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1.
J Cardiovasc Surg (Torino) ; 61(1): 24-36, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32079378

RESUMO

INTRODUCTION: Open repair (OR), fenestrated endovascular aneurysm repair (fEVAR) and endovascular exclusion using parallel graft (chEVAR) are complementary procedures used for treatment of juxtarenal abdominal aortic aneurysm (jrAAA). The aim of our study was to assess available literature and analyze dispersion of OR, fEVAR and chEVAR procedures among reported papers related to treatment of jrAAA. EVIDENCE ACQUISITION: The PubMed database was systematically searched using predefined strategy and key words related to treatment of jrAAA on September 28th, 2019. Studies were assessed for eligibility using the inclusion and exclusion criteria with at least five patients treated with at least one of the procedures while systematic reviews, meta-analysis, reviews, comments, editorials and letters were excluded as well as studies without clear classification of the location of the aneurysm, studies not specifying the number of patients treated with each of the techniques or not discriminated between aortic pathologies (juxtarenal, paravisceral and thoracoabdominal), hybrid procedures, endoanchors or with branched stent-graft. EVIDENCE SYNTHESIS: Overall, 1533 papers were identified while papers that met inclusion criteria were either representing experience of single institution (87 papers) or from multicenter studies (6 papers), national or international registries (18 papers). In the period between January 1977 and December 2017, treatment of 5664 patients with jrAAA was reported in 87 papers as a single institution report. Out of them 2531 (45%) were treated with OR, 2592 (46%) with fEVAR and 541 (9%) with chEVAR. Out of 29 institutions reporting OR, there were 11 (37.9%) with more than 100 treated patients while 21 (41.1%) out of 51 institutions that reported more than 50 jrAAA treated with fEVAR. Only four institutions reported results of all three treatment modalities. CONCLUSIONS: Based on the results reported in the literature, regardless of its complexity and costs, fEVAR for jrAAA has been accepted in substantial number of hospitals worldwide, while number of reported procedures is reaching OR.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Fatores de Risco , Resultado do Tratamento
2.
Eur J Vasc Endovasc Surg ; 59(3): 385-397, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31899100

RESUMO

OBJECTIVE: The objective was to investigate whether endovascular aneurysm repair (EVAR) has better peri-operative and late clinical outcomes than open repair for non-ruptured abdominal aortic aneurysm. METHODS: Electronic bibliographic sources (MEDLINE, EMBASE, and CENTRAL) were searched up to July 2019 using a combination of thesaurus and free text terms to identify randomised controlled trials (RCTs) comparing the outcomes of EVAR and open repair. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI). A time to event data meta-analysis was performed using the inverse variance method and the results were reported as summary hazard ratio (HR) and 95% CI. RESULTS: Seven RCTs reporting a total of 2 983 patients were included in quantitative synthesis. Three of the trials reported long term follow up that extended to 15.8 years, 14.2 years, and 12.5 years. Meta-analysis found significantly lower odds of 30 day (OR, 0.36; 95% CI 0.20-0.66) and in hospital mortality with EVAR (RD -0.03; 95% CI -0.04 to -0.02). Meta-analysis of the three trials reporting long term follow up found no significant difference in all cause mortality at any time between EVAR and open repair (HR 1.02; 95% CI 0.93-1.13; p = .62). The hazard of all cause (HR 0.62; 95% CI 0.42-0.91) and aneurysm related death within six months (HR 0.42; 95% CI 0.24-0.75) was significantly lower in patients who underwent EVAR, but with further follow up, the pooled hazard estimate moved in favour of open surgery; in the long term (>8 years) the hazard of aneurysm related mortality was significantly higher after EVAR (HR 5.12; 95% CI 1.59-16.44). The risk of secondary intervention (HR 2.13; 95% CI 1.69-2.68), aneurysm rupture (OR, 5.08; 95% CI 1.11-23.31), and death due to rupture (OR, 3.57; 95% CI 1.87-6.80) was significantly higher after EVAR, but the risk of death due to cancer was not significantly different between EVAR and open repair (OR, 1.03; 95% CI 0.84-1.25). CONCLUSION: Compared with open surgery, EVAR results in a better outcome during the first six months but carries an increased risk of aneurysm related mortality after eight years.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
3.
Eur J Vasc Endovasc Surg ; 59(3): 399-410, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31932143

