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1.
J Vasc Surg ; 77(2): 386-395.e3, 2023 02.
Artículo en Inglés | MEDLINE | ID: mdl-36152982

RESUMEN

OBJECTIVE: The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively. METHODS: A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment. RESULTS: Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results. CONCLUSIONS: EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.


Asunto(s)
Aneurisma de la Aorta Abdominal , Tratamiento Conservador , Reparación Endovascular de Aneurismas , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Análisis Costo-Beneficio , Resultado del Tratamiento
2.
Stroke ; 50(11): 3013-3020, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31547798

RESUMEN

Background and Purpose- Open-cell carotid artery stents are associated with a higher peri-procedural stroke risk than closed-cell stents. However, the effect of stent design on long-term durability of carotid artery stenting (CAS) is unknown. We compared the medium- to long-term risk of restenosis and ipsilateral stroke between patients treated with open-cell stents versus closed-cell stents in the ICSS (International Carotid Stenting Study). Methods- Patients with symptomatic carotid stenosis were randomized to CAS or endarterectomy and followed with duplex ultrasound for a median of 4.0 years. We analyzed data from patients with completed CAS procedures, known stent design, and available ultrasound follow-up. The primary outcome, moderate or higher restenosis (≥50%) was defined as a peak systolic velocity of >1.3 m/s on ultrasound or occlusion of the treated internal carotid artery and analyzed with interval-censored models. Results- Eight hundred fifty-five patients were allocated to CAS. Seven hundred fourteen patients with completed CAS and known stent design were included in the current analysis. Of these, 352 were treated with open-cell and 362 with closed-cell stents. Moderate or higher restenosis occurred significantly less frequently in patients treated with open-cell (n=113) than closed-cell stents (n=154; 5-year risks were 35.5% versus 46.0%; unadjusted hazard ratio, 0.68; 95% CI, 0.53-0.88). There was no significant difference in the risk of severe restenosis (≥70%) after open-cell stenting (n=27) versus closed-cell stenting (n=43; 5-year risks, 8.6% versus 12.7%; unadjusted hazard ratio, 0.63; 95% CI, 0.37-1.05). The risk of ipsilateral stroke beyond 30 days after treatment was similar with open-cell and closed-cell stents (hazard ratio, 0.78; 95% CI, 0.35-1.75). Conclusions- Moderate or higher restenosis after CAS occurred less frequently in patients treated with open-cell stents than closed-cell stents. However, both stent designs were equally effective at preventing recurrent stroke during follow-up. Clinical Trial Registration- URL: http://www.isrctn.com/. Unique identifier: ISRCTN25337470.


Asunto(s)
Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Diseño de Equipo/efectos adversos , Stents/efectos adversos , Accidente Cerebrovascular/cirugía , Anciano , Anciano de 80 o más Años , Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/diagnóstico por imagen , Endarterectomía Carotidea/instrumentación , Endarterectomía Carotidea/métodos , Diseño de Equipo/tendencias , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/etiología , Humanos , Internacionalidad , Masculino , Persona de Mediana Edad , Recurrencia , Stents/tendencias , Accidente Cerebrovascular/diagnóstico por imagen
3.
Eur Respir J ; 52(3)2018 09.
Artículo en Inglés | MEDLINE | ID: mdl-30002102

RESUMEN

Pulmonary endarterectomy (PEA) is the gold standard treatment for operable chronic thromboembolic pulmonary hypertension (CTEPH). However, a proportion of patients with operable disease decline surgery. There are currently no published data on this patient group. The aim of this study was to identify outcomes and prognostic factors in a large cohort of consecutive patients with CTEPH.Data were collected for consecutive, treatment-naive CTEPH patients at the Pulmonary Vascular Disease Unit of the Royal Hallamshire Hospital (Sheffield, UK) between 2001 and 2014.Of 550 CTEPH patients (mean±sd age 63±15 years, follow-up 4±3 years), 49% underwent surgery, 32% had technically operable disease and did not undergo surgery (including patient choice n=72 and unfit for surgery n=63), and 19% had inoperable disease due to disease distribution. The 5-year survival was superior in patients undergoing PEA (83%) versus technically operable disease who did not undergo surgery (53%) and inoperable due to disease distribution (59%) (p<0.001). Survival was superior in patients following PEA compared with those offered but declining surgery (55%) (p<0.001). In patients offered PEA, independent prognostic factors included mixed venous oxygen saturation, gas transfer and patient decision to proceed to surgery.Outcomes in CTEPH following PEA are excellent and superior to patients declining surgery, and strongly favour consideration of a surgical intervention in eligible patients.


