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1.
J Vasc Surg ; 76(1): 180-187.e3, 2022 07.
Artículo en Inglés | MEDLINE | ID: mdl-35276269

RESUMEN

OBJECTIVE: The importance of the profunda femoris for aortoiliac inflow procedure patency is well-recognized. We aim to quantify the characteristics of the profunda femoris and its relation to patency following aortoiliac inflow procedures. METHODS: Patients undergoing aortoiliac inflow procedures between 2009 and 2019 were identified. These were classified into aorto-bifemoral bypass (ABF), extra-anatomic bypass (EAB), femoral endarterectomy (FEA), and iliac stenting. Preoperative imaging characteristics of the profunda femoris were reviewed as well as outcomes. RESULTS: We performed 269 procedures in 202 patients. Of these, 162 were men (59.8%), with a mean age of 61 years (standard deviation, 11.45 years). A total of 123 patients (45.3%) presented with claudication, 69 (25.9%) with critical limb ischemia, and 30 (11.2%) with acute limb ischemia. Fifty patients (18.6%) underwent ABF, 44 (16.4%) underwent EAB, 57 (21.2%) underwent FEA, and 158 (58.7%) underwent iliac stenting. Fourteen patients (5.2%) underwent FEA plus iliac stenting. Fifty-two patients (19.2%) had an occluded superficial femoral artery. Twenty-four patients (8.9%) had additional outflow procedures performed during the index operation, including infrainguinal endovascular intervention in 10 patients (3.7%), infrainguinal bypass in 10 patients (3.7%), and femoropopliteal thrombectomy in 5 patients (1.9%). The mean follow-up was 17.5 months with overall 2-year primary patency (PP) of 79%. Two-year PP was 94.7% for FEA, 85.6% for ABF, 79.8% for iliac stents, and 62.5% for EAB. Unadjusted analysis revealed that loss of primary assisted patency was associated with active smoking (67.6% vs 48.6%; P = .035), lower creatinine (mean, 0.84 vs 1.06 mg/dL; P = .003), critical limb ischemia vs claudication (37.8% vs 21.4%; P = .037), and profunda femoris with fewer than five branches >2 mm in size (88.2% vs 68.5%; P = .011). Multivariate analysis confirmed that a profunda with five or more branches >2 mm in diameter was significantly associated with a lower risk of thrombosis (odds ratio, 0.30; P = .034). Size of the profunda greater than 6 mm approached statistical significance on univariate analysis (35% of the non-thrombosed vs 21% in the thrombosed; P = .073), but did not significantly affect risk of thrombosis on the multivariate analysis (odds ratio, 0.58; P = .25). The 2-year PP when all operations were considered was 76% compared with 72% for profunda with fewer than five branches > 2 mm. CONCLUSIONS: Anatomic characteristics of the profunda are associated with patency of inflow procedures. Care should be taken to assess the main profunda and branch diameters on preoperative imaging. A concomitant infrainguinal procedure should be considered in cases of profunda with inadequate large branches, to ensure long-term patency of the inflow operation.


Asunto(s)
Arteriopatías Oclusivas , Trombosis , Aorta Abdominal , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/cirugía , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/cirugía , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/etiología , Claudicación Intermitente/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Grado de Desobstrucción Vascular
2.
Arterioscler Thromb Vasc Biol ; 41(2): 808-814, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33267655

RESUMEN

OBJECTIVE: The objective of this study is to determine the role of SPA (surfactant protein A) in vascular smooth muscle cell (SMC) phenotypic modulation and vascular remodeling. Approach and Results: PDGF-BB (Platelet-derived growth factor-BB) and serum induced SPA expression while downregulating SMC marker gene expression in SMCs. SPA deficiency increased the contractile protein expression. Mechanistically, SPA deficiency enhanced the expression of myocardin and TGF (transforming growth factor)-ß, the key regulators for contractile SMC phenotype. In vivo, SPA was induced in medial and neointimal SMCs following mechanical injury in both rat and mouse carotid arteries. SPA knockout in mice dramatically attenuated the wire injury-induced intimal hyperplasia while restoring SMC contractile protein expression in medial SMCs. These data indicate that SPA plays an important role in SMC phenotype modulation and vascular remodeling in vivo. CONCLUSIONS: SPA is a novel protein factor modulating SMC phenotype. Blocking the abnormal elevation of SPA may be a potential strategy to inhibit the development of proliferative vascular diseases.


