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1.
J Vasc Surg Venous Lymphat Disord ; 7(6): 824-831, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31495764

RESUMO

BACKGROUND: Whereas numerous studies have demonstrated noninferiority of cyanoacrylate embolization (CAE) relative to endovenous laser ablation (EVLA), little is known about the natural history of the vein or the glue that is implanted. This study provides the first description of duplex ultrasound changes of the great saphenous vein (GSV) after CAE relative to EVLA as well as a pragmatic view of outcomes in clinical practice. METHODS: Patients treated with CAE and EVLA at our institution were matched by time of procedure and vein size. GSV diameter was measured at the saphenofemoral junction, midthigh, and knee. Duplex ultrasound imaging was repeated after treatment in the same noninvasive laboratory with an identical protocol. Clinical data were collected by retrospective chart review. RESULTS: Of 481 eligible patients, 119 underwent postoperative duplex ultrasound imaging. Although there was a trend toward decreased vein diameter over time in CAE patients relative to their preoperative vein diameter, this failed to reach statistical significance at the midthigh (P = .32) or at the knee (P = .511). In EVLA patients, as follow-up interval increased, the vein was less frequently visualized on ultrasound at the midthigh (P = .046) and knee (P = .038). At >2 years of follow-up, >80% of EVLA patients had no visible vein segment. Anatomic recurrence was observed in 10.5% of CAE patients and 8.2% of EVLA patients, which was not statistically significantly different (P = .60). The majority of recurrence was observed in the presence of incompetent tributaries. CONCLUSIONS: After CAE of the GSV, our results indicate that the glue cast remains for at least 3 years. Although our results suggest that the glue is broken down over time, this process is much slower than expected. In contrast, after EVLA, the vein tissue is remodeled and is no longer visible with time. In our study, which represents a pragmatic clinical population with a large (median, 9.2 mm) vein diameter, we again demonstrate no statistically significant difference in recurrence rates. Whereas CAE offers an attractive treatment option for GSV incompetence, the glue cast remains for a prolonged time, and longer follow-up studies than those currently available are indicated.

2.
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
3.
Trauma Case Rep ; 12: 24-27, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29644279

RESUMO

Traumatic dissection of the innominate artery is a rare clinical entity. Management of a patient with motorsensory compromise and dissection extending to the subclavian and right common carotid arteries is quite rare and can be quite involved. Here we present such a case and discuss the unique peri-operative decision-making in the context of what is reported in the literature. Restoration of motorsensory function is critical and in this case, requiring a multi-disciplinary team.

4.
Ann Surg Oncol ; 21(7): 2274-9, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24590437

RESUMO

BACKGROUND: Product analysis of rectal cancer resection specimens before specimen fixation may provide an immediate and relevant evaluation of surgical performance. We tested the interrater reliability (IRR) of a product analysis tool called the Total Mesorectal Excision-Quality Assessment Instrument (TME-QA). METHODS: Participants included two gold standard raters, five pathology assistants, and eight pathologists. Domains of the TME-QA reflect total mesorectal excision principles including: (1) completeness of mesorectal margin; (2) completeness of mesorectum; (3) coning of distal mesorectum; (4) physical defects; and (5) overall specimen quality. Specimens were scored independently. We used the generalizability theory to assess the tool's internal consistency and IRR. RESULTS: There were 39 specimens and 120 ratings. Mean overall specimen quality scores for the gold standard raters, pathologists, and assistants were 4.43, 4.43, and 4.50, respectively (p > 0.85). IRR for the first nine items was 0.68 for the full sample, 0.62 for assistants alone, 0.63 for pathologists alone, and 0.74 for gold standard raters alone. IRR for the item overall specimen quality was 0.67 for the full sample, 0.45 for assistants, 0.80 for pathologists, and 0.86 for gold standard raters. IRR increased for all groups when scores were averaged across two raters. CONCLUSIONS: Assessment of surgical specimens using the TME-QA may provide rapid and relevant feedback to surgeons about their technical performance. Our results show good internal consistency and IRR when the TME-QA is used by pathologists. However, for pathology assistants, multiple ratings with the averaging of scores may be needed.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/normas , Patologia Clínica/normas , Guias de Prática Clínica como Assunto/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Neoplasias Retais/cirurgia , Humanos , Prognóstico , Neoplasias Retais/patologia , Reprodutibilidade dos Testes
5.
Vasc Endovascular Surg ; 47(5): 394-6, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23632775

