RESUMEN
OBJECTIVE: Aortic dissection is a dynamic process that can progress both proximal and distal to the initial entry tear. We sought to determine associations for development of proximal progression or new type A aortic dissection (NTAD) after acute type B dissection (ATBD) and its effect on survival of the patient. METHODS: We reviewed all cases of acute aortic dissection that we managed from 1999 to 2014. Univariate and bivariate analyses were performed to identify correlates of NTAD. Multivariable regression and proportional hazards regression analysis was done to determine the effect of dissection progression on long-term survival. RESULTS: Among 477 cases of ATBD managed, 19 (4.0%) patients developed NTAD during a median follow-up of 4.1 (interquartile range, 1.4-7.7) years. Median time from diagnosis of ATBD to NTAD was 124 (interquartile range, 23-1201) days. Baseline predictors for development of NTAD at initial ATBD admission included bicuspid aortic valve (P = .006) and age <60 years (P = .012). Although not statistically significant, point estimates indicate that thoracic endovascular aortic repair was twice as frequent in NTAD cases as in non-NTAD cases. Overall 5-year survival was 70.2%. Patients who had repair of NTAD appear to have longer survival, although this effect is on the margin of statistical significance (P = .051). After risk factor and correlates of NTAD adjustment, this effect was no longer apparent (P = .089). CONCLUSIONS: The natural history of ATBD is such that there is a persistent risk of NTAD, with the highest risk in the first 6 months. Factors associated with NTAD include bicuspid aortic valve and young age. Thoracic endovascular aortic repair did not have a large effect on risk. Timely diagnosis and repair of NTAD are associated with good survival rates. Lifelong surveillance is warranted in all cases of descending thoracic aortic dissection regardless of initial treatment modality.
Asunto(s)
Aorta Torácica/patología , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Procedimientos Endovasculares/estadística & datos numéricos , Injerto Vascular/estadística & datos numéricos , Enfermedad Aguda , Adulto , Factores de Edad , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/epidemiología , Disección Aórtica/etiología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/epidemiología , Válvula Aórtica/anomalías , Aortografía/métodos , Enfermedad de la Válvula Aórtica Bicúspide , Progresión de la Enfermedad , Procedimientos Endovasculares/métodos , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/epidemiología , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento , Injerto Vascular/métodosRESUMEN
BACKGROUND: Despite recommendations for retrieval of inferior vena cava (IVC) filters, most are not removed in a timely manner. Longer IVC filter dwell times are associated with caval wall perforation and tilting that make percutaneous retrieval more difficult. Open IVC filter removal is generally reserved for patients with symptoms referable to the filter, such as chronic back and abdominal pain. We present our management algorithm and review of cases of open IVC filter removal. METHODS: Patients referred for management of implanted IVC filters from May 2010 to May 2016 were included. Demographic and imaging were reviewed for cases requiring open surgical removal. RESULTS: There were 221 percutaneous retrieval attempts in 218 patients. Successful retrieval occurred in 196 (89%) attempts. There were 7 patients who had open surgical IVC filter removal after failure of percutaneous retrieval. One patient had 2 filters and another had 3 filters. Except for 1 case with complications during the percutaneous retrieval procedure, the remaining patients all suffered from back or abdominal pain. All had significant filter strut penetration through the caval wall into adjacent structures. Postoperatively, all patients had relief of pain. There were no deaths and 1 patient had a minor ileus that spontaneously resolved. CONCLUSIONS: Patients who fail percutaneous IVC filter retrieval can expect low morbidity and prompt resolution of symptoms after open surgical removal via minilaparotomy.
Asunto(s)
Remoción de Dispositivos/métodos , Implantación de Prótesis/instrumentación , Filtros de Vena Cava , Vena Cava Inferior/cirugía , Adulto , Anciano , Algoritmos , Angiografía por Tomografía Computarizada , Vías Clínicas , Bases de Datos Factuales , Técnicas de Apoyo para la Decisión , Femenino , Humanos , Masculino , Persona de Mediana Edad , Flebografía/métodos , Diseño de Prótesis , Implantación de Prótesis/efectos adversos , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Vena Cava Inferior/diagnóstico por imagenRESUMEN
BACKGROUND: Treatment strategies for acute limb ischemia (ALI) are abundant with few established guidelines. We sought to determine nationwide ALI treatment patterns in the modern era. METHODS: Anonymous electronic surveys examining the management of ALI involving native vessel and bypass occlusion were sent to all members of the Vascular and Endovascular Surgery Society (n = 738). Treatment options included catheter-directed lysis (CDL) or pharmacomechanical (PMT) thrombolysis and open surgery. CDL management strategies were evaluated for lytic and heparin dosing, fibrinogen monitoring, and treatment duration. Influence of Rutherford category (RC), time from training, practice type, hospital size, region, and protocol use was assessed. Data were analyzed by univariate contingency tables and multinomial regression analysis. RESULTS: A total of 117 (response rate of 16%) surveys were completed. The most common management strategy RC 2a ischemia in all conduit occlusions was endovascular (prosthetic graft, 96 [82%] respondents; vein graft 96 [82%] respondents; native artery occlusion 79 [68%] respondents), while those with RC 3 ischemia were more commonly treated with open techniques (prosthetic graft, 96 [83%]; vein graft 94 [81%]; native artery occlusion 94 [80%]). Of those respondents using endovascular therapy, CDL was most commonly used in RC 2a patients, while PMT was most commonly used in RC 3 patients. Multivariate analysis identified prosthetic and vein graft occlusion were more likely to be treated via endovascular approach (odds ratio, 2.45 and 2.78, respectively; P < 0.001), while those with RC 2b (odds ratio, 0.19; P < 0.001), RC 3 (odds ratio, 0.01; P < 0.001), or in centers without a hybrid operating room (odds ratio, 0.49; P = 0.017) were more likely to be treated by open approach. Tissue plasminogen activator (TPA) dosing during catheter directed therapy was usually 1 mg/hr (77%) with variable concentrations and duration of the initial treatment of 8-24 hr (78%). Most respondents indicated having developed their own protocols and patterns of treatment varied but were influenced by training and practice environment variables. CONCLUSIONS: Management strategies vary widely in ALI. Some effects of provider training and individual protocol development were observed, and TPA protocols were influenced by increased institutional responsibility for thrombolysis. Further efforts are needed to develop consensus guidelines for ALI management.
