was 16.9% (11/71). Early postoperative CAA-related mortality rate was 2.8% (2/71); both patients died of proximal anastomotic rupture on postoperative days 4 and 15. Early CAA-related reintervention rate was 5.6% (4/71); all had an anastomotic rupture, and two were lethal. Early postoperative reintervention rate was 15.5% (11/71). Intraoperative bacteriologic samples were positive in 56.3%, and 31% had a sole microorganism. Escherichia coli was more frequently identified in the secondary aortoenteric fistula and Staphylococcus epidermidis in the infected prosthesis. Late CAA-related mortality rate was 2.8%: septic shock at 2 months in one patient and proximal anastomosis rupture at 1 year in one patient. Survival at 1 year, 3 years, and 5 years was 75%, 64%, and 54%, respectively. Multivariate analysis identified type 1 diabetes (hazard ratio, 2.49; 95% confidence interval, 1.05-5.88; P = .04) and American Society of Anesthesiologists class 4 (hazard ratio, 2.65; 95% confidence interval, 1.07-6.53; P = .035) as predictors of mortality after in situ CAA reconstruction. Reinfection rate was 4% (3/71). Late CAA-related reintervention rate was 12.7% (9/71): proximal anastomotic rupture in one, CAA branch stenosis/thrombosis in five, ureteral-CAA branch fistula in one, and distal anastomosis false aneurysm in two. Primary patency at 1 year, 3 years, and 5 years was 100%, 93%, and 93%, respectively. Assisted primary patency at 1 year, 3 years, and 5 years was 100%, 96%, and 96%, respectively. No aneurysm or dilation was observed. CONCLUSIONS: The prognosis of native or secondary aortic graft infections is poor. Aortic in situ reconstruction with CAA offers acceptable early and late results. Patients with type 1 diabetes and American Society of Anesthesiologists class 4 are at higher risk of mortality.
Assuntos
Aneurisma Infectado/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Artérias/transplante , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular/efeitos adversos , Criopreservação , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Infecções Relacionadas à Prótese/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aloenxertos , Aneurisma Infectado/diagnóstico , Aneurisma Infectado/microbiologia , Aneurisma Infectado/mortalidade , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/microbiologia , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/mortalidade , Angiografia por Tomografia Computadorizada , Remoção de Dispositivo , Procedimentos Endovasculares/mortalidade , Feminino , França , Hospitais Universitários , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: This study describes the long-term results of renal autotransplantation for renovascular hypertension performed in children who are now 21 years of age or older. METHODS: Sixteen children (4 boys, 12 girls) with a mean age of 11.2 years at the time of the procedure underwent ex-vivo surgery at the university hospital of Saint-Etienne between 1992 and 2008. Acetylsalicylic acid was used for antiplatelet therapy in the postoperative period, without routine anticoagulation. The mean follow-up period was 15 years. The clinical course of these patients was retrospectively reviewed in adulthood and the results analyzed. RESULTS: The children were treated with a mean of 2.37 drugs per patient, and the mean preoperative blood pressure of the entire patient population was 151/89 mmHg. Mean preoperative creatinine clearance was 80 ml/min/1.73 m2. There was no postoperative death. One patient experienced a thrombosis immediately after the surgery, leading to a redo surgery. In this patient diuresis was restarted, but without efficient concentration and filtration, ultimately leading the patient to have a renal transplant after 1 year. At the end of the follow-up period, eight of the 16 patients (50%) were cured and the others were improved. At the last follow-up the mean blood pressure was 127/70 mmHg, and the mean number of drugs per patient was 0.68. The mean creatinine clearance at last follow-up was 104.3 ml/min/1.73 m2. Three patients had secondary procedures, with two undergoing percutaneous angioplasty (at postoperative months 9 and 12, respectively) and one having an hepatorenal bypass at postoperative year 4. Primary patency was 12/16 (75%); primary assisted patency was 15/16 (94%); secondary patency was 16/16 (100%). CONCLUSION: This study shows that renal autotransplantation has good and stable long-term results and is an effective conservative strategy for treating renovascular hypertension in children, thus avoiding nephrectomy.
