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1.
J Cardiovasc Surg (Torino) ; 62(4): 364-368, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33829742

RESUMO

BACKGROUND: Endovascular balloon angioplasty is a common practice to treat femoropopliteal arterial lesions. The precise balloon inflation duration to obtain the best lesion dilatation is unclear. The aim of this study was to assess angiographic images after 3- and 5-minute balloon inflation in femoropopliteal de-novo atherosclerotic lesions. METHODS: We randomly assigned 61 femoropopliteal arterial lesions to undergo balloon angioplasty for 3 and 5 minutes. The primary endpoint was the rate of favorable angiographic images after balloon angioplasty. The correlation between angiographic image and degree of calcification was studied. The secondary endpoint was the need of additional ballooning or stenting of the dilated lesion. RESULTS: Thirty-two (52%) lesions were randomized to a 3-minute inflation time and 29 (48%) lesions to a 5-minute inflation time. Median lesion length was 83±32mm in the 3-minute group and 89±31mm in the 5-minute inflation group (P=0.47). After deflation, vessel recoil was significantly higher in the 3-minute group compared to the 5-minute group (P=0.04), in mild to moderate calcified lesions, 18 (56%) and 9 (31%) cases, respectively. The angiographic result after balloon angioplasty was significantly more favorable (P=0.007) in the 5-minute group with 20 (69%) cases compared to 10 (31%) cases in the 3-minute group. An increase of vessel recoil of 62% has been seen in severe calcified lesions in the 5-minute group. Additional intervention rate was significantly higher (P=0.007) in the 3-minute group compared to the 5-minute group. CONCLUSIONS: A prolonged inflation time of 5 minutes has an overall better angiographic image in the femoropopliteal segment and especially in non- or mildly calcified lesions.


Assuntos
Angiografia/métodos , Angioplastia com Balão/métodos , Arteriopatias Oclusivas/cirurgia , Artéria Femoral/cirurgia , Artéria Poplítea/cirurgia , Idoso , Arteriopatias Oclusivas/diagnóstico , Feminino , Artéria Femoral/diagnóstico por imagem , Seguimentos , Humanos , Masculino , Artéria Poplítea/diagnóstico por imagem , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Dispositivos de Acesso Vascular
2.
Vasc Endovascular Surg ; 55(1): 86-90, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32873196

RESUMO

INTRODUCTION: aortic aneurysms involving the renal and visceral arteries are endovascular challenges, especially for emergencies. We report a case of ruptured thoracoabdominal aortic aneurysm (TAAA) in a morbidly obese 71-year-old man. The patient was admitted with a stable hemodynamic state. A computed tomography angiogram (CTA) revealed a contained ruptured TAAA with an occluded celiac trunk and left renal artery due to previous nephrectomy. Due to the emergency and his comorbidities, we performed an endovascular aortic repair with the sandwich technique and 2 chimneys. Two bridging stents (chimneys) were deployed between the aorta and the target vessels (superior mesenteric and right renal arteries) in a space created in-between 2 aortic straight endografts. Ten days postoperative, acute renal failure appeared and right renal stent occlusion was diagnosed on CTA. Unfortunately, no adequate kidney revascularization could be obtained, requiring permanent hemodialysis. At a 3-month follow-up visit, the patient did well with stable aneurysm dimensions. CONCLUSIONS: encouraging outcomes of chimney-EVAR techniques, comparable to those in published reports of fenestrated-EVAR and branched-EVAR, support this procedure as a valid off-the-shelf available alternative in emergency situations. Nevertheless, only few midterm results achieved are actually available and long-term outcomes are actually unknown.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Stents , Resultado do Tratamento
4.
Vasc Endovascular Surg ; 53(2): 126-131, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30466371

