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1.
Vascular ; : 1708538120922098, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32356684

RESUMO

OBJECTIVES: Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. METHODS: From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. RESULTS: Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found (P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group (P < 0.001 and P = 0.0001, respectively). CONCLUSIONS: Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.

2.
Rev Port Cir Cardiotorac Vasc ; 27(1): 23-31, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32239822

RESUMO

Peripheral Arterial Disease (PAD) is a prevalent condition that predisposes the patients to major cardiovascular events. The majority of patients are asymptomatic, however PAD has a great impact in the patients' lifestyle due to its chronic nature. The Peripheral Arterial Questionnaire (PAQ) is a validated tool to quantify the patients' subjective experience of the disease. The aim of this work is to validate the Portuguese version of PAQ. A retrospective study of 59 patients with aortoiliac disease Trans-Atlantic Inter Society Consensus (TASC) type D from two centers in Portugal was conducted. Only 36 patients were able to answer the PAQ and two Portuguese validated questionnaires - a disease-specific (Walk Impairment Questionnaire - WIQ) and a generic one (EuroQol 5 dimensions - 5 level EQ5D-5L). Con- vergent validity of the PAQ was evaluated by correlating the extracted PAQ subscales and Summary score with the WIQ subscales and summary score, as with EQ5D-5L Summary score and EQ5D-5L index by calculating the covariance. The Portuguese version of the peripheral artery questionnaire presented a Cronbach's α for the Summary scale of 0.913. Mean inter-item correlation for the Physical Function domain was 0.471, 0.551 for the Perceived Disability, and 0.464 for Treat- ment Satisfaction. In summary, the Portuguese version of PAQ demonstrated a good level of discrimination between patients with or without symptomatic PAD and its severity and was sensitive to the presence of risk-factors relevant for PAD.

3.
Artigo em Inglês | MEDLINE | ID: mdl-32307303

RESUMO

OBJECTIVE: Ruptured abdominal aortic aneurysm (rAAA) is a lethal condition that requires acute repair to prevent death. This analysis aims to assess the nationwide trends in rAAA admission, repair and mortality in a country, Portugal, without national screening for AAA. METHODS: rAAA registered in the hospital administrative database of the National Health Service and all nationally registered deaths due to rAAA based on death certificate data were analysed. Three time periods (2000-2004, 2005-2009, and 2010-2015) were compared in patients ≥ 50 years old to assess the variations over time. RESULTS: A total of 2 275 patients ≥50 years old with rAAA were identified in the two databases from 2000 to 2015. The age standardised incidence of rAAA was 2.78 ± 0.24/100 000/year in 2000-2004, 3.17 ± 0.39/100 000/year in 2005-2009 and 3.21 ± 0.28/100 000/year in 2010-2015 (p < .001). When comparing the time periods 2000-2004 to 2005-2009, the age standardised rate of admission (n = 1460) increased from 1.57 ± 0.25/100 000/year to 2.24 ± 0.32/100 000/year (p < .001). The operative mortality rates decreased during this time period (from 55.3 ± 4.7% to 48.8 ± 4.7%, p < .001). In 2010-2015, the age standardised rate of admissions due to rAAA decreased (1.98 ± 0.22/100 000/year). Operative mortality remained stable (48.9 ± 6.2%). The rate of patient deaths outside the hospital decreased from the first to the second period (1.21 ± 0.10/100 000/year and 0.93 ± 0.29/100 000/year, respectively) but later increased (1.14 ± 0.22/100 000/year). This resulted in a higher overall rAAA related mortality in Portugal in the third period (2.20 ± 0.18/100 000/year, 2.21 ± 0.27/100 000/year and 2.26 ± 0.26/100 000/year in 2000-2004, 2005-2009, and 2010-2015, respectively, p < .001). CONCLUSION: Overall, the incidence of rAAA in Portugal has been stable over the past 10 years. The rates of admission, repair, and death due to rAAA repair seem to have reached an inflection point and are now decreasing. Mortality outside the hospital remains a matter of concern, warranting further planning of streamlined transfer networks and vascular surgical departments.

