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1.
Vasc Endovascular Surg ; 55(1): 5-10, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32869709

RESUMO

BACKGROUND: Distal bypass (DB) is the optimal treatment for patients with critical limb ischemia (CLI). However, effectiveness of DB for patients with intermittent claudication (IC) remains uncertain. This study aimed to analyze long-term results of DB for IC patients (IC-DB) compared with those of DB for CLI patients (CLI-DB). METHODS: Patients undergoing DB from January 2009 to July 2018 at a single institution were retrospectively reviewed. Operative details, primary and secondary patency, amputation free survival rate (AFS), and long-term exercise capacity using Barthel index were analyzed. RESULTS: Out of 302 DB (245 patients), 49 IC-DB were performed in 43 patients: 38 males, mean age 70.3 ± 8.0 years, diabetes mellitus 51%, chronic renal failure with hemodialysis 7%. The Great saphenous vein was used in 47 limbs, the small saphenous vein in 1, and the arm vein in 1. These grafts were bypassed in a non-reversed fashion for 35 limbs, in an in-situ fashion in 9, and in a reversed fashion in 5. The mean operative time was 173 min. The mean follow-up was 25 ± 26 months. Primary and secondary patency of IC-DB was 79% and 94% at 1 year, 71% and 90% at 3 years, 65% and 90% at 5 years, which were significantly higher than those of CLI-DB (primary patency: P = .007, secondary patency: P = .025). AFS of IC-DB and CLI-DB was 100% and 77% at 1 year, 93% and 52% at 3 years, and 90% and 43% at 5 years (IC-DB vs. CLI-DB, p < .0001). Barthel index of IC-DB unchanged at discharge (median 100) and at the last visit (median 100), showing daily activity was maintained adequately. CONCLUSIONS: DB could offer a promising approach for patients with IC because of durable graft patency, acceptable AFS, and maintenance of daily activity.


Assuntos
Claudicação Intermitente/cirurgia , Isquemia/cirurgia , Doença Arterial Periférica/cirurgia , Veia Safena/transplante , Idoso , Idoso de 80 Anos ou mais , Estado Terminal , Tolerância ao Exercício , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
2.
Ann Vasc Surg ; 69: 292-297, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32474142

RESUMO

BACKGROUND: Transtibial amputations (TTAs) of the leg have been associated with high rates of wound complications. We assessed outcomes of TTAs to determine if bundled interventions implemented at our hospital had an impact on lowering wound complications, including surgical site infections. METHODS: We assessed the impact of a surgical site infection prevention bundle (negative-pressure wound therapy, minimizing the use of staples, and a decontamination protocol for methicillin-resistant Staphylococcus aureus) on 90-day wound complications. The year of implementation of the prevention bundle was excluded, and the pre-eras and posteras were defined as the four-year period before and after implementation. The study sample consisted of a single-center cohort, with TTA cases identified using operating room scheduling software. RESULTS: A total of 182 TTAs were performed: 110 in the pre-era and 72 in the postera. The wound complication rate decreased from 22 to 17% despite fewer two-stage operations, less imaging to identify peripheral artery disease, and an increased proportion of patients with end-stage renal disease. Wound complications and revision to a higher level of amputation were more associated with indication (especially no-option peripheral artery disease with ischemic rest pains) than with any particular aspect of surgical technique. The use of drains was associated with reoperations but not higher level revision. CONCLUSIONS: Higher rates of wound complications and revision to a higher level of amputations should be expected among patients with no-option peripheral artery disease with ischemic rest pains undergoing TTAs. Drains should be avoided.


Assuntos
Amputação/efeitos adversos , Claudicação Intermitente/cirurgia , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Pacotes de Assistência ao Paciente , Doença Arterial Periférica/cirurgia , Infecção da Ferida Cirúrgica/cirurgia , Tíbia/cirurgia , Idoso , Feminino , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/fisiopatologia , Isquemia/diagnóstico , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Fluxo Sanguíneo Regional , Reoperação , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/microbiologia , Fatores de Tempo , Resultado do Tratamento , Cicatrização
3.
Ann Vasc Surg ; 68: 571.e5-571.e7, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32417286

RESUMO

We report the case of a young man who developed a lower limb claudication associated to a lower limb discrepancy secondary to a closed traumatism during childhood that had never been explored. Fifteen years later, we managed to get the young man get rid of his crippling claudication, but it was unfortunately too late to correct the lower limb asymmetry.


