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1.
Rev. cuba. angiol. cir. vasc ; 20(2): e385, jul.-dic. 2019. tab, graf
Artigo em Espanhol | LILACS | ID: biblio-1003858

RESUMO

Introducción: La coordinación entre niveles asistenciales centrada en las enfermedades frecuentes, graves y vulnerables, constituye un elemento esencial para incrementar la eficiencia del sistema sanitario con la ayuda del uso de instrumentos diagnósticos. Objetivo: Validar el Cuestionario de Edimburgo modificado para el diagnóstico de la claudicación arterial periférica en la atención primaria de salud. Métodos: Estudio de evaluación de instrumentos diagnósticos a través de un estudio explicativo observacional de corte transversal, en una muestra de 100 pacientes provenientes de la atención primaria de salud. El período de estudio fue el segundo semestre (julio-diciembre) de 2016. A todos los participantes se les realizó un examen físico vascular, se midieron los índices de presiones tobillo-brazo, se identificó la topografía de las lesiones arteriales de los miembros inferiores, se les aplicó el Cuestionario de Edimburgo modificado y se calculó su sensibilidad, especificidad, valores predictivos positivos y negativos y exactitud diagnóstica. Resultados: El examen físico vascular constató un predominio de la afección fémoro-poplítea (54,8 por ciento) seguido de la aorta-ilíaco (29,9 por ciento). Se obtuvo en la validación del Cuestionario una sensibilidad de 98 por ciento, una especificidad de 31,5 por ciento con alta probabilidad de tener falsos negativos. El valor predictivo positivo fue de 70 por ciento y el negativo de 92 por ciento. La exactitud de las pruebas diagnósticas fue de 73 por ciento, para cada prueba. Conclusiones: El uso del Cuestionario de Edimburgo modificado en la atención primaria de salud es de gran utilidad para establecer el diagnóstico clínico positivo de una claudicación intermitente por enfermedad arterial periférica(AU)


Introduction: Coordination between care levels centered in the severe, frequently and vulnerable diseases constitutes an essential element to increase the efficiency of the health system with the help of diagnostic means. Objective: To validate the modified Edinburgh Questionnaire for the diagnostic of arterial claudication in the primary health care. Methods: An assessment study of diagnostic instruments was done through of a cross-sectional, observational explicative study in a sample of 100 patients from primary health care. The study was conducted in the second semester (July-December) of 2016. A vascular physical exam was performed to all the participants where ankle- brachial pressure index was measured, the topography of the arterial occlusions of the lower limbs was identified, the modified Edinburgh Questionnaire was carried out; and the sensitivity, specificity, positive and negative predictive values and the diagnostic exactitude were calculated. Results: The vascular physical exam exhibited a predominant femoro-popliteal affectation (54,8 percent) followed of the aorta-iliac (29,9 percent). In the validation of the modified Edinburgh Questionnaire it was obtained a sensitivity of 98 percent and an specificity of 31,5 percent with high probabilities of false negative. The positive predictive value was 70 percent and the negative 92 percent. The exactitude of the diagnostic test was 73 percent for each test. Conclusions: The use of the modified Edinburgh Questionnaire in the primary health care is useful to establish the positive clinical diagnostic of an intermittent arterial claudication by Peripheral Arterial Disease(AU)


Assuntos
Humanos , Masculino , Feminino , Atenção Primária à Saúde , Inquéritos e Questionários/normas , Estudos Transversais , Doença Arterial Periférica/diagnóstico , Estudo Observacional , Claudicação Intermitente/diagnóstico
2.
Vasc Health Risk Manag ; 15: 187-208, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31308682

RESUMO

Peripheral arterial disease is a chronic vascular disease characterized by impaired circulation to the lower extremities. Its most severe stage, known as critical limb ischemia (CLI), puts patients at an increased risk of cardiovascular events, amputation, and death. The objective of this literature review is to describe the burden of disease across a comprehensive set of domains-epidemiologic, clinical, humanistic, and economic-focusing on key studies published in the last decade. CLI prevalence in the United States is estimated to be approximately 2 million and is likely to rise in the coming years given trends in important risk factors such as age, diabetes, and smoking. Hospitalization for CLI patients is common and up to 60% are readmitted within 6 months. Amputation rates are unacceptably high with a disproportionate risk for certain demographic and socioeconomic groups. In addition to limb loss, CLI patients also have reduced life expectancy with mortality typically exceeding 50% by 5 years. Given the poor clinical prognosis, it is unsurprising that the quality of life burden associated with CLI is significant. Studies assessing quality of life in CLI patients have used a variety of generic and disease-specific measures and all document a substantial impact of the disease on the patient's physical, social, and emotional health status compared to population norms. Finally, the poor clinical outcomes and increased medical resource use lead to a considerable economic burden for national health care systems. However, published cost studies are not comprehensive and, therefore, likely underestimate the true economic impact of CLI. Our summary documents a sobering assessment of CLI burden-a poor clinical prognosis translating into diminished quality of life and high costs for millions of patients. Continued prevention efforts and improved treatment strategies are the key to ameliorating the substantial morbidity and mortality associated with this disease.