RESUMO

OBJECTIVE: The aim was to assess peri-operative mortality of endovascular aneurysm repair (EVAR) vs. open repair for ruptured abdominal aortic aneurysm (AAA) and to investigate whether outcomes have improved over the years and whether there is an association between institutional caseload and peri-operative mortality. METHODS: Electronic information sources (MEDLINE, EMBASE, CINAHL and CENTRAL) were searched up to August 2019. A systematic review was carried out according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a registered protocol (CRD42018106084). Studies were selected that reported peri-operative mortality of EVAR for ruptured AAA. A proportion meta-analysis was conducted, and summary estimates of odds ratios (ORs) and 95% confidence intervals (CIs) for EVAR vs. open surgical repair were obtained using random effects models. Mixed effects regression models were developed to investigate outcome changes over time and with institutional caseload. RESULTS: One hundred and thirty-six studies were included in quantitative synthesis reporting a total of 267 259 patients (EVAR 58 273; open surgery 208 986). The pooled peri-operative mortality of EVAR and open surgical repair was 0.245 (95% CI 0.234-0.257) and 0.378 (95% CI 0.364-0.392), respectively. EVAR was associated with reduced peri-operative mortality (OR 0.54, 95% CI 0.51-0.57, p < .001). Meta-regression analysis found decreasing peri-operative mortality over the years following EVAR (p < .001) and open repair (p < .001), and a decreasing OR of peri-operative mortality in favour of EVAR (p = .053). Meta-regression found a significant positive association between peri-operative mortality and institutional case load for open repair (p = .004). CONCLUSION: If EVAR can be done, it is a better treatment for ruptured AAA in view of the reduced peri-operative mortality compared with open surgery. The outcomes of both EVAR and open surgical repair have improved over the years, and the difference in peri-operative mortality in favour of EVAR has become more pronounced. There is a significant association between peri-operative mortality and institutional case load for open repair of ruptured AAA.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Complicações Pós-Operatórias/etiologia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
8.
Angiology ; 71(3): 242-248, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31829038

RESUMO

We identified changes in renal function in patients who underwent thoracic endovascular aortic repair (TEVAR) and the factors that may influence renal function. Information on 470 consecutive patients was collected. Kidney function and contrast volume were recorded. Unpaired t test, Spearman correlation, and logistic regression were used for statistical analysis. A Kaplan-Meier curve helped clarify our follow-up findings. Mean contrast volume was 90.5 ± 21.2 mL. The change in serum creatinine was significantly correlated with (1) preexisting renal pathology (P = .033) and (2) aortic dissection (AD) involving the renal arteries (P = .019). The change in serum urea nitrogen (ΔBUN) was only significantly correlated with AD involving the renal arteries (P = .0348). Contrast volume (P = .036, odds ratio = 1.010, 95% confidence interval: 1.001-1.019) was a risk factor for contrast-induced nephropathy (CIN) after TEVAR. Survival rates and renal failure rates among no CIN, CIN, and CIN-acute kidney injury groups at longest 27 months follow-up were significantly different. Creatinine and BUN were generally elevated post-TEVAR. Contrast-induced nephropathy post-TEVAR may correlate with renal comorbidities and renal artery involvement. Contrast volume is risk factor for CIN after TEVAR. More attention needs to be paid to patient renal function during follow-up.


Assuntos
Aneurisma Dissecante/mortalidade , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/mortalidade , Rim/fisiopatologia , Adulto , Idoso , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal/mortalidade , Insuficiência Renal/fisiopatologia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
9.
Ann Vasc Surg ; 62: 183-190.e1, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30710629