Assuntos
Artéria Femoral/lesões , Claudicação Intermitente/etiologia , Desigualdade de Membros Inferiores/etiologia , Lesões do Sistema Vascular/complicações , Ferimentos não Penetrantes/complicações , Implante de Prótese Vascular , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/cirurgia , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/cirurgia , Masculino , Resultado do Tratamento , Adulto Jovem
4.
Vascular ; 28(6): 722-730, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32408857

RESUMO

OBJECTIVES: The superficial femoral artery can be used as inflow for infra-geniculate bypass, but progressive proximal occlusive disease may affect graft durability. We sought to evaluate the effect of superficial femoral artery versus common femoral artery inflow on infra-geniculate bypass patency within a large contemporary multicenter registry. METHODS: The vascular quality initiative was queried from 2013 to 2019 to identify patients with >30-day patency follow-up, Rutherford chronic limb ischemia stage 1-6, and an infra-geniculate bypass, excluding those with prior ipsilateral bypass. The cohort was stratified by inflow vessel, with primary, primary-assisted, and secondary patency serving as the primary outcome variables. Multivariate Cox-proportional hazard models and radius-based propensity-score matching were performed to reduce treatment-selection bias due to clinical covariates. RESULTS: A total of 11,190 bypass procedures were performed (8378 common femoral artery inflow, 2812 superficial femoral artery) on 10,110 patients, with a mean follow-up of 12.8 months (range 1-98). Patients receiving superficial femoral artery inflow bypasses were more commonly male (p = 0.002), obese (p < 0.0001) and had chronic, limb threatening ischemia (p < 0.0001), whereas those with common femoral artery inflow were older (p < 0.0004), and had higher baseline comorbidities including smoking (p < 0.0001), coronary disease (p < 0.0001), and pulmonary disease (p < 0.0001). On life-table analysis, there was no significant difference in three year estimated primary (32.1 vs 30.1%, p = 0.928), primary assisted (60.5 vs 65.8%, p = 0.191), or secondary patency (62.5 vs 66.7%, p = 0.139) between superficial femoral artery and common femoral artery inflow groups, respectively. A multivariate Cox model found no significant association between inflow vessel and primary patency (0.96 [0.88-1.04], HR [95%CI]), primary-assisted (1.07 [0.95-1.20], HR [95%CI]), or secondary patency (1.08 [0.96-1.22]). In a propensity-matched cohort (n = 11,151), there were small but statistically significant differences in primary, primary-assisted, and secondary patency at latest follow-up (non-time-to-event data) between groups. The largest difference was observed when evaluating secondary patency, with common femoral artery inflow having a marginally higher secondary patency of 88.1% compared to 85.6% for those with superficial femoral artery inflow at latest follow-up (p = 0.009). CONCLUSIONS: Within the vascular quality initiative, there is no significant difference in life-table determined three-year primary, primary-assisted, and secondary patency between infra-geniculate bypasses using common femoral artery inflow compared to superficial femoral artery inflow. Small, statistically significant differences exist in primary, primary-assisted, and secondary patency favoring common femoral artery inflow after propensity score matching. Long-term follow-up data are required in the vascular quality initiative to better evaluate bypass graft durability as this study was limited by a mean follow-up of one year.


Assuntos
Implante de Prótese Vascular , Artéria Femoral/cirurgia , Claudicação Intermitente/cirurgia , Isquemia/cirurgia , Doença Arterial Periférica/cirurgia , Grau de Desobstrução Vascular , Idoso , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Doença Crônica , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
5.
Ann Vasc Surg ; 68: 572.e5-572.e7, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32445884

RESUMO

Aortoiliac endarterectomy was the standard treatment for aortoiliac occlusive disease before the availability of prosthetic graft material for aortobifemoral bypass, although the number of patients appropriate for this repair continues to diminish in the endovascular era. Patients with focal aortoiliac disease are often treated with bilateral "kissing" iliac stents through an endovascular approach. However, in patients with eccentric plaque morphology or smaller caliber vessels, the risk of distal embolization and vessel rupture is not insignificant. On the other hand, if the disease is localized to the distal aortic bifurcation, an open aortobifemoral bypass may be excessive and incur additional morbidity. Our case report reviews a 60-year-old woman who presented with lifestyle-limiting claudication from an isolated aortoiliac atherosclerotic plaque who we proceeded with an open aortoiliac endarterectomy.