RESUMO

AIMS:: Stenting of the popliteal artery (PA) is generally considered inappropriate due to the high mechanical stress and bending of the artery during knee flexion. Nevertheless, vessel recoil remains problematic following angioplasty procedure for chronic total occlusions (CTOs) and adjunctive stenting may be required. The purpose of this study is to compare balloon angioplasty alone versus bailout stenting for isolated CTO of the PA. MATERIALS AND METHODS:: Between March 2012 and October 2016, 43 patients were treated with percutaneous transluminal angioplasty with balloon alone (PTA, n = 16) or bailout stenting percutaneous transluminal angioplasty and stenting (PTAS, n = 27) for de novo CTO of PA. There was no statistically significant difference between both groups with regard to patient demographics and lesions characteristics (calcification severity and lesion length). The median lesion lengths were 67 mm (39.5-78.5) in the PTA group and 94 mm (50-114) in the PTAS group ( p = 0.14). The primary outcome measure was primary patency; secondary outcomes were technical success, primary assisted patency, major amputation, and increased Rutherford classification. RESULTS:: Technical success rate was 37% and 96.3% in the PTA and PTAS groups, respectively. There was no statistical difference in 12-month primary patency rate (65.8% versus 58.7%; p = 0.15) and primary assisted patency at 12 months (75.2 versus 69.2; p = 0.47) between the 2 groups. Freedom from target lesion revascularization at 12 months was not significantly different, with 85.7% and 81.6% ( p = 0.2) in the PTA and PTAS groups, respectively. One amputation occurred in the PTA group. CONCLUSION:: This small cohort suggests that stenting as a bailout procedure in CTO of the PA provides similar results to successful balloon angioplasty. Stenting should only be performed after suboptimal balloon angioplasty with vessel recoil. Due to the large lost to follow-up, strong evidence of a therapy over the other cannot be formulated. Larger studies with longer and stronger follow-up are needed to confirm those results.


Assuntos
Angioplastia com Balão/instrumentação , Doença Arterial Periférica/cirurgia , Artéria Poplítea/cirurgia , Stents , Amputação , Angioplastia com Balão/efeitos adversos , Doença Crônica , Constrição Patológica , Bases de Dados Factuais , Humanos , Salvamento de Membro , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Intervalo Livre de Progressão , Recidiva , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
5.
Vasc Endovascular Surg ; 52(3): 181-187, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29421969

RESUMO

BACKGROUND: Prosthetic vascular graft infection (PVGI) remains a severe and challenging complication in vascular surgery with high morbidity and mortality rates. Incidence has been reported between 1% and 6%. The aim of this study was to report our experience in terms of general and surgical management as well as outcome, over 15 years. METHODS: A retrospective consecutive study was conducted of all patients treated in our department for PVGI between January 2000 and December 2015. We analyzed all data relative to primary operation, duration interval between initial surgery and infections signs, infection site, type of microorganism involved, and surgical treatment modality, as well as evaluation of short- and long-term results. RESULTS: Sixty-two patients were admitted for PVGI. Primary revascularization procedures consisted of a peripheral bypass in 42 (68%) patients and an aortic bypass in the remaining 20 (32%) patients. Median interval between primary procedure and reintervention was 3 months (interquartile range 17 [IQR 17]) in the peripheral group and 48 months (IQR 70.5) in the aortic group. Complete excision of the prosthetic graft was carried out in 85% of the cases. Thirty-day mortality was 0% and 9.5% in the aortic and peripheral group, respectively. The overall survival rate was 62.3% at 2-years, 46.4% in the aortic group, and 69.7% in the peripheral group. CONCLUSIONS: Prosthetic vascular graft infection needs a multidisciplinary management with appropriate antibiotherapy, radical removal of the infected graft, and in situ reconstruction. This strategy gives satisfactory results in terms of mortality, morbidity, patency rates, and infection control.