Asunto(s)
Arteriopatías Oclusivas/terapia , Procedimientos Endovasculares/tendencias , Oclusión de Injerto Vascular/terapia , Disparidades en Atención de Salud/tendencias , Isquemia/terapia , Trombolisis Mecánica/tendencias , Pautas de la Práctica en Medicina/tendencias , Trombectomía/tendencias , Terapia Trombolítica/tendencias , Enfermedad Aguda , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/fisiopatología , Procedimientos Endovasculares/efectos adversos , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/fisiopatología , Encuestas de Atención de la Salud , Humanos , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Trombolisis Mecánica/efectos adversos , Análisis Multivariante , Oportunidad Relativa , Trombectomía/efectos adversos , Terapia Trombolítica/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Aortic dissection remains the most common aortic catastrophe. In the endovascular era, the management of acute type B aortic dissection (ATBAD) is undergoing dramatic changes. The aim of this study is to evaluate the long-term outcomes of patients with ATBAD who were treated at our center over a 13-year period. METHODS AND RESULTS: We reviewed patients with ATBAD between 2001 and 2014, analyzing variables based on status (complicated [c] versus uncomplicated [u]) and treatment modalities. We defined cATBAD as rupture, expansion of diameter on imaging during the admission, persistent pain, or clinical malperfusion leading to a deficit in cerebral, spinal, visceral, renal, or peripheral vascular territories at presentation or during initial hospitalization. Postoperative outcomes were defined as deficits not present before the intervention. Outcomes were compared between the groups by use of Kaplan-Meier and descriptive statistics. We treated 442 patients with ATBAD. Of those 442, 60.6% had uATBAD and were treated medically, and 39.4% had cATBAD, of whom 39.0% were treated medically to 30.0% with open repair, 21.3% with thoracic endovascular aortic repair, and 9.7% with other open peripheral procedures. Intervention-free survival at 1 and 5 years was 84.8% and 62.7% for uATBAD, 61.8% and 44.0% for cATBAD-medical, 69.2% and 47.2% for cATBAD-open, and 68.0% and 42.5% for cATBAD-thoracic endovascular aortic repair, respectively (P=0.001). Overall survival was significantly related primarily to complicated presentation. CONCLUSIONS: In our experience, early and late outcomes of ATBAD were dependent on the presence of complications, with cATBAD faring worse. Although uATBAD was associated with favorable early survival, late complications still occurred, mandating radiographic surveillance and open or endovascular interventions. Prospective trials are required to better determine the optimal therapy for uATBAD.
Asunto(s)
Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/terapia , Disección Aórtica/diagnóstico , Disección Aórtica/terapia , Enfermedad Aguda , Adulto , Anciano , Disección Aórtica/mortalidad , Aneurisma de la Aorta/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Endovascular repair (ER) of axillosubclavian arterial injuries is a minimally invasive alternative to open repair (OR). The purpose of this study was to compare the outcomes of ER vs OR. METHODS: A retrospective study was performed of patients who sustained axillosubclavian arterial injuries admitted to two high-volume academic trauma centers between 2003 and 2013. Patients undergoing ER and OR were matched according to 25 different demographic and clinical variables in a 1:3 ratio using propensity scores. The primary outcome was in-hospital mortality. Secondary outcomes were complications and length of stay. RESULTS: Among 153 patients (79.7% male; mean age, 32.7 ± 15.9 years) who sustained axillosubclavian arterial injuries, 18 (11.8%) underwent ER and 135 (88.2%) had OR. Matched cases (ER, n = 18) and controls (OR, n = 54) had similar demographic and clinical data, such as age, gender, admission systolic blood pressure and Glasgow Coma Scale score, body Abbreviated Injury Scale scores, Injury Severity Score, and transfusion requirements. Patients undergoing ER had significantly lower in-hospital mortality compared with patients undergoing OR (5.6% vs 27.8%; P = .040; odds ratio, 0.7; 95% confidence interval, 0.6-0.9). Similarly, patients undergoing ER had substantially lower rates of surgical site infections and a trend toward lower rates of sepsis. Outpatient follow-up was available in 88.2% (n = 15) of the patients at a median time of 8 months (1-30 months). Two ER patients required open reintervention for stent-related complications (one for a type Ia endoleak and another for stent thrombosis). CONCLUSIONS: In our experience with axillosubclavian arterial injuries, ER was associated with improved mortality and lower complication rates. Patient follow-up demonstrates an acceptable reintervention rate after ER. Further multicenter prospective evaluation is warranted to determine long-term outcomes.
