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1.
J Vasc Surg ; 2019 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-31519509

RESUMO

OBJECTIVE: Patients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up. METHODS: Retrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics. RESULTS: The study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P = .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P = .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P = .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P = .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P = .05) were higher in the endovascular treatment group. CONCLUSIONS: EVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients.

2.
J Vasc Surg ; 70(6): 2054-2064.e3, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31327612

RESUMO

OBJECTIVE: The objectives of the present study were to summarize and pool the available data from studies that had directly compared endovascular and open repair of juxtarenal aortic aneurysms. METHODS: OVID Medline and Embase were searched for studies from January 2000 to December 2018 that had compared endovascular vs open repair of juxtarenal aortic aneurysms. Studies that had included patients with pararenal and suprarenal aneurysms were also included. The endovascular interventions included short-neck standard endovascular aneurysm repair (EVAR), parallel grafts, and fenestrated/branched EVAR. The primary outcomes were 30-day mortality, perioperative reinterventions, acute renal failure, permanent dialysis, stroke, and spinal cord ischemia. The secondary outcomes were myocardial infarction, bowel and limb ischemia, length of stay, and long-term survival. The data were pooled, and a meta-analysis using a random effects model was performed. RESULTS: A total of 20 studies met the inclusion criteria. Of the 20 studies, five had contained duplicated data and one had included only 2-year follow-up data. Therefore, 14 studies with 5121 patients (1506 endovascular, 3615 open) were included for analysis. The patients undergoing endovascular repair were older (mean difference, 3.42; 95% confidence interval [CI], 2.54-4.3; P < .001; I2 = 56%), more likely to be men (odds ratio [OR], 1.33; 95% CI, 1.02-1.73; P = .04; I2 = 33%), and more likely to have diabetes (OR, 1.24; 95% CI, 1.04-1.50; P = .02; I2 = 0%), coronary artery disease (OR, 1.64; 95% CI, 1.03-2.62; P = .04; I2 = 75%), and chronic kidney disease (OR, 1.52; 95% CI, 1.07-2.15; P = .02; I2 = 50%). Endovascular repair was associated with significantly decreased 30-day mortality (OR, 0.50; 95% CI, 0.34-0.74; P < .001; I2 = 0%). This remained significant when including only fenestrated EVAR (OR, 0.55; 95% CI, 0.36-0.85; P = .007; I2 = 0%). Endovascular repair also resulted in a significantly decreased incidence of acute renal failure (OR, 0.50; 95% CI, 0.28-0.89; P = .02; I2 = 67%), an increased incidence of spinal cord ischemia (OR, 3.14; 95% CI, 1.08-9.09; P = .03; I2 = 0%), a decreased incidence of bowel ischemia (OR, 0.50; 95% CI, 0.24-1.05; P = .07; I2 = 7%), and decreased length of stay (mean difference, -5.99 days; 95% CI, -7.42 to -4.57 days; P < .00001; I2 = 78%). No significant differences were found for the other outcomes. Of the nine studies that had reported long-term survival (1-7 years of follow-up), eight had found no significant differences between groups (data not pooled) and one study had found improved long-term survival in the open repair group. Reinterventions during follow-up were increased in the endovascular group. CONCLUSIONS: Pooling data from 14 studies, we found endovascular repair was associated with lower 30-day mortality, acute renal failure, bowel ischemia, and length of stay but with increased spinal cord ischemia. These data were limited by the risk of bias of the included studies. Further long-term studies are needed to determine whether these differences persist during long-term follow-up.