Assuntos
Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde , Isquemia/economia , Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/economia , Doença Arterial Periférica/terapia , Amputação/economia , Estado Terminal , Humanos , Incidência , Isquemia/diagnóstico , Isquemia/epidemiologia , Salvamento de Membro , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Prevalência , Qualidade de Vida , Fatores de Risco , Resultado do Tratamento , Estados Unidos/epidemiologia
3.
Medicine (Baltimore) ; 98(28): e15959, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31305390

RESUMO

The prognostic significance of systemic atherothrombosis in heart failure (HF) with preserved ejection fraction (HFpEF) remains unclear. This study aimed to investigate the relation between the presence of polyvascular disease (PVD) and cardiovascular outcomes in HFpEF patients.A total of 510 consecutive HFpEF patients were prospectively observed for up to 1500 days or until occurrence of cardiovascular events. PVD was defined as ≥2 coexistence of coronary artery disease, peripheral arterial disease, and cerebrovascular disease.Overall, 124 cardiovascular events were observed during follow-up (median: 1430 days). Kaplan-Meier curve showed HFpEF with PVD (n = 84) experienced more cardiovascular events than did those without PVD patients (44.0% vs 20.4%, log-rank: P < .001). Multivariable Cox proportional hazards analysis with significant factors from univariate analysis showed the presence of PVD (hazard ratio [HR]: 2.875, 95% [CI]: 1.894-4.365, P < .001), previous HF hospitalization (HR: 1.578, 95% CI: 1.031-2.414, P = .036), hemoglobin (HR: 0.889, 95% CI: 0.805-0.983, P = .021), serum sodium (HR: 0.946, 95% CI 0.896-1.000, P = .048), ln-BNP (per 1.0, HR: 1.255, 95% CI: 1.055-1.494, P = .010), and E/e' (HR: 1.047, 95% CI: 1.020-1.075, P < .001) significantly predicted future cardiovascular events. Multivariable Cox hazard analysis with 4 established factors (age, BNP, diabetes mellitus, and previous HF hospitalization) from the I-PRESERVE (Irbesartan in HFpEF) study showed PVD was independently associated with cardiovascular events in HFpEF patients (HR: 2.562, 95% CI: 1.715-3.827, P < .001).The presence of PVD is significantly associated with cardiovascular events in HFpEF, suggesting the importance of screening PVD in HFpEF.


Assuntos
Transtornos Cerebrovasculares/diagnóstico , Doença da Artéria Coronariana/diagnóstico , Insuficiência Cardíaca/diagnóstico , Doença Arterial Periférica/diagnóstico , Idoso , Aterosclerose/diagnóstico , Aterosclerose/epidemiologia , Biomarcadores/sangue , Transtornos Cerebrovasculares/epidemiologia , Doença da Artéria Coronariana/epidemiologia , Feminino , Seguimentos , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Doença Arterial Periférica/epidemiologia , Prevalência , Prognóstico , Estudos Prospectivos , Análise de Sobrevida , Resultado do Tratamento , Função Ventricular Esquerda
4.
ABC., imagem cardiovasc ; 32(3): 157-197, jul.-set. 2019. ilus, tab
Artigo em Português | LILACS, Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1006549
5.
Expert Rev Med Devices ; 16(8): 697-710, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31340684

RESUMO

Introduction: Peripheral arterial disease (PAD) may cause symptoms due to impaired tissue perfusion of the lower extremity. So far, assessment of PAD is mainly performed by determination of stenosis or occlusion in the large arteries and does not focus on microcirculation. Several diagnostic techniques have been recently introduced that may enable tissue perfusion measurements in the lower limb; however, most have not yet been implemented in clinical daily practice. This systematic review provides an overview of these diagnostic techniques and their ability to accurately detect PAD by peripheral tissue perfusion. Areas covered: A literature search was performed for articles that described a diagnostic technique to determine tissue perfusion in patients with known PAD compared with healthy controls. Expert opinion: So far, transcutaneous oxygen measurements are most often used to measure tissue oxygenation in PAD patients, but evidence seems too low to define this technique as a gold standard, and implementing this technique for home monitoring is difficult. New potentially suitable diagnostic tests should be non-invasive, contact-free, and quick. Further research is needed for all of these techniques before broad implementation in clinical use is justified, in hospital, and for home monitoring.