4.
Ann Vasc Surg ; 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31917222

RESUMO

BACKGROUND: Results on the management of infrarenal abdominal aortic aneurysm (AAA) from Mediterranean countries are scarce. The aim of this study was to evaluate trends in rate of and mortality after repair of intact AAA (iAAA) in Portugal. METHODS: iAAA repairs registered in the hospitals' administrative database of the National Health Service from 2000 to 2015 were retrospectively analyzed regarding demographics (age and gender) and type of repair (open surgery [OS] or endovascular repair [EVAR]). Rate and mortality were compared among three time periods: 2000-2004, 2005-2009, and 2010-2015. RESULTS: Age-standardized rate of iAAA repair increased consistently across the time periods under analysis from 3.6 ± 0.6/100,000/year in 2000-2004, to 5.6 ± 0.4/100,000/year in 2005-2009 and to 7.1 ± 0.9/100,000/year in 2010-2015 (P < 0.001). The percentage of EVAR among all iAAA repairs rose steeply from 0 to 21 ± 19% and then to 58 ± 7% (P < 0.001). The rate of OS also increased from the first to the second period, but there was a decrease in the third period (P < 0.001). The in-hospital mortality after iAAA repair decreased from 7.5 ± 1.3% to 6.6 ± 1.6% and then to 5.1 ± 1.9% (P < 0.001). This variation corresponded to a decrease in in-hospital mortality after EVAR (from 4.0 ± 3.5% to 2.8 ± 0.9%, P < 0.001) and increased in-hospital mortality after OS (7.5 ± 1.3% to 7.4 ± 1.1% to 8.3 ± 3.7%, P < 0.001). Low-volume centers (< 15 repairs/year) did not present higher mortality rates. The number of EVARs per year in a center presented a positive association with EVAR mortality (Spearman correlation of 0.696, P = 0.004). CONCLUSIONS: The rate of repair of iAAA continues to grow, especially in patients aged ≥ 75 years and did not reach an inflection point yet. This is happening along with decreased repair mortality mainly because of the increased use of EVAR. Hospital mortality for iAAA repair is still a matter of concern, warranting further investigation and planning of vascular surgical services.

6.
Int J Surg ; 71: 66-71, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31542388

RESUMO

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) occurs in 15% of patients undergoing carotid endarterectomy (CEA) with general anesthesia. Short and long-term risk of myocardial infarction (MI) and stroke have been strongly associated with the presence of MINS, with an associated mortality rate superior to 10% in the first year. Due to the absence of studies concerning CEA with regional anesthesia (RA), the present study aimed to evaluate the incidence of MINS in patients with RA and its prognostic value on cardiovascular events or death. MATERIALS AND METHODS: From January 2009 to January 2018, 156 patients from a Portuguese tertiary care medical center who underwent CEA under RA were retrieved from a prospectively gathered database. Troponin I or high-sensitive troponin I values were systematically measured in the postoperative period and studied as a binary outcome in a logistic regression model. Survival analysis was used to study the impact of MINS in time-dependent clinical outcomes such as stroke and MI. RESULTS: The incidence of MINS after CEA was 15.3%. Multivariate analysis confirmed that chronic heart failure was strongly associated with MINS (OR: 4.458, 95% CI: 1689-11.708, P < 0.001). A previously diagnosed MINS was associated with the long-term risk of MI and major adverse cardiovascular events (MACE) with hazard ratios (HR) of 3.318 (95% CI: 0.97-13.928, Breslow: P = 0.025) and 1.955 (95% CI: 1.01-4.132, Breslow: P = 0.046), respectively. CONCLUSIONS: MINS is a long-term predictor of MI and MACE. Troponin assessment after CEA should be routinely monitored in patients with a cardiovascular risk superior to 5%. Further studies concerning prophylaxis and management of MINS should be carried on, focusing on the effect of anesthetic procedure in postoperative troponin elevation.