Assuntos
Artérias/transplante , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular/efeitos adversos , Remoção de Dispositivo , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Infecções Relacionadas à Prótese/cirurgia , Veias/transplante , Idoso , Idoso de 80 Anos ou mais , Aloenxertos , Antibacterianos/uso terapêutico , Aortografia/métodos , Bélgica , Implante de Prótese Vascular/mortalidade , Angiografia por Tomografia Computadorizada , Desbridamento , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Estudos Retrospectivos , Fatores de Risco , Irrigação Terapêutica , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla
6.
Surg Technol Int ; 31: 162-167, 2017 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-29121693

RESUMO

INTRODUCTION: The aim of this study was to independently evaluate the real-world performances of Eluvia™ paclitaxel drug-eluting stents (DES) (Boston Scientific, Marlborough, Massachusetts) for the treatment of external iliac and femoropopliteal artery lesions. MATERIALS AND METHODS: We prospectively collected, and retrospectively reviewed, data for all patients who underwent an endovascular treatment with an Eluvia™ DES for the treatment of an external iliac or femoropopliteal lesion. Patient demographics, concomitant procedures, arterial lesions characteristics, procedural details, and follow-up were reviewed. RESULTS: Between April and October 2016, 15 Eluvia™ DES were placed in 15 consecutive adult patients with a technical success of 100%. The treated lesions had a mean length of 93.9 ±58 mm. Sixty percent of the lesions were total occlusions and 13% were restenosis of previous stents. An additional inflow treatment was performed in 40% of the cases. At six months, two patients were lost at follow-up and one had an occluded stent. We had a primary patency rate and freedom from TLR of 92%. All remaining patients had an improved Rutherford class, improved quality of life and wound healing, and an increase in walking distance. Survival and limb salvage rates were 100%. CONCLUSIONS: This study confirms the good result of DES, in general, and of the Eluvia™ stent, in particular, in the treatment of external iliac and femoropopliteal arterial lesions, with a primary patency rate and a freedom from TLR of 92% at six months. A larger number of patients and longer follow-up will be required to determine the true real-world efficacy of the Eluvia™ DES, but short-term experience is encouraging.


Assuntos
Stents Farmacológicos , Artéria Femoral , Paclitaxel/uso terapêutico , Doença Arterial Periférica , Artéria Poplítea , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Artéria Femoral/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/cirurgia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Artéria Poplítea/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
8.
Circ Cardiovasc Imaging ; 10(5)2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28487317

RESUMO

BACKGROUND: Inflammation and intraplaque neovascularization are acknowledged to be 2 features of plaque vulnerability, although their temporal expression and their respective value in predicting clinical events are poorly understood. To determine their respective temporal associations, we conducted a comprehensive assessment of inflammation and intraplaque neovascularization in the carotid plaque of symptomatic and asymptomatic patients. METHODS AND RESULTS: Thirty patients with severe carotid stenosis underwent 18F-fluorodeoxyglucose-positron emission tomography/computed tomographic imaging. Plaque 18F-fluorodeoxyglucose-uptake, indicative of inflammation, was measured by calculating the target:background ratio. The presence of intraplaque neovascularization during contrast-enhanced ultrasound was judged semiquantitatively; low-grade contrast enhancement (CE) suggested its absence, and high-grade CE, the presence of neovascularization. Carotid surgery was performed 1.6±1.8 days after completing both imaging modalities in all patients, and the presence of macrophages and neovessels was quantified by immunohistochemistry. We identified a significant correlation between the target:background ratio and macrophage quantification (R=0.78; P<0.001). The number of vessels was also significantly higher in carotid plaque with high-CE (P<0.001). Surprisingly, immunohistochemistry showed that high-CE and vessel number were neither associated with an elevated target:background ratio (P=0.28 and P=0.60, respectively) nor macrophage infiltration (P=0.59 and P=0.40, respectively). Finally, macrophage infiltration and target:background ratio were higher in the carotid plaque of symptomatic patients (P=0.021 and P=0.05, respectively), whereas CE grade and the presence of neovessels were not. CONCLUSIONS: Inflammation and intraplaque neovascularization are not systematically associated in carotid plaques, suggesting a temporal separation between the 2 processes. Inflammation seems more pronounced when symptoms are present. These data highlight the challenges that face any imaging strategy designed to assess plaque vulnerability.