Asunto(s)
Endarterectomía , Hipertensión Pulmonar/cirugía , Arteria Pulmonar/cirugía , Embolia Pulmonar/cirugía , Negativa del Paciente al Tratamiento , Anciano , Angioplastia de Balón , Presión Arterial , Enfermedad Crónica , Bases de Datos Factuales , Femenino , Humanos , Hipertensión Pulmonar/diagnóstico , Masculino , Persona de Mediana Edad , Prioridad del Paciente , Arteria Pulmonar/fisiopatología , Embolia Pulmonar/diagnóstico , Intercambio Gaseoso Pulmonar , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Reino Unido/epidemiología , Resistencia Vascular
4.
Lancet ; 385(9967): 529-38, 2015 Feb 07.
Artículo en Inglés | MEDLINE | ID: mdl-25453443

RESUMEN

BACKGROUND: Stenting is an alternative to endarterectomy for treatment of carotid artery stenosis, but long-term efficacy is uncertain. We report long-term data from the randomised International Carotid Stenting Study comparison of these treatments. METHODS: Patients with symptomatic carotid stenosis were randomly assigned 1:1 to open treatment with stenting or endarterectomy at 50 centres worldwide. Randomisation was computer generated centrally and allocated by telephone call or fax. Major outcomes were assessed by an independent endpoint committee unaware of treatment assignment. The primary endpoint was fatal or disabling stroke in any territory after randomisation to the end of follow-up. Analysis was by intention to treat ([ITT] all patients) and per protocol from 31 days after treatment (all patients in whom assigned treatment was completed). Functional ability was rated with the modified Rankin scale. This study is registered, number ISRCTN25337470. FINDINGS: 1713 patients were assigned to stenting (n=855) or endarterectomy (n=858) and followed up for a median of 4·2 years (IQR 3·0-5·2, maximum 10·0). Three patients withdrew immediately and, therefore, the ITT population comprised 1710 patients. The number of fatal or disabling strokes (52 vs 49) and cumulative 5-year risk did not differ significantly between the stenting and endarterectomy groups (6·4% vs 6·5%; hazard ratio [HR] 1·06, 95% CI 0·72-1·57, p=0·77). Any stroke was more frequent in the stenting group than in the endarterectomy group (119 vs 72 events; ITT population, 5-year cumulative risk 15·2% vs 9·4%, HR 1·71, 95% CI 1·28-2·30, p<0·001; per-protocol population, 5-year cumulative risk 8·9% vs 5·8%, 1·53, 1·02-2·31, p=0·04), but were mainly non-disabling strokes. The distribution of modified Rankin scale scores at 1 year, 5 years, or final follow-up did not differ significantly between treatment groups. INTERPRETATION: Long-term functional outcome and risk of fatal or disabling stroke are similar for stenting and endarterectomy for symptomatic carotid stenosis. FUNDING: Medical Research Council, Stroke Association, Sanofi-Synthélabo, European Union.


Asunto(s)
Estenosis Carotídea/terapia , Endarterectomía Carotidea , Stents , Anciano , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/prevención & control , Factores de Tiempo , Resultado del Tratamiento
5.
J Vasc Surg ; 59(5): 1418-21, 2014 May.
Artículo en Inglés | MEDLINE | ID: mdl-23768791

RESUMEN

Absent common carotid artery with independent origin of internal and external carotid arteries from the subclavian artery is a rare but recognized phenomenon. We describe one such case with an associated symptomatic proximal high-grade stenosis of the right internal carotid artery. The abnormal carotid anatomy was not initially well appreciated, resulting in a failed surgical exploration and subsequent successful endovascular carotid stenting. To our knowledge, this is the first reported case of carotid stent in a right internal carotid artery originating from the subclavian artery.