3.
J Vasc Surg ; 70(6): 1823-1830, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31126766

RESUMO

BACKGROUND: Randomized controlled trials of long-term survival for infrarenal abdominal aortic aneurysms have compared open surgical repair (OSR) with endovascular aneurysm repair (EVAR) in patients with suitable aortic anatomy for EVAR. However, in clinical practice, patients who do not meet instructions for use (IFU) criteria are often still treated by EVAR despite that some studies show higher graft-related adverse events. The goal of this study was to compare the long-term survival of EVAR and OSR in patients with anatomy outside IFU criteria for EVAR. METHODS: This multicenter retrospective cohort study included patients with at least one anatomic IFU violation for EVAR undergoing either elective EVAR or elective OSR for abdominal aortic aneurysm. Demographics, anatomic data, and follow-up data of patients were collected from three academic centers from 2003 to 2016. Device-specific IFU were used for EVAR patients, whereas generic IFU for EVAR were applied to the OSR patients. The primary outcomes were 30-day mortality and long-term all-cause mortality. Secondary outcomes were aneurysm-related mortality and perioperative complications at 30 days. Kaplan-Meier survival and Cox proportional hazards modeling were performed. Inverse propensity score weights were used to adjust for differences in treatment selection. RESULTS: The study population included 202 EVAR patients and 224 OSR patients with at least one anatomic IFU violation for EVAR. EVAR patients were older (78.1 ± 7.3 vs 70.9 ± 7.0 years; P < .001) and less likely to be hypertensive (69.3% vs 79.0%; P = .02) compared with OSR patients. OSR patients were more likely to have proximal aortic neck IFU violations (75.0% vs 47.1%; P < .001) and were less likely to have iliac IFU violations (65.2% vs 79.2%; P < .001). All-cause mortality was 37.6% in the EVAR group and 24.1% in the OSR group with a median follow-up time of 5.2 (3.5-7.2) and 5.4 (2.8-9.3) years, respectively (P < .002). Kaplan-Meier survival analysis revealed a significant association between patients undergoing OSR and increased long-term survival (log-rank P < .0001). When adjusted for possible confounders and weighted for propensity for treatment through Cox hazard modeling, the association remained significant (hazard ratio, 0.6; 95% confidence interval, 0.4-0.9). Aneurysm-related mortality was 3.5% in the EVAR group and 2.2% in the OSR group during long-term follow-up (P < .001). CONCLUSIONS: Our study identified that patients with IFU violations have higher overall long-term survival with open surgery compared with EVAR. Caution should be applied in considering standard EVAR for patients with anatomy outside of IFU.

5.
Ann Thorac Surg ; 107(1): 47-53, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30291835

RESUMO

BACKGROUND: Hybrid aortic arch surgery has evolved to include several technical variations, with most including an off-label use of a conventional thoracic endograft. We describe the early clinical outcomes of the Thoraflex Hybrid graft (Vascutek, Glasgow, Scotland) specifically designed for the treatment of complex arch and proximal descending aortic disease. METHODS: Between January 2014 and April 2017, 40 consecutive patients (66 ± 14 years of age, 45% women) underwent hybrid aortic arch and frozen elephant trunk repair with the multibranched Thoraflex Hybrid graft at 9 Canadian centers. Surgical indications included transverse arch or proximal descending aortic aneurysm in 100%, acute dissection in 10%, chronic dissection in 43%, and acute aortic rupture in 1 patient. Antegrade cerebral perfusion and moderate hypothermia (24.3 ± 1.8°C) were employed in all cases. RESULTS: All 40 device implants were successful. The 30-day or in-hospital mortality was 5%. Stroke and transient neurological deficits occurred in 5% and 3% of patients, respectively. Two (5%) patients experienced transient spinal cord ischemia-there were no instances of permanent paraplegia. Mean follow-up was 550 ± 328 days and late complications included type A aortic dissection in 1 patient, type B dissection in 2 patients, and further distal endografting in 2 patients. Survival at 30 days, 1 year, and 2 years was 95%, 95%, and 90%, respectively. CONCLUSIONS: Hybrid aortic arch and frozen elephant trunk repair with the Thoraflex Hybrid graft appears to be associated with good clinical outcomes, despite being early in the learning curve with this graft. Further investigation with this device is warranted to establish its role within the variations of hybrid arch repair.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Prótese Vascular , Procedimentos Endovasculares , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma Dissecante/mortalidade , Aneurisma da Aorta Torácica/mortalidade , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
6.
Can J Anaesth ; 66(2): 161-181, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30421146

RESUMO

PURPOSE: Whether current standards of care management for malignant hyperthermia (MH)-susceptible patients result in acceptable postoperative clinical outcomes at a population level is not known. Our objective was to determine if patients with susceptibility to MH experienced similar outcomes as patients without MH susceptibility after surgery under general anesthesia. METHODS: This was a retrospective, population-based cohort study from 1 April 2009 until 31 March 2016 in the Canadian province of Ontario. Participants were adults who underwent common in- or outpatient surgeries under general anesthesia. The exposure studied was either known or strongly suspected MH susceptibility as determined by usage of a specific physician billing code. The primary outcome was a composite of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Separate analyses were employed, based on whether a patient had in- or outpatient surgery. Inverse probability of exposure weighting based on the propensity score was used to estimate adjusted exposure effects. RESULTS: The cohort included 957,876 patients (583,254 in- and 374,622 outpatients). There were 2,900 (0.3%) patients with a known or strong suspicion of MH susceptibility. For inpatients, the primary outcome occurred in 146,192 (25.1%) of the non-MH-susceptible group and in 337 (20.1%) of the MH-susceptible group (unadjusted risk difference [RD], -5.0%; 95% confidence interval [CI], -6.9 to -3.1%; P < 0.001). In outpatients, the primary outcome occurred in 9,146 (2.4%) of the non-MH-susceptible group and in 32 (2.6%) of the MH-susceptible group (RD, 0.2%; 95% CI, -0.7 to 1.1%; P = 0.72). After adjustment, MH susceptibility was not associated with the primary outcome in either the inpatients (adjusted risk difference [aRD], 1.2%; 95% CI, -1.3 to 3.6%; P = 0.35) or outpatients (aRD, -0.1%; 95% CI -1.0 to 0.9%; P = 0.90). CONCLUSIONS: Among adults in Ontario who underwent common surgeries under general anesthesia from 2009 to 2016, known or strongly suspected MH was not associated with a higher risk of adverse postoperative outcomes. These findings support the current standard of care management for MH-susceptible patients.

