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1.
Vasc Endovascular Surg ; 55(4): 355-360, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33535904

RESUMO

BACKGROUND: Adequate seal for thoracic endovascular aortic repair (TEVAR) commonly requires landing in zone 2, but can prove to be challenging due to the tortuous and angulated anatomy of the region. OBJECTIVES: Our objective was to determine the proximal landing accuracy of zone 2-targeted TEVARs following carotid-subclavian revascularization (CSR) and its impact on clinical outcomes. METHODS: Retrospective review of patients that underwent CSR for zone 2 endograft delivery at a tertiary institute between January 2008 and March 2018 was conducted. Technical outcomes were assessed by examining the incidence of intraoperative corrective maneuvers, 1a endoleaks and reinterventions. Distance to target and incidence of LSA stump filling were examined as radiographic markers of landing accuracy. RESULTS: Zone 2-targeted TEVAR with CSR was performed in 53 patients for treatment of dissections (49%), aneurysms (30%) or trauma (21%). Nine (17%) cases required intraoperative corrective procedures: 5 (9%) proximal cuffs due to type 1a endoleak and 4 (8%) left common carotid artery (LCCA) stenting due to inadvertent coverage. Cases performed using higher resolution hybrid fluoroscopy machine compared to mobile C-arm were associated with increased proximal cuff use (OR 8.8; 95% CI 1.2-62.4). Average distance between the proximal edge of the covered graft to LCCA was 8 ± 1 mm and larger distances were not associated with higher rates of 1a endoleak. Twenty-eight (53%) cases of antegrade LSA stump filling were noted on follow-up imaging, but were not associated with higher rates of reinterventions (OR 0.8, 95% CI [0.2-4.6]). Three (6%) patients had a stroke within 30 days and 4 (8%) patients expired within 1 month. Intraoperative corrective maneuvers, post-operative 1a endoleak and reinterventions were not associated with higher rates of stroke or mortality. CONCLUSION: Using current endografts and imaging modalities, zone 2-targeted TEVARs have suboptimal technical accuracy.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Artérias Carótidas/cirurgia , Procedimentos Endovasculares , Artéria Subclávia/cirurgia , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/fisiopatologia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/fisiopatologia , Endoleak/etiologia , Endoleak/mortalidade , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
2.
Vasc Med ; 26(1): 3-10, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33350884

RESUMO

Interleukin (IL) 6 contributes to atherosclerotic plaque development through IL6 membrane-bound (IL6R and gp130) and soluble (sIL6R and sgp130) receptors. We investigated IL6 receptor expression in carotid plaques and its correlation with circulating IL6 and soluble receptor levels. Plasma samples and carotid plaques were obtained from 78 patients in the Biobank of Karolinska Endarterectomies study. IL6, sIL6R, and sgp130 were measured in plasma and IL6, IL6R, sIL6R, GP130, and sGP130-RAPS (sGP130) gene expression assessed in carotid plaques. Correlations between plaque IL6 signaling gene expression and plasma levels were determined by Spearman's correlation. Differences in plasma and gene expression levels between patients with (n = 53) and without (n = 25) a history of a cerebral event and statin-treated (n = 65) and non-treated (n = 11), were estimated by Kruskal-Wallis. IL6 and its receptors were all expressed in carotid plaques. There was a positive, borderline significant, moderate correlation between plasma IL6 and sIL6R and the respective gene expression levels (rho 0.23 and 0.22, both p = 0.05). IL6R expression was higher in patients with a history of a cerebrovascular event compared to those without (p = 0.007). Statin-treated had higher IL6R, sIL6R, and sGP130 expression levels and plasma sIL6R compared to non-treated patients (all p < 0.05). In conclusion, all components of the IL6 signaling pathways are expressed in carotid artery plaques and IL6 and sIL6R plasma levels correlate moderately with IL6 and sIL6R. Our data suggest that IL6 signaling in the circulation might mirror the system activity in the plaque, thus adding novel perspectives to the role of IL6 signaling in atherosclerosis.


Assuntos
Artérias Carótidas/metabolismo , Estenose das Carótidas/metabolismo , Receptor gp130 de Citocina/metabolismo , Interleucina-6/metabolismo , Placa Aterosclerótica , Receptores de Interleucina-6/metabolismo , Idoso , Biomarcadores/metabolismo , Artérias Carótidas/cirurgia , Estenose das Carótidas/sangue , Estenose das Carótidas/genética , Estenose das Carótidas/terapia , Estudos Transversais , Receptor gp130 de Citocina/sangue , Receptor gp130 de Citocina/genética , Endarterectomia das Carótidas , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Interleucina-6/sangue , Interleucina-6/genética , Masculino , Receptores de Interleucina-6/sangue , Receptores de Interleucina-6/genética , Transdução de Sinais
3.
Magn Reson Imaging ; 75: 45-50, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33068670