Assuntos
Hipertensão Renovascular/cirurgia , Complicações Pós-Operatórias/epidemiologia , Artéria Renal/transplante , Trombose/epidemiologia , Enxerto Vascular/efeitos adversos , Adolescente , Adulto , Criança , Quimioterapia Combinada/métodos , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Hipertensão Renovascular/diagnóstico , Hipertensão Renovascular/etiologia , Hipertensão Renovascular/fisiopatologia , Rim/irrigação sanguínea , Rim/fisiopatologia , Masculino , Inibidores da Agregação Plaquetária/uso terapêutico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Trombose/etiologia , Trombose/prevenção & controle , Transplante Autólogo/efeitos adversos , Transplante Autólogo/métodos , Resultado do Tratamento , Enxerto Vascular/métodos , Grau de Desobstrução Vascular , Adulto JovemRESUMO
BACKGROUND: Kidney recipients are increasingly older with arterial disease and extended arterial calcifications. In a kidney transplantation population, the prognosis value of aortic and iliac calcifications remains poorly explored. We aimed to assess the impact of pretransplantation aortoiliac vascular calcifications on patients, grafts survival, and cardiovascular events. METHODS: This retrospective study included kidney transplantation patients from 2006 to 2012 for whom we had available presurgery abdominal computed tomography results (n = 100). We designed a score to quantify aortoiliac calcifications. Primary end points were patient and graft survival. Secondary end points were renal function and cardiovascular morbidity. Predictive performances of calcification score were assessed using area under receiver-operating characteristic curves. Patients were classified in quartiles depending on global calcium score value. RESULTS: The cumulated rate of death and graft loss was 13% with no significant differences for survival between quartiles. No significant difference was observed in renal function (P = 0.4). Seventeen cardiovascular events were registered with a significant correlation between calcium score elevation and need of cardiovascular surgery during the follow-up (P = 0.01). Global calcium score had a predictive value of 74.5% (95% confidence interval 0.62-0.87) with 71% sensitivity and 73% specificity. CONCLUSIONS: Aortoiliac calcifications do not decrease patient and graft survival. High calcium score predict cardiovascular events and procedures during the follow-up.
Assuntos
Doenças da Aorta/complicações , Artéria Ilíaca , Transplante de Rim , Calcificação Vascular/complicações , Idoso , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Área Sob a Curva , Angiografia por Tomografia Computadorizada , Feminino , Sobrevivência de Enxerto , Humanos , Artéria Ilíaca/diagnóstico por imagem , Estimativa de Kaplan-Meier , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/mortalidadeRESUMO
An 81-year-old woman was referred for the treatment of a 79-mm-diameter short neck abdominal aortic aneurysm with highly tortuous iliac arteries. She was considered at high risk for open repair and not suitable for standard endovascular repair given the short length of the proximal neck. Delay for a manufactured custom-made fenestrated stent graft was too long given the diameter of the aneurysm. A flexible stent graft was preferred because of severe iliac tortuosity. Endovascular repair was performed using a physician-modified Anaconda stent graft with 1 fenestration for the left renal artery. The technique for device modification and implantation is described. Postoperative course was uneventful and 1-year computed tomography scan showed complete exclusion of the aneurysm sac and patent left renal artery.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia/instrumentação , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Desenho de Prótese , Resultado do TratamentoRESUMO
We present a technique of mitral valve surgery performed in a patient with severe pectus excavatum and previous Bentall surgery. Neither redo sternotomy nor conventional right minithoracotomy were thought to provide adequate surgical access to the mitral valve. We therefore opted for a combined procedure comprising sternal reconstruction and right minithoracotomy mitral valve replacement. The mitral valve was replaced and the sternum reconstructed according to the Ravitch technique.
Assuntos
Tórax em Funil/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Esterno/cirurgia , Toracotomia/métodos , Adulto , Humanos , Masculino , Reoperação , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
PURPOSE: To assess numerically the flexibility and mechanical stresses undergone by stents and fabric of currently manufactured stent-grafts. METHODS: Eight marketed stent-graft limbs (Aorfix, Anaconda, Endurant, Excluder, Talent, Zenith Flex, Zenith LP, and Zenith Spiral-Z) were modeled using finite element analysis. A numerical benchmark combining bending up to 180° and pressurization at 150 mmHg of the stent-grafts was performed. Stent-graft flexibility, assessed by the calculation of the luminal reduction rate, maximal stresses in stents, and maximal strains in fabric were assessed. RESULTS: The luminal reduction rate at 90° was <20% except for the Talent stent-graft. The rate at 180° was higher for Z-stented models (Talent, Endurant, Zenith, and Zenith LP; range 39%-78%) than spiral (Aorfix, Excluder, and Zenith Spiral-Z) or circular-stented (Anaconda) devices (range 14%-26%). At 180°, maximal stress was higher for Z-stented stent-grafts (range 370-622 MPa) than spiral or circular-stented endografts (range 177-368 MPa). At 90° and 180°, strains in fabric were low and did not differ significantly among the polyester stent-grafts (range 0.5%-7%), while the expanded polytetrafluoroethylene fabric of the Excluder stent-graft underwent higher strains (range 11%-18%). CONCLUSION: Stent design strongly influences mechanical performances of aortic stent-grafts. Spiral and circular stents provide greater flexibility, as well as lower stress values than Z-stents, and thus better durability.