7.
Eur J Vasc Endovasc Surg ; 57(3): 382-391, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30393063

RESUMO

OBJECTIVES: Patients with infrainguinal peripheral arterial disease often undergo multiple revascularisation procedures. Although many centres have adopted an endovascular first approach, some are reluctant to do so for fear of compromising the outcomes of any subsequent bypasses. All studies that compared the outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention were analysed. METHODS: A systematic review was conducted of MEDLINE, EMBASE, and CENTRAL databases for studies comparing outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention for peripheral arterial disease. Abstracts and full text studies were screened independently by two reviewers with data abstraction done in duplicate. Dichotomous outcome measures were reported using the OR and 95% CI, and pooled using random effects models. RESULTS: Abstracts were screened (2,528), with 50 selected for full text review. Of these, 15 studies involving 11,886 patients met the inclusion criteria. Pooling the results of studies comparing primary bypass with bypass after failed endovascular intervention showed no significant difference in 30 day mortality (OR 1.00; 95% CI 0.65-1.54), or 30 day amputation rates (OR 1.26; 95% CI 0.95-1.65). Interestingly, one year amputation free survival was higher in the patients who had primary bypass (OR 1.30; 95% CI 1.10-1.52) compared with patients who had bypass after failed endovascular therapy. There was also worse one year primary patency (OR 1.65; 95% CI 1.04-2.62) for patients with prior failed endovascular intervention. The review demonstrated a trend towards higher rates of early graft occlusion (OR 4.54; 95% CI 0.97-21.28). CONCLUSIONS: Meta-analysis of the existing literature comparing primary bypass with bypass following failed endovascular intervention shows worse one year amputation free survival and worse primary patency in those patients who undergo bypass after failed endovascular intervention. There is also a trend towards higher rates of early graft occlusion, although these results were not statistically significant. These conclusions are limited by observational study design, inconsistent patient selection, and significant heterogeneity between studies.


Assuntos
Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Oclusão de Enxerto Vascular/epidemiologia , Doença Arterial Periférica/cirurgia , Veia Safena/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/etiologia , Humanos , Salvamento de Membro , Masculino , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Sobrevida , Falha de Tratamento
8.
CMAJ ; 190(43): E1273-E1280, 2018 10 29.
Artigo em Inglês | MEDLINE | ID: mdl-30373740

RESUMO

BACKGROUND: Curcumin, a popular herbal supplement from the plant turmeric, has prevented ischemic reperfusion and toxin-induced injury in many animal studies and a single-centre randomized human trial. We sought to test whether perioperative oral curcumin (compared with placebo) affects the inflammatory response and risk of postrepair complications after elective abdominal aortic aneurysm repair in humans. METHODS: We conducted a parallel-group, randomized, placebo-controlled trial of patients from 10 hospitals in Canada who were scheduled to undergo elective repair of an unruptured abdominal aortic aneurysm (November 2011 to November 2014). Patients in the treatment group received perioperative oral curcumin (2000-mg doses 8 times over 4 d). Patients, health care providers and local research staff were unaware of the treatment assignment. The primary outcomes were median concentrations of 4 bio markers indicating injury and inflammation (postoperative urine interleukin-18 and perioperative rise in serum creatinine, plasma N-terminal pro-B-type natriuretic peptide and plasma high-sensitivity C-reactive protein). RESULTS: Baseline characteristics were similar in the 2 groups (606 patients overall; median age 76 yr). More than 85% of patients in each group took more than 80% of their scheduled capsules. Neither curcumin nor placebo significantly affected any of the 4 biomarkers (p > 0.05 for all comparisons). Regarding the secondary outcomes, there was a higher risk of acute kidney injury with curcumin than with placebo (17% v. 10%, p = 0.01), but no between-group difference in the median length of hospital stay (5 v. 5 days, p > 0.9) or the risk of clinical events (9% v. 9%, p = 0.9). INTERPRETATION: Curcumin had no beneficial effects when used in elective abdominal aortic aneurysm repair. These findings emphasize the importance of testing turmeric and curcumin before espousing their health benefits, as is currently done in the popular media. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT01225094.