Assuntos
Técnicas e Procedimentos Diagnósticos , Perfusão , Doença Arterial Periférica/diagnóstico , Humanos , Imagem por Ressonância Magnética , Viés de Publicação , Tomografia Óptica
6.
Vasc Med ; 24(4): 332-338, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31195896

RESUMO

Loss to follow-up (LTF) has been associated with worse outcomes after procedures. We sought to identify differences in lower extremity peripheral vascular intervention (PVI) patients with and without LTF, and to determine if LTF impacted survival. Patients in the PVI registry of the Vascular Quality Initiative (VQI) were included (n = 39,342), where t-test and chi-squared analysis were used to compare those with and without LTF. Multivariable logistic regression was used to identify factors associated with LTF while Cox regression analysis was applied to compare survival among those with and without LTF. The overall 1-year follow-up rate was 91.6%. LTF patients were more often male, Hispanic, of black race, and had a higher rate of diabetes, coronary artery disease, congestive heart failure, and dialysis. LTF patients had a higher prevalence of critical limb ischemia, underwent popliteal or distal intervention, and were intervened upon urgently. There was also a higher rate of postoperative complications, and a lower rate of technical success for LTF patients. After controlling for center effects, the independent variables associated with LTF included male sex, age, diabetes, dialysis dependence, ASA class 3 or greater, as well as complications requiring admission. Preoperative aspirin, preadmission home living status, prior carotid intervention, and discharge aspirin were protective against LTF. Adjusted survival analysis showed decreased survival in LTF, with those returning face-to-face surviving longer than those with phone follow-up. Efforts should be focused on understanding these differences to improve follow-up rates and help improve overall survival.


Assuntos
Perda de Seguimento , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos
7.
Gastroenterology ; 157(3): 682-691.e2, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31152740

RESUMO

BACKGROUND & AIMS: Proton pump inhibitors (PPIs) are effective at treating acid-related disorders. These drugs are well tolerated in the short term, but long-term treatment was associated with adverse events in observational studies. We aimed to confirm these findings in an adequately powered randomized trial. METHODS: We performed a 3 × 2 partial factorial double-blind trial of 17,598 participants with stable cardiovascular disease and peripheral artery disease randomly assigned to groups given pantoprazole (40 mg daily, n = 8791) or placebo (n = 8807). Participants were also randomly assigned to groups that received rivaroxaban (2.5 mg twice daily) with aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), or aspirin (100 mg) alone. We collected data on development of pneumonia, Clostridium difficile infection, other enteric infections, fractures, gastric atrophy, chronic kidney disease, diabetes, chronic obstructive lung disease, dementia, cardiovascular disease, cancer, hospitalizations, and all-cause mortality every 6 months. Patients were followed up for a median of 3.01 years, with 53,152 patient-years of follow-up. RESULTS: There was no statistically significant difference between the pantoprazole and placebo groups in safety events except for enteric infections (1.4% vs 1.0% in the placebo group; odds ratio, 1.33; 95% confidence interval, 1.01-1.75). For all other safety outcomes, proportions were similar between groups except for C difficile infection, which was approximately twice as common in the pantoprazole vs the placebo group, although there were only 13 events, so this difference was not statistically significant. CONCLUSIONS: In a large placebo-controlled randomized trial, we found that pantoprazole is not associated with any adverse event when used for 3 years, with the possible exception of an increased risk of enteric infections. ClinicalTrials.gov Number: NCT01776424.


Assuntos
Aspirina/administração & dosagem , Doenças Cardiovasculares/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Hemorragia Gastrointestinal/prevenção & controle , Pantoprazol/administração & dosagem , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Bomba de Prótons/administração & dosagem , Rivaroxabana/administração & dosagem , Idoso , Aspirina/efeitos adversos , Doenças Cardiovasculares/diagnóstico , Método Duplo-Cego , Esquema de Medicação , Enterocolite Pseudomembranosa/induzido quimicamente , Enterocolite Pseudomembranosa/microbiologia , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Pantoprazol/efeitos adversos , Doença Arterial Periférica/diagnóstico , Inibidores da Agregação de Plaquetas/efeitos adversos , Estudos Prospectivos , Inibidores da Bomba de Prótons/efeitos adversos , Medição de Risco , Fatores de Risco , Rivaroxabana/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
8.
Angiol Sosud Khir ; 25(2): 25-33, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31149988