Asunto(s)
Arteria Axilar/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Arteria Subclavia/cirugía , Lesiones del Sistema Vascular/cirugía , Adolescente , Adulto , Arizona , Arteria Axilar/diagnóstico por imagen , Arteria Axilar/lesiones , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Escala de Coma de Glasgow , Mortalidad Hospitalaria , Hospitales de Alto Volumen , Humanos , Puntaje de Gravedad del Traumatismo , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Puntaje de Propensión , Radiografía , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/lesiones , Texas , Factores de Tiempo , Centros Traumatológicos , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico , Lesiones del Sistema Vascular/mortalidad , Adulto JovenRESUMEN
OBJECTIVE: The current Society for Vascular Surgery Clinical Practice Guidelines suggest urgent (<24 hours) thoracic endovascular aortic repair for grade (G) II to G IV blunt thoracic aortic injuries (BTAIs). The purpose of this study was to determine whether some patients may require more emergency treatment. METHODS: We reviewed imaging variables of prospectively collected BTAI patients between 1999 and 2014. We used computed tomographic angiography to classify BTAIs into four categories: G I, intimal tear; G II, intramural hematoma; G III, aortic pseudoaneurysm; and G IV, free rupture. Specific examination of G III injuries was undertaken in an effort to predict aortic-related mortality (ARM) before repair. For this subset, we examined pseudoaneurysm size, lesion/normal aortic diameter ratio, and mediastinal hematoma location and size. RESULTS: Among 331 patients with BTAIs, 86 died before imaging. Admission computed tomographic angiography was available for 205 patients (71.2% male; mean age, 39.3 years) with BTAIs (24 G I, 49 G II, 124 G III, 8 G IV). The mean Injury Severity Score was 35.6, and 22.4% had hypotension (<90 mm Hg). Overall mortality was 11.2% (G I/G II, 4.1%; G III/G IV, 15.3%; P = .02). ARM was 2.4% (G I/G II, 0%; G III/G IV, 3.8%; P = .09). ARM was significantly greater in G IV (3 of 8 [37.5%]) than G III (2 of 124 [1.6%]) vs G I/II (0 of 73 [0%]) injuries (P < .0001). Medical management alone was used in 53 (20 G I, 18 G II, 13 G III, and 2 G IV). Open repair was performed in 51 (3 G I, 9 G II, 36 G III, and 3 G IV) at a mean time to repair (TTR) of 10.6 hours. Thoracic endovascular aortic repair was conducted for 101 patients (1 G I, 22 G II, 75 G III, and 3 G IV) at a mean TTR of 9.4 hours. Median TTR for the overall population of BTAI patients was 24.0 hours from admission. (G I, 64.5 hours; G II, 24.0 hours; G III, 19.7 hours; and G IV, 3.5 hours). ARM occurred in four of five patients before planned repair (2 G III and 2 G IV), 7.0 ± 3.6 hours from admission. No G I/II ARM occurred. Among eight G IV injuries, there were three ARMs. Focus on G III injuries through regression analysis demonstrated that early clinical/imaging variables (eg, mediastinal hematoma dimensions and lesion/normal aortic diameter ratio) were not significant predictors of ARM. CONCLUSIONS: Injury grade is a predictor of ARM among patients with BTAIs. Aggressive use of the current Society for Vascular Surgery Clinical Practice Guidelines at a busy level I trauma center resulted in low rates of ARM. In this setting, identification of additional physiologic and radiographic criteria indicating the need for emergency (vs urgent) repair of aortic pseudoaneurysms remains elusive.
Asunto(s)
Aorta Torácica/lesiones , Traumatismos Torácicos/mortalidad , Lesiones del Sistema Vascular/mortalidad , Heridas no Penetrantes/mortalidad , Adulto , Aorta Torácica/diagnóstico por imagen , Aortografía/métodos , Causas de Muerte , Angiografía por Tomografía Computarizada , Urgencias Médicas , Procedimientos Endovasculares , Femenino , Adhesión a Directriz , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Valor Predictivo de las Pruebas , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Texas , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/terapia , Factores de Tiempo , Centros Traumatológicos , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/terapia , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/terapia , Adulto JovenRESUMEN
BACKGROUND: Acute aortic dissection (AAD) can cause limb ischemia due to branch vessel occlusion. A minority of patients have persistent ischemia after central aortic repair and require peripheral arterial revascularization. We investigated whether the need for limb revascularization is associated with adverse outcomes. METHODS: We reviewed our cases of AAD from 2000 to 2014 and identified patients with malperfusion syndromes (coronary, cerebral, spinal, visceral, renal, or peripheral ischemia). Patients with DeBakey I/II (Stanford type A) dissection had urgent open repair of the ascending aorta. Patients with DeBakey III (Stanford type B) dissection were initiated on anti-impulse medical therapy and had either open aortic repair or thoracic endovascular aortic repair for malperfusion syndromes. Patients with persistent lower limb ischemia after aortic repair usually had either extra-anatomic bypass grafting or iliac stenting. Some DeBakey III patients had peripheral revascularization without central aortic repair. We performed univariate and multivariate analysis to determine the effects of need for limb revascularization and clinical outcomes. RESULTS: We treated 1,015 AAD patients (501 [49.4%] DeBakey I/II and 514 [50.6%] DeBakey III) with a mean age of 59.7 ± 14.5 years (67.5% males). Aortic repair was performed in all DeBakey I/II patients and in 103 (20.0%) DeBakey III patients. Overall 30-day mortality was 11.3%. Lower limb ischemia was present in 104 (10.3%) patients and was more common in DeBakey I/II compared with DeBakey III dissections (65.4% vs. 34.6%; odds ratio [OR] 2.1, confidence interval [CI] 1.4-3.2; P = 0.001). Among the 40 patients who required limb revascularization, there was no difference in need for revascularization between DeBakey I/II and III patients. Patients requiring limb revascularization were more likely to have mesenteric ischemia compared with the rest of the cohort in both DeBakey I/II (P = 0.037) and DeBakey III dissections (P < 0.001) with worse 10-year survival (21.9 % vs. 59.2%, P < 0.001). When adjusted for other malperfusion syndromes, patients with limb revascularization had similar long-term survival compared to uncomplicated dissection patients (P = 0.960). CONCLUSIONS: Patients requiring lower limb revascularization after treatment for AAD are more likely to have mesenteric ischemia and worse survival. The need for limb revascularization is a marker for more extensive dissection and should prompt evaluation for visceral malperfusion.
Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Isquemia Mesentérica/cirugía , Enfermedad Aguda , Adulto , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Disección Aórtica/fisiopatología , Angiografía de Substracción Digital , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/mortalidad , Aneurisma de la Aorta/fisiopatología , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Isquemia Mesentérica/diagnóstico por imagen , Isquemia Mesentérica/mortalidad , Isquemia Mesentérica/fisiopatología , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Flujo Sanguíneo Regional , Estudios Retrospectivos , Factores de Riesgo , Circulación Esplácnica , Stents , Resultado del TratamientoRESUMEN
OBJECTIVE: Abdominal aortic vascular graft infection often involves several different organisms. Antibiotic polymethyl methacrylate (PMMA) beads may be effective in controlling infection after débridement, but bacterial species identification and antibiotic susceptibility are often not available at the time of operation, generating a need for a broad-spectrum drug combination for empirical use. We sought to determine an effective antibiotic in PMMA beads for use in abdominal vascular graft infection. METHODS: PMMA beads were impregnated with combinations of antibiotics, consisting of daptomycin, tobramycin, and meropenem. Antibiotics were selected on the basis of activity spectrum and heat stability. Beads were placed on separate agar plates with vancomycin-resistant Enterococcus faecalis, Klebsiella pneumoniae, Staphylococcus epidermidis, and methicillin-resistant Staphylococcus aureus. Antibiotic inhibition was recorded by use of a modified agar-based disk-diffusion method. RESULTS: Daptomycin alone was not active against K. pneumoniae (average = 0 mm). Tobramycin alone was not active against vancomycin-resistant E. faecalis, K. pneumoniae, or methicillin-resistant S. aureus. Tobramycin and daptomycin in combination had moderate broad-spectrum activity with 8- to 14-mm mean inhibition halos. Meropenem showed strong activity against all tested organisms with >15-mm mean inhibition halos. The addition of daptomycin to meropenem provided improved coverage of gram-positive organisms. The presence of tobramycin reduced the efficacy of meropenem. CONCLUSIONS: Antibiotic PMMA beads containing 10% meropenem with 2.5% daptomycin had excellent in vitro activity against typical bacterial species associated with abdominal vascular graft infections. The addition of antibiotic beads may be a useful adjunct in managing such cases. Further studies are required to determine efficacy in clinical practice.
Asunto(s)
Antibacterianos/administración & dosificación , Aorta Abdominal/cirugía , Infección de la Herida Quirúrgica/tratamiento farmacológico , Prótesis Vascular , Daptomicina/administración & dosificación , Técnicas In Vitro , Meropenem , Polimetil Metacrilato , Tienamicinas/administración & dosificación , Tobramicina/administración & dosificaciónRESUMEN
BACKGROUND: We report on our experience with treatment of adults requiring de novo or redo open aortic coarctation repair mostly by a resection and interposition graft technique. METHODS: We retrospectively reviewed all patients older than 16 years requiring open repair of aortic coarctation. Indications for repair, operative details, and outcomes were analyzed. RESULTS: Between 1996 and 2011, we treated 29 adult aortic coarctation patients with open repair. The mean age was 42 years (range, 17-69 years), and there were 15 men. Nine patients had previous repair with recurrence; the remaining 20 had native coarctation. Thoracic aortic aneurysms were present in 22 patients (76%), ranging in size from 3.0 to 9.6 cm (mean, 4.8 cm). Four patients had intercostal artery aneurysms (range, 1.0-2.5 cm), four had left subclavian artery aneurysms, and four had ascending/arch aneurysms. The most common repair was resection of aortic coarctation with interposition graft replacement (93%). Two patients without aneurysm had bypasses from the proximal descending thoracic aorta to the infrarenal aorta without aortic resection. There was no in-hospital mortality, stroke, or paraplegia. Long-term survival was 89% during a median follow-up of 81 months (interquartile range, 47-118 months), with no patient requiring reoperation on the repaired segment. CONCLUSIONS: Open repair of native and recurrent adult aortic coarctation has acceptable morbidity and low mortality. Especially in patients with concomitant aneurysm, resection with interposition graft replacement provides a safe and durable repair option.
Asunto(s)
Aneurisma de la Aorta/cirugía , Coartación Aórtica/cirugía , Implantación de Prótesis Vascular , Adolescente , Adulto , Factores de Edad , Anciano , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/etiología , Coartación Aórtica/complicaciones , Coartación Aórtica/diagnóstico , Implantación de Prótesis Vascular/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Reoperación , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Considering new guidelines for retrievable inferior vena cava filters (IVCFs), we examine our initial experience after establishing a comprehensive filter removal program in our level 1 trauma center. We evaluated the technical and financial feasibility of this program and barriers to IVCF retrieval, including insurance status and costs, in trauma patients. METHODS: Trauma patients receiving IVCFs from May 2011 to 2013 were consented and prospectively enrolled in the study program. Retrieval rates were assessed for the years before study initiation. Primary outcome was IVCF retrieval. Hospital financial data for retrieval were examined and univariate analysis performed. Hospital cost-to-charge and payment-to-charge ratios were assessed. RESULTS: Before study initiation from April 2009 to 2011, 66 IVCFs were placed in trauma patients with only 2 retrievals in 2 years. During the study period, 247 trauma patients had IVCF placement of which 111 (45%) were enrolled. The main reason for nonenrollment was lack of referral by the implanting team. Retrieval was attempted in 100 outpatients with success in 85 (85%). Patients enrolled in the program were more likely to have their filters removed (73% vs. 18%; odds ratio, 12.6; 95% confidence interval, 6.6-24.3; P < 0.001). Mean time from placement to attempt was 6.2 ± 4.0 months (range, 0.5-31.8). Of the total attempts, 29% were nonresource patients, 11% had Medicaid, and 60% had commercial insurance including Medicare patients. Chances of successful retrieval were higher if performed later during the study (P = 0.03). Successful retrieval was not related to insurance status (P = not significant). The mean total hospital charges related to retrieval were $4,493 (range, $2,510-$9,106). Successful retrieval contributed to lower total charges (P < 0.01). Factors contributing to higher total charges were retrieval attempt later in study period (P = 0.01) and commercial insurance status (P = 0.04). CONCLUSIONS: The rate of IVCF placement in trauma patients increased 4-fold over 4 years. The rate of IVCF retrieval increased more than 14-fold during the same period after establishment of the retrieval program. Elective outpatient retrieval of IVCFs in all eligible trauma patients is financially feasible without loss to the health care system even in regions with high rates of uninsured. A major barrier to successful filter retrieval was lack of patient referral into the program by implanting physicians. Hospital administration and physician outreach are important determinants of successful IVCF retrieval in trauma patients.
