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1.
Praxis (Bern 1994) ; 109(9): 705-723, 2020 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-32635848

RESUMO

Diagnostic and Therapeutic Management of Carotid Artery Disease Abstract. A quarter of all ischemic strokes is caused by atherosclerotic obliterations of the extra- and intracranial brain-supplying vessels. The prevalence of atherosclerotic extracranial carotid stenosis rises up to 6-15 % from the age of 65. The risk of stroke in symptomatic carotid stenosis, i.e. after stroke or transient ischemic attack (TIA), is very high at 25 % within 14 days. Conservative therapy is the cornerstone of treatment by controlling the risk factors, treatment with platelet aggregation inhibitors and antihypertensive and lipid-lowering medication. Carotid endarterectomy (CEA) is the first line treatment for symptomatic patients with a >50 % and asymptomatic patients with a >60 % carotid stenosis. In order to ensure the best possible treatment of patients with asymptomatic and symptomatic carotid stenosis, interdisciplinary cooperation in diagnostics, therapy and aftercare in a neuromedical centre of maximum care is necessary.


Assuntos
Doenças das Artérias Carótidas , Estenose das Carótidas , Endarterectomia das Carótidas , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Doenças das Artérias Carótidas/diagnóstico , Doenças das Artérias Carótidas/terapia , Humanos , Fatores de Risco , Stents , Resultado do Tratamento
4.
Medicine (Baltimore) ; 99(27): e20916, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32629688

RESUMO

INTRODUCTION: Evolving techniques in the field of therapeutic bronchoscopy have led to the return of rigid bronchoscopy in the treatment of complex central airway disease. Rigid bronchoscopy is typically performed under general anesthesia because of the strong stimulation caused by metal instruments. Anesthesia for rigid bronchoscopy is challenging to administer because anesthesiologists and interventionists share the same working channel: the airway. Previously reviewed anesthetic methods are used primarily for short procedures. Balanced anesthesia with ultrasound-guided superior laryngeal nerve (SLN) block and total intravenous anesthesia might provide anesthesia for a prolonged procedure and facilitate patient recovery. PATIENT CONCERNS: A patient with obstructed endobronchial stent was referred for therapeutic rigid bronchoscopy, which requires deeper anesthesia than flexible bronchoscopy. There were concerns of the stronger stimulation of the rigid bronchoscopy, lengthy duration of the procedure, higher risk of hypoxemia, and the difficulty of mechanical ventilation weaning after anesthesia due to the patients co-morbidities. DIAGNOSIS: A 66-year-old female patient presented with a history of breast cancer with lung metastases. Right main bronchus obstruction due to external compression of lung metastases was relieved through insertion of an endobronchial stent, but obstructive granulation developed after 4 months. Presence of the malfunctioning stent caused severe cough and discomfort. Removal of the stent by using a flexible bronchoscope was attempted twice but failed. INTERVENTIONS: Regional anesthesia of the upper airway through ultrasound-guided SLN block combined with intratracheal 2% lidocaine spray was performed to assist in total intravenous anesthesia (TIVA) during rigid bronchoscopy. OUTCOMES: The patient maintained steady spontaneous breathing throughout the procedure without laryngospasm, bucking, or desaturation. Emergence from anesthesia was smooth and rapid after propofol infusion was discontinued. The surgery lasted 2.5 hours without discontinuity, and no perioperative pulmonary or cardiovascular complications were noted. CONCLUSION: Ultrasound-guided SLN block is a simple technique with a high success rate and low complication rate. Application of SLN block to assist TIVA provides sufficient anesthesia for lengthened therapeutic rigid bronchoscopy without interruption and facilitates patient recovery.


Assuntos
Obstrução das Vias Respiratórias/cirurgia , Anestesia , Broncopatias/cirurgia , Broncoscopia/instrumentação , Bloqueio Nervoso , Idoso , Neoplasias da Mama/patologia , Broncoscopia/métodos , Feminino , Humanos , Nervos Laríngeos , Neoplasias Pulmonares/secundário , Metástase Neoplásica , Stents , Ultrassonografia de Intervenção
5.
JAMA ; 324(3): 279-290, 2020 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-32692391

RESUMO

Importance: Perioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery. Observations: Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose ß-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without ß-blocker use; P = .005) and mortality (3.1% vs 2.3% without ß-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration. Conclusions and Relevance: Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.