RESUMO

The protocols of performing treadmill tests (TMT) in patients presenting with peripheral artery disease have over the last decades undergone significant changes, with the alterations concerning not only the speed and time values of the load, but also the parameters measured. Currently, there is no unified generally accepted method of TMT, hence the need for an optimal protocol for carrying out this type of examination, which would help obtain reliable results in assessment of everyday life functional activity of patients and efficacy of various methods of treatment for peripheral atherosclerosis. The choice of an optimal methodology of performing a TMT in patients with intermittent claudication is extremely important because studying the haemodynamic parameters alone not always clearly reflect functional peculiarities of the course of the disease, since they depend not only on the presence of arterial stenoses or occlusions, but also on the activity of oxidative enzymes, endothelial and mitochondrial dysfunction, taking therapeutic agents, concomitant pathology and a series of other factors. The article is a review of the related literature contained in such databases as the Medline, PubMed, Russian Science Citation Index (RSCI) and Scopus and concerning TMT in patients with peripheral artery disease. The authors summarized the information from a total of 63 literature sources over the period from the 1970s to 2018.


Assuntos
Teste de Esforço , Doença Arterial Periférica , Humanos , Claudicação Intermitente/diagnóstico , Doença Arterial Periférica/diagnóstico , Federação Russa , Caminhada
9.
J Vasc Surg ; 69(6S): 126S-136S, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31159976

RESUMO

BACKGROUND: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence. METHODS: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies. RESULTS: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low. CONCLUSIONS: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.


Assuntos
Implante de Prótese Vascular , Procedimentos Endovasculares , Isquemia/terapia , Doença Arterial Periférica/terapia , Veia Safena/transplante , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Doença Crônica , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Salvamento de Membro , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Intervalo Livre de Progressão , Medição de Risco , Fatores de Risco , Veia Safena/fisiopatologia , Stents , Fatores de Tempo , Grau de Desobstrução Vascular
10.
J Vasc Surg ; 69(6S): 3S-125S.e40, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159978

RESUMO

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.


Assuntos
Cardiologia/normas , Medicina Baseada em Evidências/normas , Isquemia/terapia , Doença Arterial Periférica/terapia , Técnicas de Imagem Cardíaca/normas , Doença Crônica , Consenso , Testes de Função Cardíaca/normas , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Valor Preditivo dos Testes , Fatores de Risco , Terminologia como Assunto , Resultado do Tratamento
11.
J Vasc Surg ; 69(6): 1863-1873.e1, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159987

RESUMO

BACKGROUND: The overall use of intensive care units (ICUs) in the United States has been steadily increasing and is associated with tremendous health care costs. We suspect that the burden of ICU utilization after elective infrainguinal lower extremity bypass (LEB) procedures is high, despite relatively low risks of complications in the immediate postoperative period. We sought to identify the burden of ICU utilization after elective LEB in patients with claudication. METHODS: We queried the Premier Healthcare Database for all adult patients undergoing first recorded elective infrainguinal LEB for claudication from 2009 to 2015. Baseline characteristics and ICU utilization on postoperative day 0 (POD 0) were identified for each patient using Premier room and board chargemaster codes. A bivariate logistic regression was performed and postestimation concordance statistics were calculated to identify predictors of postoperative ICU vs regular surgical floor admission immediately after surgery. RESULTS: There were 6010 patients who met the selection criteria, of whom 2772 (46.1%) were admitted to the ICU and 3238 (53.9%) to the regular surgical floor on POD 0. Whereas patient-level factors were responsible for minor differences found in postoperative admission to the ICU after elective LEB, hospital characteristics made up the majority of variation in admission practices. Specifically, patients undergoing elective infrainguinal LEB in rural, nonteaching, small hospitals and those in certain geographic regions were more likely to be admitted to the ICU than to the floor (all, P < .001). Patient-level factors were poorly predictive of admission to the ICU immediately postoperatively, with C statistics ranging from 0.50 to 0.53. In contrast, hospital-level factors had higher C statistics ranging from 0.51 to 0.66, with geographic location being the strongest predictor of post-LEB ICU admission. There were no significant differences in the incidence of postoperative wound complications, major adverse limb events, major adverse cardiac events, or in-hospital mortality between groups (all, P ≥ .32). The median total hospital cost was $2340 higher for ICU compared with floor admission ($13,273 [interquartile range, $10,136-$17,883] vs $10,927 [interquartile range, $8342-$14,523]; P < .001). CONCLUSIONS: Nearly half of patients are admitted to an ICU directly after elective infrainguinal LEB for claudication. This practice is associated with significantly higher hospital cost and is predominantly influenced by hospital-level rather than by patient-level factors. Perioperative morbidity and mortality were similar regardless of postoperative disposition. To minimize ICU utilization, postoperative care intensity should be determined by clinical severity of the patient rather than by hospital routine.