RESUMO

BACKGROUND: There is varying evidence regarding the effects of body mass index (BMI) on outcomes of endovascular aneurysm repair (EVAR). This study investigates the effects of BMI on an index of perioperative and postoperative outcomes after EVAR. METHODS: Four hundred ninety-two patients who underwent elective EVAR at Mount Sinai Hospital were included in this study. Patients were classified as either normal weight (BMI = 18.5-25), overweight (BMI = 25-30), or obese (BMI>30). Chi-squared tests were used to determine significant differences between weight classes across an index of outcomes. The following outcomes were collected: intraoperative complications (e.g., conversion to open), perioperative complications (e.g., hematoma, bowel ischemia, and so forth), and postoperative outcomes (endoleak, sac enlargement, sac shrinkage, access site infection, prolonged postoperative length of stay, reintervention, stroke, claudication/lower extremity ischemia, deep vein thrombosis, limb occlusion, renal complications, abdominal aortic aneurysm (AAA) rupture, AAA-related mortality, and all-cause mortality). Kaplan-Meier survival analysis and a log-rank test were used to determine meaningful differences in all-cause mortality following EVAR between the respective weight classes. Subsequently, multivariate Cox proportional hazards were performed for selection of outcomes, with weight classes as predictors. Finally, a multivariate logistic regression was performed for postoperative hospital stay. Subgroup multivariate analysis was also performed examining only class I obese patients, rather than all obese patients. RESULTS: Overweight patients were significantly less likely to experience all-cause mortality up to 9 years after EVAR than normal-weight patients in both Kaplan-Meier and multivariable Cox proportional hazards models. Obese patients similarly had a lower risk of mortality in Kaplan-Meier analysis, but this did not persist in the multivariate analysis. Overweight patients were also significantly less likely to require a postoperative hospital stay longer than 1 day when compared with normal-weight patients. Finally, obese patients were less likely to have a sac shrinkage greater than 5 mm after EVAR, but were also less likely to have an endoleak. CONCLUSIONS: This study adds to the debate on the effects of BMI on outcomes of EVAR. Obesity was not a risk factor for negative perioperative or postoperative outcomes after EVAR with the exception of decreased sac shrinkage. Obese patients were less likely to have an endoleak, and overweight patients were protected against all-cause mortality and longer postoperative hospital stays.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Índice de Massa Corporal , Procedimentos Endovasculares , Obesidade/complicações , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Obesidade/diagnóstico , Obesidade/mortalidade , Valor Preditivo dos Testes , Fatores de Proteção , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
10.
Ann Vasc Surg ; 62: 223-231, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31200065

RESUMO

BACKGROUND: A hybrid approach of aortic arch and descending aorta pathology, involving surgical debranching of the great vessels after endovascular stenting, has been increasingly used as an alternative to entirely open surgical repair. This study reviews and reports our single-center experience with hybrid aortic arch repair over the span of a decade. METHODS: A total of 43 patients who underwent hybrid arch repair from 2005 to 2015 were identified. Key endpoints included the presenting pathology, perioperative details, and postoperative outcomes. RESULTS: The mean age was 64.9 years at the commencement of surgery (61.4% men [n = 27] and 38.6% women [n = 16]). Presenting pathologies included aneurysms (77%), dissections (16%), pseudoaneurysms (5%), and transections (2%). While most procedures were multistaged, single-stage interventions were completed for 16.3% (n = 7) of patients. Emergent surgeries were performed in 23.3% of cases; the remaining 76.7% of cases were elective. The proximal extents of endovascular repair were zone 0 (n = 4), zone 1 (n = 12), zone 2 (n = 20), and zone 3 (n = 1). The remaining 6 patients had had aberrant or anomalous distal origins of a great vessel that required debranching. Technical success rates of surgical revascularizations and subsequent endovascular stenting were both 100%. The 30-day perioperative event rates for mortality, stroke, and cardiac events were 7.0% (n = 3), 4.7% (n = 2), and 9.3% (n = 4), respectively. At the end of 2-year follow-up, total mortality and stroke rates were 11.6% (n = 5) and 7.0% (n = 3), respectively. The 2-year primary patency of the revascularizations was 97.8%, and the associated primary-assisted patency was 100%. Secondary interventions were necessary for 32% (n = 12) of the patients, 67% of which (n = 8) were warranted because of endoleaks. The remaining secondary interventions were required to resolve device migration (n = 1), stent graft stenosis (n = 1), and disease progression (n = 2). CONCLUSIONS: Hybrid approaches are viable alternatives to entirely open surgical treatments of acute and chronic aortic arch pathology and may be particularly attractive for high-risk patients. Surgical revascularizations appear durable, but endovascular reintervention is not uncommon and highlights the need for careful surveillance after repair.


Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento
11.
Ann Vasc Surg ; 62: 35-44, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31201971

RESUMO

BACKGROUND: Iliac branch devices (IBDs) can treat iliac and aortoiliac aneurysms (AIAs) less invasively than open surgery (OS) and preserve pelvic perfusion. Our hypothesis was that the rates of perioperative complications after treatment for AIAs are similar between IBDs and hypogastric occlusion with coil and cover (C&C), and lower than OS. METHODS: We identified patients undergoing elective AIA repair by IBD, C&C, and OS (all with infrarenal clamps) within the National Surgical Quality Improvement Program (NSQIP) vascular aneurysm specific Participant User Files (2012-2016). Baseline characteristics, procedural variables, and 30-day outcomes were compared. The primary outcomes were any major complication or death. Secondary outcomes included minor complications, total operative time, total and intensive care unit length of stay (LOS), and reinterventions. Multivariable logistic regression assessed differences in major complications between IBD and C&C/OS after adjusting for patient and procedural variables. RESULTS: We identified 593 patients (83% men, mean age 71.6 ± 9 years) undergoing elective AIA repair (IBD = 283, C&C = 118, and OS = 192). Patient age and American Society of Anesthesiology (ASA) classification varied significantly between groups. Mean aneurysm diameter was higher for OS and similar between IBD and C&C (5.9 cm vs. 5.5 cm and 5.2 cm, respectively, P < 0.001). OS was associated with higher rate of major complications (65.5% vs. IBD: 8.8% and C&C: 13.6%, P=<0.001) and higher mortality (3.6% vs. IBD: 0.7% and C&C: 0%, P = 0.017). Minor complications and reinterventions were similar. IBD patients had significantly shorter total operative time and total and intensive care unit LOS. After adjustment, OS was associated with higher major complications compared with IBD (Odds ratio [OR]: 11.3, 95% confidence interval [CI]: 5.8-21.9, P < 0.001), primarily because of the use of transfusions (major complications excluding transfusions OR: 1.3, 95% CI: 0.6-2.8, P = 0.52). Major complications between IBD and C&C were similar (OR: 1.6, 95% CI: 0.8-3.4, P = 0.23). CONCLUSIONS: The use of IBDs for elective treatment of AIAs is associated with favorable perioperative outcomes and a lower rate of major complications compared with OS, primarily because of fewer transfusions. IBDs use has perioperative outcomes similar to C&C with the associated benefit of preserving pelvic perfusion. Pending long-term durability results for this technique, IBDs appear to be associated with several perioperative advantages in patients with AIAs compared with OS and C&C.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Aneurisma Ilíaco/cirurgia , Pelve/irrigação sanguínea , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/instrumentação , Embolização Terapêutica/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Aneurisma Ilíaco/mortalidade , Aneurisma Ilíaco/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
12.
Ann Vasc Surg ; 62: 63-69, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31201979

RESUMO

INTRODUCTION: Coverage of one or both renal arteries may be required to facilitate endovascular aneurysm repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic aneurysms (rAAAs). We sought to understand the consequences of renal coverage during these emergent procedures. METHODS: Using the VQI data set from 2013 to 2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included inhospital mortality, composite permanent dialysis/30-day death, and 1-year survival. RESULTS: Overall, there were 2,278 patients presenting with ruptured aneurysms. Most patients had no renal artery coverage (n = 2,230; 98%), followed by single renal artery coverage (n = 30; 1.2%), and finally bilateral renal artery coverage (n = 18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of inhospital mortality (odds ratio [OR] = 5.7, ±4; P = 0.030), permanent dialysis/30-day death (OR = 9.5, ±7; P = 0.016), and permanent dialysis (OR = 47.5, ±47; P < 0.001). Two patients with bilateral renal coverage did not suffer permanent dialysis/death. Single renal artery coverage significantly increased the odds of permanent dialysis/30-day death (OR = 2.8, ±1.6; P = 0.044) driven mainly by its effect on the outcome of permanent dialysis (OR = 12.3, ±6; P < 0.001). Unadjusted Kaplan-Meier one-year survival estimates were significantly lower with bilateral renal coverage (hazard ratio [HR] = 3.4, P = 0.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR = 3.5, P = 0.002); however, single renal coverage did not significantly affect survival in unadjusted or adjusted models. CONCLUSIONS: Bilateral renal coverage in rAAA significantly increases inhospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its effect on permanent dialysis, it does not significantly affect inhospital mortality or one-year survival and may be a viable option for select patients with rAAAs.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Renal/cirurgia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Desenho de Prótese , Sistema de Registros , Artéria Renal/diagnóstico por imagem , Diálise Renal , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
13.
Ann Vasc Surg ; 62: 206-212, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31449938