Assuntos
Doenças Cardiovasculares/etiologia , Complicações Pós-Operatórias/etiologia , Medição de Risco/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas Adrenérgicos beta/efeitos adversos , Fatores Etários , Idoso , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Biomarcadores/sangue , Angiografia Coronária , Ecocardiografia Transesofagiana , Eletrocardiografia/métodos , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Insuficiência Cardíaca/diagnóstico , Doenças das Valvas Cardíacas/diagnóstico , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Isquemia Miocárdica/diagnóstico , Revascularização Miocárdica , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Stents/efeitos adversos , Acidente Vascular Cerebral/induzido quimicamente , Fatores de Tempo , Estados Unidos/epidemiologia
6.
Zhejiang Da Xue Xue Bao Yi Xue Ban ; 49(1): 131-136, 2020 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-32621412

RESUMO

Stenting for iliac vein stenosis or compression has become a common therapeutic approach in recent years. The antithrombotic therapy after the stent deployment, however, reaches no consensus. Medications strategies and patients' prognoses differ in non-thrombotic, acute thrombotic and chronic thrombotic these three circumstances. Non-thrombotic patients usually possess satisfactory stent patency whatever antithrombotic therapy is used. Anticoagulant is the basic medication for acute thrombotic patients, benefits from additional antiplatelet drug remains to be clarified. In terms of chronic thrombotic patients, their prognoses are unsatisfactory under all antithrombotic therapies. In this review, we outlined the recent progress of antithrombotic therapy after iliac vein stenting, aiming to provide feasible medication plans for each circumstance.


Assuntos
Fibrinolíticos , Veia Ilíaca , Stents , Constrição Patológica/tratamento farmacológico , Constrição Patológica/cirurgia , Fibrinolíticos/uso terapêutico , Humanos , Veia Ilíaca/cirurgia , Resultado do Tratamento , Grau de Desobstrução Vascular
7.
Medicine (Baltimore) ; 99(27): e21017, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32629723

RESUMO

INTRODUCTION: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an alternative treatment option for patients with acute cholecystitis, especially for those who are unsuitable for cholecystectomy. Recently used luminal apposing metal stents (LAMS) in EUS-GBD has several advantages over standard metal stents. However, there is no current guideline on where to locate the LAMS when transgastric approach is required. This study reports a case of gastric outlet obstruction (GOO) by placing LAMS too close to the pyloric ring. PATIENT CONCERNS: A 79-year-old female patient was referred to our department for evaluation of a large hepatic mass on abdominal ultrasound. Abdominal pain on right upper quadrant and spiking fever up to 38 °C appeared after liver biopsy. Abdominal ultrasound showed thickened GB wall and positive sonographic Murphy sign. DIAGNOSES: Intrahepatic cholangiocarcinoma with multiple lung and intrahepatic metastasis, acute cholecystitis, and pyloric ring obstruction caused by flange of LAMS in EUS-GBD. INTERVENTIONS: EUS-GBD via transgastric approach was performed with LAMS. After complete deployment of stent, esophagogastroduodenoscopy showed complete GOO by flange of LAMS. A gastroduodenal metal stent was inserted to relieve the GOO. OUTCOMES: The patient recovered well. She did not complain about obstruction induced symptom such as vomiting or abdominal fullness after gastroduodenal stent insertion. CONCLUSION: To the best of our knowledge, this is the first case report of EUS-GBD induced GOO. If physicians use LAMS as a transgastric approach in EUS-GBD, the puncture site should be carefully selected considering the size of the flange.