Assuntos
Cuidados Críticos/economia , Custos Hospitalares , Claudicação Intermitente/economia , Claudicação Intermitente/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/economia , Doença Arterial Periférica/cirurgia , Enxerto Vascular/economia , Idoso , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Unidades de Terapia Intensiva/economia , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/mortalidade , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/economia , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
12.
Clin Podiatr Med Surg ; 36(3): 361-370, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31079603

RESUMO

The accurate assessment of peripheral perfusion is a critical step in caring for a diabetic patient with active ulceration. This article guides the provider through diagnostic and therapeutic options. The perfusion assessment begins with a physical examination and augmented using noninvasive tests. Although some of these tests can be performed at the bedside, often a dedicated vascular laboratory is required. Additional cross-sectional imaging studies or formal angiography should be performed as well. These tools aid in the creation of the best therapeutic plan, which aims to restore perfusion and allow for rapid wound healing via open or endovascular means.


Assuntos
Diabetes Mellitus/fisiopatologia , Pé Diabético/cirurgia , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/cirurgia , Índice Tornozelo-Braço , Circulação Sanguínea/fisiologia , Pressão Sanguínea/fisiologia , Pé Diabético/diagnóstico por imagem , Diagnóstico por Imagem , Procedimentos Endovasculares , Pé/irrigação sanguínea , Pé/diagnóstico por imagem , Humanos , Doença Arterial Periférica/fisiopatologia , Exame Físico , Pulso Arterial , Procedimentos Cirúrgicos Vasculares
13.
Diabetes Res Clin Pract ; 152: 9-15, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31078668

RESUMO

AIM: To evaluate the impact of below-the-ankle (BTA) arterial disease in people with ischemic diabetic foot ulcers (DFUs). METHODS: Patients with ischemic DFUs treated by a pre-set limb salvage protocol including peripheral revascularization were included. They were divided in two groups according to the involvement of BTA arteries (BTA+) or not (BTA-). Not healing, minor amputation, major amputation and mortality have been evaluated as primary outcome. Revascularization failure has been evaluated as secondary outcome. RESULTS: The study group was composed of 272 patients, 120 (44.1%) belonging to BTA+ group and 152 (55.9%) to BTA-. After 1 year of follow-up the outcomes for BTA+ and BTA- were respectively: not healing (40.8 vs 17.8%, p < 0.0001), minor amputation (80.8 vs 20.4%, p < 0.0001), major amputation (18.3 vs 6.6%, p = 0.002), mortality (16.7% vs 10.5%, p = 0.001). The rate of revascularization failure was respectively 38.3 vs 11.2%, p < 0.0001. At the multivariate analysis BTA arterial disease resulted an independent predictor of not healing [OR 3.5 (CI 95% 2.3-6.1) p = 0.0001], minor amputation [OR 3.1 (1.5-5.9) p < 0.0001] and revascularization failure [OR 3.5 (1.9-6.3) p = 0.0001]. BTA+ patients with successful BTA revascularization showed lower rate of not healing (37.8 vs 89.1%) p < 0.0001, minor amputation (74.3 vs 91.3%) p = 0.002 and major amputation (8.1 vs 34.8%) p = 0.0003 in comparison to patients with unsuccessful BTA revascularization. CONCLUSION: BTA arterial disease severely impairs the outcomes of diabetics with ischemic foot ulcers. BTA revascularization reduces the rate of not healing, minor and major amputation.