Assuntos
Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Inflamação/fisiopatologia , Neovascularização Patológica/fisiopatologia , Placa Aterosclerótica/diagnóstico por imagem , Placa Aterosclerótica/fisiopatologia , Idoso , Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/fisiopatologia , Meios de Contraste , Feminino , Fluordesoxiglucose F18 , Humanos , Masculino , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Estudos Prospectivos , Compostos Radiofarmacêuticos , Ultrassonografia
9.
World J Surg ; 37(7): 1727-34, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23604302

RESUMO

BACKGROUND: Arterial anastomosis in transplant patients with severe aortic and iliac atheromatosis is technically challenging and may jeopardize the success of the transplantation procedure. The aim of this retrospective study was to report short- and long-term results of a consecutive series of kidney transplant patients in whom the renal artery was implanted on a prosthetic vascular graft. MATERIALS AND METHODS: Medical charts and outpatient clinical records of patients who had undergone renal artery implantation on a prosthetic graft were reviewed. Data on patient characteristics, indications for transplantation, prior vascular procedures, surgical technique, and postoperative and long-term outcome were collected. RESULTS: The renal artery was implanted on a prosthetic graft in the course of 27 kidney transplantation procedures. Patients were divided into three groups according to the timing of the vascular intervention in relation to the transplantation. In group A (n = 22), the vascular prosthesis was implanted before kidney transplantation, in group B (n = 2), prosthetic iliac artery replacement and kidney transplantation were performed simultaneously, while in group C (n = 3), the vascular prosthesis was implanted after kidney transplantation. After a median follow-up of 50.5 months, one case of early arterial thrombosis was observed (3.7 %). Infectious complications occurred in two patients (7.4 %) related to mycotic pseudoaneurysms. One hematoma and one evisceration were also encountered, but no late arterial thrombosis nor stenosis were noted. Mean creatinine levels at 1 and 5 years of follow-up were 1.32 ± 0.36 and 1.27 ± 0.56 mg/dl, respectively. Five-year patient and graft survival rates were 85.2 and 74 %, respectively. CONCLUSIONS: Grafting of the renal artery to a vascular prosthesis is feasible and yields good results, despite the technical difficulties involved. We stress the importance of good teamwork.


Assuntos
Prótese Vascular , Artéria Ilíaca/cirurgia , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Artéria Renal/transplante , Enxerto Vascular/métodos , Adulto , Idoso , Estudos de Viabilidade , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento
11.
Hepatogastroenterology ; 58(109): 1377-83, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21937411

RESUMO

BACKGROUND/AIMS: Undiagnosed occlusive disease of celiac trunk and/or superior mesenteric artery may lead to life-threatening complications after pancreatoduodenectomy. METHODOLOGY: Retrospective analysis of a consecutive series of 171 patients scheduled for pancreatico- duodenectomy or total pancreatectomy. RESULTS: The prevalence of arterial occlusive disease was 5.9% (10 patients), including complete celiac artery occlusive disease in 2 patients (1.2%). Preoperative diagnosis was achieved in 90% of the patients by lateral-views of imaging studies. In arterial stenosis <50% (3 patients), abstention was always successful. In arterial stenosis >50%, successful treatment options included abstention (n=1), preoperative endovascular dilatation (n=1) or stenting (n=1), division of the median arcuate ligament with (n=1) or without (n=1) postoperative endovascular stenting, and aorto-hepatic bypass (2 patients). No early postoperative ischemic complications occurred. However, one patient died from late intestinal ischemia. CONCLUSIONS: Arterial occlusive disease is rare in patients undergoing pancreatico-duodenectomy but expose the patient to severe complications if undiagnosed. A tailored management according to the type of arterial stenosis, to patients' indication for surgery and to patients' arterial anatomy is indicated. Surgical and endovascular management may be successfully combined.