Asunto(s)
Angioplastia de Balón/instrumentación , Arteria Carótida Común/anomalías , Arteria Carótida Interna , Estenosis Carotídea/terapia , Stents , Arteria Subclavia/anomalías , Anciano , Angiografía de Substracción Digital , Arteria Carótida Común/diagnóstico por imagen , Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/diagnóstico , Humanos , Angiografía por Resonancia Magnética , Masculino , Arteria Subclavia/diagnóstico por imagen , Resultado del Tratamiento
6.
J Vasc Interv Radiol ; 24(4): 528-33, 2013 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-23462063

RESUMEN

PURPOSE: To assess the effectiveness of flow reversal as an alternative means of cerebral protection by using transcranial Doppler recordings and diffusion-weighted imaging (DWI) as surrogate markers of brain injury. MATERIALS AND METHODS: Eighteen patients with symptomatic carotid artery disease were recruited. Magnetic resonance imaging was performed before the intervention and at 3 and 24 hours and 30 days after the intervention to detect new ischemic lesions with DWI. Transcranial Doppler recordings were made during the procedure to assess for microembolic signals (MESs). Data were compared against data from a historical control cohort of patients who underwent CAS placement with or without filter protection (n = 15 each) under the same protocol in a different study. RESULTS: There were fewer periprocedural new lesions on DWI in the reverse-flow cohort compared with the historical control cohort with filter protection (P = .084). Reverse flow revealed significantly fewer MESs during the whole procedure compared with the filter-protected group (P = .01) but not the unprotected group (P = .55). There was a marked decrease in MES counts for reverse flow protection during the embologenic stages of the procedure (P = .004). CONCLUSIONS: Use of the reverse flow device was associated with fewer overall lesions on DWI and proportionately fewer positive scans compared with the use of filter-type devices (P = .08, not significant). Transcranial Doppler recordings demonstrated a significant reduction in embolization to the brain during carotid artery stent placement with the use of reverse-flow cerebral protection.


Asunto(s)
Angioplastia/instrumentación , Isquemia Encefálica/prevención & control , Enfermedades de las Arterias Carótidas/terapia , Circulación Cerebrovascular , Imagen de Difusión por Resonancia Magnética , Embolia Intracraneal/prevención & control , Perfusión/métodos , Stents , Ultrasonografía Doppler Transcraneal , Anciano , Angioplastia/efectos adversos , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiología , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/diagnóstico , Enfermedades de las Arterias Carótidas/fisiopatología , Dispositivos de Protección Embólica , Femenino , Humanos , Embolia Intracraneal/diagnóstico , Embolia Intracraneal/etiología , Masculino , Persona de Mediana Edad , Proyectos Piloto , Valor Predictivo de las Pruebas , Factores de Tiempo , Resultado del Tratamiento
7.
Expert Rev Cardiovasc Ther ; 21(5): 347-356, 2023 May.
Artículo en Inglés | MEDLINE | ID: mdl-37128666

RESUMEN

OBJECTIVES: This umbrella review aims to quality assess published meta-analyses, conduct a de-novo meta-analysis of the available randomized control trials (RCTs), and test the hypothesis that there is a long-term difference in mortality between OSR and EVAR. METHODS: A systematic search was conducted in MEDLINE and EMBASE's bibliographic databases (June 2022). Data were extracted using standardized extraction forms. The methodological quality of publications was assessed using the ROBIS tool. Data were analyzed with 'one-stage' and 'two-stage' approaches. RESULTS: According to two-stage analysis, EVAR has significantly favorable mortality for up to four years (increasing evidence). Subsequently, until the longest available time period, there is no difference between EVAR and OSR; all the results are statistically non-significant.In one stage analysis, the Cox model demonstrated a non-significant (weak evidence) hazard ratio of 1.03 (95% confidence interval [CI]: 0.94-1.12) in favor of OSR. The best-fitting parametric model (generalized gamma), leads to an hazard ratio of 0.97 (95% CI: 0.93-1.01) in favor of EVAR, with the results approaching significance (weak evidence). CONCLUSION: The results of this umbrella systematic review and meta-analysis failed to demonstrate any difference in long-term mortality following planned EVAR, compared with OSR of infrarenal AAA.