RESUMO

An infected aortic endograft is an uncommon event, and when it happens it can be of significant morbidity and mortality to the patient. We present here a case of a patient with an infected aortic endograft following percutaneous translumbar sac embolization for a type II endoleak leading to sac expansion. The cultured pathogen was Propionibacterium acnes, a commonly occurring skin bacterium that leads to the clinical condition "acne vulgaris." The patient underwent graft explantation and reconstruction with autogenous femoral vein. To our knowledge, there are no previously published reports of aortic graft infections with P acnes.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Infecções por Bactérias Gram-Positivas/microbiologia , Propionibacterium acnes/isolamento & purificação , Infecções Relacionadas à Prótese/microbiologia , Stents/efeitos adversos , Idoso , Antibacterianos/uso terapêutico , Aneurisma da Aorta Abdominal/diagnóstico , Implante de Prótese Vascular/instrumentação , Remoção de Dispositivo , Procedimentos Endovasculares/instrumentação , Veia Femoral/transplante , Infecções por Bactérias Gram-Positivas/diagnóstico , Infecções por Bactérias Gram-Positivas/cirurgia , Humanos , Masculino , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/cirurgia , Procedimentos Cirúrgicos Reconstrutivos , Reoperação , Resultado do Tratamento
6.
J Vasc Surg ; 57(6): 1676-83, 1683.e1, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23719040

RESUMO

BACKGROUND: The objective of this study is to provide an up-to-date meta-analysis on the short- and long-term mortality rates of elective repair of abdominal aortic aneurysms (AAAs) via the open and endovascular approaches. METHODS: MEDLINE, EMBASE, and Cochrane Central Register of Controlled trials, conference proceeding from major vascular meetings were searched for randomized trials comparing open vs elective endovascular aneurysm repair (EVAR) of AAAs. A random-effects model was used for analysis. Risk ratio (RR) and 95% confidence intervals (CIs) of open vs EVAR were calculated for short- and long-term mortality and reintervention rates. RESULTS: The analysis encompassed four randomized controlled trials with a total of 2783 patients. The open repair group resulted in significantly increased 30-day postoperative all-cause mortality compared with EVAR repair group (3.2% vs 1.2%; RR, 2.81; 95% CI, 1.60-4.94); however, there is no statistical difference in the long-term all-cause mortality between both groups (RR, 0.97; 95% CI, 0.86-1.10). Interestingly, fewer patients underwent reintervention procedures in the open repair group compared with those who had EVAR repair (9.3% vs 18.9%; RR, 0.49; 95% CI, 0.40-0.60), but this finding is doubtful due to the large heterogeneity. Lastly, no statistical difference in long-term mortality rates attributable to cardiovascular disease (CVD), aneurysm related, or stroke were found between the two types of repair. CONCLUSIONS: Results of this meta-analysis demonstrate that the 30-day all-cause mortality rate is higher with open than with EVAR repair; however, there is no statistical difference in the long-term all-cause and cause-specific mortality between both groups. The reintervention rate attributable to procedural complication was higher in the EVAR group. Because of the equivalency of long-term outcomes and the short-term benefits of EVAR, an endovascular-first approach to AAAs can be supported by the meta-analysis.


Assuntos
Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Cirúrgicos Eletivos , Humanos , Reoperação/estatística & dados numéricos , Procedimentos Cirúrgicos Vasculares
7.
Am J Surg ; 205(2): 151-5, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23062572

RESUMO

BACKGROUND: Motivation in teaching, mainly studied in disciplines outside of surgery, may also be an important part of intraoperative teaching. We explored techniques surgeons use to motivate learners in the operating room (OR). METHODS: Forty-four experienced surgeon teachers from multiple specialties participated in 9 focus groups about teaching in the OR. Focus groups were transcribed and subjected to qualitative thematic analysis by 3 reviewers through an iterative, rigorous process. RESULTS: Analysis revealed 8 motivational techniques. Surgeons used motivation techniques tacitly, describing multiple ways that they facilitate resident motivation while teaching. Two major categories of motivational techniques emerged: (1) the facilitation of intrinsic motivation; and (2) the provision of factors to stimulate extrinsic motivation. CONCLUSIONS: Surgeons unknowingly but tacitly and commonly use motivation in intraoperative teaching and use a variety of techniques to foster learners' intrinsic and extrinsic motivation. Motivating learners is 1 vital role that surgeon teachers play in nontechnical intraoperative teaching.


Assuntos
Docentes de Medicina , Controle Interno-Externo , Internato e Residência , Motivação , Salas Cirúrgicas , Autonomia Pessoal , Especialidades Cirúrgicas/educação , Adulto , Feminino , Grupos Focais , Humanos , Relações Interprofissionais , Aprendizagem , Masculino , Pessoa de Meia-Idade , Ontário , Pesquisa Qualitativa , Amostragem
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