Assuntos
Anestesia por Condução/efeitos adversos , Endarterectomia das Carótidas/efeitos adversos , Infarto do Miocárdio/mortalidade , Complicações Pós-Operatórias/mortalidade , Troponina/sangue , Idoso , Anestesia Geral/efeitos adversos , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Endarterectomia das Carótidas/métodos , Feminino , Insuficiência Cardíaca/complicações , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
7.
Rev Port Cir Cardiotorac Vasc ; 26(2): 131-137, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31476814

RESUMO

BACKGROUND: Type B aortic dissection (TBAD) is associated with high morbidity and mortality. The DISSECT classification aims to reunite clinical and anatomical characteristics of interest to clinicians involved in its management. This paper aims to characterize a cohort of patients admitted for type B aortic dissection in a tertiary institution. METHODS: This is a retrospective study that included all patients admitted to the hospital due to TBAD from 2006 to 2016. The computerized tomographic angiography that enabled the TBAD diagnosis were reevaluated using DISSECT classification. RESULTS: Thirty-two patients were included in this case series. As to DISSECT classification, 79.3% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental Extent), 28% presented with Complications, and 28% had partial Thrombosis of false lumen. Six patients underwent intervention during the follow-up period. At 12 months, overall survival was 75.4%±8.3% and survival free of aorta-related mortality was 87.0±6.1%. Survival free of aortic dilatation was 82.6±9.5%. In univariate analysis, the presence of complications and chronic kidney disease associated with increased overall and aorta-related mortality rates. Hypertension was associated with aortic dilatation. CONCLUSIONS: The outcomes after TBAD in a Portuguese center are reported. All interventions in TBAD were performed due to complications. The presence of complications and chronic kidney disease was associated with overall mortality and aorta-related mortality and hypertension with aortic dilatation. DISSECT classification was possible to apply in all patients.


Assuntos
Aneurisma Dissecante , Aneurisma da Aorta Torácica , Aneurisma Dissecante/classificação , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/terapia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/terapia , Angiografia por Tomografia Computadorizada , Humanos , Estudos Retrospectivos , Resultado do Tratamento
8.
Ann Vasc Surg ; 61: 193-202, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31382007

RESUMO

BACKGROUND: A number of awake patients undergoing carotid endarterectomy (CEA) present from test clamp neurological deficits (NDs) during the procedure. Current guidelines advocate tighter Doppler ultrasound (DUS) surveillance in these patients because of probable higher likelihood of hemodynamic stroke (class 1 grade C), although evidence is lacking regarding benefit. The aim for the study is the assumption that patients who present ND have a higher risk of developing a complete stroke if the ipsilateral carotid artery becomes occluded, and for this reason, surveillance over restenosis of endarterectomy in this group is justifiable; hence, the authors would like to contribute to this matter presenting their experience on restenosis in this specific group of patients. METHODS: Data were prospectively collected between 2009 and 2018 for patients of a university tertiary referral center who underwent CEA under regional anesthesia and developed alterations in the neurologic monitoring during internal carotid artery (ICA) test clamping. Control patients were consecutively selected as the next patient submitted to the same procedure but who did not develop neurologic alterations. Patients who did not present to the first postoperative evaluation were excluded (4-6 weeks). Primary outcome was any restenosis (>30%; >50%; >70%) detected by DUS evaluations between 16 and 30 months of follow-up. Clinical adverse events such as stroke, myocardial infarction, acute heart failure, and all-cause death were assessed 30 days after the procedure and in the subsequent long-term surveillance period. A multivariate analysis of factors with significant associations to restenosis identified in a univariate analysis was performed by binary logistic regression. Kaplan-Meier analysis and life tables were used to evaluate time-dependent variables. RESULTS: Ninety patients with ND and 94 controls were included. Those with ND had a higher prevalence of obesity, mean age, and scores of American Society of Anesthesiologist physical status, as well as a lower mean degree of ipsilateral stenosis (82.3% vs. 85.8%, P = 0.032) and a higher mean degree of contralateral stenosis (67.8% vs. 61.1%, P = 0.030). The incidence of restenosis after 2 years did not differ significantly between groups. The univariate analysis yielded two significant associations to restenosis >50%, which remained significant after adjustment: ipsilateral stenosis (1.927 + -0.656, P = 0.02) and peripheral arterial disease (3.006 + -1.101, P = 0.048). NDs were not found to be associated to restenosis (P = 0.856). After a median follow-up period of 52 months, patients with NDs did not have a higher incidence of stroke (90.6%, standard deviation [SD]: 3.5%; ND: 91.1%, SD: 3.6%, P = 0.869), major adverse cardiovascular events (ND: 69.2%, SD: 5.5%; control, 73.6%, SD: 5.2%, P = 0.377), or all-cause death (ND: 90.6%, SD: 3.5%; control: 91.1, SD: 3.6%, P = 0.981) than controls. The presence of any restenosis was not associated with later stroke rate (ND: 89.5%, SD: 3.2%; control: 100%, P = 0.515). CONCLUSIONS: Cost-effective DUS surveillance after CEA requires the definition of evidence-based factors associated with restenosis and late stroke. The present study does not support the assumption that patients who presented NDs during the ICA test clamping present a higher risk of developing late stroke. This group of patients also did not present a higher incidence of restenosis. For these reasons, tighter DUS surveillance in this group seems not justifiable. Results from other groups are required to support this position.