Assuntos
Colangiocarcinoma/complicações , Obstrução da Saída Gástrica/etiologia , Neoplasias Hepáticas/diagnóstico por imagem , Stents/efeitos adversos , Idoso , Colecistite Aguda/etiologia , Drenagem/métodos , Endossonografia/métodos , Feminino , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/patologia , Obstrução da Saída Gástrica/cirurgia , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/secundário , Resultado do Tratamento , Ultrassonografia/métodos , Ultrassonografia de Intervenção/instrumentação
8.
Medicine (Baltimore) ; 99(25): e20637, 2020 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-32569194

RESUMO

Stroke is one of the diseases that seriously threaten the survival and health of human beings. In Europe and the United States, stroke is the second leading cause of death after heart disease and tumors. Stroke is also one of the fatal diseases in Asian countries. On average, about 1.5 million new stroke patients are added each year in China, and the incidence of stroke is increasing year by year. About 80% of all stroke patients are ischemic stroke, and symptomatic internal carotid atherosclerotic stenosis is another important cause of ischemic stroke. Ipsilateral carotid stenosis ≥50% increases the incidence of transient cerebral ischemia and stroke in the carotid artery region by 10% to 15%, and is also closely related to the recurrence of acute and long-term stroke in patients. Therefore, the clinical application and efficacy of carotid stenting in patients with symptomatic internal carotid artery stenosis are analyzed and evaluated to provide a basis for the selection of clinical treatment options.The clinical data of patients with symptomatic carotid stenosis who underwent carotid stenting and the clinical data of conservative treatment of patients with symptomatic carotid stenosis were retrospectively analyzed, and the carotid stenosis rate, symptoms, and National Institute of Health stroke scale where compared before and after surgery. And activities of daily living score. Because the control group treatment method in this article is completely free for patients to choose, and belongs to a retrospective analysis, the results suggest that it can provide a high-quality treatment approach for the treatment of patients with symptomatic carotid stenosis, without causing any harm to the patient, So no ethical approval is needed, and no patient informed consent is required.In recent years, with the continuous advancement of science and technology and new stent materials, intravascular interventional technology has developed rapidly. In continuous clinical practice and research, the safety and effectiveness of stent technology have also been gradually improved. Arterial stenting has gradually become an important method for the treatment of atherosclerotic carotid stenosis. This technique can not only improve the symptoms and prognosis of patients with symptomatic internal carotid stenosis, but also prevent the occurrence of ischemic events. The promotion of this technology has the effect of reducing disability and mortality.The alternative therapy of drug therapy, namely arterial stent implantation, has become a new way to treat atherosclerotic stroke. This treatment technology can quickly relieve the abnormal hemodynamics of distal blood vessels caused by arterial stenosis, which is ischemic. Cerebrovascular disease provides new ideas for treatment. Carotid angioplasty and stenting for symptomatic internal carotid stenosis under a distal cerebral protection device is a safe and effective treatment.


Assuntos
Estenose das Carótidas/cirurgia , Stents , Atividades Cotidianas , Idoso , Angiografia , Artéria Carótida Interna , Estenose das Carótidas/tratamento farmacológico , Procedimentos Endovasculares , Feminino , Humanos , Masculino , Estudos Retrospectivos , Acidente Vascular Cerebral/prevenção & controle
9.
Khirurgiia (Mosk) ; (5): 70-75, 2020.
Artigo em Russo | MEDLINE | ID: mdl-32500692

RESUMO

One of significant achievements of modern endoscopy is development of retrograde biliary stenting for obstructive jaundice. This method ensured widespread application of endoscopic decompression in the treatment of patients with malignant biliary obstruction as preparation before radical surgery and final palliative care. Endoscopic retrograde transpapillary stenting firmly took its place together with antegrade and percutaneous stenting. There are certain advantages of this technique including minimally invasiveness and favorable quality of life. However, this approach is associated with some drawbacks associated with stent occlusion and difficult correction of this complication. The maximum diameter of the plastic stent (PS) is determined by the width of the working channel of the duodenoscope. In this regard, self-expandable metal stents (SEMS) were developed to increase the diameter of bile drainage channel. SEMS are associated with prolonged function. However, there is another problem. It is a germination of SEMS followed by impossible removal of the stent for its subsequent replacement. A further step in development of endoscopic biliary stents was the use of special SEMS coating to exclude tumor or granulation ingrowth. The problem of biliary stent occlusion remains relevant despite some improvement of stenting results. Mechanisms of occlusion of biliary stents and prevention of these events are discussed in this review.