Assuntos
Anti-Inflamatórios não Esteroides/administração & dosagem , Aneurisma da Aorta Abdominal/cirurgia , Curcumina/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios não Esteroides/efeitos adversos , Biomarcadores/sangue , Proteína C-Reativa/análise , Creatinina/sangue , Curcumina/efeitos adversos , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Interleucina-18/urina , Masculino , Peptídeo Natriurético Tipo C/sangue , Assistência Perioperatória/métodos , Resultado do Tratamento
9.
J Vasc Surg Venous Lymphat Disord ; 6(6): 779-787.e6, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30336907

RESUMO

OBJECTIVE: The objective of this study was to compare the nontumescent-based endovenous therapies with the standard tumescent-based endovenous therapies in regard to clinical effectiveness and procedural outcomes in patients with saphenofemoral incompetence and varicose veins. METHODS: The following databases were searched for studies that were randomized or quasi-randomized trials comparing nontumescent-based endovenous procedures with those requiring tumescence: Cochrane Central Register of Controlled Trials (1950-January 2017), MEDLINE (1946-January 2017), and Embase (1950-January 2017). There were no restrictions based on language or publication status. In the case of ongoing studies, the World Health Organization's International Clinical Trials Registry Platform and the online ClinicalTrials.gov registry were also searched. We also reviewed reference lists of articles relevant to our study to ensure a more complete review. Two authors independently screened and selected studies to be included. These two authors also independently assessed the risk of bias using the Cochrane risk of bias tool. Data were extracted and pooled using a random-effects model. RESULTS: A total of nine studies were found in the literature search, of which five were included in analysis. Four outcomes were reviewed. A significant difference was found between the comparator groups for mean intraprocedural pain score (effect estimate, -0.66), favoring nontumescent-based therapies. There was no difference for Venous Clinical Severity Score (effect estimate, -0.21) for clinical assessment and the Aberdeen Varicose Vein Questionnaire score (effect estimate, 0.27) for the disease-specific quality of life between the groups. The outcome of failure of truncal ablation at 30 days had no significant difference between the groups (risk ratio, 1.27), although a subgroup analysis demonstrated a trend toward improved results with the novel nontumescent-based treatments (risk ratio, 0.21) compared with the old nontumescent-based treatments (risk ratio, 8.6). CONCLUSIONS: Currently available evidence from reasonable-quality clinical trials comparing tumescent-based with non-tumescent-based endovenous therapies shows no overall difference between the groups on a number of outcomes. Mean intraprocedural pain score appears to favor nontumescent-based interventions. Newer randomized trials comparing the treatment modalities are needed to further clarify the benefits of nontumescent-based therapies, particularly with regard to long-term outcomes.


Assuntos
Anestesia Local , Embolização Terapêutica , Procedimentos Endovasculares/métodos , Veia Safena , Escleroterapia , Varizes/terapia , Insuficiência Venosa/terapia , Anestesia Local/efeitos adversos , Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Medição de Risco , Fatores de Risco , Veia Safena/diagnóstico por imagem , Escleroterapia/efeitos adversos , Resultado do Tratamento , Varizes/diagnóstico por imagem , Insuficiência Venosa/diagnóstico por imagem
11.
Ann Cardiothorac Surg ; 7(3): 414-421, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-30155421

RESUMO

Management of the left subclavian artery (SCA) during aortic arch surgery is associated with several challenges, including preserving distal perfusion, achieving hemostasis and preventing posterior circulation stroke and spinal cord injury. The most common challenge remains its deep position in the chest, often exacerbated by posterior and apical displacement from an arch aneurysm. We discuss several management options consisting of pre-, intra- and post-operative strategies and their respective advantages, disadvantages and clinical outcomes. A clinical algorithm is proposed to help guide decision-making in managing the difficult left SCA during aortic arch repair.