Asunto(s)
Remoción de Dispositivos/economía , Costos de Hospital , Centros Traumatológicos/economía , Filtros de Vena Cava/economía , Tromboembolia Venosa/prevención & control , Adulto , Ahorro de Costo , Análisis Costo-Beneficio , Remoción de Dispositivos/efectos adversos , Estudios de Factibilidad , Femenino , Precios de Hospital , Humanos , Seguro de Salud/economía , Masculino , Medicaid/economía , Medicare/economía , Persona de Mediana Edad , Oportunidad Relativa , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Filtros de Vena Cava/efectos adversos , Tromboembolia Venosa/economía , Adulto JovenRESUMEN
Mortality rates associated with acute type B aortic dissection (ABAD) complicated by malperfusion remains significant. Optimal management of patients with ABAD is still debatable. We present a case report of a 50-year-old man who was admitted due to ABAD. He was treated medically with his pain resolved and he was discharged on oral antihypertensive medications. One month after initial diagnosis, he was readmitted with abdominal pain, nausea, vomiting, and diarrhea. On imaging, an extension of the aortic dissection into the visceral arteries with occlusion of the celiac and superior mesenteric arteries (SMA) was noted. He underwent thoracic endovascular aortic repair (TEVAR) and bypass grafting to the SMA. Despite the intervention, the patient developed large bowel, liver, and gastric ischemia and underwent bowel resection. He died from multi-organ failure. In selected cases of uncomplicated ABAD, TEVAR should be considered and when TEVAR fails and visceral malperfusion develops, an aggressive revascularization of multiple visceral arteries should be attempted.
Asunto(s)
Aneurisma de la Aorta Torácica/complicaciones , Disección Aórtica/complicaciones , Arteria Celíaca/fisiopatología , Arteria Mesentérica Inferior/fisiopatología , Isquemia Mesentérica/etiología , Grado de Desobstrucción Vascular , Enfermedad Aguda , Administración Oral , Disección Aórtica/diagnóstico , Disección Aórtica/fisiopatología , Disección Aórtica/terapia , Antihipertensivos/administración & dosificación , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/terapia , Aortografía/métodos , Implantación de Prótesis Vascular , Arteria Celíaca/diagnóstico por imagen , Arteria Celíaca/cirugía , Procedimientos Endovasculares , Resultado Fatal , Humanos , Masculino , Arteria Mesentérica Inferior/diagnóstico por imagen , Arteria Mesentérica Inferior/cirugía , Isquemia Mesentérica/diagnóstico , Isquemia Mesentérica/fisiopatología , Isquemia Mesentérica/cirugía , Persona de Mediana Edad , Insuficiencia Multiorgánica/etiología , Circulación Esplácnica , Tomografía Computarizada por Rayos X , Insuficiencia del TratamientoRESUMEN
OBJECTIVE: Despite advances in perioperative care, long-term and amputation-free survival rates are poor after resection of infected abdominal aortic grafts. We reviewed our cases to determine the rate of reinfection and risk factors for mortality and limb loss. METHODS: We reviewed cases with infrarenal aortic graft infection from 1999 to 2013. Cases requiring graft excision were included for analysis. Thoracic and thoracoabdominal aortic grafts were excluded. Reconstruction types included both extra-anatomic and in situ grafts. Patient comorbidities, surgical outcomes, and known reinfection rates were assessed. Univariate and Kaplan-Meier analysis were performed. RESULTS: Twenty-eight patients had resection of infected infrarenal abdominal aortic grafts during the study period. Most patients (26/28; 93%) had infected aortoiliac or aortofemoral prosthetic bypass grafts, but two of 28 patients had infected endovascular aortoiliac stent grafts. The median age was 69 years (range, 46-86 years), with 68% men and 32% women. Aortoenteric fistulae or graft-enteric erosions were noted in 12 of 28 (43%) patients at operation. There were 79% of patients who had in situ reconstruction, including 4 (14%) with polyester, 1 (4%) with polytetrafluoroethylene, 3 (11%) with cadaveric homograft, 3 (11%) with composite grafts, and 11 (39%) with native femoropopliteal vein grafts. Five (18%) patients had extra-anatomic bypass and one had excision without revascularization. In-hospital mortality after initial graft excision and revascularization occurred in two (7%) patients. Seven (25%) patients had evidence of reinfection after a median of 20 months, of whom five underwent reintervention with two additional in-hospital deaths. All in-hospital deaths occurred in patients with graft-enteric contamination. Overall limb salvage and survival at a mean follow-up of 2.5 years were 82% and 46%, respectively, and did not differ among revascularization types (P = .85 and .74). One-year amputation-free survival was 47% overall. Three patients with native femoropopliteal vein graft repair required amputation in follow-up. Diabetes was the only observed risk factor for amputation (P = .05). Risks for mortality included history of cerebrovascular disease (P = .05) and shock on presentation (P = .04). No other comorbid condition, type of revascularization, or perioperative complication was associated with limb loss or mortality on univariate analysis. CONCLUSIONS: Revascularization after excision of infected abdominal aortic grafts can be done with acceptable in-hospital morbidity and mortality. Reinfection is problematic, regardless of revascularization conduit, and is associated with limb loss and death. New and aggressive local anti-infective strategies are warranted.