Assuntos
Tornozelo/irrigação sanguínea , Pé Diabético/complicações , Pé Diabético/diagnóstico , Isquemia/complicações , Isquemia/diagnóstico , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Amputação , Tornozelo/patologia , Articulação do Tornozelo/fisiopatologia , Estudos de Coortes , Pé Diabético/mortalidade , Pé Diabético/cirurgia , Feminino , Humanos , Isquemia/mortalidade , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/mortalidade , Prognóstico , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Cicatrização/fisiologia
14.
Eur J Vasc Endovasc Surg ; 57(6): 868-875, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31126835

RESUMO

OBJECTIVES: The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on arterial stiffness in patients undergoing vascular surgery. METHODS: This was a randomised, sham controlled, double blind, single centre study. Patients undergoing open abdominal aortic aneurysm repair, surgical lower limb revascularisation surgery or carotid endarterectomy were recruited. A RIPC or a sham procedure was performed, using a blood pressure cuff, along with preparation for anaesthesia. The RIPC protocol consisting of four cycles of 5 min of ischaemia, followed by 5 min of reperfusion was applied. Arterial stiffness and haemodynamic parameters were measured pre-operatively and 20-28 h after surgery. Two primary outcomes were selected: augmentation index and pulse wave velocity. RESULTS: Ninety-eight patients were randomised. After dropouts 44 and 46 patients were included in the RIPC and sham groups, respectively. Both groups were comparable. There were no statistically significant differences in augmentation index (p = .8), augmentation index corrected for heart rate of 75 beats per minute (p = .8), pulse wave velocity (p = .7), large artery elasticity indices (p = .8), small artery elasticity indices (p = .6), or mean arterial pressure (p = .7) changes between the RIPC and sham groups. There occurred statistically significant (p ≤ .01) improvement in augmentation index (-5.8% vs. -5.5%), augmentation index corrected for a heart rate of 75 beats per minute (-2.5% vs. -2%), small artery elasticity indices (0.7 mL/mmHg × 100 vs. 0.9 mL/mmHg × 100), and mean arterial pressure post-operatively in both the RIPC and the sham groups (change median values in RIPC and sham groups, respectively). CONCLUSIONS: RIPC had no significant effect on arterial stiffness, but there was significant improvement in arterial stiffness after surgery in both groups. Arterial stiffness and haemodynamics may be influenced by surgery or anaesthesia or oxidative stress or all factors combined. Further studies are needed to clarify these findings. CLINICALTRIALS.GOV: NCT02689414.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Doenças das Artérias Carótidas/cirurgia , Precondicionamento Isquêmico/métodos , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Oclusão Terapêutica/métodos , Extremidade Superior/irrigação sanguínea , Rigidez Vascular , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/fisiopatologia , Pressão Arterial , Doenças das Artérias Carótidas/diagnóstico , Doenças das Artérias Carótidas/fisiopatologia , Método Duplo-Cego , Estônia , Feminino , Humanos , Precondicionamento Isquêmico/efeitos adversos , Precondicionamento Isquêmico/instrumentação , Masculino , Manometria , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Análise de Onda de Pulso , Oclusão Terapêutica/efeitos adversos , Oclusão Terapêutica/instrumentação , Fatores de Tempo , Torniquetes , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
15.
Vasc Med ; 24(4): 313-323, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31023156

RESUMO

The role of cilostazol after endovascular therapy (EVT) of peripheral artery disease (PAD) remains unclear. We conducted a meta-analysis for all studies reporting the outcomes of cilostazol after EVT of PAD from January 2000 through November 2018 with the outcomes of interest including primary patency, major adverse limb events (MALE), target lesion revascularization (TLR), and major amputation. We included eight studies (three randomized controlled trials (RCTs) and five observational studies) with a total of 3846 patients (4713 lesions). During a mean follow-up duration of 12.5 ± 5 months, the use of cilostazol was associated with higher primary patency (OR 2.28, 95% CI (1.77, 2.94), p < 0.001, I2 = 24%), lower risk of TLR (OR 0.37, 95% CI (0.26, 0.52), p < 0.001, I2 = 0%), and lower risk of major amputation (OR 0.15, 95% CI (0.04, 0.62), p = 0.008, I2 = 0%). The use of cilostazol in RCTs was associated with significantly higher odds of primary patency compared with observational studies (OR 3.37 vs 2.28, p-interaction = 0.03). After further subgroup analysis, cilostazol remained associated with higher primary patency regardless of the use of anticoagulants (warfarin) (p-interaction = 0.49). We conclude that the use of cilostazol after EVT of femoropopliteal and iliac lesions is associated with improved primary patency and lower risk of major amputation and TLR. The favorable impact of cilostazol is independent of the use of warfarin. PROSPERO identifier: CRD42018092715.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Cilostazol/uso terapêutico , Procedimentos Endovasculares , Doença Arterial Periférica/terapia , Idoso , Idoso de 80 Anos ou mais , Amputação , Fármacos Cardiovasculares/efeitos adversos , Cilostazol/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Fatores de Proteção , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular/efeitos dos fármacos
16.
Vasc Med ; 24(4): 306-312, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31023166