Assuntos
Doenças da Aorta/cirurgia , Arteriopatias Oclusivas/cirurgia , Endarterectomia , Artéria Ilíaca/cirurgia , Claudicação Intermitente/cirurgia , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/fisiopatologia , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/fisiopatologia , Feminino , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Pessoa de Meia-Idade , Resultado do Tratamento
6.
Ann Vasc Surg ; 66: 518-528, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32035265

RESUMO

BACKGROUND: Arterial reconstruction (AR) for limb ischemia may improve ambulatory function (AF) and health-related quality of life (HR-QoL). However, the efficacy of AR in terms of HR-QoL varies in studies, probably because of cohort differences in disease severity, hemodynamic outcomes, and observation duration. We assessed HR-QoL for patients with various severities of ischemia in a 3-year observational study. METHODS: We conducted a single-center 3-year observational study using Short Form 36 in patients with chronic limb ischemia. Between 2001 and 2009, 515 consecutive patients had AR, and 330 who underwent elective AR consented to the study. Of the 330 patients (claudicants 49%, critical limb ischemia [CLI] 51%), 307 underwent bypass and 23 endovascular therapy. Postal questionnaires were sent after AR, and 8 domains, the physical and mental component summary (PCS and MCS) scores, and the patient-reported AF were compared, and negative predictors were identified. RESULTS: Overall, the MCS was minimally affected, but AF and the PCS were impaired. After AR, these measures were significantly improved, and maximum recovery was attained at 6 months. In subgroup analysis, significant predictors of a negative impact on postoperative PCS included age ≥80, CLI, physical aftereffects of stroke (PAS), and previous major amputation (PMA). Of these, PMA was associated with the lowest PCS score, followed by PAS; for these patients, AR contributed minimally to HR-QoL recovery. PCS scores of claudicants attained a maximum value at 6 months; however, PCS scores of CLI patients were significantly lower than intermittent claudication patients (P < 0.0001), and patients with major tissue loss required 2 years to attain maximum PCS recovery. CONCLUSIONS: This 3-year observational study verified the efficacy of AR in improving AF and HR-QoL. Age ≥80, CLI, PAS, and PMA were definitive predictors, and for patients with the latter 2, AR contributed minimally to improving HR-QoL.


Assuntos
Procedimentos Endovasculares , Tolerância ao Exercício , Claudicação Intermitente/cirurgia , Isquemia/cirurgia , Doença Arterial Periférica/cirurgia , Qualidade de Vida , Enxerto Vascular , Caminhada , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/fisiopatologia , Isquemia/diagnóstico , Isquemia/fisiopatologia , Japão , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Estudos Prospectivos , Recuperação de Função Fisiológica , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Grau de Desobstrução Vascular
7.
Eur J Vasc Endovasc Surg ; 59(4): 587-596, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31926836

RESUMO

OBJECTIVE: The aim of this study was to determine the survival of patients after use of paclitaxel coated devices (PCX), as a recent meta-analysis of randomised trials reported higher mortality in patients treated with PCX balloons and stents METHODS: A retrospective health insurance claims analysis of patients covered by the second largest insurance fund in Germany, BARMER, was used to identify index femoropopliteal arterial interventions between 1 January 2010 and 31 December 2018. To ensure first PCX exposure, patients with prior deployment of PCX were excluded. The study cohort was stratified into patients with chronic limb threatening ischaemia (CLTI) and intermittent claudication (IC), then into balloons vs. stents cohorts. Within each stratum PCX were compared with uncoated devices. Propensity score matching was used to balance the study groups. Survival was evaluated using the Kaplan-Meier method and Cox regression. RESULTS: There were 37 914 patients (mean age 73.3 years; 48.8% female) included in the study. The annual proportion of PCX use increased from 3% to 39% during the study period for CLTI and from 4% to 48% for IC (both p < .001). Paclitaxel coated balloons and stents were associated with improved overall survival (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.77-0.90), amputation free survival (HR 0.85, 95% CI 0.78-0.91), and freedom from major cardiovascular events (HR 0.82, 95% CI 0.77-0.89) vs. uncoated devices at five years for CLTI. In IC cohort, mortality was significantly lower after using drug coated balloons (DCB) (HR 0.87, 95% CI 0.76-0.99) or combined DCB and drug eluting stents (HR 0.88, 95% CI 0.80-0.98). CONCLUSION: In this large health insurance claims analysis, rapid adoption of PCX, higher long term survival, better amputation free survival, and lower rates of major cardiovascular events were seen after their use for the treatment of CLTI.