12.
Am J Physiol Heart Circ Physiol ; 315(4): H855-H870, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-29932769

RESUMO

It has long been known that chronic metabolic disease is associated with a parallel increase in the risk for developing peripheral vascular disease. Although more clinically relevant, our understanding about reversing established vasculopathy is limited compared with our understanding of the mechanisms and development of impaired vascular structure/function under these conditions. Using the 13-wk-old obese Zucker rat (OZR) model of metabolic syndrome, where microvascular dysfunction is sufficiently established to contribute to impaired skeletal muscle function, we imposed a 7-wk intervention of chronic atorvastatin treatment, chronic treadmill exercise, or both. By 20 wk of age, untreated OZRs manifested a diverse vasculopathy that was a central contributor to poor muscle performance, perfusion, and impaired O2 exchange. Atorvastatin or exercise, with the combination being most effective, improved skeletal muscle vascular metabolite profiles (i.e., nitric oxide, PGI2, and thromboxane A2 bioavailability), reactivity, and perfusion distribution at both individual bifurcations and within the entire microvascular network versus responses in untreated OZRs. However, improvements to microvascular structure (i.e., wall mechanics and microvascular density) were less robust. The combination of the above improvements to vascular function with interventions resulted in an improved muscle performance and O2 transport and exchange versus untreated OZRs, especially at moderate metabolic rates (3-Hz twitch contraction). These results suggest that specific interventions can improve specific indexes of function from established vasculopathy, but either this process was incomplete after 7-wk duration or measures of vascular structure are either resistant to reversal or require better-targeted interventions. NEW & NOTEWORTHY We used atorvastatin and/or chronic exercise to reverse established microvasculopathy in skeletal muscle of rats with metabolic syndrome. With established vasculopathy, atorvastatin and exercise had moderate abilities to reverse dysfunction, and the combined application of both was more effective at restoring function. However, increased vascular wall stiffness and reduced microvessel density were more resistant to reversal. Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/reversal-of-microvascular-dysfunction/ .


Assuntos
Atorvastatina/farmacologia , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Síndrome Metabólica/terapia , Microcirculação/efeitos dos fármacos , Microvasos/efeitos dos fármacos , Músculo Esquelético/irrigação sanguínea , Doenças Vasculares Periféricas/terapia , Condicionamento Físico Animal/métodos , Esforço Físico , Animais , Biomarcadores/sangue , Modelos Animais de Doenças , Epoprostenol/sangue , Hemodinâmica/efeitos dos fármacos , Masculino , Síndrome Metabólica/sangue , Síndrome Metabólica/patologia , Síndrome Metabólica/fisiopatologia , Microvasos/patologia , Microvasos/fisiopatologia , Modelos Cardiovasculares , Músculo Esquelético/metabolismo , Óxido Nítrico/metabolismo , Consumo de Oxigênio/efeitos dos fármacos , Doenças Vasculares Periféricas/sangue , Doenças Vasculares Periféricas/patologia , Doenças Vasculares Periféricas/fisiopatologia , Ratos Zucker , Fluxo Sanguíneo Regional , Corrida , Tromboxano A2/sangue , Fatores de Tempo
13.
J Vasc Surg ; 68(5): 1517-1523.e3, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29779961

RESUMO

OBJECTIVE: Patient-based decision aids and other multimedia tools have been developed to help enrich the preoperative discussion between surgeon and patient. Use of these tools, however, can be time-consuming and logistically challenging. We investigated whether simply showing patients their images from preoperative computed tomography (CT) or angiography would improve patients' satisfaction with the preoperative discussion. We also examined whether this improved the patient's understanding and trust and whether it contributed to increased preoperative anxiety. METHODS: Patients undergoing either elective abdominal aortic aneurysm repair or lower limb revascularization were randomly assigned to either standard perioperative discussion or perioperative discussion and review of images (CT image or angiogram). Randomization was concealed and stratified by surgeon. Primary outcome was patient satisfaction with the preoperative discussion as measured by a validated 7-item scale (score, 0-28), with higher scores indicating improved satisfaction. Secondary outcomes included patient understanding, patient anxiety, patient trust, and length of preoperative discussion. Scores were compared using t-test. RESULTS: Overall, 51 patients were randomized, 25 to the intervention arm (discussion and imaging) and 26 to the control arm. Most patients were male (69%), and the average age was 70 years. Forty percent of patients underwent abdominal aortic aneurysm repair, whereas 60% underwent lower limb revascularization. Patient satisfaction with the discussion was generally high, with no added improvement when preoperative images were reviewed (mean score, 24.9 ± 3.02 vs 24.8 ± 2.93; P = .88). Similarly, there was no difference in the patient's anxiety, level of trust, or understanding when the imaging review was compared with standard discussion. There was a trend toward longer preoperative discussions in the group that underwent imaging review (8.18 vs 6.35 minutes; P = .07). CONCLUSIONS: Showing patients their CT or angiography images during the preoperative discussion does not improve the patient's satisfaction with the consent discussion. Similarly, there was no effect on the patient's trust, understanding, or anxiety level. Our conclusions are limited by the lack of a standardized measure of patient understanding and not measuring outcomes postoperatively, both of which should be considered in future studies.