Asunto(s)
Traumatismos de las Arterias Carótidas/metabolismo , Músculo Liso Vascular/metabolismo , Miocitos del Músculo Liso/metabolismo , Proteína A Asociada a Surfactante Pulmonar/genética , Remodelación Vascular , Animales , Becaplermina/farmacología , Arterias Carótidas/efectos de los fármacos , Arterias Carótidas/metabolismo , Arterias Carótidas/patología , Traumatismos de las Arterias Carótidas/genética , Traumatismos de las Arterias Carótidas/patología , Células Cultivadas , Modelos Animales de Enfermedad , Hiperplasia , Masculino , Ratones Endogámicos C57BL , Ratones Noqueados , Músculo Liso Vascular/efectos de los fármacos , Músculo Liso Vascular/patología , Miocitos del Músculo Liso/efectos de los fármacos , Miocitos del Músculo Liso/patología , Neointima , Proteínas Nucleares/metabolismo , Fenotipo , Proteína A Asociada a Surfactante Pulmonar/metabolismo , Ratas Sprague-Dawley , Transducción de Señal , Transactivadores/metabolismo , Factor de Crecimiento Transformador beta1/metabolismo , Remodelación Vascular/efectos de los fármacos
3.
World J Surg ; 34(3): 532-7, 2010 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-20049440

RESUMEN

BACKGROUND: Measurement of the parathyroid hormone (PTH) level following total thyroidectomy (TTx) may allow prediction of postoperative hypocalcemia. We present an algorithmic method of managing hypocalcemia pre-emptively, based on the PTH level 1 h after operation. MATERIALS AND METHODS: We examined 423 consecutive patients undergoing TTx at a single institution. A subset of patients were managed using an algorithm involving routine postoperative oral calcium administration and the early addition of oral calcitriol in patients with a low 1-h postoperative PTH level. Algorithm patients were compared to a concurrent, conventionally managed group. Outcomes measured included serum calcium levels, symptoms of hypocalcemia, postoperative complications, and receipt of intravenous (i.v.) calcium. RESULTS: The algorithm was applied in 135 patients, and 288 patients were managed conventionally. Critically low calcium levels (total calcium <7.5 mg/dl [1.88 mmol/l] or ionized calcium <0.94 mmol/l) were less common in algorithm patients (10.6% vs. 25.3%; p < 0.005). Much of this difference was attributable to the protective impact of the algorithm on patients undergoing TTx for cancer, 30% of whom developed critically low calcium levels when managed conventionally. Among patients requiring i.v. calcium, algorithm patients received fewer doses (1.29 vs. 1.86; p < 0.05). Low 1-h PTH levels were found in 21% (28/133) of algorithm patients, but these did not correlate with low calcium levels, suggesting that the algorithm compensated adequately for temporary hypoparathyroidism. No patients developed hypercalcemia. CONCLUSIONS: An algorithmic approach incorporating early postoperative PTH levels and routine administration of oral calcium reduces the risk of severe hypocalcemia after total thyroidectomy.


Asunto(s)
Algoritmos , Calcio/sangre , Hipocalcemia/prevención & control , Hormona Paratiroidea/sangre , Complicaciones Posoperatorias/prevención & control , Tiroidectomía/efectos adversos , Calcio/administración & dosificación , Femenino , Humanos , Hipocalcemia/sangre , Hipocalcemia/etiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/sangre
4.
Arch Surg ; 143(10): 1008-10, 2008 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-18936381

RESUMEN

With the advent of the 80-hour workweek, much attention has been focused on the benefits of shorter work hours regarding resident fatigue and reduced medical errors. Along with this change, however, there has been more reliance on multiple teams of residents who assume the care of inpatients at different times. In this new paradigm, a safe and effective sign-out process is needed to ensure a seamless transition of care from one resident to another. Several studies have been published on the sign-out process among interns in internal medicine, but the literature is sparse with regards to the best way to hand over care of a busy inpatient surgical service. To aid in this process, the Halsted surgical interns performed a review of the current literature on this topic. They also reflected on their personal experiences and developed a 10-point method for safe and effective sign-outs. This process is emphasized for incoming interns and used across the various surgical services at The Johns Hopkins Hospital.


Asunto(s)
Internado y Residencia/organización & administración , Administración de la Seguridad/organización & administración , Carga de Trabajo , Centros Médicos Académicos , Adulto , Continuidad de la Atención al Paciente , Eficiencia Organizacional , Femenino , Cirugía General/educación , Cirugía General/normas , Humanos , Masculino , Atención al Paciente/métodos , Manejo de Atención al Paciente , Sensibilidad y Especificidad , Gestión de la Calidad Total , Tolerancia al Trabajo Programado
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