Assuntos
Artéria Femoral/efeitos dos fármacos , Claudicação Intermitente/mortalidade , Paclitaxel/uso terapêutico , Doença Arterial Periférica/mortalidade , Idoso , Idoso de 80 Anos ou mais , Fármacos Cardiovasculares/uso terapêutico , Constrição Patológica/etiologia , Feminino , Artéria Femoral/cirurgia , Humanos , Claudicação Intermitente/cirurgia , Isquemia/mortalidade , Isquemia/cirurgia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/cirurgia , Estudos Retrospectivos , Dispositivos de Acesso Vascular/estatística & dados numéricos
8.
Ann Vasc Surg ; 62: 498.e7-498.e10, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31449942

RESUMO

Popliteal artery aneurysms (PAAs) are the most common peripheral arterial aneurysms and develop almost exclusively (>90%) in men who have a history of tobacco abuse at an average age of 65 years. Most PAAs are caused by chronic inflammation secondary to atherosclerotic disease; other nondegenerative causes of PAAs include arterial trauma, infection, Behçet's disease, medial fibromuscular dysplasia, or popliteal artery entrapment. Few case reports have been published on idiopathic congenital PAAs. We report a case of a 26-year-old man who presented with progressive claudication and subsequent acute limb ischemia due to the thrombosis of a large idiopathic PAA. Our case demonstrates that the differential diagnosis of young adult or pediatric patients presenting with signs of acute limb ischemia or claudication should include a symptomatic PAA.


Assuntos
Aneurisma/complicações , Claudicação Intermitente/etiologia , Isquemia/etiologia , Doença Arterial Periférica/etiologia , Artéria Poplítea , Trombose/etiologia , Doença Aguda , Adulto , Aneurisma/diagnóstico por imagem , Aneurisma/fisiopatologia , Aneurisma/cirurgia , Fasciotomia , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Claudicação Intermitente/cirurgia , Isquemia/diagnóstico por imagem , Isquemia/fisiopatologia , Isquemia/cirurgia , Ligadura , Masculino , 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 , Veia Safena/transplante , Trombose/diagnóstico por imagem , Trombose/fisiopatologia , Trombose/cirurgia , Resultado do Tratamento , Enxerto Vascular
9.
Ann Vasc Surg ; 62: 133-141, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31494265

RESUMO

BACKGROUND: The natural history of intermittent claudication (IC) is that only 25% of patients will experience worsening of their claudication symptoms, and only approximately 1-3% will progress to major amputation. The impact of increasing use of endovascular therapies on the natural history of IC has not been well established. The purpose of this study is to evaluate the incidence and identify predictors of major and minor amputations after peripheral vascular intervention (PVI) for IC. METHODS: A retrospective cohort of patients treated for IC was derived from the national PVI Vascular Quality Initiative database evaluating both preoperative and intraoperative variables from 2003 to 2017. We examined rates of major or minor amputations after ipsilateral PVI for IC. Multivariable logistic regression models were created to identify predictors of amputation along with Kaplan-Meier (KM) plots to estimate amputation-free survival. RESULTS: We identified 11,887 PVI procedures for patients undergoing elective treatment for IC without a previous history of lower extremity PVI or bypass. Major and minor amputations occurred at a combined rate of 1.08% (n = 128). Minor amputations occurred in 0.56% (n = 67) of patients at 1 year, whereas major amputations were reported in 0.51% (n = 61) of cases. KM plots of amputation-free survival revealed that patients with preoperative ankle brachial indexes (ABIs) <0.2 or noncompressible ABIs (>1.3) had significantly higher rates of any amputation compared with subjects with ABIs between 0.20-0.49, 0.50-0.89, and 0.90-1.30 (log rank, <0.001). Multivariate analysis showed that patients with preoperative symptomatic congestive heart failure (CHF) (odds ratio [OR], 6.48; 95% confidence interval [95% CI], 2.43-17.20; P < 0.001), American Society of Anesthesiologists (ASA) class IV (OR, 9.34; 95% CI, 1.94-44.89; P = 0.005), and nonwhite race (OR, 3.32; 95% CI, 1.50-7.36; P = 0.003) had significant increase in risk of major amputation after PVI. Odds of major or minor amputation were increased when patients underwent only a tibial-level intervention (major: OR, 6.26; 95% CI, 1.50-26.10; P = 0.012 and minor: OR, 7.04; 95% CI, 1.02-8.51; P = 0.001). CONCLUSIONS: With relation to amputation, the natural history of IC does not appear to be impacted by PVI sicker patients with higher ASA or symptomatic CHF, and those with isolated tibial interventions are at higher risk for amputation, and we cannot determine if this is due to patient substrate, presentation, or the intervention itself. Importantly, there are key prognostic preoperative and intraoperative indicators that can assist the clinician with predicting patients who are at a higher risk of amputation.