RESUMO

BACKGROUND: We describe the long-term follow-up of patients treated for infrarenal abdominal aortic aneurysms and penetrating ulcers by placement of tubular aortic endografts at our institution from 2010 to present. METHODS: This is a retrospective study using clinical data of patients treated from 2010 to present by placement of either a single aortic tubular endograft or by two overlapping endografts, using the "trombone technique." Aortic dimensions were measured from the preoperative computed tomography scans using three-dimensional reconstruction. The primary outcome was aortic reintervention. Secondary outcomes were aorta-related mortality, endoleaks, and postoperative complications. RESULTS: Twenty-eight patients were identified. Nine patients were treated for saccular aneurysms, and nineteen patients presented with penetrating aortic ulcers. The median follow-up was 31 months (range: 4-99). Twenty patients were treated with a single tubular device, while eight patients were treated using two overlapping devices. Aortic reintervention occurred in four patients (14.3%), all were treated initially with a single device. No aortic mortality occurred during follow-up. No aneurysm ruptures occurred. Four patients died during follow-up of unrelated causes. Endoleaks occurred in ten patients (35%). Five endoleaks were of type I (17.8%), of which three were of distal type (10.7%). Five endoleaks were of type II (17.8%). Shorter distal landing zones than 20 mm were present in two of the cases with a distal type I endoleak (P = 0.0232). Postoperative complications occurred in three (10.7%) patients including one myocardial infarction and two wound complications from a surgical cut down in the groin. CONCLUSIONS: The technique shows an acceptable postoperative complication rate but is characterized by high rate of occurrence of type I endoleaks and aortic reintervention in our series. Endovascular techniques using tubular endografts should be limited to cases with long proximal and distal sealing zones. The trombone technique seems preferable.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Úlcera/cirurgia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Causas de Morte , Endoleak/etiologia , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Reoperação , Estudos Retrospectivos , Fatores de Risco , Suíça , Fatores de Tempo , Resultado do Tratamento , Úlcera/diagnóstico por imagem , Úlcera/mortalidade
14.
Ann Vasc Surg ; 62: 295-303, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31449946

RESUMO

BACKGROUND: The vast majority of patients undergoing hemodialysis (HD) are anemic. The severity of anemia in these patients may influence the postoperative outcomes and the durability of vascular access. Thus, the purpose of this study is to assess the association between anemia and adverse outcomes in patients undergoing HD access placement (arteriovenous grafts and fistula). METHODS: Patients with chronic kidney disease stages IV and V recorded in the Vascular Quality Initiative Hemodialysis database between 2011 and 2017 were included. Patients were divided into 3 study groups based on preoperative hemoglobin (Hgb) levels: normal/mild anemia (Hgb: females ≥10 g/dL, males ≥12 g/dL), moderate anemia (Hgb: females: 7-9.9 g/dL, males: 9-11.9 g/dL), and severe anemia (Hgb: females<7 g/dL, males<9 g/dL). Multivariable logistic and Cox regression analyses were implemented to evaluate the association between anemia and 30-day mortality and primary patency (PP) at 1 year. RESULTS: A total of 28,000 patients undergoing HD access surgery were identified (normal/mild [42%], moderate [49%], and severe [9%] anemia). Postoperative bleeding (2.1% vs. 2.2% vs. 2.2%) and 30-day outcomes including swelling (0.4% vs. 0.5% vs. 0.7%) and wound infection (0.4% vs. 0.3% vs. 0.1%) were similar in mild/normal, moderate, and severe anemia groups, respectively (All P > 0.05). However, 30-day mortality was significantly higher in patients with severe anemia compared with normal/mild and moderate anemia (2.1% vs. 1.1% and 1.1%, P < 0.001). After adjusting for potential confounders, severe anemia was associated with 90% higher risk of 30-day mortality (odds ratio [95% confidence interval]: 1.90 [1.20-3.00], P = 0.006) and 17% increase in PP loss at 1 year (adjusted hazard ratio [95% confidence interval]: 1.17 [1.02-1.35], P = 0.01) compared with the normal/mild anemia group. However, no significant difference was seen between normal/mild and moderate anemia. CONCLUSIONS: In this large study of patients undergoing HD access placement, severe anemia was associated with 90% increased risk of 30-day mortality and 17% increased risk of loss of PP compared with those with normal/mild anemia. Management of severe anemia before surgery might be indicated to reduce operative mortality and improve the durability of HD access.