Asunto(s)
Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/métodos , Complicaciones Posoperatorias , Factores de Riesgo , Resultado del Tratamiento
8.
Cerebrovasc Dis ; 29(3): 282-9, 2010 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-20090320

RESUMEN

BACKGROUND: Our aim was to determine whether filter protection reduces embolisation to the brain during carotid artery stenting (CAS). METHODS: Thirty patients with symptomatic carotid artery stenosis > or =70% (North American Symptomatic Carotid Endarterectomy Trial) were randomly assigned to filter-protected or unprotected CAS. Diffusion-weighted magnetic resonance imaging (DWI) of the brain was performed before and at 3 time points after CAS. In a subset of patients, high-intensity transient signals on transcranial Doppler (TCD) were recorded with categorisation of emboli. Data were independently reviewed off-site. RESULTS: There were no significant differences in mean age, proportion of octogenarians or presenting symptoms between the groups. On procedural DWI (1-3 and 24 h after stenting), there were 7/24 (29%) and 4/22 (18%) new lesions in protected and unprotected patients respectively (p = 0.38). At 30 days there were 9/33 (26%) and 4/33 (12%) lesions in protected and unprotected patients, respectively (p = 0.1). On TCD there were significantly more signals in total as well as particulate emboli during filter-protected CAS (426.5 and 251.3) than during unprotected CAS (165.2 and 92) - p = 0.01 and 0.03, respectively. CONCLUSIONS: Filter-protected CAS is associated with an increase in new lesions on DWI and significantly higher rates of total and particulate microembolisation on TCD than unprotected CAS. The clinical significance of these findings requires further study.


Asunto(s)
Angioplastia/instrumentación , Estenosis Carotídea/terapia , Filtración/instrumentación , Embolia Intracraneal/prevención & control , Stents , Anciano , Anciano de 80 o más Años , Angioplastia/efectos adversos , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Distribución de Chi-Cuadrado , Imagen de Difusión por Resonancia Magnética , Femenino , Humanos , Embolia Intracraneal/diagnóstico , Embolia Intracraneal/etiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler Transcraneal
9.
CVIR Endovasc ; 3(1): 41, 2020 Jun 26.
Artículo en Inglés | MEDLINE | ID: mdl-32592080

RESUMEN

BACKGROUND: The COVID-19 pandemic has had an unprecedented effect upon the National Health Service (NHS). Like other specialties, Interventional Radiology (IR) rapidly adapted to the evolving situation. Members of BSIR were surveyed to obtain a snapshot of the experiences of UK IRs in response to COVID-19. An electronic survey was compiled using Google Forms, approved by the BSIR Council Officers and distributed to BSIR members by email on 18 th April 2020. A total of 228 responses were received. The survey was open for a 14-day period and the data analysed in Microsoft Excel 365. The response rate was 29% (228/800). RESULTS: Two thirds of respondents work in a Tertiary unit and 33% deliver IR in a District Hospital. 84% have a day-case facility. After the COVID-19 crisis, 81% of respondents were able to maintain 24-7 On-call service. 59% of respondents had been required change their day to day practice to allow the on-call service to continue. 55% of respondents were involved in providing a central line service. Of those questioned, 91% continued to offer endovascular services, 98% genitourinary and 92% hepatobiliary services, although a degree of service reduction was described. 38% have provided IR trainees with additional training material during this pandemic. CONCLUSIONS: This survey has confirmed that the responses of UK IR departments to the COVID-19 crisis have ensured vital on-call and urgent services have continued, including ongoing availability of most IR sub-specialties. Availability of a day case facility has possibly influenced the positive response.

10.
Cardiovasc Intervent Radiol ; 42(1): 28-33, 2019 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-30288590

RESUMEN

BACKGROUND: Percutaneous endovascular aneurysm repair (PEVAR) has been shown to have high success rates, shorter operating times and length of stay compared to open access. However, there exists a lack of long-term follow-up data on these patients, and questions remain regarding longer-term outcomes. This study aims to assess the long-term complications and evolution of accessed vessels post-PEVAR. METHODS: Sixty-one cases of bilateral PEVAR (122 groins) with > 36 months follow-up were analysed. Vessel diameter, calcification, dissection, lymphocele, pseudoaneurysm and thrombus formation were reviewed at 30th day and at the most recent follow-up CT. Notes were reviewed for groin infections, haematomas and nerve injury. Complications were considered 'major' if they required intervention or treatment. RESULTS: Mean follow-up time from procedure to most recent scan was 49.9 months. There were no major short- or long-term complications. The early complication rate was 9.8%, with six pseudoaneurysms, four dissections, one thrombus, one nerve injury and no lymphoceles, haematomas or groin infections. The long-term complication rate was 0.8%, with only one pseudoaneurysm. The remainder of early complications resolved naturally without intervention. Accessed vessel showed significantly (P ≤ 0.05) increased diameter and calcification between 30th day and last follow-up scan. CONCLUSION: This study provides the largest clinical cohort and the longest mean follow-up time reported in the literature and demonstrates the long-term safety of PEVAR. PEVAR has a very low long-term complication rate, without any major complications in our cohort. The accessed common femoral arteries do not show stenosis or thrombosis. Minor short-term complications appear to gradually resolve without intervention. Larger multi-centre studies are recommended.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Anciano , Anciano de 80 o más Años , Femenino , Arteria Femoral/cirugía , Ingle/irrigación sanguínea , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/terapia , Factores de Tiempo , Resultado del Tratamiento
11.
Heart ; 105(19): 1456-1463, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31292190