Assuntos
Amputação , Claudicação Intermitente/cirurgia , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Amputação/efeitos adversos , Bases de Dados Factuais , Feminino , Humanos , Incidência , Claudicação Intermitente/epidemiologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Intervalo Livre de Progressão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
10.
Ann Vasc Surg ; 64: 409.e1-409.e5, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31634595

RESUMO

BACKGROUND: Chronic thrombosis of an abdominal aortic aneurysm (AAA) is a rare entity and the ideal management is debatable. METHODS AND RESULTS: A 74-year-old man presented with an enlarging chronically thrombosed AAA and incapacitating bilateral claudication, worse on the left side. We opted for an endovascular approach. Under local anesthesia and via a left axillary and left femoral cutdown, an aorto-uni-iliac stent graft (Endurant, Medtronic) was implanted down the left common iliac artery. A femorofemoral crossover bypass was not necessary because the right leg circulation was considered adequate on completion of the endovascular procedure. He had an uneventful recovery. His left leg symptoms were completely resolved and he was able to walk with only moderate right leg claudication after 300-400m. CONCLUSIONS: Endovascular treatment of a chronically thrombosed AAA can be performed under local anesthesia and is a safe alternative to open surgery in high-risk patients. The long-term results need further investigation.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Ilíaca/cirurgia , Claudicação Intermitente/cirurgia , Trombose/cirurgia , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Doença Crônica , Procedimentos Endovasculares/instrumentação , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Masculino , Recuperação de Função Fisiológica , Stents , Trombose/diagnóstico por imagem , Trombose/fisiopatologia , Resultado do Tratamento
11.
Ann Vasc Surg ; 64: 409.e7-409.e9, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31634612

RESUMO

The axillary bilateral femoral bypass is often utilized as an alternative to in-line aortic reconstruction in patients with multiple medical comorbidities, who would be unable to tolerate open abdominal surgery with an aortic clamp, or patients with mycotic aneurysms, or infected grafts. Idealized fluid mechanics suggest that there would be equal flow in an axillary bilateral femoral bypass when compared to in-line reconstruction. However, in a non-idealized state, friction results in kinetic energy loss and decreased volume flow to the lower extremities in the longer, smaller diameter graft. Although older or less active people may tolerate the lower volume flow of a long segment extra-anatomic bypass, there is growing evidence that a subset of patients will be symptomatic from reduced flow volumes. Here we present 3 patients in whom symptomatic relief was achieved with the addition of a contralateral axillary femoral bypass and ligation of the previous femorofemoral component.


Assuntos
Aneurisma Infectado/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Artéria Axilar/cirurgia , Implante de Prótese Vascular/efeitos adversos , Artéria Femoral/cirurgia , Claudicação Intermitente/cirurgia , Isquemia/cirurgia , Doença Arterial Periférica/cirurgia , Adulto , Idoso , Aneurisma Infectado/diagnóstico por imagem , Aneurisma Infectado/fisiopatologia , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Artéria Axilar/diagnóstico por imagem , Artéria Axilar/fisiopatologia , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/etiologia , Claudicação Intermitente/fisiopatologia , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Isquemia/fisiopatologia , Ligadura , Masculino , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/etiologia , Doença Arterial Periférica/fisiopatologia , Reoperação , Fatores de Risco , Terapia de Salvação , Resultado do Tratamento
12.
Ann Vasc Surg ; 63: 460.e5-460.e8, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31629841

RESUMO

Several surgical sealant devices are commercially available after their rigorous clinical testing with no apparent complications reported so far in the current literature. Cyanoacrylate glue can be used to stabilize the anastomoses and permit a better tensile strength in cardiovascular surgery. We first report the case of a 71-year-old male patient presenting with symptoms of progressive limitation of walking distance, 13 months after a successful femoroinfrapopliteal bypass surgery, because of a calcified tissue extrinsically stenosizing the first segment of the previous bypass graft, caused by the use of cyanoacrylate glue.