Assuntos
Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Consentimento Livre e Esclarecido , Extremidade Inferior/irrigação sanguínea , Educação de Pacientes como Assunto/métodos , Satisfação do Paciente , Doença Arterial Periférica/diagnóstico por imagem , Idoso , Ansiedade/psicologia , Aneurisma da Aorta Abdominal/psicologia , Aneurisma da Aorta Abdominal/cirurgia , Comunicação , Compreensão , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Doença Arterial Periférica/psicologia , Doença Arterial Periférica/cirurgia , Relações Médico-Paciente , Valor Preditivo dos Testes , Estudos Prospectivos , Confiança
14.
J Vasc Surg ; 68(4): 1157-1165, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29784566

RESUMO

OBJECTIVE: Duplex ultrasound as a preoperative assessment tool in the clinic may help identify anatomic factors predictive of fistula maturation. Preoperative point-of-care ultrasound (POCUS) offers surgeons an alternative to routine formal vein mapping as it can be performed by the operator during the initial clinic visit. We sought to determine the impact of POCUS as an adjunct to physical examination on arteriovenous fistula maturation. METHODS: All consecutive patients undergoing first-time dialysis access creation from December 2007 to December 2014 were retrospectively reviewed. Surgeons who routinely use POCUS to assess preoperative maximal vein diameter and quality were compared with surgeons who relied only on physical examination. All access and patency definitions were in accordance with the Society for Vascular Surgery's reporting standards. The effects of POCUS on fistula maturation rate and fistula abandonment were analyzed using logistic regression, controlling for comorbidities of the patient, anticoagulant use, and location of fistula. RESULTS: A total of 316 patients were included in the study; 250 patients were assessed exclusively with physical examination, and 66 patients underwent preoperative ultrasound examination by the vascular surgeon in the clinic. The primary failure rate in the ultrasound group was 18% compared with 47% (P < .001) in the group of patients who did not undergo ultrasound examination. In patients without preoperative ultrasound, there were higher rates of new access creation (31% vs 9%; P < .001) and fistula abandonment (66% vs 39%; P < .001). Multivariable analysis demonstrated that fistulas created without preoperative ultrasound were associated with a 3.56 greater risk of failure (95% confidence interval, 1.67-7.59; P = .001) compared with fistulas in the POCUS group. Similarly, the rate of fistula abandonment was 2.63 times higher (95% confidence interval, 1.38-5.05; P = .003) when ultrasound was not used preoperatively. Time to functional fistula maturation was better in the ultrasound group (P < .001). At 1 year, 12% of fistulas in the ultrasound group and 32% in the clinical examination group had yet to be cannulated. Secondary patency at 1 year was better in the POCUS group at 73% compared with 59% in the group with no preoperative ultrasound (P = .01). CONCLUSIONS: POCUS as an adjunct to physical examination for dialysis access patients leads to decreased rates of primary failure, new access creation, and fistula abandonment compared with patients who undergo only physical examination. Ultrasound examination improved times to functional fistula maturation and secondary patency. Further studies are required to compare POCUS with formal preoperative vein mapping for arteriovenous fistula planning.


Assuntos
Derivação Arteriovenosa Cirúrgica , Testes Imediatos , Cuidados Pré-Operatórios/métodos , Diálise Renal , Ultrassonografia Doppler Dupla , Extremidade Superior/irrigação sanguínea , Veias/diagnóstico por imagem , Veias/cirurgia , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Distribuição de Qui-Quadrado , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Exame Físico , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Veias/fisiopatologia
15.
Surgery ; 2018 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-29699806