9.
Scand Cardiovasc J ; 53(5): 266-273, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31251084

RESUMO

Objetives. Carotid endarterectomy (CEA) is an established treatment for carotid stenosis (CS). However, this procedure is not risk-free and it is insufficient to control disseminated atherosclerosis. Our aim was to determine long-term cardiovascular morbidity and mortality after CEA and identify associated risk predictors. Design. Consecutive cohorts of CEAs performed between 2010 and 2018 in two Portuguese hospitals were retrospectively analysed. The major end-points were acute myocardial infarction (AMI), stroke, all-cause death and major adverse cardiovascular events (MACE). Results. 248 patients (mean age 69 years; 79% male) were enrolled in the study. 24% had postoperative complications. At 52 months median follow-up, 9 ± 2.0% (mean ± standard error) of patients experienced an acute myocardial infarction (AMI), 12 ± 2.4% a stroke and 26 ± 3.2% a MACE. All-cause mortality rate was 21 ± 3.0%. Multivariate analysis identified coronary artery disease (CAD) as significant predictor of AMI (p < .001; Hazard Ratio (HR):9.628; 95% Confidence Interval (95%CI):2.805-33.046), whereas no statistically significant risk factor of stroke was found. Predictors of death included left sided CS (p = .042; HR:1.886; 95%CI:1.024-3.475), chronic kidney disease (CKD) (p = .007; HR:2.352; 95%CI:1.266-4.372) and anticoagulant medication (p = .015; HR:2.107; 95%CI:1.216-6.026), while statin use was significantly protective (p = .049; HR:0.482; 95%CI:0.233-0.998). Concerning MACE, male gender (p = .040; HR:1.709; 95%CI:1.025-2.849), tobacco use (p = .004; HR:2.181; 95%CI:1.277-3.726), CAD (p = .002; HR:2.235; 95%CI:1.340-3.727) and CKD (p < .001; HR:3.029; 95%CI:1.745-5.258) were risk predictors. Conclusions. Patients continue to have high rates of AMI, MACE and death after CEA. Prior CAD is a risk factor for future AMI, whereas CKD is a significant predictor of MACE and death. Aggressive best medical treatment and risk factors modification should be advised in all patients with systemic atherosclerosis.


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Idoso , Estenose das Carótidas/mortalidade , Causas de Morte , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Portugal , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
11.
Rev Port Cir Cardiotorac Vasc ; 25(1-2): 55-60, 2018.
Artigo em Português | MEDLINE | ID: mdl-30317711

RESUMO

Abdominal aortic aneurysm (AAA) remains a relevant cause of mortality in Western countries. There is a need for continuous identification of risk factors for aneurysmal progression and predictors of treatment response to optimize the therapeutic strategy to be offered to these patients. Vascular calcification has been studied in several capillary beds as a cardiovascular risk factor. However, the importance of abdominal aortic calcification (AC) in AAA remains incompletely clarified, and the available evidence is scattered and heterogeneous. The objective of this review is to describe the possible impact of AC on aneurysmal progression and rupture, as well as on the response to endovascular correction. It should be noted that the establishment of a validated, quick and easy to use method for assessing AC would be of great clinical and/or research utility.


