ABSTRACT
Introduction: Endovascular aneurysm sealing (EVAS) appeared to be an innovative alternative to conventional endovascular abdominal aortic aneurysm repair. However, high rates of midterm failure of EVAS led to withdrawal of the device from the market. The study aim was to report midterm outcomes of patients treated with EVAS alone or associated with chimneys (Ch-EVAS) and the management of their complications. Methods: In this single centre study, all consecutive Nellix implants between 2013 and 2016 were included. The primary endpoint was device failure: (1) a triad of caudal migration of the Nellix stents >5 mm, separation of the endobags (>5 mm), and sac enlargement (>5 mm), with or without visible endoleak, (2) secondary aneurysm rupture, (3) surgical explant of the graft, or (4) any intervention for a type I endoleak. Overall mortality, aneurysm related mortality, and re-intervention rates were analysed. Results: Fifty patients (male n = 43, female n = 7) were included. Median follow-up was 3.05 years (interquartile range [IQR] 0.52, 4.63) and follow up index was 0.51 (IQR 0.10, 0.88). Device failures occurred in 17 patients (34%). Overall and aneurysm related mortality rates during the follow up period were 30% and 13%. Fourteen (28%) patients required re-interventions. Five EVAS patients (17%) presented with complications. Type Ia endoleaks were managed by device explantation for three patients, and endovascular aneurysm repair in Nellix for two patients. Type Ib endoleaks were managed with an iliac branched device and limb extension. Nine Ch-EVAS patients (42.9%) presented with complications. Type Ia endoleaks were was managed by Nellix stent prolongation and renal extension, two multibranched thoraco-abdominal devices, and two device explantations. Type Ib endoleaks were managed by limb extension and stent complications by stent angioplasty and iliorenal bypass. Conclusion: The midterm outcome of EVAS is poor. All patients who underwent EVAS implantation must be informed and should undergo frequent surveillance. Open repair and device explantation should be considered as the primary treatment.
ABSTRACT
Peripheral arterial disease of the lower limbs (PAD) is a widespread disease whose diagnosis and treatment are still inadequate, despite several available current national and international recommendations. Screening for PAD is recommended in patients presenting with lower limb symptoms (claudication) and in those at risk. For all patients with PAD, initial management measures include treatment of cardiovascular risk factors, lifestyle modification, exercise training and antithrombotic therapy, at least for any symptomatic PAD. Revascularization is discussed on a case-by-case basis, depending on the stage of the disease, in a multidisciplinary setting. A diagnostic algorithm for PAD is presented, together with the basic principles of comprehensive disease management.
La maladie artérielle périphérique des membres inférieurs (MAP) est une maladie très répandue dont le diagnostic et le traitement sont encore insuffisants malgré l'existence de plusieurs recommandations nationales et internationales. Le dépistage de la MAP est recommandé chez les patients présentant des symptômes au niveau des membres inférieurs (claudication) et chez les personnes à risque. La prise en charge initiale de la MAP comprend le traitement des facteurs de risque cardiovasculaire, la modification du mode de vie, l'entraînement à l'exercice physique et le traitement antithrombotique, si symptomatique. La revascularisation est discutée au cas par cas en fonction du stade de la maladie dans un cadre multidisciplinaire. Un algorithme diagnostique de la MAP ainsi que les bases de prise en charge globale de la maladie sont présentés.
Subject(s)
Peripheral Arterial Disease , Humans , Risk Factors , Peripheral Arterial Disease/diagnosis , Peripheral Arterial Disease/therapy , Intermittent Claudication/diagnosis , Lower Extremity , ExerciseABSTRACT
Infections associated with arterial reconstructions of the lower limbs are associated with high morbidity. This article reviews the risk factors for infection associated with this surgery and the preventive measures. These include smoking cessation and glycemic control preoperatively; avoiding unnecessary exposure to antibiotics or corticosteroids; optimal peripheral wound care; rigorous antisepsis and antibiotic prophylaxis in the operating theatre ; and finally, meticulous post-operative wound monitoring. The benefit of Staphylococcus aureus decolonization in vascular surgery is less clearly established than in cardiac and thoracic surgery, but it is still recommended in cases of implant placement or where there is a high risk of S. aureus infection, depending on the planned approach and type of surgery.
Les infections associées aux reconstructions artérielles des membres inférieurs sont grevées d'une morbidité élevée. Cet article revoit les facteurs de risque d'infection associés à cette chirurgie et les mesures de prévention. Ces dernières incluent l'arrêt du tabac et le contrôle glycémique en préopératoire ; l'absence d'exposition inutile aux antibiotiques ou aux corticostéroïdes ; les soins de plaies périphériques optimaux ; une antisepsie et une antibioprophylaxie au bloc opératoire rigoureuses et, finalement, un suivi de plaie postopératoire minutieux. Le bénéfice de la décolonisation à Staphylococcus aureus dans le cadre de la chirurgie vasculaire est moins clairement établi qu'en chirurgies cardiaque et thoracique, mais celle-ci reste recommandée en cas de mise en place d'implant ou de risque élevé d'infection à S. aureus, selon la voie d'abord et le type de chirurgie prévue.
Subject(s)
Staphylococcal Infections , Surgical Wound Infection , Humans , Surgical Wound Infection/epidemiology , Surgical Wound Infection/prevention & control , Surgical Wound Infection/drug therapy , Staphylococcus aureus , Anti-Bacterial Agents/therapeutic use , Staphylococcal Infections/drug therapy , Antibiotic Prophylaxis/adverse effects , Vascular Surgical Procedures/adverse effectsABSTRACT
Peripheral arterial disease (PAD) is a major health problem in Switzerland, as myocardial infarction or stroke, all three sharing common cardiovascular (CV) risk factors and similar pathophysiological mechanisms (atherosclerosis). Unfortunately, PAD is still often overlooked, despite being fraught with significant morbidity/mortality and increasing the patient's overall CV risk. It is therefore essential to improve secondary prevention in order to decrease this burden and the overall CV risk of the patient. We will review the treatment targets for CV risk factors as secondary prevention in patients with PAD and see how the use of a vascular passport may improve management.
La maladie artérielle périphérique (MAP) est une problématique de santé majeure en Suisse, au même titre que l'infarctus du myocarde ou l'AVC, tous les trois partageant des facteurs de risque cardiovasculaire (FRCV) communs et des mécanismes physiopathologiques similaires (athérosclérose). Malheureusement, l'importance de la MAP est encore souvent sous-estimée, alors qu'elle est grevée d'une morbidité et d'une mortalité importantes et augmente le risque cardiovasculaire (CV) global du patient. Il est capital d'améliorer la prévention secondaire afin de diminuer ce fardeau et le risque CV global du patient. Nous allons passer en revue les cibles de traitement des FRCV en prévention secondaire chez les patients avec MAP et voir comment l'utilisation d'un passeport vasculaire permet d'améliorer la prise en charge.