RESUMO

BACKGROUND: Laparoscopic splenectomy is a second-line therapy for immune thrombocytopenia with a sustained success rate of 66%. In a climate of new available medical therapies for immune thrombocytopenia, the comparative safety and efficacy of laparoscopic splenectomy are worthy of attention. The purpose of this study is to identify factors predictive of laparoscopic splenectomy success that will enable preoperative prognostication. METHODS: A retrospective cohort study was conducted of patients undergoing laparoscopic splenectomy for immune thrombocytopenia. The data collected evaluated response to medical and surgical therapy, which was defined on a platelet level of 50 × 109/L with no bleeding events. Univariate and multivariate analyses were conducted to evaluate factors predictive of laparoscopic splenectomy success, with an additional subanalysis planned to assess for laparoscopic splenectomy safety in individuals ≥65 years. RESULTS: One hundred forty-one patients were reviewed. Operative outcomes showed a 3.6% conversion rate and 8.5% complication rate. Disease remission was achieved in 78.7% of patients. Response to initial corticosteroid therapy was associated with a laparoscopic splenectomy success rate of 90% and increased odds of surgical success by 5.58 over individuals with no response to corticosteroids. Age did not confer an increased risk of failure or complications. CONCLUSION: Laparoscopic splenectomy is a safe and effective intervention for immune thrombocytopenia regardless of age. Initial response to corticosteroids is associated with laparoscopic splenectomy success rate of 90% and improved odds of surgical success. Laparoscopic splenectomy should be the standard second-line therapy for immune thrombocytopenia, especially in patients responding to corticosteroids.

16.
Can J Cardiol ; 34(3): 262-273, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29395709

RESUMO

BACKGROUND: Frozen elephant trunk (FET) surgery offers a new alternative in the management of complex thoracic aortic aneurysms and dissections. We performed a systematic review and meta-analysis of comparator observational studies evaluating the efficacy of FET compared with conventional aortic arch surgery, primarily focusing on mortality and stroke as well as the secondary outcomes of spinal cord ischemia, major bleeding, and operative time. METHODS: We searched MEDLINE, EMBASE, PubMed, and the Cochrane Library for trials and studies comparing the FET technique with conventional surgery in patients with aortic aneurysms or dissections, or both. The overall quality of evidence was low, as assessed by Grading of Recommendations, Assessment, Development, and Evaluation, based primarily on the risk of bias secondary to study design, plausible confounding, and imprecision. RESULTS: Meta-analysis revealed a significant reduction in mortality (12 studies, 1803 patients: odds ratio [OR], 0.55; 95% CI, 0.39-0.78) and a nonsignificant reduction in stroke (12 studies, 1803 patients: OR, 0.78; 95% CI, 0.52-1.15) favouring FET; however, FET was associated with a significant increase in spinal cord ischemia (9 studies, 1476 patients: OR, 2.20; 95% CI, 1.10-4.37). No significant differences between groups were observed regarding major bleeding, cardiopulmonary bypass time, or cross-clamp time. CONCLUSIONS: Current evidence suggests that FET surgery is associated with lower mortality in patients with thoracic aneurysmal disease and dissections, without a significant increase in stroke, bleeding, or operative times. However, the risk of spinal cord ischemia is increased in patients who undergo FET. A well-powered randomized trial is needed to evaluate this evolving field.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Mortalidade Hospitalar , Aneurisma Dissecante/diagnóstico por imagem , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Prótese Vascular , Feminino , Seguimentos , Humanos , Masculino , Desenho de Prótese , Medição de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
17.
Ann Surg ; 268(2): 357-363, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-28486392

RESUMO

OBJECTIVE: To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients. BACKGROUND: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described. METHODS: This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring. RESULTS: The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%-22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%-20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%-3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46-25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1-29.1) and without an ischemic feature (12.2%; 95% CI, 5.3-25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6-82.4). CONCLUSIONS: Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.


Assuntos
Isquemia Miocárdica/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Troponina T/sangue , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/sangue , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/etiologia , Razão de Chances , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos
18.
J Vasc Surg ; 67(1): 126-133, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28760581