Assuntos
Anemia/sangue , Derivação Arteriovenosa Cirúrgica , Implante de Prótese Vascular , Hemoglobinas/metabolismo , Diálise Renal , Insuficiência Renal Crônica/terapia , Idoso , Anemia/diagnóstico , Anemia/mortalidade , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/mortalidade , Biomarcadores/sangue , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Diálise Renal/efeitos adversos , Diálise Renal/mortalidade , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Grau de Desobstrução Vascular
16.
Semin Thorac Cardiovasc Surg ; 31(4): 679-685, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31279912

RESUMO

Frozen Elephant Trunk (FET) combines the advantages of open and endovascular surgery for the treatment of complex aortic arch pathologies extending into the descending aorta. At University Hospital Essen, operative skills were developed to make FET surgery safer including guidance and control of FET deployment into the descending aorta by angioscopy and facilitation of arch repair by moving the distal anastomosis to Zone 2 and more proximally. Selective whole body perfusion during the arch repair was used to improve organ protection under moderate hypothermia. Our results demonstrate acceptable mortality in this high risk patient population and reduction of postoperative morbidity in the last years. With regard to the rate of exclusion of aneurysms in the distal arch and the false lumen in acute aortic dissection, FET should be the treatment of choice in both. In chronic aortic dissection and extensive descending aortic aneurysms, FET represents a safe first stage procedure and provides an ideal docking place in the mid-descending aorta for a second endovascular or open thoracoabdominal aortic repair, if required.


Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Doenças da Aorta/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Desenho de Prótese , Fatores de Risco , Resultado do Tratamento
17.
Semin Thorac Cardiovasc Surg ; 31(4): 674-678, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31271851
18.
Ann Vasc Surg ; 60: 76-84.e1, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31220590

RESUMO

BACKGROUND: Treatment of common and internal iliac aneurysms is usually done by open surgery. A novel iliac branch endoprosthesis (IBE) is commercially available with encouraging initial results. Our objective is to compare perioperative outcomes of patients with iliac aneurysms treated by open surgery (OS) versus endovascular repair with IBE. METHODS: The study was a retrospective, single-center review of patients who were treated for aortoiliac or isolated common and/or internal iliac artery aneurysms from 2014 to 2017. Patients with connective tissue disorders, infected grafts, or thoracoabdominal aneurysms were excluded. Primary outcomes were perioperative mortality, length of hospital (LOS) and intensive care unit (ICU) stay, estimated blood loss, need for red blood cell transfusion (RBC), and perioperative reinterventions. RESULTS: Sixty-seven patients (96% male) were treated with OS (n = 25, mean age 68 ± 8 years) or IBE (n = 42, mean age 73 ± 8 years; P = 0.02) with 1 symptomatic patient in each group. Perioperative mortality occurred in 1 patient in the OS group (4%), with no mortality in the IBE group (P = 0.37) Total LOS and ICU stay was higher for OS compared to IBE (total stay 7.5 ± 3.4 vs. 1.7 ± 1.4 days for IBE, P < 0.0001 and ICU LOS 3.3 ± 2.1 vs. 0.1 ± 0.4 days, P < 0.0001). Estimated blood loss was higher for patients undergoing OS (4,732 ± 2,540 mL) compared to patients treated with IBE (263 ± 451 mL, P < 0.0001), resulting in higher RBC transfusion requirements (1.5 ± 2.4 vs. 0.2 ± 0.8 units, P = 0.001). Five patients in the OS group had early procedure-related reinterventions, while 2 patients in the IBE group required reintervention for access site complications (20% vs. 4.7%, P = 0.09). CONCLUSIONS: Endovascular repair of iliac aneurysms with IBE is feasible and is associated with lower blood loss, LOS and ICU stay, and had lower RBC transfusion requirements. Cost analysis and long-term follow-up will be needed to define the value of this modality for iliac artery aneurysm repair.