Assuntos
Aneurisma da Aorta Abdominal/complicações , Ruptura Aórtica/etiologia , Calcificação Vascular/diagnóstico , Aneurisma da Aorta Abdominal/terapia , Ruptura Aórtica/terapia , Progressão da Doença , Procedimentos Endovasculares , Humanos , Fatores de Risco , Calcificação Vascular/complicações , Calcificação Vascular/terapia
12.
Eur J Vasc Endovasc Surg ; 56(5): 663-671, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30115505

RESUMO

OBJECTIVES: Perivascular adipose tissue (PVAT) is currently seen as a paracrine organ that produces vasoactive substances, including inflammatory agents, which may have an impact on the vasculature. In this study PVAT density was quantified in patients with an aortic aneurysm and compared with those with a non-dilated aorta. Since chronic inflammation, as the pathway to medial thinning, is a hallmark of abdominal aortic aneurysms (AAAs), it was hypothesised that PVAT density is higher in AAA patients. METHODS: In this multicentre retrospective case control study, three groups of patients were included: non-treated asymptomatic AAA (n = 140), aortoiliac occlusive disease (AIOD) (n = 104), and individuals without aortic pathology (n = 97). A Hounsfield units based analysis was performed by computed tomography (CT). As a proxy for PVAT, the density of adipose tissue 10 mm circumferential to the infrarenal aorta was analysed in each consecutive CT slice. Intra-individual PVAT differences were reported as the difference in PVAT density between the region of the maximum AAA diameter (or the mid-aortic region in patients with AIOD or controls) and the two uppermost slices of infrarenal non-dilated aorta just below the renal arteries. Furthermore, subcutaneous (SAT) and visceral (VAT) adipose tissue measurements were performed. Linear models were fitted to assess the association between the study groups, different adipose tissue compartments, and between adipose tissue compartments and aortic dimensions. RESULTS: AAA patients presented higher intra-individual PVAT differences, with higher PVAT density around the aneurysm sac than the healthy neck. This association persisted after adjustment for cardiovascular risk factors and diseases and other fat compartments (ß = 13.175, SE 4.732, p = .006). Furthermore, intra-individual PVAT differences presented the highest correlation with aortic volume that persisted after adjustment for other fat compartments, body mass index, sex, and age (ß = 0.566, 0.200, p = .005). CONCLUSION: The results suggest a relation between the deposition of PVAT and AAA pathophysiology. Further research should explore the exact underlying processes.


Assuntos
Tecido Adiposo/cirurgia , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma Aórtico/cirurgia , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
13.
J Endovasc Ther ; 25(3): 334-342, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29557221

RESUMO

PURPOSE: To report midterm results of the "pave-and-crack" technique to facilitate safe and effective scaffolding of heavily calcified femoropopliteal lesions in preparation for delivery of a Supera interwoven stent. METHODS: Data were collected retrospectively on 67 consecutive patients (mean age 71±8 years; 54 men) treated with this technique between November 2011 and February 2017 at a single center. A third (22/64, 34%) of the patients had critical limb ischemia (CLI). Most lesions were TASC D (52/67, 78%), and the majority were occlusions (61/66, 92%). The mean lesion length was 26.9±11.2 cm. Nearly two-thirds (40/64, 62%) had grade 4 calcification (Peripheral Arterial Calcium Scoring System). To prepare for Supera stenting, the most heavily calcified segments of the lesion were predilated aggressively to obliterate recoil. A Viabahn stent-graft was then implanted to "pave" the lesion and protect from vessel rupture as aggressive predilation continued until the calcified plaque was "cracked" before lining the entire lesion with a Supera stent. Patency and target lesion revascularization (TLR) rates were estimated using the Kaplan-Meier method. RESULTS: Procedural success was achieved in 100% and technical success (residual stenosis <30%) in 98% (66/67). The mean cumulative stent lengths were 16±9 cm for the Viabahn and 23±12 cm for the Supera. Only 2 complications occurred (distal embolization and access-site pseudoaneurysm). Two CLI patients died within 30 days, and 3 patients (all claudicants) underwent a TLR. Patients were followed for a mean 19±18 months, during which another 2 CLI patients died and 1 patient had a major amputation. One-year primary and secondary patency estimates were 79% and 91%, respectively; freedom from TLR was 85%. CONCLUSION: Despite severe lesion calcification, patients experienced high technical success and a safe and durable therapy at midterm follow-up with the femoropopliteal "pave-and-crack" technique.