RESUMO

PURPOSE: To characterize the intracranial vascular features extracted from time of flight (TOF) images and their changes from baseline to follow-up in patients undergoing carotid revascularization, using arterial spin labeling (ASL) cerebral blood flow (CBF) measurement as a reference. METHODS: In this retrospective study, brain TOF and ASL images of 99 subjects, acquired before, within 48 h, and/or 6 months after, carotid revascularization surgery were analyzed. TOF images were analyzed using a custom software (iCafe) to quantify intracranial vascular features, including total vessel length, total vessel volume, and number of branches. Mean whole-brain CBF was calculated from ASL images. ASL scans showing low ASL signal in the entire flow territory of an internal carotid artery (ICA), which may be caused by labeling failure, were excluded. Changes and correlations between time points were analyzed separately for TOF intracranial vascular features and ASL CBF. RESULTS: Similar to ASL CBF, TOF vascular features (i.e. total vessel length, total vessel volume and number of branches) increased dramatically from baseline to post-surgery, then returned to a level slightly higher than the baseline in long-term follow-up (All P < 0.05). Correlation between time points was observed for all three TOF vascular features but not for ASL CBF. CONCLUSION: Intracranial vascular features, including total vessel length, total vessel volume and number of branches, extracted from TOF images are useful in detecting brain blood flow changes induced by carotid revascularization surgery.


Assuntos
Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/cirurgia , Revascularização Cerebral , Processamento de Imagem Assistida por Computador , Angiografia por Ressonância Magnética , Adulto , Artérias Carótidas/fisiologia , Circulação Cerebrovascular , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Software
5.
J Surg Res ; 257: 294-305, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32871430

RESUMO

BACKGROUND: Drug-eluting stents impair post-angioplasty re-endothelialization thus compromising restenosis prevention while heightening thrombotic risks. We recently found that inhibition of protein kinase RNA-like endoplasmic reticulum kinase (PERK) effectively mitigated both restenosis and thrombosis in rodent models. This motivated us to determine how PERK inhibition impacts re-endothelialization. METHODS: Re-endothelialization was evaluated in endothelial-denuded rat carotid arteries after balloon angioplasty and periadventitial administration of PERK inhibitor in a hydrogel. To study whether PERK in smooth muscle cells (SMCs) regulates re-endothelialization by paracrinally influencing endothelial cells (ECs), denuded arteries exposing SMCs were lentiviral-infected to silence PERK; in vitro, the extracellular vesicles isolated from the medium of PDGF-activated, PERK-upregulating human primary SMCs were transferred to human primary ECs. RESULTS: Treatment with PERK inhibitor versus vehicle control accelerated re-endothelialization in denuded arteries. PERK-specific silencing in the denuded arterial wall (mainly SMCs) also enhanced re-endothelialization compared to scrambled shRNA control. In vitro, while medium transfer from PDGF-activated SMCs impaired EC viability and increased the mRNA levels of dysfunctional EC markers, either PERK inhibition or silencing in donor SMCs mitigated these EC changes. Furthermore, CXCL10, a paracrine cytokine detrimental to ECs, was increased by PDGF activation and decreased after PERK inhibition or silencing in SMCs. CONCLUSIONS: Attenuating PERK activity pharmacologically or genetically provides an approach to accelerating post-angioplasty re-endothelialization in rats. The mechanism may involve paracrine factors regulated by PERK in SMCs that impact neighboring ECs. This study rationalizes future development of PERK-targeted endothelium-friendly vascular interventions.


Assuntos
Angioplastia com Balão/efeitos adversos , Reestenose Coronária/prevenção & controle , Miócitos de Músculo Liso/efeitos dos fármacos , Inibidores de Proteínas Quinases/administração & dosagem , Reepitelização/efeitos dos fármacos , eIF-2 Quinase/antagonistas & inibidores , Angioplastia com Balão/instrumentação , Animais , Artérias Carótidas/efeitos dos fármacos , Artérias Carótidas/patologia , Artérias Carótidas/cirurgia , Reestenose Coronária/etiologia , Modelos Animais de Doenças , Stents Farmacológicos/efeitos adversos , Células Endoteliais/efeitos dos fármacos , Células Endoteliais/patologia , Endotélio Vascular/citologia , Endotélio Vascular/efeitos dos fármacos , Endotélio Vascular/patologia , Humanos , Masculino , Músculo Liso Vascular/citologia , Músculo Liso Vascular/efeitos dos fármacos , Músculo Liso Vascular/patologia , Miócitos de Músculo Liso/metabolismo , Miócitos de Músculo Liso/patologia , Comunicação Parácrina/efeitos dos fármacos , Comunicação Parácrina/genética , RNA Interferente Pequeno/metabolismo , Ratos , Reepitelização/genética , eIF-2 Quinase/genética
6.
Vasc Endovascular Surg ; 55(3): 265-268, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33357042

RESUMO

INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%-specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass. METHODS: All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries. RESULTS: 35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8). CONCLUSION: Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.


Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Artéria Axilar/cirurgia , Implante de Prótese Vascular , Artérias Carótidas/cirurgia , Procedimentos Endovasculares , Artéria Subclávia/cirurgia , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/fisiopatologia , Artéria Axilar/diagnóstico por imagem , Artéria Axilar/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Desenho de Prótese , Retratamento , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
7.
J Med Vasc ; 45(5): 260-267, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32862983

RESUMO

OBJECTIVE: Carotid endarterectomy has traditionally been the strategy for the surgical management of carotid stenosis. Alongside the usual techniques, this study presents another technique: endarterectomy with systematized resection-anastomosis. MATERIAL AND METHODS: A retrospective study from January 2006 to December 2018, included all patients managed for carotid stenosis at Meaux hospital with the "endarterectomy with systematized resection-anastomosis" technique. The perioperative death and stroke rate were evaluated according to the judgment criterion "homolateral ischemic stroke and any stroke or perioperative death". Statistical analysis of the data was performed using SPSS software. RESULTS: For 415 carotids operated, we identified 240 managed with this technique. The average age was 71.7±9.6 years, 70% men and 30% women. The main cardiovascular risk factor was hypertension (76.7%), 24.2% of patients had an ischemic heart disease history, 43.7% homolateral ischemic stroke and 29% transient ischemic attack. Bilateral lesions were diagnosed in 6.2% of patients and 7.5% had contralateral occlusion. Carotid stenosis was symptomatic in 52.9% of patients. The average stenosis rate observed was 82.9±8.1% on computed tomography angiogram and 83.7±7.7% on magnetic resonance angiogram. The shunt was used in 45.4% of procedures. The average length of stay was 5.9±2.3 days. All patients had satisfactory results in terms of patency and anatomical appearance on the 1st check. In the post-operative period during the first month, complications occurred in 12.5% of patients (1.6% acute coronary syndrome, 0.8% neurological event, 0.8% death, 0.4% infection, 12.1% hematoma, 1.6% recovery for bleeding). The overall perioperative death and stroke rate was 2.6%. Myocardial infarction and sepsis were the causes of death for the 2 patients in the peri operative period. The mean duration of follow-up was 21.2 months, without any restenosis or occurrence of neurological complications. One patient died beyond the 1st month of follow-up without established cause, and the overall mortality rate was 1.3%. CONCLUSION: Thromboendarterectomy with "systematized" anastomosis resection represents an angioplasty method for carotid stenosis surgical management under visual control.


Assuntos
Artérias Carótidas/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Isquemia Encefálica/etiologia , Artérias Carótidas/diagnóstico por imagem , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
8.
Stroke ; 51(9): 2620-2629, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32811386

RESUMO

BACKGROUND AND PURPOSE: Transcarotid artery revascularization (TCAR) is comprised of carotid artery stent placement with cerebral protection via proximal carotid artery clamping and reversal of cerebral arterial flow. The aim of the present study was to evaluate the safety and efficacy of TCAR performed by a broad group of physicians with variable TCAR experience. METHODS: The ROADSTER 2 study is a prospective, open label, single arm, multicenter, postapproval registry for patients undergoing TCAR. Patients considered at high risk for complications from carotid endarterectomy with symptomatic stenosis ≥50% or asymptomatic stenosis ≥80% were included. The primary end point was procedural success, which encompassed technical success plus the absence of stroke, myocardial infarction, or death within the 30-day postoperative period. Secondary end points included technical success and individual/composite rates of stroke, death, and myocardial infarction (MI). All patients underwent independent neurological assessments before the procedure, within 24 hours, and at 30 days after TCAR. An independent clinical events committee adjudicated all major adverse events. RESULTS: Between 2015 and 2019, 692 patients (Intent to Treat Population) were enrolled at 43 sites. Sixty cases had major protocol violations, leaving 632 patients adhering to the Food and Drug Administration-approved protocol (per-protocol population). The majority (81.2%) of operators were TCAR naïve before study initiation. Patients underwent TCAR for neurological symptoms in 26% of cases, and all patients had high-risk factors for carotid endarterectomy (anatomic-related 44%; physiological 32%; both 24%). Technical success occurred in 99.7% of all cases. The primary end point of procedural success rate in the Intent to Treat population was 96.5% (per-protocol 97.9%). The early postoperative outcomes in the Intent to Treat population included stroke in 13 patients (1.9%), death in 3 patients (0.4%), and MI in 6 patients (0.9%). The composite 30-day stroke/death rate was 2.3%, and stroke/death/MI rate was 3.2%. In the per-protocol population, there were strokes in 4 patients (0.6%), death in one patient (0.2%), and MI in 6 patients (0.9%) leading to a composite 30-day stroke/death rate of 0.8% and stroke/death/MI rate of 1.7%. CONCLUSIONS: TCAR results in excellent early outcomes with high technical success combined with low rates of postprocedure stroke and death. These results were achieved by a majority of operators new to this technology at the start of the trial. Adherence to the study protocol and peri-procedural antiplatelet therapy optimizes outcomes. Longer-term follow-up data are needed to confirm these early outcomes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02536378.