Assuntos
Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Aneurisma Ilíaco/cirurgia , Stents , Idoso , Idoso de 80 Anos ou mais , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Aneurisma Ilíaco/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
Ann Vasc Surg ; 60: 435-446.e1, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31200054

RESUMO

BACKGROUND: Insufficient evidence is available to recommend a particular strategy for the treatment of type 1a endoleaks (T1aELs) after endovascular abdominal aneurysm repair (EVAR). The aim of this study was to report outcomes of the different treatment modalities proposed for persistent and late-occurring T1aEL after EVAR. METHODS: A systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library) was undertaken until August 2018. Studies about treatment of T1aEL after EVAR (excluding intraoperative treatments during the first EVAR) presenting a series of 5 or more patients with extractable outcome data (at least intraoperative and/or early results) were included. Meta-analyses of proportions were performed using a random-effects model. RESULTS: A total of 39 nonrandomized studies were included (714 patients; 88.1% males, 95% confidence interval [CI] 84.5-91.7; weighted mean age 75.76 years, 95% CI 74.11-77.4). Overall estimated technical success (TS) and clinical success (CS) rates were 93.2% (95% CI 90.5-95.8) and 88.2% (95% CI 84.5-91.9), respectively. Two hundred eighteen patients underwent proximal extension (98.1% TS, 95% CI 96.3-99.8), 131 chimney EVAR (93.9% TS, 95% CI 89.9-97.9), 97 fenestrated EVAR (86.2% TS, 95% CI 77.3-95.1), 90 open conversion (96.5% TS, 95% CI 93-100), 71 embolization (95.2% TS, 95% CI 90.4-100), 35 endostapling (57.2% TS, 95% CI 14.1-100), and 72 conservative treatment (75.4% CS, 95% CI 56.4-94.5). Estimated overall 30-day mortality was 3.2% (95% CI 1.7-4.7), and it was higher for patients undergoing open surgery (6.6%, 95% CI 1.7-11.5). Overall, endoleak resolution during the mean follow-up of 19.4 months (95% CI 15.45-23.36) was maintained in 91% of the patients (95% CI 87.7-94.3). CONCLUSIONS: T1aEL repair appeared generally feasible, with good early to midterm outcomes. Different treatments are available, and the choice should be based on endoleak characteristics, aortic anatomy, and the patient's surgical risk. Conservative treatment and endoleak embolization should be considered only in selected cases, such as low-flow endoleaks and unfit patients.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Embolização Terapêutica , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/mortalidade , Tomada de Decisão Clínica , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/mortalidade , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/mortalidade , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Reoperação , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
20.
Vasc Endovascular Surg ; 53(6): 458-463, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31185832

RESUMO

BACKGROUND: Few long-time follow-up studies describe all complications, treatment outcome of complications, and mortality in relation to endovascular aneurysm repair (EVAR). The purpose of this study was to evaluate the incidence and treatment outcome including mortality of radiological visible complications related to the EVAR procedure at a single center with up to 10 years' surveillance. MATERIALS AND METHODS: Patients treated with EVAR from March 2006 to March 2016 at a Danish university hospital, 421 in total, were included. Patient and aneurysm characteristics, follow-up, and secondary intervention data were collected from a national database and medical records. Follow-up computed tomography angiography and plain abdominal X-ray reports were reviewed for complications. Scans and X-rays with suspected complications were evaluated by an interventional radiologist. RESULTS: A total of 172 complications in 147 patients, mainly in the beginning of the follow-up period, were found; 35% had a least one complication. The main part of complications (62%) was type II endoleaks, followed by stent graft stenosis (11%), type I endoleaks (9%), and stent graft occlusion (7%). A total of 66 (38%) complications, observed in 55 patients, were treated with reintervention, of which 77% were treated with endovascular procedures and 23% with surgical treatment, that is, 13% of all studied patients had a complication that required a reintervention. The remaining 2 of the 3 complications were treated conservatively. We found no increased all-cause mortality in connection with having a complication including those requiring reintervention. CONCLUSION: We presented a 10-year single-center study of EVAR. Many patients treated with EVAR had a radiological visible complication, mainly in the beginning of the follow-up period. Only a smaller fraction required reintervention and having a reintervention-requiring complication was not connected to increased mortality.


Assuntos
Aneurisma/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Idoso , Aneurisma/diagnóstico por imagem , Aneurisma/epidemiologia , Aneurisma/mortalidade , Implante de Prótese Vascular/mortalidade , Dinamarca/epidemiologia , Procedimentos Endovasculares/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
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