Assuntos
Cianoacrilatos/efeitos adversos , Oclusão de Enxerto Vascular/etiologia , Claudicação Intermitente/etiologia , Veia Safena/transplante , Enxerto Vascular/efeitos adversos , Idoso , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/cirurgia , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Claudicação Intermitente/cirurgia , Masculino , Reoperação , Veia Safena/diagnóstico por imagem , Veia Safena/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
14.
J Vasc Surg ; 72(1): 241-249, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31839346

RESUMO

OBJECTIVE: Interventional approaches to managing intermittent claudication vary widely. According to Society for Vascular Surgery guidelines, any invasive treatment of claudication must offer long-term benefit at low risk of complications. Our aim was to evaluate contemporary claudication intervention patterns and functional outcomes. METHODS: The Vascular Study Group of New England database (2003-2018) was queried for peripheral vascular interventions (PVIs), infrainguinal bypasses, and suprainguinal bypasses for claudication. Perioperative and 1-year outcomes were evaluated. RESULTS: There were 7051 PVIs, 2527 infrainguinal bypasses, and 849 suprainguinal bypasses performed for claudication. Treatment levels were iliac (52.2%), femoral-popliteal (54%), and tibial (5.7%). Isolated tibial interventions were completed in 1.7% of patients. Infrainguinal bypasses were most often to the popliteal artery (81.2%); however, in 18.8% of cases, bypasses were to tibial targets. Suprainguinal bypasses originated primarily from the abdominal aorta (88.6%) but also from the axillary artery (10.6%) and thoracic aorta (0.8%). Common perioperative complications were access site hematoma in 4.9% of PVIs and cardiac complications in 3.7% of infrainguinal bypasses and 11.3% of suprainguinal bypasses. Overall, 30-day mortality was 0.4% to 2%. After 1 year, of patients initially ambulating without assistance, 2.4% to 3.6% required assistance and 0.3% to 1.3% were nonambulatory. Ipsilateral reintervention/amputation-free survival, major amputation-free survival, and survival at 1 year were 81.4% to 90.6%, 92.9% to 94.1%, and 95.3% to 97%, respectively. CONCLUSIONS: Multisegment PVI was the most commonly performed intervention for claudication; however, a subset of patients received treatments supported by limited evidence, including isolated tibial PVI and bypasses with axillary inflow and tibial outflow. Interventions had low perioperative morbidity and mortality, yet patients were still at risk for worse functional status and limb loss at 1 year, emphasizing the importance of careful patient selection, medical optimization, and informed consent.


Assuntos
Amputação , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Claudicação Intermitente/cirurgia , Doença Arterial Periférica/cirurgia , Idoso , Bases de Dados Factuais , Deambulação com Auxílio , Progressão da Doença , Feminino , Nível de Saúde , Humanos , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , New England , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Intervalo Livre de Progressão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
15.
Eur J Vasc Endovasc Surg ; 59(5): 817-822, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31866238

RESUMO

OBJECTIVE: To investigate the risk of procedure-related major amputation attributable to revascularization for intermittent claudication (IC) in a population-based observational cohort study. METHODS: All patients who underwent open or endovascular lower limb revascularisation for IC in Sweden between 12 May 2008 and 31 December 2012 were identified from the Swedish National Quality Registry for Vascular Surgery (Swedvasc) and data on above ankle amputations were extracted from the National Patient Registry. Any uncertainty regarding amputation level and laterality was resolved by reviewing medical charts. For the final analysis, complete medical records of all patients with IC, having ipsilateral amputation after the revascularisation procedure, were reviewed. Patients wrongly classified as having IC were excluded. Ipsilateral amputations within one year of the revascularisation were defined as procedure related. RESULTS: Altogether, 5 860 patients revascularised for IC were identified of whom 109 were registered to have undergone a post-operative ipsilateral lower limb amputation during a median follow up of 3.9 years (standard deviation 1.5 y). Seventeen were duplicate registrations and 51 were patients with chronic limb threatening ischaemia, misclassified as IC in the registry. One patient had not undergone any revascularisation, one was revascularised for a popliteal artery aneurysm, one was revascularised for acute limb ischaemia, one had a minor amputation only, and one patient was not amputated at all. Twenty-seven were amputated more than one year after the procedure. Thus, the major amputation rate within one year of revascularisation for IC was 0.2% (n = 9/5 860). CONCLUSION: Revascularisation for IC in a contemporary setting confers a low but existing risk of procedure related major amputation within the first post-procedural year.