Assuntos
Angioplastia com Balão/métodos , Artéria Femoral , Isquemia/terapia , Doença Arterial Periférica/terapia , Artéria Poplítea , Calcificação Vascular/terapia , Idoso , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/instrumentação , Angioplastia com Balão/mortalidade , Estado Terminal , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Artéria Poplítea/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Stents , Fatores de Tempo , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/mortalidade , Grau de Desobstrução Vascular
14.
Artigo em Inglês | MEDLINE | ID: mdl-29430885

RESUMO

BACKGROUND: The main objective of this study was to assess the correlation between three semiquantitative and one computerized method based on Agatston Score (AS), when measuring abdominal aortic calcification (AAC) in abdominal aortic aneurysm (AAA) patients. Secondary aim was to access differences in AAC upon clinical variables, when different methods of calcium scoring are used. METHODS: This was an observational, retrospective, cross-sectional study. A database of AAA patients consecutively submitted to elective repair between 2008 and 2015 was used. Patients were excluded if they did not have preoperative imaging or presented scans incompatible with at least one of the whole set of calcification methods tested. Calcification measures were performed using AS, aortic calcification index (ACI), AAC-8 and AAC-24 methods. The Pearson's correlation was used for primary analysis. RESULTS: Study population comprised 102 patients, 95% males, with a median age of 71 (interquartile range, IQR 66-76) years. AAAs presented median aortic diameter of 60 (54- 70) mm. Pearson's correlation with AS was 0.816 for ACI, 0.703 for AAC-8 and 0.648 for AAC-24. ACI also presented the highest ICC for intraobserver agreement (0.972) and for interobserver agreement (0.966). ACI was associated more often to demographic and clinical variables in the dataset that associated with the computerized method. CONCLUSIONS: ACI is suggested as a fast and easy-to-use method of assessing AAC in AAA patients. Its use should be encouraged to study AAC in AAA over other semiquantitative methods, in research settings.

15.
Vasc Endovascular Surg ; 52(3): 226-232, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29433408

RESUMO

Injuries of the supra-aortic trunk after blunt chest trauma are rare. This is a case report of a blunt traumatic lesion of the innominate artery (IA) origin that exhibited aortic arch involvement with a focus on imaging and treatment. A 41-year-old fisherman presented an IA injury secondary to a high-impact blunt chest trauma. Upon physical examination, vital signs were stable and upper extremity pulses were present. In addition to several bone fractures (costal ribs, clavicle, scapula, temporal, maxillary, and sphenoid), computed tomography angiography revealed dissection/pseudoaneurysm of the IA sparing the bifurcation. The patient underwent emergent angiography, which confirmed that the IA dissection was not ruptured, but it was unclear whether there was a pseudoaneurysm at the origin of the IA or aortic arch involvement. The patient was considered for open surgery. An ascending aorta-to-IA bypass was achieved by the off-pump beating heart approach. The IA stump was carefully observed, but oversewing was not possible due to the extension of the intimal-medial lesions into the artic arch. An on-pump intervention was then required for aortic angioplasty with a pericardial patch that was reinforced by Gel Seal. The postoperative course was uneventful. The patient was discharged without any complications. Conventional surgery provides good results and should remain in the armamentarium for the treatment of traumatic lesions at the IA origin, particularly if aortic arch involvement cannot be ruled out, to ensure a truly patient-tailored approach.


Assuntos
Aneurisma Dissecante/etiologia , Falso Aneurisma/etiologia , Tronco Braquiocefálico/lesões , Traumatismos Torácicos/etiologia , Lesões do Sistema Vascular/etiologia , Ferimentos não Penetrantes/etiologia , Adulto , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/cirurgia , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/cirurgia , Tronco Braquiocefálico/diagnóstico por imagem , Tronco Braquiocefálico/cirurgia , Angiografia por Tomografia Computadorizada , Humanos , Masculino , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/cirurgia , Resultado do Tratamento , Ultrassonografia Doppler em Cores , Enxerto Vascular , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgia
16.
Rev Port Cir Cardiotorac Vasc ; 25(3-4): 133-140, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30599470