RESUMEN

Improved and durable control of hypertension is a global priority for healthcare providers and policymakers. There are several lifestyle measures that are proven to result in improved blood pressure (BP) control. Moreover, there is incontrovertible evidence from large scale randomised controlled trials (RCTs) that antihypertensive drugs lower BP safely and effectively in the long-term resulting in substantial reduction in cardiovascular morbidity and mortality. Importantly, however, evidence is accumulating to suggest that patients neither sustain long-term healthy behaviours nor adhere to lifelong drug treatment regimens and thus alternative measures to control hypertension warrant further investigation. Endovascular renal denervation (RDN) appears to hold some promise as a non-pharmacological approach to lowering BP and achieves renal sympathectomy using either radiofrequency energy or ultrasound-based approaches. This treatment modality has been evaluated in clinical trials in humans since 2009 but initial studies were compromised by being non-randomised, without sham control and small in size. Subsequently, clinical trial design and rigour of execution has been greatly improved resulting in recent sham-controlled RCTs that demonstrate short-term reduction in ambulatory BP without any significant safety concerns in both medication-naïve and medication-treated hypertensive patients. Despite this, the joint UK societies still feel that further evaluation of this therapy is warranted and that RDN should not be offered to patients outside of the context of clinical trials. This document reviews the updated evidence since our last consensus statement from 2014 and provides a research agenda for future clinical studies.


Asunto(s)
Arteria Renal/inervación , Arteria Renal/cirugía , Simpatectomía , Ensayos Clínicos como Asunto , Humanos , Ablación por Radiofrecuencia , Sociedades Médicas , Reino Unido
13.
Lancet Neurol ; 17(7): 587-596, 2018 07.
Artículo en Inglés | MEDLINE | ID: mdl-29861139

RESUMEN

BACKGROUND: The risk of stroke associated with carotid artery restenosis after stenting or endarterectomy is unclear. We aimed to compare the long-term risk of restenosis after these treatments and to investigate if restenosis causes stroke in a secondary analysis of the International Carotid Stenting Study (ICSS). METHODS: ICSS is a parallel-group randomised trial at 50 tertiary care centres in Europe, Australia, New Zealand, and Canada. Patients aged 40 years or older with symptomatic carotid stenosis measuring 50% or more were randomly assigned either stenting or endarterectomy in a 1:1 ratio. Randomisation was computer-generated and done centrally, with allocation by telephone or fax, stratified by centre, and with minimisation for sex, age, side of stenosis, and occlusion of the contralateral carotid artery. Patients were followed up both clinically and with carotid duplex ultrasound at baseline, 30 days after treatment, 6 months after randomisation, then annually for up to 10 years. We included patients whose assigned treatment was completed and who had at least one ultrasound examination after treatment. Restenosis was defined as any narrowing of the treated artery measuring 50% or more (at least moderate) or 70% or more (severe), or occlusion of the artery. The degree of restenosis based on ultrasound velocities and clinical outcome events were adjudicated centrally; assessors were masked to treatment assignment. Restenosis was analysed using interval-censored models and its association with later ipsilateral stroke using Cox regression. This trial is registered with the ISRCTN registry, number ISRCTN25337470. This report presents a secondary analysis, and follow-up is complete. FINDINGS: Between May, 2001, and October, 2008, 1713 patients were enrolled and randomly allocated treatment (855 were assigned stenting and 858 endarterectomy), of whom 1530 individuals were followed up with ultrasound (737 assigned stenting and 793 endarterectomy) for a median of 4·0 years (IQR 2·3-5·0). At least moderate restenosis (≥50%) occurred in 274 patients after stenting (cumulative 5-year risk 40·7%) and in 217 after endarterectomy (29·6%; unadjusted hazard ratio [HR] 1·43, 95% CI 1·21-1·72; p<0·0001). Patients with at least moderate restenosis (≥50%) had a higher risk of ipsilateral stroke than did individuals without restenosis in the overall patient population (HR 3·18, 95% CI 1·52-6·67; p=0·002) and in the endarterectomy group alone (5·75, 1·80-18·33; p=0·003), but no significant increase in stroke risk after restenosis was recorded in the stenting group (2·03, 0·77-5·37; p=0·154; p=0·10 for interaction with treatment). No difference was noted in the risk of severe restenosis (≥70%) or subsequent stroke between the two treatment groups. INTERPRETATION: At least moderate (≥50%) restenosis occurred more frequently after stenting than after endarterectomy and increased the risk for ipsilateral stroke in the overall population. Whether the restenosis-mediated risk of stroke differs between stenting and endarterectomy requires further research. FUNDING: Medical Research Council, the Stroke Association, Sanofi-Synthélabo, and the European Union.