Asunto(s)
Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Prótesis Vascular/efectos adversos , Remoción de Dispositivos , Infecciones Relacionadas con Prótesis/cirugía , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Aortografía/métodos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Remoción de Dispositivos/efectos adversos , Supervivencia sin Enfermedad , Femenino , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/mortalidad , Recurrencia , Reoperación , Factores de Riesgo , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Management of limb and other malperfusion syndromes is controversial in acute type A aortic dissection. We assessed our hypothesis that urgent proximal aortic repair resolves most cases of limb ischemia without additional peripheral revascularization. METHODS: We retrospectively reviewed operative cases of acute type A aortic dissection from 1999 to 2011. Our standard technique involved urgent replacement of the ascending aorta and hemiarch. Persistent limb ischemia after aortic repair was treated by bypass surgery. Comparisons between groups both with and without limb ischemia were made. RESULTS: We repaired 335 cases during the study period. Sixty-one patients had limb ischemia (18.2%), of whom 51 were classified with lower limb ischemia (15.2%). All patients with upper limb ischemia survived to discharge without limb loss or death. Only 11 of the 51 patients with lower limb ischemia (21.6%) required peripheral revascularization after aortic repair. There was one case of lower limb loss resulting from delayed recognition of persistent ischemia. Renal dysfunction occurred in 21% of patients with isolated lower limb ischemia and in 31% of patients with uncomplicated dissection (P = .29). In-hospital mortality was 13.7% overall and 8.0% in patients with isolated lower limb ischemia (P = .89). There was no difference in long-term survival between isolated limb ischemia and uncomplicated cases (P = .54). CONCLUSIONS: Most cases of limb ischemia resolve after immediate repair of acute type A aortic dissection. There is no difference in renal dysfunction or in-hospital or long-term mortality between patients with isolated limb ischemia and those with nonmalperfusion dissection. If ischemia persists, limb salvage is successful if revascularization is expeditious.
Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Extremidad Superior/irrigación sanguínea , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico , Disección Aórtica/mortalidad , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/mortalidad , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Isquemia/diagnóstico , Isquemia/etiología , Isquemia/mortalidad , Estimación de Kaplan-Meier , Riñón/fisiopatología , Enfermedades Renales/etiología , Enfermedades Renales/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Análisis Multivariante , Modelos de Riesgos Proporcionales , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Acute type A aortic dissection can extend into arch vessels, including the common carotid arteries. Although several reports describe concomitant endovascular repair of common carotid artery dissection (CCAD) during open ascending aortic repair, the criteria for repair, natural history, and risk of stroke are unclear. We examine the literature and our experience with nonoperative management of CCAD after acute aortic dissection repair to determine the risk of stroke and the need for carotid revascularization. METHODS: We queried our cases of type A aortic dissection over a 10-year period from January 2002 to December 2011. Imaging was reviewed to determine the presence of CCAD and degree of true-lumen stenosis. Analysis was performed to determine risk of stroke and survival on initial presentation and during follow-up. Survival functions between excluded groups and those with and without CCAD were compared using log-rank statistics. RESULTS: We repaired 288 cases of acute type A aortic dissection during the study period. Adequate carotid imaging was available in 179 patients and comprised the study group. We identified 43 cases with CCAD (group A, 24.0%) and 136 cases without it (group B, 76.0%). History of previous stroke was not a risk factor for new stroke in either group (P = .517). Bilateral CCAD occurred in 16 cases (37.2%). Stroke on initial presentation was more common in group A (18.6%) than in group B (8.1%; odds ratio, 2.6; 95% confidence interval, 0.97-6.95; P = .051). Degree of stenosis or false-lumen thrombosis did not affect rate of stroke on presentation. The degree of postoperative true-lumen stenosis ranged from 0% (resolution) to 90%. No patient with CCAD had stroke or required carotid revascularization after discharge on follow-up. The 5-year, stroke-free survival rates in groups A and B were 69.7% and 73.6% (P = .820), respectively. CONCLUSIONS: CCAD, due to extension from aortic arch dissection, has a low risk of subsequent stroke after the initial event. Based on current data, there is little evidence to suggest that aortic origin CCAD requires repair in the absence of recurrent symptoms, regardless of the degree of stenosis or false-lumen patency. Recommended optimal medical therapy includes either aspirin or anticoagulation for 6 months after initial presentation. Additional longitudinal studies are needed.
Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Enfermedades de las Arterias Carótidas/terapia , Arteria Carótida Común , Enfermedad Aguda , Adulto , Anciano , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico , Disección Aórtica/mortalidad , Anticoagulantes/uso terapéutico , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Enfermedades de las Arterias Carótidas/diagnóstico , Enfermedades de las Arterias Carótidas/etiología , Enfermedades de las Arterias Carótidas/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Inhibidores de Agregación Plaquetaria/uso terapéutico , Modelos de Riesgos Proporcionales , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: We established a program for retrieval of inferior vena cava (IVC) filters within our hospital system. When percutaneous retrieval fails, we only recommend open surgical removal for symptoms and other complications. We examined our outcomes with conservative management of unsuccessful percutaneous retrieval and open surgical removal for symptomatic/complicated IVC filters. METHODS: All patients with history of IVC filter placement who were referred to us for retrieval between 2010 and 2016 were evaluated. Before retrieval, patients were evaluated for risk of future venous thromboembolic events and ongoing need for IVC filtration. Asymptomatic patients with unsuccessful percutaneous filter retrieval were recommended to have annual follow-up with plain abdominal radiographs and to take daily low-dose aspirin. Patients with symptoms referable to the indwelling filter and those with complications were offered open surgical removal. RESULTS: There were 213 patients with a history of IVC filter placement who underwent 220 percutaneous attempts for retrieving 214 IVC filters (four patients had two attempts, one patient had three attempts). Technical success in percutaneously retrieving the filter was 180 of 214 (84.1%) at a median of 5.5 months (interquartile range [IQR], 3.5-9.2) from implant. The median filter dwell time was significantly longer in unsuccessful compared with successful retrieval attempts (8.3 months [IQR, 4.3-15.1 months] vs 5.5 months [IQR, 3.2-8.7 months]; P = .011). Of the 34 filters in 33 patients that could not be retrieved percutaneously, all had either significant filter barb penetration through the caval wall or a tilt angle of greater than 15°. The majority of patients (67%) remained asymptomatic without any further complications over a mean follow-up of 24 months (IQR, 12-50 months). No asymptomatic patients developed symptoms or complications over the follow-up period. Two of the five patients who were symptomatic underwent open surgical removal via minilaparotomy. An additional six patients who failed percutaneous retrieval at other institutions were referred to us for open surgical removal owing to symptoms or complications. Technical success for all open surgical removal of IVC filters was 100%. All patients had resolution of their symptoms after percutaneous or open surgical removal. CONCLUSIONS: Asymptomatic patients with unsuccessful percutaneous IVC filter retrieval seem to have low complications in midterm follow-up despite significant filter strut penetration. Without symptoms or other complications, such patients do not require referral for open surgical filter removal. Symptomatic patients can expect low morbidity and resolution of symptoms after percutaneous or open surgical removal. Further studies are needed to determine the cost-effectiveness of routinely removing asymptomatic IVC filters.
Asunto(s)
Remoción de Dispositivos/efectos adversos , Migración de Cuerpo Extraño/terapia , Falla de Prótesis , Filtros de Vena Cava , Vena Cava Inferior/cirugía , Adulto , Enfermedades Asintomáticas , Femenino , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/etiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Insuficiencia del Tratamiento , Vena Cava Inferior/diagnóstico por imagenRESUMEN
Objectives: One of the challenges of spine surgery is the need for adequate exposure of the anterolateral spinal column. Improved retractor systems with integrated lighting minimize the need for large thoracotomy, flank, or abdominal incisions. In 2013, we began using the NuVasive MaXcess® system via a minimal-access lateral incision for thoracic and thoracolumbar spine exposures. These small-access approaches may not offer adequate exposure when bleeding and other complications arise. We sought to determine the feasibility and outcomes of a minimal-access retractor during anterolateral spine exposures. Methods: An institutional-review-board-approved retrospective chart review was performed of all patients who underwent anterolateral thoracic and lumbosacral spine exposure at an academic hospital between December 1999 and April 2017. Cervical and posterior spine exposures were not included. Information regarding patient demographics, comorbid conditions, operative techniques, exposure, estimated blood loss, length of stay, and intraoperative and postoperative complications was collected. Data for standard exposure vs. minimally invasive exposures were compared. Results: Between December 1999 and April 2017, 223 anterolateral spinal exposures were performed at our institution. Of those, 122 (54.7%) patients had true lateral exposures, with 22 (18%) using the minimally invasive retractor. The mean age of our patient population was 57 years (19-89), with 65 (53%) men and a mean body mass index of 29.0 (17.4-58.6). In the standard exposure group, complications occurred in 22 (22%) patients, whereas only two (9%) complications occurred in the minimal-access group. There were no significant differences in overall intraoperative and postoperative complications, except for cardiopulmonary complications, which were reduced in the minimally invasive group (p < 0.019). Patients with minimally invasive exposure had a significantly shorter length of stay than those with standard exposure (7 vs. 13 days, p = 0.001). Conclusions: Minimal-access techniques using advanced retractor systems are both feasible and safe compared to standard techniques allowing for similar lateral spine exposure, but with smaller incisions, fewer cardiopulmonary complications, and shorter lengths of stay.
RESUMEN
BACKGROUND: Acute type A aortic dissection (ATAAD) is a surgical emergency associated with high mortality and morbidity. We analyzed our 15-year experience in the management of ruptured ATAAD (rATAAD) and non-rATAAD to determine the predictors of early and late mortality. METHODS: We reviewed all cases with ATAAD between 1999 and 2014. Patients were grouped into rATAAD and non-rATAAD based on intraoperative confirmation. Clinical data on preoperative characteristics and in-hospital and long-term outcomes were analyzed to determine risk factors for early and long-term mortality. Survival was analyzed using Kaplan-Meier and log rank statistics. RESULTS: Of the 489 total ATAAD repairs, 75 patients (15.3%) had rATAAD. The rATAAD patients were older compared with non-rATAAD (64.4 ± 16.2 versus 57.3 ± 14.2 years, respectively; p = 0.0001) and commonly female (31 of 75 [41.3%] versus 107 of 414 [25.9%], respectively; p = 0.006). Early mortality was higher among rATAAD patients that among non-rATAAD patients (19 of 75 [25.3%] versus 48 of 414 [11.6%], respectively; p = 0.002); predictors included rupture, age, malperfusion syndrome, and coronary artery disease. Patients aged 70 years or more with malperfusion syndrome had a 7.7-fold risk of 24-hour mortality (p = 0.0003) that was augmented by rATAAD (p = 0.004). Long-term survival was lower among rATAAD than non-rATAAD (57.4% versus 78.2%, respectively, at 5 years; p < 0.0001); independent predictors included rupture (p = 0.01), low glomerular filtration rate (p = 0.001), and high-risk group (p = 0.004). These risk factors were used to construct a predictive model for estimating the probability of early mortality in ATAAD. CONCLUSIONS: Rupture is associated with significantly higher mortality in ATAAD. This predictive model provides surgical risk assessment for early mortality after rATAAD. For acceptable surgical candidates, immediate aortic repair can provide favorable outcomes.