RESUMO

INTRODUCTION: Digital subtraction angiography (DSA) was considered the gold standard method for peripheral artery disease (PAD) evaluation. Notwithstanding, recent developments of computed tomography angiography (CTA) have improved the specificity and sensibility of this method. The main objective of this study is to characterize a cohort of patients with lower limb PAD and clarify if there are differences upon groups using different preoperative imaging methods (DSA or CTA). METHODS: This retrospective study focused on patients with PAD that underwent surgical intervention (endovascular revascularization or open surgery). CTA group included all patients submitted to this method as their pre-operative exam, between March 2009 and April 2017. DSA group included patients submitted to DSA as their pre-operative exam within the same period. The groups were compared regarding intervention details, ankle-brachial index (ABI) variation, reintervention, major amputation and mortality rates, and hospital length of stay. RESULTS: One hundred and two patients were included (33 CTA and 69 DSA). DSA group presented more below the knee lesions with TASC C or D classification (p=0.002), as well as runoff vessels scarcity (p=0.001). There were no differences in the endovascular/open surgery ratio (p=0.308), ABI alteration with intervention (p=0.860), reintervention rates (p=0.236), major amputation (p=0.999), mortality (p=0.574), or hospital length of stay (p=0.933). CONCLUSION: CTA seems to achieve equivalent performance to DSA for morphological and therapeutic planning of PAD. Nevertheless, extrapolation to patients with TASC C or D distal lesions cannot be performed.


Assuntos
Angiografia Digital , Angiografia por Tomografia Computadorizada , Extremidade Inferior/diagnóstico por imagem , Doença Arterial Periférica/diagnóstico por imagem , Humanos , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/cirurgia , Doença Arterial Periférica/cirurgia , Cuidados Pré-Operatórios , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodos
17.
Vascular ; 25(3): 307-315, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27694555

RESUMO

Spinal cord ischemia remains the Achilles' heel of thoracic and thoracoabdominal diseases management. Great improvements in morbidity and mortality have been obtained with the endovascular approach TEVAR (Thoracic Endovascular Aortic Repair) but this devastating complication continues to severely affect the quality of life, even if the primary success of the procedure - dissection/aneurysm exclusion - has been achieved. Several strategies to deal with this complication have been published in the literature over the time. Knowledge and technology have been evolving from identification of the risk factors associated with spinal cord ischemia, including lessons learned from open surgery, and from developments in the collateral network concept for spinal cord perfusion. In this comprehensive review, the authors cover several topics from the traditional measures comprising haemodynamic control, cerebrospinal drainage and neuroprotective drugs, to the staged-procedures approach, the emerging MISACE (minimally invasive selective segmental artery coil-embolization) and innovative neurologic monitoring such as NIRS (near-infrared spectroscopy) of the collateral network.


Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Isquemia do Cordão Espinal/prevenção & controle , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Circulação Colateral , Procedimentos Endovasculares/efeitos adversos , Hemodinâmica , Humanos , Fluxo Sanguíneo Regional , Fatores de Risco , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Resultado do Tratamento
18.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 112, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701345

RESUMO

Introduction The rupture of thoracoabdominal aneurysms (rTAA) represents one of the major challenges to the vascular surgeon. Recent developments in the endovascular armamentarium and the high mortality from open surgery make endovascular treatment an attractive option. Devices to be used in an emergency environment should be "off-the-shelf" and include, among others, EVAR snorkel/chimney and branched endoprosthesis (T-branch, Cook®). METHODS: We describe the case of a 70-year-old patient who was admitted to the emergency room due continuous low back pain with 3 days of evolution. RESULTS: The tomographic computer angiography showed a type III thoracoabdominal aneurysm, with a transverse maximum diameter of 75x81mm in the infrarenal aorta and an exuberant hematoma in the left retroperitoneum, but no active extravasation of the contrast was observed (Figure 1). There was still marked tortuosity and moderate iliac calcification. It was decided to place a branched endoprosthesis (34 mm diameter at the top and 18 mm at the bottom). The branched endoprosthesis was extra-corporeally oriented, and introduced through a right femoral approach. The final position was verified with the digital subtraction angiography in anteroposterior incidence, ensuring that the distal border of each branch was 1.5 to 2 cm above the target vessel and that the stent marks presented the desired position. After the endoprosthesis was opened, the branches are catheterized by the left axillary access, however, it was verified that the endoprosthesis had an antero-posteriorly inverted implantation. It was possible to catheterize the superior mesenteric artery and the left renal artery (celiac trunk occlusion was documented intraoperatively); occlusion of the remaining endoprosthesis branches was performed with an Amplatzer. The patient evolved with multiorgan dysfunction and died at 24 hours post-operatively. CONCLUSION: Implantation of an off-the-shelf branched endoprosthesis requires specific anatomical criteria such as aortic diameter> 25mm to allow catheterization of the vessels, the possibility of incorporating each target vessel at a 90o angle in relation to each branch and visceral arteries with a diameter between 4 and 8 mm. Anatomy review is important to understand the lengths and positions of the branches. It should be borne in mind that it is possible that the device might have to be rotated during implantation to better align the marks and that both incidences (anteroposterior and profile) may be useful in confirming the position, something that should be thoroughly pursued to safeguard a correct implantation regardless of the initial stent position in your delivery system.