Assuntos
Colestase/cirurgia , Neoplasias do Sistema Digestório/complicações , Endoscopia do Sistema Digestório , Icterícia Obstrutiva/cirurgia , Stents/efeitos adversos , Colestase/etiologia , Descompressão Cirúrgica/instrumentação , Endoscopia do Sistema Digestório/efeitos adversos , Endoscopia do Sistema Digestório/instrumentação , Endoscopia do Sistema Digestório/métodos , Humanos , Icterícia Obstrutiva/etiologia , Cuidados Paliativos
10.
Zhonghua Wei Chang Wai Ke Za Zhi ; 23(6): 602-605, 2020 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-32521983

RESUMO

Objective: To observe preventive effect of intestinal stent against anastomotic leakage after rectal cancer operation. Methods: A retrospective cohort study was carried out. Clinical data of 107 patients with low rectal cancer undergoing laparoscopic radical resection from January 2015 to August 2019 were retrospectively analyzed. Intestinal stent was placed intraoperatively in 48 cases and was not placed in 59 cases. Postoperative Wexner score for anal function and incidence of anastomotic leakage were compared between patients with and without intstinal stent. Results: There was no significant differences in age, distance between tumor and the anal verge, operative time and postoperative Wexner score for anal function between the two groups (all P>0.05). After a month of follow-up, the incidence of anastomotic leakage was 16.9% (10/59) in the non-stent group, while no anastomotic leakage was found in the stent group (P=0.002). Conclusion: Placement of intestinal stent can effectively prevent anastomotic leakage after low rectal cancer surgery.


Assuntos
Anastomose Cirúrgica/métodos , Fístula Anastomótica/prevenção & controle , Protectomia/efeitos adversos , Neoplasias Retais/cirurgia , Reto/cirurgia , Stents , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/instrumentação , Fístula Anastomótica/etiologia , Humanos , Protectomia/métodos , Implantação de Prótese , Estudos Retrospectivos , Fatores de Risco
12.
J Endovasc Ther ; 27(3): 385-393, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32517556

RESUMO

Purpose: To summarize the experience and outcomes of total endovascular repair of thoracoabdominal aortic disease using 3-dimensional (3D) printed models to guide on-site creation of fenestrations in aortic stent-grafts. Materials and Methods: From April 2018 to March 2019, 34 patients (mean age 58±14 years; 24 men) with thoracoabdominal aortic disease were treated in our department. Nineteen patients had thoracoabdominal aortic dissection and 15 had thoracoabdominal aortic aneurysm. Preoperatively, a 3D printed model of the aorta was made according to computed tomography images. In the operating room, the main aortic stent-graft was completely released in the 3D printed model, and the position of each fenestration or branch was marked on the stent-graft. The fenestrations were then made using an electric pen. Wires were sewn to the edge of the fenestrations using nonabsorbable sutures. After customization, the aortic stent-graft was reloaded into the delivery sheath and deployed. Results: The printing process took ~5 hours (1 hour for image reconstruction, 3 hours for printing, and 1 hour for postprocessing). The physician-modified stent-grafts had a total of 107 fenestrations secured by 102 bridging stent-grafts, including 73 covered stents and 29 bare stents. The average procedure time was 5.6±1.2 hours, including a mean 1.3 hours for stent-graft customization. No renal insufficiency or paraplegia occurred. Two branch arteries were lost during the operation. One patient (3%) died 1 week after surgery from a retrograde dissection rupture. One patient developed a minor cerebral infarction postoperatively. The mean follow-up time was 8.5 months. There was 1 endoleak from a fenestration (coil embolized) and 4 distal ruptures of the aortic dissection (3 treated and 1 observed). Conclusion: Three-dimensional printing can be used to guide creation of fenestrated stent-grafts for the treatment of thoracoabdominal aortic diseases involving crucial branches. This technique appears to be more accurate than the traditional measurement method, with short-term follow-up demonstrating the safety and reliability of the method. However, further research and development are needed.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Desenho Assistido por Computador , Procedimentos Endovasculares/instrumentação , Impressão Tridimensional , Desenho de Prótese , Stents , Adulto , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Aortografia , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Anatômicos , Modelos Cardiovasculares , Modelagem Computacional Específica para o Paciente , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Fluxo de Trabalho
13.
Am Heart J ; 225: 10-18, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32470635