Assuntos
Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/cirurgia , Revascularização Cerebral/métodos , Dispositivos de Proteção Embólica , Procedimentos Neurocirúrgicos/métodos , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Determinação de Ponto Final , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/cirurgia , Inibidores da Agregação de Plaquetas/uso terapêutico , Estudos Prospectivos , Sistema de Registros , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/cirurgia , Resultado do Tratamento
9.
Stroke ; 51(9): 2863-2871, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32811389

RESUMO

Transcarotid revascularization is an alternative to transfemoral carotid artery stenting, designed to avoid aortic arch manipulation and concomitant periprocedural stroke. This article aims to perform a detailed analysis on the quality of the currently available evidence on safety and efficacy of transcarotid artery revascularization. Although current evidence is promising, independent randomized controlled studies comparing transcarotid artery revascularization with carotid endarterectomy in recently symptomatic patients are lacking and will be necessary to establish the true value of transcarotid artery revascularization in carotid artery revascularization.


Assuntos
Artérias Carótidas/cirurgia , Revascularização Cerebral/efeitos adversos , Revascularização Cerebral/métodos , Procedimentos Endovasculares/métodos , Procedimentos Neurocirúrgicos/métodos , Stents/efeitos adversos , Resultado do Tratamento , Artérias Carótidas/fisiopatologia , Humanos , Segurança do Paciente
12.
Cardiovasc Pathol ; 49: 107258, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32674045

RESUMO

BACKGROUND: Advanced atherosclerotic plaques tend to indicate an increased risk of cerebral ischemic events. SH2 domain-containing protein tyrosine phosphatase 1 (SHP-1) is a class I classical nonreceptor protein tyrosine phosphatase associated with plaque stability, as shown by analysis of a Gene Expression Omnibus (GEO) dataset showing differences in mRNA levels. However, the correlation between SHP-1 and human carotid plaque stability at the protein level remains unclear. METHODS AND RESULTS: Thirty-nine carotid plaque tissue samples were acquired from 39 carotid artery stenosis patients after carotid endarterectomy. Hematoxylin and eosin, Masson trichrome, and CD68 staining was performed for pathological characterization, and immunohistochemical staining for SHP-1 was carried out. Within stable and unstable plaques, SHP-1 mainly accumulated in the necrotic area, plaque shoulder, and fibrous cap, similar to the distribution of CD68. A quantitative analysis of SHP-1 was carried out. The relative SHP-1-positive cell area was higher in the vulnerable group than in the stable group (P < .001). The number of symptomatic patients in the vulnerable group was no greater than that in the stable group (P = .098). Moreover, the integrated optical density (IOD)/area of SHP-1 was significantly higher in the vulnerable group than in the stable group (P < .001). Besides, SHP-1 colocalized with CD68 and vascular cell adhesion protein 1(VCAM-1). CONCLUSIONS: We demonstrate that SHP-1 expression increases during carotid atherosclerotic plaque progression. The protein expression of SHP-1 was related to an increase in plaque instability in not only symptomatic but also asymptomatic patients with carotid artery stenosis. SHP-1 may play a role in atherosclerosis progression by macrophage polarization-mediated efferocytosis. Furthermore, SHP-1 may become a promising biomarker for plaque vulnerability in the future.


Assuntos
Artérias Carótidas/enzimologia , Estenose das Carótidas/enzimologia , Placa Aterosclerótica , Proteína Tirosina Fosfatase não Receptora Tipo 6/análise , Idoso , Apoptose , Biomarcadores/análise , Artérias Carótidas/patologia , Artérias Carótidas/cirurgia , Estenose das Carótidas/patologia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Feminino , Fibrose , Humanos , Macrófagos/enzimologia , Macrófagos/patologia , Masculino , Pessoa de Meia-Idade , Necrose , Fagocitose , Ruptura Espontânea , Regulação para Cima
13.
Ann Vasc Surg ; 69: 158-162, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32554199