Assuntos
Arteriopatias Oclusivas/complicações , Artéria Celíaca , Pancreaticoduodenectomia/efeitos adversos , Idoso , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Artéria Mesentérica Superior , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
12.
Ann Vasc Surg ; 24(8): 1137.e13-9, 2010 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21035713

RESUMO

A Gore TAG Excluder stent graft was deployed in a 35-year-old woman for an isthmic saccular aneurysm. At 12-hour follow-up, we diagnosed a proximal collapse. A Palmaz stent was used to reopen the proximal segment. Two months later, she presented with a transient ischemic attack (embolic process) related to a suboptimal apposition of the Palmaz stent in the distal aortic arch. This led to open surgical replacement of the ascending aorta and aortic arch with reimplantation of the supraaortic branches. Reopening of a stent graft collapse with a Palmaz stent might be a short-term solution; however, its presence can lead to embolic complications.


Assuntos
Falso Aneurisma/terapia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/terapia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Falha de Prótese , Stents , Adulto , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/cirurgia , Angioplastia com Balão , Aorta Torácica/anormalidades , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Embolia Intracraniana/etiologia , Ataque Isquêmico Transitório/etiologia , Desenho de Prótese , Tomografia Computadorizada por Raios X , Falha de Tratamento
13.
World J Surg ; 34(11): 2648-61, 2010 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-20607257

RESUMO

OBJECTIVE: Combined vascular and pancreatic resection improves long-term survival of patients suffering from ductal adenocarcinoma of the pancreatic head. This study was designed to compare the results of surgical resection in patients with pancreatic cancer with or without vascular resection. Late 10-year disease-free survival was considered as an indicator of patients' disease cure. METHODS: A total of 149 consecutive patients have undergone pancreatoduodenectomy without vascular resection (group 1: 82 patients), with isolated venous resection (group B: 67 patients), or with arterial and/or venous resection (group C: 8 patients). RESULTS: The duration of surgery and blood losses were significantly more important in groups B and C compared with group A; however, postoperative morbidity and mortality rates were similar. R1 resection was significantly more frequent in groups B (42%) and C (50%) compared with group A (13%; p = 0.0002), but there were more advanced tumors in these groups, as demonstrated by a lower Karnowsky index, higher Ca 19-9 plasmatic level, greater tumor size, more advanced stage in the AJCC classification, and more tumor location in the uncinate process of the pancreas. Ten-year overall and disease-free survivals were significantly better in group A (19 and 20%) compared with group B (2.8 and 0%) and group C (0% and 0%). Multivariate analysis proved vascular resection and metastatic nodal status as being independent predictive factors of disease-free survival. CONCLUSIONS: Vascular resection combined to pancreatoduodenectomy for pancreatic cancer increases local resectability without increasing mortality and morbidity rates but does not improve patients' disease cure rate.


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Procedimentos Cirúrgicos Vasculares , Adulto , Idoso , Idoso de 80 Anos ou mais , Artérias/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Veias/cirurgia
14.
Acta Chir Belg ; 110(1): 10, 2010 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27389979
15.
Circulation ; 120(11 Suppl): S120-6, 2009 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-19752356