Asunto(s)
Estenosis Carotídea/cirugía , Endarterectomía Carotidea/métodos , Oclusión de Injerto Vascular/epidemiología , Stents , Accidente Cerebrovascular/cirugía , Anciano , Estenosis Carotídea/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/diagnóstico por imagen , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Riesgo , Factores de Riesgo , Resultado del Tratamiento , Ultrasonografía
15.
Diagn Interv Radiol ; 23(2): 144-149, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28093377

RESUMEN

PURPOSE: A significant proportion of patients undergoing surgery have an increased incidence of acute pulmonary embolus (PE). We analyzed all patients who had a retrievable inferior vena cava (IVC) filter placed preoperatively for PE prophylaxis and investigated the long-term outcomes of the patients who did not have their filter removed. METHODS: Patients who underwent retrievable IVC filter insertion and attempted removal were identified from the radiology information systems database in a large tertiary referral university teaching hospital. Results of all clinical investigations (including computed tomography, magnetic resonance imaging, ultrasonography, and plain radiography) while the IVC filters were in situ were reviewed. RESULTS: In total, 393 retrievable IVC filters were inserted, 254 with the indication of preoperative thromboembolic prophylaxis. Recurrent PE was reported in five patients (1.9%) despite the IVC filter. Of the 254 retrievable filters inserted prior to surgery, an attempt at retrieval was made in 168 filters (66.1%). Successful retrieval at the first attempt occurred in 143 cases (85.1%), while 25 cases failed or were aborted (14.9%). No attempt at retrieval was made in 86 (33.9%) patients and a significant proportion of these patients had undergone cancer surgery (P < 0.0107). In those patients where there was no attempt at retrieval, there was an association between cancer surgery and a shorter absolute survival time (P < 0.0001). CONCLUSION: The majority of attempted filter retrievals were successful, and a proportion of nonretrieved IVC filters are accounted for in patients who underwent cancer surgery and ultimately died with the filter in situ. A departmental protocol is recommended to ensure the filter is removed where appropriate and possible.


Asunto(s)
Embolia Pulmonar/epidemiología , Filtros de Vena Cava/estadística & datos numéricos , Vena Cava Inferior/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Remoción de Dispositivos/estadística & datos numéricos , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Embolia Pulmonar/prevención & control , Estudios Retrospectivos , Centros de Atención Terciaria , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Ultrasonografía , Vena Cava Inferior/diagnóstico por imagen , Adulto Joven
16.
Stroke ; 37(2): 435-9, 2006 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-16373639

RESUMEN

BACKGROUND AND PURPOSE: To assess the benefits of carotid artery stenting before coronary artery bypass surgery to reduce the risk of stroke occurring during the cardiac procedure. METHODS: A prospective cohort study was performed in patients undergoing carotid artery stenting before coronary artery bypass surgery, or combined bypass and valve replacement procedures, to assess the procedures effectiveness in stroke prevention. Outcome measures including 30-day post stenting and cardiac surgery neurological complication and all-cause mortality rates were assessed. RESULTS: A total of 52 patients were included. Two patients underwent aortic valve replacements at the same time as coronary revascularization. No neurological complications occurred because of the stenting procedure. One cardiac death not related to coronary artery bypass surgery occurred in the 30-day follow-up period for the stent procedure. An additional 6 (11.5%) outcome events (3 strokes and 3 deaths) occurred in the 30-day follow-up period after the cardiac procedure. Three patients died of cardiac causes while awaiting their cardiac bypass procedure. CONCLUSIONS: Our results are comparable to those in patients that undergo staged or combined carotid endarterectomy before cardiac surgery. Our small cohort study adds to the limited world literature on the subject but is not sufficiently powered to recommend alterations in practice.