RESUMO

BACKGROUND: There is no current consensus on the best criteria for selective shunting during carotid endarterectomy (CEA). The choice of continuous neurologic assessment during awake CEA, intraoperative electroencephalogram, or carotid stump pressure monitoring as the basis for shunt placement is primarily dependent on surgeon preference. Our goal is to define a safe stump pressure threshold as a guide for selective shunting. METHODS: The study is a single-surgeon retrospective review of consecutive patients who underwent CEA under general anesthesia with selective shunting based on intraoperative stump pressure measurements from 2001 to 2019. Demographic and periprocedural variables were analyzed using standard statistical techniques. RESULTS: Among 399 patients, 68% were male with a mean age of 70. One-third of the patients were symptomatic, with amaurosis fugax in 12%, transient ischemic attack in 7%, and stroke in 16%. In total, 60 (15%) patients underwent shunting: 34 for a confirmed preoperative acute ischemic stroke, 22 for a stump pressure <30 mm Hg, and 4 for other indications. Overall 30-day death, ischemic ipsilateral stroke, myocardial infarction, and cranial nerve palsy rates were 0.5%, 0.8%, 1.8%, and 1.0%, respectively. No strokes occurred due to hypoperfusion, and all stroke symptoms resolved prior to discharge with a mean length of stay of 1.6 days. CONCLUSIONS: This is one of the largest contemporary series of CEA using a 30 mm Hg threshold for selective shunting that demonstrated exceedingly low 30-day death and stroke events. Intraoperative carotid stump pressure measurements are a useful guide for selective shunting and reduction in perioperative stroke complications after CEA.


Assuntos
Pressão Arterial , Isquemia Encefálica/prevenção & controle , Artérias Carótidas/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Artérias Carótidas/fisiopatologia , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Estenose das Carótidas/fisiopatologia , Constrição , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
14.
Ann Vasc Surg ; 69: 17-26, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32505683

RESUMO

BACKGROUND: The aim of our study is to examine the perioperative outcomes of carotid-subclavian bypass or transposition (CS-BpTp) versus endovascular techniques (ETs) for left subclavian artery (LSA) revascularization during nontraumatic zone 2 thoracic endovascular aortic repair (TEVAR). METHODS: We used prospectively collected data from the Society for Vascular Surgery Vascular Quality Initiative (VQI) to identify patients who had undergone TEVAR at participating centers (2013-2018). Patients were eligible for inclusion if they had undergone nontraumatic zone 2 TEVAR and concomitant LSA revascularization. Our main exposure of interest was LSA revascularization technique, CS-BpTp, or any ET. If a patient underwent multiple TEVAR procedures during the study period, the first case involving zone 2 was used for analysis. Preoperative patient characteristics were reviewed between treatment groups. The primary outcomes were mortality, transient ischemic attack (TIA)/stroke, and spinal cord ischemia (SCI). All outcomes were assessed up to 30 days postoperatively. RESULTS: A total of 837 patients were included in the study. The pathologies most frequently treated were aneurysm in 248 (34%) and dissection in 326 (45%). Overall, 721 subjects (86%) underwent CS-BpTp while 116 subjects (16%) underwent ETs. The latter included the following techniques: 23 chimney grafts, 3 scallops, 15 fenestrated grafts, and 75 branched grafts. Mortality was equal at 3% for both groups (P = 0.67). The rate of TIA/stroke was not significantly different in both groups (5.5% vs. 5%, P = 0.78). Similarly, the rate of SCI was 3% in the entire cohort without significant differences seen between treatment groups (P = 1). Multivariate logistic regression could not identify either CS-BpTp or ETs as independent predictors for death or TIA/stroke. CONCLUSIONS: Within VQI, LSA revascularization during nontraumatic zone 2 TEVAR is safely and effectively achieved with either CS-BpTp or ETs across all nontraumatic thoracic aortic diseases. These techniques appear to be associated with similar perioperative outcomes in selected patients with low rates of mortality and major neurologic morbidity. Although no differences were seen in the proportion of early type I or III endoleaks, further prospective studies are warranted to elucidate the long-term durability of ETs compared with CS-BpTp.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Artérias Carótidas/cirurgia , Procedimentos Endovasculares , Artéria Subclávia/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Canadá , Artérias Carótidas/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Isquemia do Cordão Espinal/etiologia , Acidente Vascular Cerebral/etiologia , Artéria Subclávia/diagnóstico por imagem , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
15.
Ann Vasc Surg ; 69: 174-181, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32502678