RESUMO

Coronary calcification limits optimal stent expansion and apposition and worsens safety and effectiveness outcomes of percutaneous coronary intervention (PCI). Current ablative technologies that modify calcium to optimize stent deployment are limited by guidewire bias and periprocedural complications related to atheroembolization, coronary dissection, and perforation. Intravascular lithotripsy (IVL) delivers pulsatile ultrasonic pressure waves through a fluid-filled balloon into the vessel wall to modify calcium and enhance vessel compliance, reduce fibroelastic recoil, and decrease the need for high-pressure balloon (barotrauma) inflations. IVL has been used in peripheral arteries as stand-alone revascularization or as an adjunct to optimize stent deployment. STUDY DESIGN AND OBJECTIVES: Disrupt CAD III (clinicaltrials.gov identifier: NCT03595176) is a prospective, multicenter, single-arm study designed to assess safety and efficacy of the Shockwave coronary IVL catheter to optimize coronary stent deployment in patients with de novo calcified coronary stenoses. The primary safety end point is freedom from major adverse cardiovascular events (composite of cardiac death, myocardial infarction, and target vessel revascularization) at 30 days compared to a prespecified performance goal. The primary effectiveness end point is procedural success without in-hospital major adverse cardiovascular events. Enrollment will complete early in 2020 with clinical follow-up ongoing for 2 years. CONCLUSION: Disrupt CAD III will evaluate the safety and effectiveness of the Shockwave coronary IVL catheter to optimize coronary stent deployment in patients with calcified coronary stenoses.


Assuntos
Calcinose/terapia , Estenose Coronária/terapia , Litotripsia , Cardiomiopatias/terapia , Desenho de Equipamento , Humanos , Litotripsia/efeitos adversos , Litotripsia/instrumentação , Estudos Prospectivos , Stents
14.
Nan Fang Yi Ke Da Xue Xue Bao ; 40(3): 423-426, 2020 Mar 30.
Artigo em Chinês | MEDLINE | ID: mdl-32376577

RESUMO

OBJECTIVE: To compare the safety, efficacy and complications of LVIS stent-assisted coil embolization and Solitaire stent-assisted coil embolization for management of intracranial wide-neck carotid aneurysms. METHODS: We retrospectively analyzed the data of 86 patients with intracranial wide-neck carotid aneurysm treated in our hospital between June, 2016 and June, 2019. Forty-three of the patients received LVIS stent-assisted coil tamponade and the other 43 received Solitaire stentassisted coil tamponade. Arteriography was performed during, immediately after, and at 3 months after the surgery. The immediate embolization rate, surgical complications (vascular spasm, acute thrombus, coil escape, and bleeding), and the recurrence rate were compared between the two groups. RESULTS: In the LVIS stent group, 37 aneurysms were completely embolized, 5 were nearly fully embolized, and 1 was partially embolized, as compared with the numbers of 35, 6, and 2 in the Solitaire stent group, respectively. Surgery-related complications occurred in 5 patients in LVIS stent group and 3 in Solitaire stent group. Follow-up digital subtraction angiography (DSA) at 3 months after the operation revealed 4 recurrent aneurysms, including 1 in LVIS group and 3 in Solitaire stent group. All the patients had favorable outcomes that did not differ significantly between the two groups. CONCLUSIONS: Stent-assisted spring coils can achieve a high rate of complete and near-total embolization for intracranial aneurysms and is associated with a low incidence of neurological complications and favorable prognosis of the patients. The embolization rate, complications and recurrence rate are comparable between LVIS stent and Solitaire stent.