Asunto(s)
Implantación de Prótesis Vascular/métodos , Arterias Carótidas/patología , Enfermedades de las Arterias Carótidas/cirugía , Puente de Arteria Coronaria/métodos , Endarterectomía Carotidea/métodos , Proyectos de Investigación , Anciano , Angioplastia/métodos , Aorta/patología , Enfermedades de las Arterias Carótidas/complicaciones , Ensayos Clínicos como Asunto , Estudios de Cohortes , Endarterectomía Carotidea/efectos adversos , Femenino , Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Stents , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del Tratamiento
17.
BMJ Open ; 6(5): e011245, 2016 05 09.
Artículo en Inglés | MEDLINE | ID: mdl-27160845

RESUMEN

OBJECTIVES: To estimate the clinical and economic impact of drug-eluting endovascular treatment strategies for femoropopliteal artery disease compared with current standard of care. DESIGN: Systematic literature search to pool target lesion revascularisations (TLR). Model-based per-patient cost impact and quasi-cost-effectiveness projection over 24 months based on pooled TLRs and current reimbursement. SETTING: The UK's National Health Service (NHS). PARTICIPANTS: Patients presenting with symptomatic femoropopliteal disease eligible for endovascular treatment. INTERVENTIONS: Current National Institute for Health and Care Excellence (NICE) guideline-recommended treatment with percutaneous transluminal balloon angioplasty (PTA) and bailout bare metal stenting (BMS) versus primary BMS placement, or drug-coated balloon (DCB), or drug-eluting stent (DES) treatment. PRIMARY AND SECONDARY OUTCOME MEASURES: 24-month per-patient cost impact to NHS (primary outcome). SECONDARY OUTCOMES: pooled 24-month TLR rates; numbers needed to treat (NNTs); cost per TLR avoided and estimated incremental cost-effectiveness ratio (ICER) in £ per quality-adjusted life year (QALY). RESULTS: N=28 studies were identified, reporting on 5167 femoropopliteal lesions. Over 24 months, DCB, DES and BMS reduced TLRs of de novo lesions from 36.2% to 17.6%, 19.4% and 26.9%, respectively, at an increased cost of £43, £44 and £112. NNTs to avoid 1 TLR in 24 months were 5.4, 6.0 and 10.8, resulting in cost per TLR avoided of £231, £264 and £1204. DCB was estimated to add 0.011 QALYs, DES 0.010 QALYs and BMS 0.005 QALYs, resulting in estimated ICERs of £3983, £4534 and £20 719 per QALY gained. A subset analysis revealed more favourable clinical and economic outcomes for a 3.5 µg/mm(2) DCB with urea excipient, compared with the rest of DCBs. A modest reduction of 10% in DCB and DES prices made drug-eluting treatments dominant. CONCLUSIONS: Widespread adoption of drug-eluting endovascular therapies for femoropopliteal disease would add meaningful clinical benefit at reasonable additional costs to the NHS. Based on currently available data, DCBs offer the highest clinical and economic value.


Asunto(s)
Stents Liberadores de Fármacos/economía , Costos de la Atención en Salud/estadística & datos numéricos , Enfermedad Arterial Periférica/economía , Enfermedad Arterial Periférica/terapia , Procedimientos Quirúrgicos Vasculares/economía , Angioplastia de Balón/economía , Angioplastia de Balón/instrumentación , Análisis Costo-Beneficio , Arteria Femoral , Humanos , Números Necesarios a Tratar , Arteria Poplítea , Años de Vida Ajustados por Calidad de Vida , Medicina Estatal/economía , Reino Unido , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos
18.
Clin Res Cardiol ; 105(6): 544-52, 2016 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-26802018