Assuntos
Amputação , Procedimentos Endovasculares , Claudicação Intermitente/cirurgia , Idoso , Idoso de 80 Anos ou mais , Amputação/estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Suécia
16.
J Cardiovasc Surg (Torino) ; 61(2): 196-199, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29745216

RESUMO

BACKGROUND: According to the guidelines, bypass surgery is still the golden standard treatment in patients with femoropopliteal TASC C and D lesions and life-style limiting claudication or critical limb ischemia. Over the past few decades, endovascular therapy has made great advancements. However, the success rates of surgical and endovascular procedures cannot be directly compared. According to the surgical term "patency," vessel patency can be maintained even in case of a high grade stenosis, whereas according to the endovascular primary patency definition, being binary restenosis, patency is lost from the moment there is a re-narrowing at any location within the treated segment. METHODS: One hundred consecutive patients with a previously implanted femoropopliteal bypass which was primary patent according to the surgical definition were included in this study. Once enrolled, duplex ultrasonography was performed, measuring the Peak Systolic Velocity Ratio for proximal and distal anastomosis. RESULTS: Out of the 100 bypasses that were considered patent according to the surgical definition, Peak Velocity Ratio of ≥2.4 were detected in 11 patients. CONCLUSIONS: Based on these findings a 78% primary patency according to the open vascular criteria turned into ~70% primary patency using the stricter endovascular criteria. In the light of these findings, one might conclude that modern endovascular treatment of long TASC C and D femoropopliteal lesions yielded similar results in terms of primary patency as above-the-knee bypasses.


Assuntos
Procedimentos Endovasculares/métodos , Artéria Femoral/cirurgia , Oclusão de Enxerto Vascular/epidemiologia , Claudicação Intermitente/cirurgia , Doença Arterial Periférica/cirurgia , Artéria Poplítea/cirurgia , Anastomose Cirúrgica , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/métodos , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Claudicação Intermitente/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Doença Arterial Periférica/diagnóstico por imagem , Prognóstico , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Ultrassonografia de Intervenção , Grau de Desobstrução Vascular/fisiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/métodos
17.
Pain Med ; 20(Suppl 2): S9-S13, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31808531

RESUMO

OBJECTIVE: Postlaminectomy syndrome diagnoses secondary to adjacent segment degeneration are a substantial and rising cause of morbidity in the United States. Emerging spinal cord neuromodulation technologies have produced successful outcomes for postlaminectomy neuropathic pain but are less effective in treating neurogenic claudication secondary to recurrent lumbar stenosis. Percutaneous interspinous process decompression systems can be used as a salvage treatment modality for persistent structural neurogenic claudication in postlaminectomy syndrome or after spinal cord stimulator implantation. METHODS: This paper is a review of emerging evidence for efficacious utilization of percutaneous interspinous process decompression. RESULTS: A recent pragmatic trial of subjects who underwent percutaneous interspinous process decompression for lumbar stenosis with intermittent neurogenic claudication reported that 63% (26/41) maintained minimal clinically important improvement in visual analog scale (VAS) leg pain, 61% (25/41) in VAS back pain, 78% (32/41) in function objective values, and 88% (36/41) reported satisfaction with treatment at 12 months postop. All subjects in a small case series of seven individuals with postlaminectomy adjacent-segment disease reported postoperative satisfaction scores of 3 or 4 on a 0-4 scale and were also able to decrease or wean completely off controlled pain medications. In another study, there was a significant decrease in average leg pain (60% improvement, P < 0.0001, N = 25) and axial low back pain (58% improvement, P < 0.0001, N = 25) in patients who underwent one- or two-level percutaneous interspinous process decompression as a rescue treatment for reemerging neurogenic claudication after spinal cord stimulator implantation. CONCLUSIONS: The spine often is a focus of progressive disease. Furthermore, mechanical changes associated with spinal instrumentation can lead to additional disease at adjacent levels. Many individuals will present with symptomatic neurogenic claudication recalcitrant to multimodal management strategies, including even the most sophisticated neuromodulation technologies. Implementation of salvage percutaneous interspinus process decompression implantation in cases of adjacent segment degeneration or incomplete spinal cord stimulation can decompress structural causes of neurogenic claudication while sparing the patient from more invasive surgical reoperation techniques.


Assuntos
Descompressão Cirúrgica , Claudicação Intermitente/cirurgia , Região Lombossacral/cirurgia , Estenose Espinal/cirurgia , Descompressão Cirúrgica/métodos , Humanos , Claudicação Intermitente/etiologia , Manejo da Dor/métodos , Complicações Pós-Operatórias/cirurgia , Estenose Espinal/complicações
18.
Pain Med ; 20(Suppl 2): S32-S44, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31808530

RESUMO

OBJECTIVE: Lumbar spinal stenosis (LSS) is a degenerative spinal condition affecting nearly 50% of patients presenting with lower back pain. The goal of this review is to present and summarize the current data on how LSS presents in various populations, how it is diagnosed, and current therapeutic strategies. Properly understanding the prevalence, presentation, and treatment options for individuals suffering from LSS is critical to providing patients the best possible care. RESULTS: The occurrence of LSS is associated with advanced age. In elderly patients, LSS can be challenging to identify due to the wide variety of presentation subtleties and common comorbidities such as degenerative disc disease. Recent developments in imaging techniques can be useful in accurately identifying the precise location of the spinal compression. Treatment options can range from conservative to surgical, with the latter being reserved for when patients have neurological compromise or conservative measures have failed. Once warranted, there are several surgical techniques at the physician's disposal to best treat each individual case.