RESUMO

Common carotid artery (CCA) intima-media thickness (IMT) is associated with coronary heart disease and can be measured on ultrasound images either by hand or with an automated edge detector. The association of CCA IMT with incident peripheral artery disease (PAD) is poorly studied. We studied 5467 participants of the Multi-Ethnic Study of Atherosclerosis composed of non-Hispanic white, Chinese, Hispanic, and African American participants with a mean age of 61.9 years (47.8% men). Framingham Risk Factors, manual-traced IMT (mt-IMT), and edge-detected IMT (ed-IMT) were entered into multivariable Cox proportional hazards models with incident PAD as the outcome. There were 87 events during a median follow-up of 12.2 years. In fully adjusted models and expressing the hazard ratios (HR) as an increment in SD values, both mt-IMT and ed-IMT were significantly associated with incident PAD: HR 1.36 (95% CI: 1.15, 1.61) and 1.29 (95% CI: 1.04, 1.60), respectively. We conclude that ed- and mt-CCA IMT measurements are associated with incident PAD. ClinicalTrials.gov Identifier: NCT00063440.


Assuntos
Artéria Carótida Primitiva/diagnóstico por imagem , Espessura Intima-Media Carotídea , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/etnologia , Interpretação de Imagem Assistida por Computador , Doença Arterial Periférica/etnologia , Idoso , Idoso de 80 Anos ou mais , Índice Tornozelo-Braço , Feminino , Humanos , Incidência , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
17.
Blood Purif ; 47 Suppl 2: 25-30, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30943475

RESUMO

BACKGROUND: Peripheral arterial disease (PAD) has increased in association with the increase in the numbers of patients with kidney disease or diabetes. The aim of this study was to assess the prevalence of PAD in hemodialysis patients with diabetes. METHODS: To examine the usefulness of the cardio-ankle vascular index (CAVI) to screen for the presence of PAD, cross-sectional studies of 100 patients undergoing chronic hemodialysis were performed. The CAVI and other inflammatory markers were evaluated. RESULTS: The CAVI was markedly elevated in patients with a history of PAD or cardiovascular disease. When dialysis patients were classified on the basis of CAVI quartiles, increased CAVI was associated with other risk factors for PAD. CONCLUSION: The prevalence of PAD is high in elderly diabetic patients on hemodialysis. The present findings suggest that the CAVI can be a useful index that predicts the occurrence of macrovascular complications in dialysis patients with diabetes.


Assuntos
Complicações do Diabetes/etiologia , Nefropatias/complicações , Doença Arterial Periférica/etiologia , Diálise Renal , Idoso , Índice Tornozelo-Braço , Estudos Transversais , Complicações do Diabetes/diagnóstico , Feminino , Humanos , Nefropatias/terapia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Prevalência , Fatores de Risco , Rigidez Vascular
18.
Ann Vasc Surg ; 59: 195-201, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31034949

RESUMO

BACKGROUND: Compartment syndrome (CS) is a feared complication after revascularization for acute limb ischemia (ALI), and patients often undergo prophylactic 4-compartment fasciotomy at the time of revascularization to avoid developing CS and its associated complications. However, fasciotomy carries its own morbidity and surgeons may opt against this initially. The subsequent development of CS would mandate fasciotomy in a delayed fashion. We sought to investigate relationships between fasciotomy timing and patient outcomes. METHODS: Patients who underwent lower extremity revascularization for ALI from 2005 to 2017 were retrospectively identified from an institutional database. Fasciotomy was classified as either prophylactic (occurring with revascularization) or delayed. Associations among patient characteristics, comorbidities, fasciotomy timing, and patient outcomes were evaluated. RESULTS: A total of 138 patients met study inclusion criteria. Forty-two patients (30.4%) underwent fasciotomy, and of these, 8 (19%) were delayed. Patients with higher Rutherford ALI classification were more likely to undergo fasciotomy (I 4.2%, IIA 13.2%, IIB 53.3%, P < 0.001), and patients with coronary artery disease were less likely (16.1% vs. 83.9% fasciotomy, P = 0.003). Ischemia time >6 hr was noted in 66.7% of patients, although this was not significantly associated with fasciotomy occurrence (≤6 hr 21.7% fasciotomy vs. >6 hr 34.8% fasciotomy, P = 0.17). Patients undergoing delayed fasciotomy were more likely to require major amputation within 30 days (50% vs. 5.9%, P = 0.002). CONCLUSIONS: The decision to perform prophylactic fasciotomy in the setting of ALI is complex. When not performed, the subsequent development of CS requiring delayed fasciotomy appears to be associated with increased risk of major amputation at 30 days. This suggests that a liberal approach to prophylactic fasciotomy at the time of revascularization may improve limb salvage rates.