Assuntos
Prótese Vascular , Análise de Elementos Finitos , Stents , Aneurisma da Aorta Abdominal/cirurgia , Fenômenos Mecânicos , Desenho de PróteseRESUMO
The case is reported of a surgical aortic valvular stenosis with a severely calcified ascending aortic root in a 76-year-old woman. The morphology and size of the aortic annulus were unsuitable for transcatheter aortic valve implantation (TAVI); thus, surgery was scheduled. Aortic calcifications allowed a transverse aortotomy 4 cm superior to the sinotubular junction, with a remote endoaortic view of the valve. A Medtronic 3f Enable sutureless bioprosthesis was then implanted after aortic annular decalcification. Sutureless bioprostheses are new tools that promise to reduce technical difficulties and cross-clamp times in minimally invasive aortic valve replacement surgery. In addition, sutureless techniques may have other possible advantages in special circumstances requiring full sternotomy access, such as in the present case.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Calcinose/cirurgia , Cateterismo Cardíaco/métodos , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Índice de Gravidade de Doença , Idoso , Valva Aórtica/patologia , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/patologia , Estenose da Valva Aórtica/fisiopatologia , Bioprótese , Calcinose/patologia , Calcinose/fisiopatologia , Feminino , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Imageamento Tridimensional , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Carotid angioplasty and stenting has been proposed as an alternative to carotid endarterectomy (CEA) in patients deemed as at high risk for this surgical procedure. To date, definitely accepted criteria to identify "high-risk" patients for CEA do not exist. Our objective was to assess the relevance of numerous supposed high-risk factors in our experience, as well as their possible effect on our early postoperative results. METHODS: A retrospective review of 1,033 consecutive CEAs performed during a 5.6-year period at a single institution was conducted (Vascular Surgery Department, St. Etienne University Hospital, France). Early results in terms of mortality and neurologic events were recorded. Univariate and multivariate analyses for early risk of stroke, myocardial infarction, and death were performed, considering the influence of age, sex, comorbidities, clinical symptoms, and anatomic features. RESULTS: The cumulative 30-day stroke and death rate was 1.2%. A total of 10 strokes occurred and resulted in three deaths. The postoperative stroke risk was significantly higher in the subgroup of patients treated for symptomatic carotid artery disease: 2,6% (P = 0,004). Univariate analysis and logistic regression did not show statistical significance for 30-day results in any of the considered variables. CONCLUSION: Patients with significant medical comorbidities, contralateral carotid occlusion, and high carotid lesions can undergo surgery without increased complications. Those parameters should not be used as exclusion criteria for CEA.
Assuntos
Artéria Carótida Interna/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Hospitais Universitários/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/mortalidade , Distribuição de Qui-Quadrado , Endarterectomia das Carótidas/mortalidade , Feminino , França , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Razão de Chances , Seleção de Pacientes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: Aberrant subclavian artery (ASCA) occurs rarely but is one of the most frequent anatomical variations of the supra-aortic trunks. No consensus has been established on its best treatment. The goal of this study was to report the outcomes of ASCA treated by the hybrid approach. METHODS: This non-interventional retrospective multicentre analysis included patients treated for ASCA by the hybrid approach in 12 French university hospitals between 2007 and 2019. The hybrid approach was defined as an endovascular procedure combined with open surgery or a hybrid stent graft. Patients were divided in 4 groups (from less to more complex treatment). The primary end point was 30-day mortality. The secondary end points were 30-day complications and late mortality. RESULTS: This study included 43 patients. The mean age was 65 (SD, standard deviation: 16) years. Symptoms were found in 33 patients. Subclavian revascularization combined with aberrant subclavian artery occlusion was undertaken in 13 patients. Unilateral and bilateral subclavian revascularization combined with a thoracic aortic stent graft was undertaken in 11 and 6 patients, respectively. Total aortic arch repair combined with a thoracic aortic stent graft was undertaken in 13 patients. Thirty-day mortality was 2.3% with a technical success rate of 95.3%. The 30-day major postoperative complication rate was 16.3%: 4 strokes, 2 tamponades, 1 acute respiratory distress syndrome. Mean follow-up was 56.3 (SD: 44.7) months. The late mortality was 18.6%. CONCLUSIONS: The ASCA hybrid approach is feasible, safe and effective with low early mortality. Morbidity is rather high. However, it increases with the complexity of the hybrid approach, which should be kept as simple as possible if the anatomical morphology allows.
Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Anormalidades Cardiovasculares , Procedimentos Endovasculares , Idoso , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Anormalidades Cardiovasculares/cirurgia , Procedimentos Endovasculares/efeitos adversos , Humanos , Estudos Retrospectivos , Artéria Subclávia/anormalidades , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND AND AIM OF THE STUDY: Redo aortic valve surgery (AVS) in patients with patent pedicled internal thoracic artery (ITA) grafts remains a challenging procedure because of the possibility of injury to the grafts and difficulties in optimal myocardial protection. This procedure is associated with a significant mortality and morbidity. Different approaches to myocardial protection and ITA graft dissection and control have been described. An intraoperative technique is proposed that provides endovascular control of the ITA graft, using an angioplasty balloon positioned during cross-clamping. METHODS: Ten consecutive patients with previous coronary artery bypass grafting (CABG) and a patent pedicled ITA who underwent AVS were studied. The ITA grafts were occluded by using an angioplasty balloon during cross-clamping, but were not dissected and controlled. RESULTS: Endovascular control of the ITA graft was feasible in all cases, without complication. Two intraoperative complications (both graft injuries) were observed; one injury of an ITA graft, and one injury of a radial artery graft. There was no postoperative mortality. One myocardial infarct was related to the injury of a radial graft. The clamped ITA grafts were studied at two months after the procedure in five patients, and showed all grafts to be patent. At a mean follow up of 13 months, all patients were alive without any coronary events. CONCLUSION: The endovascular control of a patent ITA graft during redo AVS is a safe and simple technique that reduces the risk of ITA graft injury and also improves myocardial protection.
Assuntos
Valva Aórtica/cirurgia , Oclusão com Balão , Implante de Prótese Vascular , Procedimentos Endovasculares , Implante de Prótese de Valva Cardíaca , Anastomose de Artéria Torácica Interna-Coronária , Artéria Torácica Interna/transplante , Idoso , Idoso de 80 Anos ou mais , Oclusão com Balão/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Constrição , Procedimentos Endovasculares/efeitos adversos , Feminino , França , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Artéria Torácica Interna/fisiopatologia , Pessoa de Meia-Idade , Reoperação , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
PURPOSE: To evaluate the medium-term outcomes following aortic aneurysm repair utilizing fenestrated endografts performed in 13 French academic centers. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data. All patients had asymptomatic aneurysms involving or close to the visceral-bearing abdominal aorta and were judged to be at high-risk for open surgical repair. Fenestrated endografts were designed using computed tomography reconstructions performed on three-dimensional workstations. The procedures were conducted under fluoroscopic control by experienced endovascular teams. All patients were evaluated with computed tomography, duplex ultrasound, and plain film radiograph at discharge, 6, 12, 18, and 24 months, and annually thereafter. RESULTS: Eighty patients (78 males) were treated over 44 months (May 2004-January 2008). Median age and aneurysm size were 78 years (range: 48-90 years) and 59 mm (range: 47-82 mm), respectively. A total of 237 visceral vessels were perfused through a fabric fenestration (median of 3 per patient). One early conversion to open surgery was required. Completion angiography showed that 234 of 237 (99%) target vessels were patent. Two patients (2.5%) died within 30 days of device implantation. Predischarge imaging identified 9 (11%) endoleaks: 3 type I, 5 type II, and 1 type III. The median duration of follow-up was 10 months (range: 1-38 months). No aneurysms ruptured or required open conversion during the follow-up period. Four of 78 (5%) died during follow-up (actuarial survival at 24 months 92%), none of these deaths were aneurysm related. Aneurysm sac size decreased by more than 5 mm in 33%, 53%, and 58% at 6, 12, and 18 months, respectively. One patient had sac enlargement within the first year, associated with a persistent type II endoleak. In-stent stenoses or occlusion affected 4 renal arteries. Secondary procedures were performed in 8 patients (10%) during follow-up, 5 to correct endoleaks and 3 to correct threatened visceral vessels. CONCLUSIONS: The use of endovascular prostheses with graft material incorporating the visceral arteries is safe in high risk patients with high risk aneurysms. In the medium-term it is effective in preventing rupture. However, meticulous follow-up to assess sac behavior and visceral ostia is critical to ensure optimal results.