RESUMO

BACKGROUND: The presence of significant preoperative aortic insufficiency (AI) or the need for cusp repair has been suggested as a risk factor for poorer outcomes after aortic valve (AV)-sparing surgery. We analyzed the influence of these factors on the mid-term outcomes of AV surgery. METHODS AND RESULTS: Between 1996 and 2008, 164 consecutive patients underwent elective AV-sparing surgery. Severe preoperative AI (grade > or =3+) was present in 93 patients (57%), and 54 (33%) had a bicuspid valve. Root repair was performed with either the reimplantation (74%) or the remodeling (26%) technique, and cusp repair was performed in 90 patients (55%). Mean clinical follow-up was 57 months. Hospital mortality was 0.6%. Cusp repair was required in 52% of the patients with preoperative AI < or =2+ and in 57% of those with AI > or =3+ (P=0.6). Cusp repair was required more frequently in bicuspid versus tricuspid valves (91% versus 38%, P<0.001). Overall survival at 8 years was 88+/-8%. Freedom from AV reoperation at 8 years was similar with preoperative AI < or =2+ versus preoperative AI > or =3+ (89+/-11% versus 90+/-7%, P=0.7) and with versus without cusp repair (84+/-17% versus 92+/-8%, P=0.5). Freedom from recurrent AI (grade > or =3+) at 5 years was also similar between groups (90+/-10% versus 89+/-8%, P=0.9, and 90+/-8% versus 89+/-9%, P=0.8, respectively). By multivariate analyses, predictors of recurrent AI > or =2+ were preoperative left ventricle end-diastolic diameter and AI >1+ on discharge echocardiography. CONCLUSIONS: With a systematic approach to cusp assessment and repair, AV-sparing surgery for root pathology has an acceptable mid-term outcome, irrespective of preoperative AI or need for cusp repair.


Assuntos
Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Adulto , Idoso , Insuficiência da Valva Aórtica/etiologia , Ecocardiografia , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do Tratamento
16.
Ann Thorac Surg ; 87(6): 1735-40, 2009 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19463587

RESUMO

BACKGROUND: Repair of rheumatic mitral valves has met with limited success because hemodynamic obstruction may persist after repair because of residual diseased leaflet tissue and lack of suppleness. Over the past decade, we have developed and implemented an aggressive approach to rheumatic mitral valve repair with radical excision of the diseased leaflets area, and subvalvular apparatus and subsequent reconstruction, with the objective of removing all diseased valvular tissue. METHODS: From July 1996 to June 2007, 78 patients underwent mitral valve repair for rheumatic valve disease. Over the same time interval, 54 patients underwent mitral valve replacement. Mean age was 56.4 +/- 16 years. Clinical follow-up (mean 60 +/- 36 months) was complete in 100% of patients, and echocardiographic follow-up (mean 52 +/- 37 months) was 96% complete. RESULTS: There was no hospital mortality or early reoperations. Overall survival was 94% +/- 6% at 8 years, and 95% of patients were in New York Heart Association functional class II or less. Three patients (4%) required reoperation for mitral restenosis and 2 underwent re-repair. At 8 years of follow-up, freedom from cardiac death and mitral valve reoperation were 98% +/- 2% and 94% +/- 5%, respectively. Freedom from valve-related events at 5 and 10 years was 90% +/- 8% and 86% +/- 11%, and freedom from significant mitral regurgitation was 98% +/- 2% at 5 years and 83% +/- 9% at 8 years. CONCLUSIONS: A more aggressive approach to resection of diseased valvular tissue with subsequent reconstruction is feasible, with good midterm results, and may extend the scope of valve repair in rheumatic disease patients.


Assuntos
Doenças das Valvas Cardíacas/etiologia , Doenças das Valvas Cardíacas/cirurgia , Valva Mitral , Cardiopatia Reumática/complicações , Cardiopatia Reumática/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
17.
J Thorac Cardiovasc Surg ; 137(2): 286-94, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19185138