Assuntos
Amputação , Síndromes Compartimentais/cirurgia , Fasciotomia/efeitos adversos , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Tempo para o Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/etiologia , Bases de Dados Factuais , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
Angiology ; 70(8): 737-746, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31030528

RESUMO

GlycA, a composite biomarker of systemic inflammation, is associated with cardiovascular disease (CVD) and mortality, but its relationship with peripheral artery disease (PAD) is unknown. We assessed whether plasma GlycA is associated with ankle-brachial index (ABI), carotid plaque (CP), and incident clinical PAD among 6466 Multi-Ethnic Study of Atherosclerosis participants without CVD at baseline. GlycA, ABI, and CP were measured at baseline. Both ABI and CP were remeasured at 10 years. Incident clinical PAD was ascertained from hospital records. We used logistic, Cox, and linear mixed regression models adjusted for demographic and lifestyle factors. Mean (standard deviation, SD) was 62 (10) years for age and 381 (61) µmol/L for GlycA; 53% were women. GlycA was associated with both prevalent low ABI ≤0.8 (prevalence odds ratio [95% confidence interval, CI] per SD increment in GlycA, 1.65 [1.39-1.97]) and CP (1.19 [1.11-1.27]) at baseline. There were no significant associations of GlycA with incident low ABI, incident CP, or 10-year change in ABI or CP score. We identified 110 incident cases of PAD after 79 590 person-years. The hazard ratio (95% CI) of incident PAD per SD increment in GlycA was 1.38 (1.14-1.66). In conclusion, GlycA was associated with prevalent low ABI, prevalent CP, and incident PAD after a median of 14 years.


Assuntos
Aterosclerose/sangue , Biomarcadores/sangue , Inflamação/sangue , Doença Arterial Periférica/sangue , Idoso , Aterosclerose/diagnóstico , Aterosclerose/terapia , Feminino , Humanos , Inflamação/diagnóstico , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Placa Aterosclerótica/sangue , Placa Aterosclerótica/diagnóstico , Modelos de Riscos Proporcionais , Medição de Risco , Fatores de Risco
20.
Clin Chim Acta ; 495: 215-220, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30981846

RESUMO

BACKGROUND: Peripheral artery disease (PAD) becomes more prevalent with advancing age and is associated with elevated risk of cardiovascular events and shortened life expectancy. We investigated the prognostic performance of cardiac and vascular biomarkers in a cohort of PAD patients. METHODS: A total of 95 PAD patients were enrolled (mean age 68 years, range 47 to 86 years, 73 males). Carotid intima-media thickness (cIMT), ankle brachial index (ABI), high sensitive cardiac troponin T, and N-terminal pro-B-type Natriuretic Peptide (NT-proBNP) were measured. RESULTS: During a median follow-up time of 9.5 years, 44 patients died and 51 patients survived. Upon Kaplan-Meier survival analysis hs-TnT (P < .001) or NT-proBNP levels (P < .001) above the median but not cIMT above the median (P = .488) or ABI below the median (P < .436)were associated with reduced survival rate. Upon univariate cox regression and after adjustment for age, gender, prior cerebral artery disease, and diabetes mellitus only the association between hs-cTnT and mortality remained significant (HR 1.93, 95% CI 1.33-2.79, P < .001). In receiver operating curve analysis hs-cTnT (area under the curve [AUC]: 0.77, 95% CI: 0.67-0.87, P < .001) NT-proBNP (AUC: 0.74, 95% CI: 0.64-0.84, P < .001) as well as hs-cTnT, and NT-proBNP combined (AUC: 0.79, 95% CI: 0.69-0.88, P < .001) were superior to cIMT (AUC: 0.64, 95%, CI: 0.53-0.76, P = .022) and ABI (AUC: 0.57, 95% CI: 0.44-0.68, P = .313) in discriminating risk for mortality. CONCLUSION: hs-cTnT and NT-proBNP should be taken into account for prognosis of patients with PAD.


Assuntos
Miocárdio/metabolismo , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Idoso , Idoso de 80 Anos ou mais , Índice Tornozelo-Braço , Aterosclerose/complicações , Biomarcadores/sangue , Espessura Intima-Media Carotídea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Doença Arterial Periférica/sangue , Doença Arterial Periférica/complicações , Prognóstico
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