Assuntos
Embolização Terapêutica , Aneurisma Intracraniano , Angiografia Cerebral , Seguimentos , Humanos , Estudos Retrospectivos , Stents , Resultado do Tratamento
15.
Z Gastroenterol ; 58(7): 664-671, 2020 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-32380554

RESUMO

Standard therapy for benign stenoses of the biliary tract are coated metal stents or multi-stenting with plastic stents. Uncoated metal stents are not recommended because tissue ingrowth and overgrowth may render them impossible to remove with acceptable risk.We report a patient with chronic calcifying pancreatitis and cholestasis who, after unsuccessful multistenting with a total of 15 stent changes, was implanted with an uncoated metal stent in the common bile duct as second-line therapy. After this stent had been in place for six years and had to be balloon-cleaned 19 times during this time, the indication for removal came up. A fully coated metal stent of the same diameter but 2 cm longer was inserted into the lumen of the uncoated stent. It was left in place for 9 months and cleaned once during this time. Then, via ERCP, both stents were extended in a telescope-like manner, mobilized using a forceps and finally removed from the bile duct. Afterwards, the patient remained symptomless and free from cholestasis.The stent-in-stent technique for removing uncoated stents was first described for the esophagus. Our case shows that it can also be used in the biliary tract and even after an extended period of time.


Assuntos
Colestase/cirurgia , Ducto Colédoco/cirurgia , Remoção de Dispositivo/métodos , Pancreatite/cirurgia , Stents , Colangiopancreatografia Retrógrada Endoscópica , Humanos , Metais
16.
Cardiovasc Ther ; 2020: 4351469, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32405323

RESUMO

Aim: To evaluate the clinical impact of ß-blocker in patients with adequate left ventricular ejection function (LVEF) who underwent percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Methods: A total of 10,724 consecutive patients who underwent PCI throughout 2013 were prospectively enrolled in the study. Among these, we analyzed 5,631 ACS patients who were discharged with LVEF ≥ 40%. Patients were then compared according to the ß-blocker prescription at discharge. Results: During a 2-year follow-up, no significant association was observed of ß-blocker use with all-cause mortality (with ß-blockers 47/5,043 (0.9%) vs. without ß-blocker use 8/588 (1.4%); hazard ratio (HR) 0.762, 95% confidence interval 0.36 to 1.64; P = 0.485), cardiac death, myocardial infarction (MI), or major adverse cardiovascular and cerebrovascular events. Subgroup analysis demonstrated that the ß-blocker use at discharge reduced the 2-year mortality in patients with unstable angina (UA) (HR 0.42, 95% CI 0.19 to 0.94, P = 0.034). Landmark analysis at 1 year showed that patients with UA who were discharged with ß-blockers had lower mortality (HR 0.17, 95% CI 0.04-0.65, P = 0.010) and cardiac death (HR 0.12, 95% CI 0.01-0.99, P = 0.049) than those discharged without ß-blockers. However, the benefit was lost beyond 1 year. No differences in outcomes were recorded in the AMI or overall population. Conclusions: We present that ß-blocker significantly lowers the rate of all-cause death up to 1 year, in UA patients who have undergone PCI and have adequate LVEF. Its role in patients with AMI also deserves further exploration.