RESUMO

BACKGROUND: A variety of devices exist for endovascular aneurysm repair (EVAR). Device-specific instructions for use (IFU) detail anatomic constraints to application and deployment of devices and are developed from rigorous bench testing. Nonadherence to IFU occurs frequently to avoid open surgery. The purpose of this study was to determine if IFU violations are associated with increased risk of graft-related adverse events (GRAEs) during follow-up. METHODS: This multicenter retrospective observational study included patients undergoing elective endovascular repair for abdominal aneurysmal disease with three different devices. Demographics, anatomic data, and follow-up data were collected on patients from 2005 to 2014. IFU violations were device specific and included neck diameter, length, and angulation and iliac artery diameter and length. GRAEs included a composite outcome of reintervention, migration, endoleak (type II excluded), rupture, limb occlusion, sac growth, and aneurysm-related mortality during the follow-up period. Kaplan-Meier survival and Cox proportional hazards modeling were performed. Any IFU violations as well as neck-specific IFU violations were analyzed. RESULTS: In 461 patients undergoing EVAR, 43.8% had at least one IFU violation. Patients with IFU violations were more likely to have peripheral vascular disease (12.4% vs 7.3%) and were less likely to be male (78.7% vs 90.3%). The most frequent IFU violations included diameter deviations of the neck (15.2%) and of the iliac artery (21.4%). Overall, the GRAE rate was 12.8%. Median follow-up time was 1.9 and 2.1 years for patients with and without an IFU violation, respectively. Kaplan-Meier survival revealed a significant association between the presence of an IFU violation and GRAEs (log-rank, P = .031). When adjusted for clinical variable through Cox hazard modeling, the association remained significant (hazard ratio 1.8; 95% confidence interval, 1.05-3.1). When neck-specific violations were considered independently, Kaplan-Meier survival (log-rank, P = .003) and Cox modeling (hazard ratio, 2.2; 95% confidence interval, 1.2-4.0) revealed a significant association between neck-specific IFU violation and GRAEs. CONCLUSIONS: A total of 43.8% of patients undergoing EVAR had a device-specific IFU violation, indicating that implanters are pushing the boundaries of device capabilities. Our study identified that any IFU violation was significantly associated with GRAEs over time. Caution should be applied to patients being considered for EVAR when IFU deviations exist.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Fidelidade a Diretrizes/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Prótese Vascular/efeitos adversos , Prótese Vascular/normas , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/métodos , Implante de Prótese Vascular/normas , Angiografia por Tomografia Computadorizada/métodos , Procedimentos Cirúrgicos Eletivos/instrumentação , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/normas , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Seleção de Pacientes , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Stents/efeitos adversos , Stents/normas , Fatores de Tempo , Resultado do Tratamento
19.
J Vasc Surg ; 67(6): 1717-1726.e5, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29248240

RESUMO

OBJECTIVE: Volume-outcome relationships for open abdominal aortic aneurysm (AAA) repair have received less attention in publicly funded health systems. Furthermore, the roles of surgeon seniority (years of experience) and composite volume (encompassing all major arterial cases) on outcomes after open AAA repair are less well known. We sought to determine the effects of surgeon volume, surgeon years of experience, and composite volume on outcomes after elective open AAA repairs performed in Ontario, Canada. METHODS: Using a population-based, prospectively collected health administrative database, all elective open AAA repairs occurring in the province of Ontario from 2005 to 2014 were identified. Surgeon annual volume was classified by quintiles, with the highest volume quintile acting as the reference category. Multivariable logistic regression modeling was used, adjusting for patient factors (age, sex, comorbidities, year of procedure, income) to investigate the relationship between surgeon annual volume and 30-day mortality, 30-day major complications, 30-day reoperations, 1-year mortality, and 1-year reoperations (related to index procedure). The potential effects of annual surgeon composite volume and surgeon years of experience on postoperative outcomes were also explored. RESULTS: A total of 7211 elective open AAA repairs performed by 101 surgeons were identified between 2005 and 2014. Most of the operations were performed by vascular surgeons (81.5%), followed by cardiac (12.1%) and general surgeons (6.1%). Median number of procedures in the lowest quintile group was 3 repairs/y, whereas the highest quintile group performed 54 repairs/y. Overall 30-day mortality was 3%. No difference in mortality was detected in comparing the lowest with the highest volume groups (1.89% vs 3.01%; adjusted odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33). The lowest volume group exhibited a higher 30-day complication rate (28.0% vs 20.4%; OR, 1.54; 95% CI, 1.15-2.06) and 30-day reoperation rate (10.53% vs 6.73%; OR, 1.64; 95% CI, 1.13-2.38) compared with the highest volume group. No effect of surgeon volume on 1-year mortality or 1-year reoperation was observed. Similarly, composite volume and surgeon years of experience were not associated with postoperative outcomes. CONCLUSIONS: In a single-payer system with a relatively high number of open AAA repairs/surgeon per year, surgeon annual volume had no effect on postoperative mortality but was associated with lower postoperative complication and reoperation rates.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Complicações Pós-Operatórias/epidemiologia , Reoperação/tendências , Medição de Risco , Cirurgiões/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Idoso , Competência Clínica , Procedimentos Cirúrgicos Eletivos , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Razão de Chances , Ontário/epidemiologia , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Procedimentos Cirúrgicos Vasculares
20.
J Vasc Surg ; 66(4): 1307-1308, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28942858
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