Assuntos
Aorta/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Prótese Vascular , Idoso , Idoso de 80 Anos ou mais , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
Ascending aortic pseudoaneurysm following prior cardiac or aortic surgery is a rare entity that requires reoperation. Surgical repair is a complex procedure associated with high operative mortality. We report the case of a 76-year-old male patient with an ascending aortic pseudoaneurysm developing from distal anastomosis of a Dacron aorto-aortic prosthesis. This high-risk patient had previously undergone multiple cardiovascular operations and was treated by performing an extra-anatomic bypass between the descending thoracic aorta and supra-aortic vessels, followed by endovascular stent graft placement, avoiding median re-sternotomy.
Assuntos
Falso Aneurisma/cirurgia , Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Esternotomia , Toracotomia , Idoso , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/etiologia , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Evolução Fatal , Humanos , Masculino , Reoperação , Choque Séptico/etiologia , Stents , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Nowadays, most patients who undergo colorectal surgery are discharged early. An early predictor of septic complications could avoid readmissions and decrease morbidity. CRP could be a good predictor allowing a safe discharge. METHODS: A prospective, observational study was conducted from November 2007 to October 2008. All patients who underwent elective colorectal surgery were included. Clinical (temperature, pulse, abdominal tenderness, bowel movements) and laboratory data (C-reactive protein, leukocyte count) were recorded and evaluated as early predictors of septic complications (namely, anastomotic leaks). All detected leaks were considered fistulas, independently of their clinical significance. Clinical and inflammatory parameters were analyzed with univariate and multivariate techniques; logistic regression was performed and areas under the receiver operating characteristic curve were compared. RESULTS: A total of 133 patients were included. The overall incidence of anastomotic leaks was 15.5% and mortality was 4.5%. C-reactive protein at postoperative days 2 and 4 was a good predictor of anastomotic leak (areas under the curve were 0.715 and 0.845, respectively) and other postoperative septic complications (areas under the curve were 0.804 and 0.787), showing the highest accuracy among clinical and laboratory data. A cutoff of 125 mg/l in the level of C-reactive protein at postoperative day 4 yielded a sensitivity of 81.8% and a negative predictive value of 95.8% for the detection of anastomotic leakage. CONCLUSIONS: C-reactive protein is a simple way to ensure a safe discharge from hospital after elective colorectal surgery. Patients with CRP values >125 mg/l on the fourth postoperative day should not be discharged.
Assuntos
Proteína C-Reativa/metabolismo , Cirurgia Colorretal , Complicações Pós-Operatórias/sangue , Sepse/sangue , Idoso , Anastomose Cirúrgica , Biomarcadores/sangue , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Fatores de RiscoRESUMO
BACKGROUND: To compare the outcome of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) in patients with and without associated common iliac artery aneurysm (CIAA) extending to the iliac bifurcation. METHODS: Review of 157 patients who underwent endovascular aneurysm repair between 1999 and 2007. Group 1 included 133 patients with and without CIAA and suitable distal common iliac neck (type A, B, C, or D). Group 2 included 24 patients with associated CIAA extending to the iliac bifurcation (type E). Stent-grafts were Powerlink (Endologix, Irvine, CA) in 42, Zenith (Cook, Bjaeverskov, Danemark) in 55, and Talent (Medtronic, Sunnyvale, CA) in 60 patients. Forty patients had aorto-uni-iliac stent-grafts. RESULTS: No difference in overall mortality and AAA rupture was observed. AAA-related complication-free survival at 5 year was 72 +/- 5% and 41 +/- 14% in group 1 and 2, respectively (p = 0.006). Secondary intervention-free survival was 84 +/- 5% and 55 +/- 12% in group 1 and 2, respectively (p = 0.0008). Incidence of distal type 1 endoleak and stent-graft thrombosis was 17 and 8 % in group 2, 3.8 and 0.8 % in group 1, respectively (p = 0.07 and p = 0.01, respectively). CONCLUSION: AAA-related complications and secondary interventions occur more frequently in patients with type E AAA. Distal type 1 endoleak and stent-graft thrombosis are more frequent in these patients. These results warrant further development of technologies that are better adapted for treatment of CIAAs, such as branched and flexible stent-grafts.