Assuntos
Dor nas Costas/cirurgia , Vértebras Lombares/cirurgia , Estenose Espinal/diagnóstico , Estenose Espinal/cirurgia , Dor nas Costas/complicações , Descompressão Cirúrgica/métodos , Humanos , Claudicação Intermitente/cirurgia , Dor Lombar/complicações , Estenose Espinal/complicações
19.
Eur J Vasc Endovasc Surg ; 58(5): 738-745, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31526633

RESUMO

OBJECTIVES: This systematic review aimed to identify evidence based quality indicators for invasive revascularisation of symptomatic peripheral arterial occlusive disease (PAOD). METHODS: A systematic search of clinical practice guidelines, consensus statements, systematic reviews, and meta-analyses reporting quality indicators in patients undergoing invasive open and percutaneous revascularisations for symptomatic PAOD (PROSPERO registration number: CRD42019116317) was performed. Furthermore, a grey literature search was conducted involving databases of professional vascular medical organisations. The identified publications were screened independently by two reviewers for possible inclusion and full texts of potentially relevant records were independently evaluated for eligibility. Disagreement was resolved by discussion involving a third reviewer. RESULTS: From 685 articles initially identified, one systematic review and one consensus statement focusing on quality indicators were selected for inclusion in the review. From these sources, a total of three process quality indicators matched the search criteria: one on pharmacological intervention, another on smoking cessation, and a third on surveillance of lower extremity vein bypass grafts. The grey literature search revealed an additional 31 structure, process, and outcome quality indicators. CONCLUSIONS: This study revealed a lack of published evidence based quality indicators concerning invasive treatment for PAOD in the literature. An additional 31 indicators from the databases of professional societies and organisations have not been incorporated in prior guidelines. Interestingly, no indicator related to patient reported outcomes could be identified from either high quality sources or grey literature. Further research and harmonisation of different quality indicators is needed to enhance their evidence and subsequently improve patient centred decision making on invasive treatment.


Assuntos
Doença Arterial Periférica , Indicadores de Qualidade em Assistência à Saúde , Procedimentos Cirúrgicos Vasculares , Humanos , Claudicação Intermitente/etiologia , Claudicação Intermitente/cirurgia , Avaliação de Resultados em Cuidados de Saúde , Doença Arterial Periférica/complicações , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/normas
20.
Ann Vasc Surg ; 61: 468.e5-468.e8, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31376545

RESUMO

Endarterectomy of the common and profunda femoris is currently performed for treatment of atherosclerotic lesions involving femoral bifurcation. Misperception of surgical risk in terms of morbidity and mortality has induced the trend to extend the indication for treatment to patients with mild symptoms at presentation, at the cost of unnecessary increased complication rate and mortality risk, which persists even after patient discharge. We report the case of a giant infected femoral pseudoaneurysm occurring in a 74-year-old patient, previously treated with femoral artery endarterectomy with prosthetic patch closure because of mild claudication. Surgically managed with en block resection and autologous vein reconstruction, his postoperatory course was further complicated by fatal sepsis. Complications for femoral artery endarterectomy, including infectious and fatal events, need a close follow-up of these patients to promptly diagnose and treat any event which may occur, preventing its evolution to more challenging and potentially life-threatening clinical scenario.


Assuntos
Falso Aneurisma/microbiologia , Aneurisma Infectado/microbiologia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular/efeitos adversos , Endarterectomia , Artéria Femoral/cirurgia , Claudicação Intermitente/cirurgia , Doença Arterial Periférica/cirurgia , Infecções Relacionadas à Prótese/microbiologia , Idoso , Falso Aneurisma/diagnóstico , Falso Aneurisma/cirurgia , Aneurisma Infectado/diagnóstico , Aneurisma Infectado/cirurgia , Remoção de Dispositivo , Evolução Fatal , Artéria Femoral/microbiologia , Humanos , Claudicação Intermitente/diagnóstico por imagem , Masculino , Doença Arterial Periférica/diagnóstico por imagem , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/cirurgia , Veia Safena/transplante , Sepse/microbiologia , Índice de Gravidade de Doença , Resultado do Tratamento
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