Assuntos
Síndrome Coronariana Aguda/terapia , Antagonistas Adrenérgicos beta/uso terapêutico , Alta do Paciente , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/fisiopatologia , Causas de Morte , China , Progressão da Doença , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Estudos Prospectivos , Fatores de Risco , Stents , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda
17.
Medicina (B Aires) ; 80(3): 241-247, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32442938

RESUMO

The second part of the Inter-Society Argentine Consensus on Urinary Tract Infection (UTI) includes the analysis of special situations. In patients with urinary catheter, urine culture should be requested only in the presence of UTI symptomatology, before instrumentation of the urinary tract, or as a post-transplant control. The antibiotics recommended for empirical treatment in patients without risk factors are third-generation cephalosporins or aminoglycosides. UTIs associated with stones are always considered complicated. In case of obstruction with urosepsis, an emergency drainage should be performed via a percutaneous nefrostomy or ureteral stenting. In patients with stents or ureteral prostheses, such as double J catheters, empirical treatment should be based on epidemiology, prior antibiotics, and clinical status. Before the extracorporeal lithotripsy procedure, bacteriuria should be investigated and antibiotic prophylaxis should be administered in case of positive result, according to the antibiogram. First generation cephalosporins or aminoglycosides are valid alternatives. The use of antibiotic prophylaxis with first-generation cephalosporins or aminoglycosides before percutaneous nephrolithotomy is recommended. Transrectal prostatic biopsy can be associated with infectious complications, such as UTI or acute prostatitis, mainly due to Escherichia coli or other enterobacteria. In patients without risk factors for multiresistant bacteria and negative urine culture, prophylaxis with intravenous amikacin or ceftriaxone is recommended. In patients with positive urine culture, prophylaxis will be performed according to the antibiogram, from 24 hours before to 24 hours post-procedure. For the targeted treatment of post-transrectal biopsy prostatitis, carbapenems for 3-4 weeks are the treatment of choice.


Assuntos
Anti-Infecciosos Urinários/uso terapêutico , Consenso , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/etiologia , Argentina , Feminino , Humanos , Litotripsia/efeitos adversos , Masculino , Nefrolitíase/complicações , Nefrolitotomia Percutânea/efeitos adversos , Prostatite/tratamento farmacológico , Prostatite/etiologia , Fatores de Risco , Stents/efeitos adversos , Cateteres Urinários/efeitos adversos
20.
Rev Assoc Med Bras (1992) ; 66(2): 153-159, 2020 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-32428149

RESUMO

OBJECTIVES: To prospectively investigate the alterations and normal ranges of ureteral jet dynamics after double-J-stent (DJS) removal in patients who underwent renal transplantation (RTx). METHODS: Patients who underwent RTx were prospectively evaluated between November 2017 and June 2018. After RTx, Doppler ultrasonography (D-US) was performed on all patients after DJS removal. Renal artery resistive index (RA-Ri), renal pelvis anterior-posterior diameter (RP-APD), pelvicalyceal system dilation (PCSD), and ureteral jet flow dynamics (maximum and average velocity; JETmax and JETave) were measured by D-US. Also, patients' demographics, estimated glomerular filtration rate (eGFR) levels, and acute rejection were investigated in the study. Patients were assessed two different times by D-US, about 6 and 12 weeks after DJS removal, and the two different measurements were compared with the Wilcoxon test and Chi-square test. RESULTS: A total of 25 patients were evaluated in the study. Nonobstructive PCSD rate (12% vs 8%), JETave (18.8 vs 12.9 cm/sec), and JETmax (29.2 vs 20 cm/sec) levels were significantly decreased (p values are 0.01, 0.010 and 0.014, respectively). In addition, monophasic and square pattern rates were significantly observed to increase over time (p=0.035); however, ureteral jet patterns were correlated between the two different D-US measurements (R=0.225, p=0.032). CONCLUSION: After RTx, dilation rate and ureteral jet flow velocities were significantly decreased, and monophasic and square JETpattern rates were significantly increased over time. Ureteral jet dynamics can provide useful information about the follow-up of peristaltic activity in the pelvic-ureteric system.


Assuntos
Transplante de Rim/efeitos adversos , Stents/efeitos adversos , Ureter/fisiopatologia , Cateterismo Urinário/efeitos adversos , Urodinâmica/fisiologia , Adulto , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estatísticas não Paramétricas , Fatores de Tempo , Ultrassonografia Doppler/métodos , Ureter/diagnóstico por imagem , Adulto Jovem
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