RESUMO

BACKGROUND: The purpose of this study is to record our institution's experience in the management of extracranial carotid artery aneurysms (ECCAs) over the past 15 years. METHODS: A retrospective chart review was performed on consecutive patients with ECCAs from April 2003 to December 2017. Outpatient and inpatient clinic charts were reviewed. All the patients were treated by open surgery between 2003 and 2008. For other patients, the treatment methods included open surgery, endovascular surgery, and hybrid operations which were dependent on the aneurysm anatomy, as well as conservative management. In open series, a carotid shunt was applied and transcranial color Doppler was selectively used for intraoperative monitoring of cerebral blood flow. The resected aneurysm sacs were tested with hematoxylin and eosin stains. Each case was reexamined one month after the patients were discharged from the hospital. A questionnaire survey, a clinical examination, and duplex ultrasonography or computed tomography angiography imaging were carried out. The patients were then reexamined three and six months after surgery and then annually. RESULTS: Thirty ECCAs were treated in 30 patients-14 men and 16 women, with a mean age of 54 ± 13 years. Four types of carotid aneurysms were identified: type I, II, III, and V, with 17, 3, 1, and 9 patients, respectively. From 2003 to 2008, there were eight patients (type I: seven; type II: one), and all were treated by open surgery and one suffered transient cranial nerve palsy. From 2009 to 2017, two patients were treated with conservative management, ten were treated with open surgery, nine were treated with endovascular surgery, and one was treated with hybrid operation. Among the patients who were treated with open surgery, two suffered neck hematoma. All patients recovered well without complications in the endovascular surgery group. Twenty-seven patients presented for follow-up and without contralateral aneurysms or other complications. CONCLUSIONS: The optimal treatment of ECCAs is dependent on the morphology of the carotid artery and properties of aneurysms. Open surgical repair is a suitable and safe procedure for type I ECCAs when the aneurysms are concomitant with kinking in the internal carotid artery. Endovascular treatment is an effective alternative to open surgery for false ECCA repair.


Assuntos
Aneurisma/terapia , Implante de Prótese Vascular , Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/terapia , Embolização Terapêutica , Procedimentos Endovasculares , Veia Safena/transplante , Técnicas de Sutura , Adulto , Idoso , Aneurisma/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , China , Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Stents , Técnicas de Sutura/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
16.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 31(3): 112-118, mayo-jun. 2020. ilus, tab
Artigo em Inglês | IBECS | ID: ibc-192415

RESUMO

OBJECTIVE: Understanding the relationship between the carotid artery, optic nerve and the anterior clinoid process is the basis of surgical approaches performed in the subchiasmal region. The location of the optic chiasm, the length of the optic nerves, and the distance and angle between the optic nerves determine the route of surgical approaches. We have determined the types of optic chiasm to study the relationship between vascular and neural structures in this region. MATERIALS AND METHODS: Thirty autopsy specimens were investigated at the Bursa Forensic Medicine Institute for optic chiasm types and the relationship between the neural and vascular anatomical structures of the sellar-parasellar and subchiasmal region was examined between June 2016 and November 2016. RESULTS: In this study, 4 prefix types (13%), 6 postfix types (20%), and 20 central types (67%) of chiasm were defined. Furthermore, we measured this angle between two optic nerves, which indirectly shows the location of chiasm according to the diaphragma sellae, and then detected the mean value of this angle as 87.1 ± 11.6°. The "limit" value to designate a chiasm as prefix was measured in the current study as ≥ 101.1°. The angle between optic nerves ranged from a mean value of 69.9 ± 3.7° in 6 cases with postfix chiasm, to a mean value of 104.0±2.1° in 4 cases with prefix chiasm and a mean value of 88.8 ± 6.7° in 20 cases with central chiasm. CONCLUSIÓN: In this study, we showed that the relationship among optic chiasma types, optic nerves and bony and vascular structures around the sellar area was effective at determining the surgical approach to this región


OBJETIVO: Comprender la relación entre la arteria carótida, el nervio óptico y la apófisis clinoides anterior es la base de los tratamientos quirúrgicos realizados en la región subquiasmática. La ubicación del quiasma óptico, la longitud de los nervios ópticos, y la distancia y el ángulo entre dichos nervios determinan la vía de acceso quirúrgico. Hemos determinado los tipos de quiasma óptico para estudiar la relación entre las estructuras vasculares y neurales en esta región. MATERIALES Y MÉTODOS: Entre junio y noviembre de 2016, se analizaron 30 muestras de autopsia en el Instituto de Medicina Legal de Bursa (Turquía) para determinar los tipos de quiasma óptico, y examinar la relación entre las estructuras anatómicas neurales y vasculares de las regiones selar-paraselar y subquiasmática. RESULTADOS: En este estudio, se definieron 4 casos de quiasma prefijado (13%), 6 de quiasma posfijado (20%) y 20 de quiasma central (67%). Además, medimos el ángulo entre 2 nervios ópticos que muestra indirectamente la ubicación del quiasma según el diafragma selar, y luego detectamos el valor medio de este ángulo (87,1 ± 11,6°). El valor «límite» para designar un quiasma como «prefijado» se midió en el estudio actual como ≥ 101,1°. El valor medio del ángulo entre los nervios ópticos osciló entre 69,9 ± 3,7° en los 6 casos de quiasma posfijado, 104,0 ± 2,1° en los 4 casos de quiasma prefijado y 88,8 ± 6,7° en los 20 casos de quiasma central. CONCLUSIÓN: En este estudio, pusimos de manifiesto que la relación entre los tipos de quiasma óptico, los nervios ópticos y las estructuras óseas y vasculares alrededor del área selar fue eficaz para determinar el acceso quirúrgico en esta región