RESUMO

OBJECTIVE: Valve repair for aortic insufficiency requires a tailored surgical approach determined by the leaflet and aortic disease. Over the past decade, we have developed a functional classification of AI, which guides repair strategy and can predict outcome. In this study, we analyze our experience with a systematic approach to aortic valve repair. METHODS: From 1996 to 2007, 264 patients underwent elective aortic valve repair for aortic insufficiency (mean age - 54 +/- 16 years; 79% male). AV was tricuspid in 171 patients bicuspid in 90 and quadricuspid in 3. One hundred fifty three patients had type I dysfunction (aortic dilatation), 134 had type II (cusp prolapse), and 40 had type III (restrictive). Thirty six percent (96/264) of the patients had more than one identified mechanism. RESULTS: In-hospital mortality was 1.1% (3/264). Six patients experienced early repair failure; 3 underwent re-repair. Functional classification predicted the necessary repair techniques in 82-100% of patients, with adjunctive techniques being employed in up to 35% of patients. Mid-term follow up (median [interquartile range]: 47 [29-73] months) revealed a late mortality rate of 4.2% (11/261, 10 cardiac). Five year overall survival was 95 +/- 3%. Ten patients underwent aortic valve reoperation (1 re-repair). Freedoms from recurrent Al (>2+) and from AV reoperation at 5 years was 88 +/- 3% and 92 +/- 4% respectively and patients with type I (82 +/- 9%; 93 +/- 5%) or II (95 +/- 5%; 94 +/- 6%) had better outcomes compared to type III (76 +/- 17%; 84 +/- 13%). CONCLUSION: Aortic valve repair is an acceptable therapeutic option for patients with aortic insufficiency. This functional classification allows a systematic approach to the repair of Al and can help to predict the surgical techniques required as well as the durability of repair. Restrictive cusp motion (type III), due to fibrosis or calcification, is an important predictor for recurrent Al following AV repair.


Assuntos
Insuficiência da Valva Aórtica/classificação , Insuficiência da Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Insuficiência da Valva Aórtica/mortalidade , Criança , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Técnicas de Sutura , Resultado do Tratamento , Adulto Jovem
18.
Circulation ; 118(14 Suppl): S216-21, 2008 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-18824757

RESUMO

BACKGROUND: Bilateral internal thoracic arteries (BITA) demonstrated superiority over other grafts to the left coronary system in terms of patency and survival benefit. Several BITA configurations are proposed for left-sided myocardial revascularization, but the ideal BITA assemblage is still unidentified. METHODS AND RESULTS: From 03/2003 to 08/2006, 1297 consecutive patients underwent isolated bypass surgery in our institution. 481 patients met the inclusion criteria for randomization, and 304 (64%) were randomized. Patients were allocated to BITA in situ grafting (n=147) or Y configuration (n=152) then evaluated for clinical, functional, and angiographic outcome after 6 months and 3 years. Patient telephone interviews were conducted every 3 months and a stress test performed twice yearly under the referring cardiologist's supervision. Angiographic follow-up was performed 6 months after surgery. The primary and secondary end points were, respectively, major adverse cerebrocardiovascular events (MACCE) and the proportion of ITA grafts that were completely occluded at follow-up angiography. More arterial anastomoses were performed in patients randomized to the Y than the in situ configuration (3.2 versus 2.4; P<0.001). No significant difference between the 2 groups in terms of hospital mortality or morbidity was found. At follow-up, there was no significant difference in any MACCE rate between the 2 groups. 450 out of 464 anastomosis (97%) in the BITA Y group and 287 of 295 (97%) in the BITA in situ group were controlled patent (P=0.99). CONCLUSIONS: Excellent patency rates were achieved using both BITA configurations with no significant differences in terms of MACCE up to 19 months postoperatively, but longer-term results remain to be established.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Artéria Torácica Interna/transplante , Idoso , Angiografia Coronária , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Fatores de Tempo , Grau de Desobstrução Vascular
19.
J Thorac Cardiovasc Surg ; 136(2): 482-8, 2008 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-18692661