Assuntos
Aneurisma Roto , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aneurisma Roto/complicações , Aneurisma Roto/cirurgia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/cirurgia , Aortografia , Prótese Vascular , Humanos , Desenho de Prótese , Stents , Resultado do Tratamento
19.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 147, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701378

RESUMO

INTRODUCTION: Amniotic membrane (AM) is an option as a cover in varicose leg ulcers, promoting epithelization. Anti-inflammatory and analgesic proprieties are described, as well as high levels of growth factors and angiogenesis. The costs are inferior to surgical plasty. The aim of this work is to describe the results of AM in the treatment of varicous leg ulcers in a group of patients refractory to the best medical treatment. METHODS: A pilot prospective trial was conducted. Thirteen patients were selected for the treatment with AM from an outpatient clinic. The inclusion criteria included: ulcer area inferior to 100 cm2, ulcer size variation inferior to 30% in the last month, duration superior to 2 years and refractory to best medical treatment including compressive therapy. The exclusion criteria were ABI>0,8m active infection, bone exposure, severe myopathy of the low limb and acute decompensation of systemic chronic disease. The first five cases were applied on the enfermary (mean stay 3 days), the last 8 patients were applied in the outpatient clinic. After the treatment behavioral reinforcement was made. RESULTS: The mean sample age was 56 YO (50-71), 70% were female, 30% were diabetic, and post-thrombotic syndrome was present in 54% (7), only one patient was an active smoker. After 2 years a recurrence was observed in 23% (3) cases. CONCLUSION: AM is effective in the treatment of varicose ulcers unresponsive to best medical treatment.


Assuntos
Âmnio , Úlcera Varicosa , Idoso , Âmnio/transplante , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Úlcera Varicosa/cirurgia , Cicatrização
20.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 151, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701382

RESUMO

INTRODUCTION: Spinal cord ischemia (SCI) is a feared complication after endovascular correction of thoracic aortic diseases (TEVAR). The guidelines of the European Society for Vascular Surgery recommend prophylactic lumbar drainage (LD) of cerebrospinal fluid in high-risk patients undergoing TEVAR. Our institutional protocol considers as high-risk patients as: coverage of the origin of the Adamkiewicz artery (T9-T12), aortic coverage >15 cm, involvement of collaterals (treated or untreated abdominal aortic aneurysm, left subclavian artery revascularization or bilateral occlusion of the internal iliac arteries) and symptomatic SCI. The objective of the study was to demonstrate the efficacy and safety of LD in preventing or treating SCI after TEVAR. METHODS: Patients submitted to LD in the perioperative period of TEVAR under the institutional protocol, between May 2015 and April 2017, were prospectively included. PRIMARY OUTCOME: prevention and/or reversal of neurological symptoms (efficacy). Secondary Outcome: complications related to the technique (safety). RESULTS: We included 8 patients with thoracoabdominal aneurysms and 1 patient with type B aortic dissection, aged 63- 75 years. Eight interventions were elective and one was urgent. The LD catheter was placed before surgery in 8 cases and in the postoperative period in 1 case due to symptomatology of SCI that reverted after liquor drainage. Of those placed pre-operatively, 2 had symptoms of SCI in the postoperative period, which alleviated with increased drainage and hemodynamic and hemoglobin optimization. The patient undergoing urgent TEVAR for ruptured thoracoabdominal aneurysm evolved with multiorgan dysfunction and death 24 hours after surgery. There were no other complications. CONCLUSION: In this initial experience, the institutional protocol with LD placement proved to be safe and effective in preventing and treating SCI after TEVAR.


Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Isquemia , Doenças da Medula Espinal , Idoso , Aorta Torácica , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Humanos , Isquemia/prevenção & controle , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Doenças da Medula Espinal/prevenção & controle , Stents , Fatores de Tempo , Resultado do Tratamento
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