Assuntos
Humanos , Variação Anatômica , Quiasma Óptico/anatomia & histologia , Nervo Óptico/anatomia & histologia , Artérias Carótidas/anatomia & histologia , Cadáver , Quiasma Óptico/cirurgia , Nervo Óptico/cirurgia , Artérias Carótidas/cirurgia , Autopsia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos
17.
J Surg Res ; 253: 280-287, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32402853

RESUMO

BACKGROUND: The autologous vein remains the standard conduit for lower extremity and coronary artery bypass grafting despite a 30%-50% 5-y failure rate, primarily attributable to intimal hyperplasia (IH) that develops in the midterm period (3-24 mo) of graft maturation. Our group discovered that externally strengthening vein grafts by cross-linking the adventitial collagen with photochemical tissue passivation (PTP) mitigates IH in an arteriovenous model at 4 wk. We now investigate whether this effect is retained in the midterm period follow-up. METHODS: Six Hanford miniature pigs received bilateral carotid artery interposition vein grafts. In each animal, the external surface of one graft was treated with PTP before grafting, whereas the opposite side served as the untreated control. The grafts were harvested after 3 mo. Ultrasound evaluation of all vein grafts was performed at the time of grafting and harvest. The grafts were also evaluated histomorphometrically and immunohistologically for markers of IH. RESULTS: All vein grafts were patent at 3 mo except one graft in the PTP-treated group because of early technical failure. The control vein grafts had significantly greater IH than PTP-treated grafts at 3 mo, as evidenced by the intimal area (2.6 ± 1.0 mm2versus 1.4 ± 1.5 mm2, respectively, P = 0.045) and medial area (5.1 ± 1.9 mm2versus 2.7 ± 2.4 mm2, respectively, P = 0.048). The control grafts had an increased presence and proliferation of mural myofibroblasts with greater smooth muscle actin and proliferating cell nuclear antigen staining. CONCLUSIONS: PTP treatment to the external surface of the vein grafts decreases IH at 3 mo after arteriovenous grafting and may prevent future graft failure.


Assuntos
Artérias Carótidas/cirurgia , Neointima/prevenção & controle , Fotoquimioterapia/métodos , Veia Safena/transplante , Enxerto Vascular/métodos , Túnica Adventícia/efeitos dos fármacos , Túnica Adventícia/efeitos da radiação , Animais , Colágeno/química , Colágeno/efeitos dos fármacos , Colágeno/efeitos da radiação , Feminino , Corantes Fluorescentes/administração & dosagem , Luz , Neointima/diagnóstico , Neointima/etiologia , Neointima/patologia , Rosa Bengala/administração & dosagem , Veia Safena/diagnóstico por imagem , Veia Safena/patologia , Suínos , Porco Miniatura , Transplante Autólogo/efeitos adversos , Túnica Íntima/diagnóstico por imagem , Túnica Íntima/patologia , Enxerto Vascular/efeitos adversos , Grau de Desobstrução Vascular
18.
J Cardiovasc Magn Reson ; 22(1): 38, 2020 05 21.
Artigo em Inglês | MEDLINE | ID: mdl-32434582

RESUMO

BACKGROUND: It has been proved that multi-contrast cardiovascular magnetic resonance (CMR) vessel wall imaging could be used to characterize carotid vulnerable plaque components according to the signal intensity on different contrast images. The signal intensity of plaque components is mainly dependent on the values of T1 and T2 relaxation. T1 mapping recently showed a potential in identifying plaque components but it is not well validated by histology. This study aimed to validate the usefulness of in vivo T1 mapping in assessing carotid vulnerable plaque components by histology. METHODS: Thirty-four subjects (mean age, 64.0 ± 8.9 years; 26 males) with carotid plaques referred to carotid endarterectomy were prospectively enrolled and underwent 3 T CMR imaging from May 2017 to October 2017. The T1 values of intraplaque hemorrhage (IPH), necrotic core (NC) and loose matrix (LM) which were identified on multi-contrast vessel wall images or histology were measured on in-vivo T1 mapping. The IPHs were divided into two types based on the proportion of the area of fresh hemorrhage on histology. The T1 values of different plaque components were compared using Mann-Whitney U test and the agreement between T1 mapping and histology in identifying and quantifying IPH was analyzed with Cohen's Kappa and intraclass correlation coefficient (ICC). RESULTS: Of 34 subjects, 19 had histological specimens matched with CMR imaging. The mean T1 values of IPH (651 ± 253 ms), NC (1161 ± 182 ms) and LM (1447 ± 310 ms) identified by histology were significantly different. The T1 values of Type 1 IPH were significantly shorter than that of Type 2 IPH (456 ± 193 ms vs. 775 ± 205 ms, p < 0.001). Moderate to excellent agreement was found in identification (kappa = 0.51, p < 0.001), classification (kappa = 0.40, p = 0.028) and segmentation (ICC = 0.816, 95% CI 0.679-0.894) of IPHs between T1 mapping and histology. CONCLUSIONS: The T1 values of carotid plaque components, particularly for intraplaque hemorrhage, are differentiable, and the stage of intraplaque hemorrhage can be classified according to T1 values, suggesting the potential capability of assessment of vulnerable plaque components by T1 mapping.