Asunto(s)
Aneurisma Roto/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Medición de Riesgo/métodos , Procedimientos Quirúrgicos Vasculares/mortalidad , Enfermedad Aguda , Disección Aórtica/mortalidad , Aneurisma Roto/mortalidad , Aneurisma de la Aorta Torácica/mortalidad , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Texas/epidemiología , Factores de TiempoRESUMEN
Isolated nonatherosclerotic axillary artery disease is a rare condition. External axillary artery compression can result in occlusion or aneurysm formation and subsequent upper extremity ischemia or distal thromboembolism. Chronic compression from use of crutches and repetitive stretching/compression of the axillary artery secondary to overhead motion during high-performance athletic activities are often implicated as the cause. The uniqueness of these lesions and clinical setting requires a high index of suspicion for axillary artery pathology. Prompt diagnosis with arteriography and surgical treatment is necessary given the propensity for thromboembolism. We present a case highlighting this rare phenomenon in a collegiate baseball pitcher.
RESUMEN
BACKGROUND: Blunt thoracic aortic injuries (BTAIs) are composed of a spectrum of lesions ranging from intimal tear to rupture, yet optimal management and ultimate outcome have not been clearly established. METHODS: This is a retrospective multicenter study of BTAIs from January 2008 to December 2013. Demographics, diagnosis, treatment, and in-hospital outcomes were analyzed. RESULTS: Nine American College of Surgeons-verified Level I trauma centers contributed data from 453 patients with BTAIs. After exclusion of patients expiring before imaging (58) and transfers (13), 382 patients with imaging diagnosis were available for analysis (Grade 1, 94; Grade 2, 68; Grade 3, 192; Grade 4, 28). Hypotension was present on admission in 56 (14.7%). Computed tomographic angiography was used for diagnosis in 94.5%. Nonoperative management (NOM) was selected in 32%, with two in-hospital failures (Grade 1, Grade 4) requiring endovascular salvage (thoracic endovascular aortic repair [TEVAR]). Open repair (OR) was completed in 61 (16%). TEVAR was conducted in 198 (52%), with 41% of these requiring left subclavian artery coverage. Complications of TEVAR included endograft malposition (6, 3.0%), endoleak (5, 2.5%), paralysis (1, 0.5%), and stroke (2, 1.0%). Six TEVAR failures were treated by repeat TEVAR (2) or OR (4). Overall in-hospital mortality was 18.8%, and aortic-related mortality was 6.5% (NOM, 9.8%; OR, 13.1%; TEVAR, 2.5%) (Grade 1, 0%; Grade 2, 2.9%; Grade 3, 5.2%; Grade 4, 46.4%). The majority of aortic-related deaths (18 of 25) occurred before the opportunity for repair. Independent predictors of aortic-related mortality among BTAI patients were higher chest Abbreviated Injury Scale (AIS) score, grade, and Injury Severity Score (ISS); TEVAR was protective (p = 0.03; odds ratio, 0.21; confidence interval, 0.05-0.88). CONCLUSION: Failures and aortic-related mortality of NOM following BTAI Society of Vascular Surgery Grade 1 to 3 injuries are rare. TEVAR seems independently protective against aortic-related mortality. Early complications of TEVAR have decreased relative to previous reports. Prospective long-term follow-up data are required to better refine indications for intervention. LEVEL OF EVIDENCE: Level IV.
Asunto(s)
Traumatismos Torácicos/terapia , Heridas no Penetrantes/terapia , Escala Resumida de Traumatismos , Adulto , Angiografía , Femenino , Mortalidad Hospitalaria , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Sistema de Registros , Estudios Retrospectivos , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/mortalidad , Tomografía Computarizada por Rayos X , Centros Traumatológicos , Resultado del Tratamiento , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/mortalidadRESUMEN
INTRODUCTION: Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH). Our purpose was to analyze our experience and report outcomes after repair of acute type A aortic dissection with IMH. METHODS: We analyzed all patients from a single center who underwent open repair for acute type A aortic dissection with IMH. RESULTS: Between 2000 and 2013, we performed 418 repairs for acute type A aortic dissection. These were divided into 2 groups of patients: 64 patients (15%) with type A IMH and 354 patients (85%) with typical dissection. Those with IMH were older (62.4 ± 13.9 years vs 56.7 ± 14.7 years; P < .0046) and presented with reduced renal function (ie, glomerular filtration rate) (P < .0341), less frequently with distal malperfusion, and less frequently with rupture (P < .0116). With IMH, the time from presentation to repair was, by strategy, longer (median, 67 vs 6 hours; P < .0001), but no mortality occurred within 3 days of presentation. Mortality with IMH did not differ from typical dissection: 7 out of 64 patients (10.9%) versus 52 out of 354 patients (14.7%; P = .4276). A lower incidence of postoperative dialysis in the IMH group approached significance: 6 out of 63 patients (9.5%) versus 64 out of 347 patients (18.4%; P = .0820). When adjusted for age and renal function, late survival was improved with IMH (P < .0343). CONCLUSIONS: Repair of acute type A aortic dissection with IMH is associated with significant early morbidity and mortality, differing minimally from typical aortic dissection. Although expectant repair within 3 days may be applied, the purposeful delay imparted little advantage. Improved late outcomes may be seen with IMH, but continued long-term surveillance is required for verification.