RESUMO

OBJECTIVE: Despite its theoretic advantage over saphenous vein grafts, the right gastroepiploic artery graft has not been accepted as the ideal conduit to revascularize the right coronary artery. We therefore prospectively randomized these 2 grafts types to compare their clinical, functional, and angiographic evolution at 6 months and 3 years. METHODS: From 2003 to 2006, 1397 consecutive patients underwent isolated revascularization at the University of Louvain Medical School. Of this group, 370 patients met the inclusion criteria for randomization and 66% of those were randomized. The right coronary artery was revascularized with saphenous vein grafts in 116 patients and with right gastroepiploic arteries in 122 patients. All patients underwent angiographic control 6 months postoperatively. The end points were major adverse cerebrocardiovascular events and proportion of grafts patent or functional at follow-up angiography. RESULTS: There were no significant differences between the 2 groups in terms of hospital events. At follow-up there was no significant difference in major adverse cerebrocardiovascular events between the 2 groups. At the 6-month angiographic follow-up, 91% of the anastomoses in the right gastroepiploic artery group and 95% of the anastomoses in the saphenous vein graft group were controlled patent (P = .92). In nonoccluded right coronary arteries, the proportion of patent grafts was significantly lower and the proportion of nonfunctioning grafts was significantly higher in the right gastroepiploic artery group than in the saphenous vein graft group. CONCLUSION: There were no significant patency or major adverse cerebrocardiovascular events rate differences between the 2 groups; however, the number of functional grafts was significantly higher in the saphenous vein graft group. Careful selection of the coronary target is mandatory to obtain good results in gastroepiploic artery grafting.


Assuntos
Angiografia Coronária , Ponte de Artéria Coronária/métodos , Artéria Gastroepiploica/transplante , Veia Safena/transplante , Idoso , Ponte de Artéria Coronária/efeitos adversos , Teste de Esforço , Feminino , Oclusão de Enxerto Vascular/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Grau de Desobstrução Vascular
20.
J Am Coll Cardiol ; 51(2): 120-5, 2008 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-18191734

RESUMO

OBJECTIVES: The purpose of this study was to define the pre-operative angiographic variables that could influence graft patency and flow pattern. BACKGROUND: Saphenous vein grafts (SVG) and pedicled right gastroepiploic artery (RGEA) grafts are routinely used to revascularize the right coronary artery (RCA). Little is known about the predictive value of objective pre-operative angiographic parameters on the 6-month graft patency and on the interest of these parameters to select the optimal graft material in individual cases. METHODS: We prospectively enrolled 172 consecutive patient candidates for coronary revascularization. Revascularization of the RCA was randomly performed with SVG in 82 patients or with the RGEA in 90 patients. Both groups were comparable with respect to all pre-operative continuous and discrete variable and risk factors. All patients underwent a systematic angiographic control 6 months after surgery. Pre-operative angiographic parameters included minimal lumen diameter (MLD), percent stenosis and reference diameter of the RCA measured by quantitative angiography (CAAS II system, Pie Medical, Maastricht, the Netherlands), location of the stenosis, run off of the RCA, and regional wall motion of the revascularized territory. RESULTS: A significant difference in the distribution of flow patterns was observed between SVG and RGEA. In multivariate analysis, graft-dependent flow pattern was significantly associated with both MLD and percent stenosis of the RCA in the RGEA group but with percent stenosis only in the SVG group. In the RGEA group, the proportion of patent grafts was higher when MLD was below a threshold value lying in the third MLD quartile (0.77 to 1.40 mm). CONCLUSIONS: Pre-operative angiography predicts graft patency in RGEA, whereas the flow pattern in SVG is significantly less influenced by quantitative angiographic parameters.


Assuntos
Ponte de Artéria Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/cirurgia , Artéria Gastroepiploica/transplante , Veia Safena/transplante , Grau de Desobstrução Vascular/fisiologia , Idoso , Angiografia Coronária/métodos , Ponte de Artéria Coronária/efeitos adversos , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/prevenção & controle , Estenose Coronária/mortalidade , Feminino , Seguimentos , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias , Cuidados Pré-Operatórios/métodos , Probabilidade , Estudos Prospectivos , Valores de Referência , Medição de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
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