Assuntos
Artérias Carótidas/diagnóstico por imagem , Artérias Carótidas/patologia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/patologia , Imagem por Ressonância Magnética , Placa Aterosclerótica , Idoso , Artérias Carótidas/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Ruptura Espontânea , Índice de Gravidade de Doença
19.
World Neurosurg ; 140: 109-113, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32437993

RESUMO

BACKGROUND: Acute stroke resolution via endovascular thrombectomy requires transcarotid access when transfemoral access is not possible. Although postoperative complications such as cervical hematoma and airway compression have been reported, an appropriate postprocedural management is largely unknown yet. We aim to provide new insights and learning points from our experience using the Jaw Elevation Device (JED) as a tool to facilitate recovery post surgery. CASE DESCRIPTION: A 79-year-old female underwent endovascular thrombectomy via transcervical, transcarotid access for a left internal carotid artery occlusion. No intraprocedural complications were reported. After successful thrombectomy, manual compression was applied in the carotid artery, and to achieve neck immobilization a JED was used for 4 hours after the procedure. No complications occurred. CONCLUSIONS: JED appears to be a reasonable option to facilitate patient recovery due to its capacity to maintain the airway, provide mild compression for hemostasis, and prevent cervical hematoma through a comfortable neck immobilization.


Assuntos
Procedimentos Endovasculares/métodos , Imobilização/instrumentação , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/cirurgia , Feminino , Humanos , Arcada Osseodentária , Pescoço , Recuperação de Função Fisiológica , Acidente Vascular Cerebral/etiologia
20.
Ann Vasc Surg ; 67: 208-212, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32439530

RESUMO

BACKGROUND: Overtreatment and overuse of resources are leading causes of rising health care costs. Identification and elimination process of low value services is important in reducing such costs. At many institutions it is routine to send excised plaque after carotid endarterectomy (CEA) for pathology evaluation. With more than 140,000 CEAs performed annually in the United States, this represents an opportunity for potential cost savings. We set out to examine the cost and clinical use of pathology evaluation of plaque after CEA. METHODS: We performed a retrospective review of patients undergoing CEA at a single institution from 2016 to 2019. Patients were excluded if they had a prolonged postoperative length of stay or if they had a preoperative stroke. Demographics, perioperative outcomes, and billing costs were recorded. RESULTS: We identified 82 total CEAs, of which 42 were excluded according to the aforementioned exclusion criteria. We reviewed 40 CEAs. Mean age of this cohort was 67.2 (±8.3) years. Most (72.5%) were asymptomatic at the time of admission, whereas 27.5% presented with a transient ischemic attack. Mean postoperative length of stay was 1.8 days. The primary insurers were 39.5% private, 39.5% Medicare, and 21.1% Medicaid. Mean total charges for the hospitalization were $83,367 (±$42,874). Of this total, professional fees were $3,512 (±$980) and facility fees were $80,395 (±$42,886). Mean pathology charges were $285 (±$88). The pathology professional fee was $61 (±$27), which represented 1.82% (±0.88) of the professional costs. Reimbursement for the facility pathology charge was $229 (±$57) and for the professional pathology charge was $25 (±$14). All plaque samples were submitted for gross examination and hematoxylin and eosin staining. The correlation rate for the clinical and pathologic diagnosis was 100%. The pathology reports simply read "atherosclerotic plaque" and "calcific plaque" in 32.5% and 45% of samples. For the remaining plaques, 12.5% and 10% of reports also noted fibrosis and degenerative changes, respectively. There were no clinical implications or decisions made based on the pathology reports. Cost of pathology evaluation was on average $285, with an average reimbursement of $235. With 140,000 CEAs done annually, this represents a potential $32.9-$39.9 million saved to the health care system. CONCLUSIONS: Pathology evaluation of carotid plaque incurs significant costs to the health care system with no clear value for the postoperative care of the patient. Hospital policy regarding mandatory pathologic examination and surgeon preferences regarding plaque analysis should be more closely examined.


Assuntos
Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/economia , Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas/economia , Custos Hospitalares , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Placa Aterosclerótica , Cuidados Pós-Operatórios/economia , Idoso , Biópsia/economia , Artérias Carótidas/patologia , Doenças das Artérias Carótidas/patologia , Redução de Custos , Análise Custo-Benefício , Feminino , Humanos , Reembolso de Seguro de Saúde/economia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Desnecessários/economia
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