RESUMEN

BACKGROUND: Renal denervation (RDN) may lower blood pressure (BP); however, it is unclear whether medication changes may be confounding results. Furthermore, limited data exist on pattern of ambulatory blood pressure (ABP) response-particularly in those prescribed aldosterone antagonists at the time of RDN. METHODS: We examined all patients treated with RDN for treatment-resistant hypertension in 18 UK centres. RESULTS: Results from 253 patients treated with five technologies are shown. Pre-procedural mean office BP (OBP) was 185/102 mmHg (SD 26/19; n = 253) and mean daytime ABP was 170/98 mmHg (SD 22/16; n = 186). Median number of antihypertensive drugs was 5.0: 96 % ACEi/ARB; 86 % thiazide/loop diuretic and 55 % aldosterone antagonist. OBP, available in 90 % at 11 months follow-up, was 163/93 mmHg (reduction of 22/9 mmHg). ABP, available in 70 % at 8.5 months follow-up, was 158/91 mmHg (fall of 12/7 mmHg). Mean drug changes post RDN were: 0.36 drugs added, 0.91 withdrawn. Dose changes appeared neutral. Quartile analysis by starting ABP showed mean reductions in systolic ABP after RDN of: 0.4; 6.5; 14.5 and 22.1 mmHg, respectively (p < 0.001 for trend). Use of aldosterone antagonist did not predict response (p > 0.2). CONCLUSION: In 253 patients treated with RDN, office BP fell by 22/9 mmHg. Ambulatory BP fell by 12/7 mmHg, though little response was seen in the lowermost quartile of starting blood pressure. Fall in BP was not explained by medication changes and aldosterone antagonist use did not affect response.


Asunto(s)
Presión Sanguínea , Hipertensión/cirugía , Riñón/irrigación sanguínea , Arteria Renal/inervación , Simpatectomía/métodos , Sistema Nervioso Simpático/cirugía , Anciano , Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Monitoreo Ambulatorio de la Presión Arterial , Resistencia a Medicamentos , Quimioterapia Combinada , Femenino , Humanos , Hipertensión/diagnóstico , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Antagonistas de Receptores de Mineralocorticoides , Visita a Consultorio Médico , Sistema de Registros , Estudios Retrospectivos , Simpatectomía/efectos adversos , Sistema Nervioso Simpático/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Reino Unido
19.
J Am Coll Cardiol ; 39(5): 841-6, 2002 Mar 06.
Artículo en Inglés | MEDLINE | ID: mdl-11869850

RESUMEN

OBJECTIVES: The aim of this study was to evaluate the feasibility and safety of carotid artery stenting (CAS) with a filter protection system. BACKGROUND: Neurologic events linked to the embolization of particulate matter to the cerebral circulation may complicate CAS. Strategies designed to capture embolic particles during carotid intervention are being evaluated for their efficacy in reducing the risk of these events. METHODS: Between September 1999 and July 2001, a total of 162 patients (164 hemispheres) underwent CAS with filter protection (NeuroShield, MedNova Ltd., Galway, Ireland) according to prospective protocols evaluating the filter system at three institutions. RESULTS: Angiographic success was achieved in 162 of the procedures (99%) and filter placement was successful in 154 (94%) procedures. Carotid access was unsuccessful in two cases (1%) and filter placement in eight cases (5%). Of the latter, five procedures were completed with no protection and three were completed using alternative protection devices. On an intention-to-treat basis, the overall combined 30-day rate of all-stroke and death was 2% (four events: two minor strokes and two deaths). This includes one minor stroke in a patient with failed filter placement and CAS completed without protection. There was one cardiac arrhythmic death and one death from hyperperfusion-related intracerebral hemorrhage. There were no major embolic strokes. CONCLUSIONS: Carotid artery stenting with filter protection is technically feasible and safe. Early clinical outcomes appear to be favorable and need to be confirmed in a larger comparative study.


Asunto(s)
Implantación de Prótesis Vascular/instrumentación , Arterias Carótidas/cirugía , Enfermedades de las Arterias Carótidas/cirugía , Filtración/instrumentación , Stents , Accidente Cerebrovascular/prevención & control , Anciano , Anciano de 80 o más Años , Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Diseño de Equipo , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Radiografía , Accidente Cerebrovascular/diagnóstico por imagen , Factores de Tiempo , Resultado del Tratamiento
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