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2.
Medicine (Baltimore) ; 98(48): e18002, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770213

RESUMO

RATIONALE: Mesenteric venous thrombosis is an uncommon but potentially fatal condition that can cause bowel ischemia. It results from a systemic hypercoagulable state or abdominal infection draining into the portal venous system. Several cases regarding portomesenteric venous thrombosis as a complication of appendicitis were reported in adults, but there are far fewer reports in pediatric patients. The mortality rate of the condition is high if untreated, especially in children, reaching up to 50%. PATIENT CONCERNS: A healthy 15-year-old male with no significant past medical history presented with right lower quadrant pain, lethargy, and fever. The computed tomography scan showed a focal thrombosis at the superior mesenteric vein branch and an inflamed appendix. DIAGNOSES: Mesenteric venous thrombosis complicating acute appendicitis. INTERVENTIONS: Intravenous antibiotics along with anticoagulants and laparoscopic appendectomy OUTCOMES:: After 1 month, a follow-up ultrasonography revealed full resolution of the thrombosis. LESSONS: Appendicitis is one of the most frequently encountered causes of pediatric surgical emergencies; therefore, physicians should be conscious of mesenteric venous thrombosis as a possible complication of acute appendicitis, irrespective of whether patients have thrombophilic conditions or not.


Assuntos
Apendicite/complicações , Isquemia Mesentérica/terapia , Veias Mesentéricas/cirurgia , Doença Aguda , Adolescente , Antibacterianos/uso terapêutico , Anticoagulantes/uso terapêutico , Apendicectomia/métodos , Apendicite/terapia , Humanos , Masculino , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/etiologia , Veias Mesentéricas/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Ultrassonografia
3.
BMJ Case Rep ; 12(9)2019 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-31551317

RESUMO

Mesenteric ischaemia represents an uncommon complication of splanchnic vein thrombosis which requires a high level of suspicion to diagnose in a timely manner. This report discusses a case of portal, splenic and superior mesenteric vein thrombosis leading to mesenteric ischaemia and infarct in a 79-year-old man. The diagnosis of acute mesenteric ischaemia and splanchnic vein thrombosis remains difficult due to the non-specific symptoms of these conditions. As diagnosis does continue to improve, treatment of acute mesenteric ischaemia using medical management has become increasingly possible before ischaemia advances to the point at which surgical resection is required.


Assuntos
Isquemia Mesentérica/etiologia , Veias Mesentéricas/patologia , Veia Porta/patologia , Veia Esplênica/patologia , Trombose Venosa/complicações , Dor Abdominal , Idoso , Diagnóstico Diferencial , Humanos , Jejuno/cirurgia , Masculino , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/cirurgia , Veias Mesentéricas/diagnóstico por imagem , Veia Porta/diagnóstico por imagem , Veia Esplênica/diagnóstico por imagem , Tomógrafos Computadorizados , Trombose Venosa/diagnóstico por imagem
4.
J Med Vasc ; 44(5): 318-323, 2019 Sep.
Artigo em Francês | MEDLINE | ID: mdl-31474341

RESUMO

INTRODUCTION: Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries. METHODS: We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018. RESULTS: Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (>70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day. CONCLUSION: Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.


Assuntos
Angioplastia , Isquemia Mesentérica/terapia , Oclusão Vascular Mesentérica/terapia , Idoso , Angioplastia/efeitos adversos , Angioplastia/instrumentação , Doença Crônica , Feminino , Humanos , Masculino , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Circulação Esplâncnica , Stents , Fatores de Tempo , Resultado do Tratamento
6.
Trials ; 20(1): 519, 2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31429792

RESUMO

BACKGROUND: Chronic mesenteric ischemia (CMI) is the result of insufficient blood supply to the gastrointestinal tract and is caused by atherosclerotic stenosis of one or more mesenteric arteries in > 90% of cases. Revascularization therapy is indicated in patients with a diagnosis of atherosclerotic CMI to relieve symptoms and to prevent acute-on-chronic mesenteric ischemia, which is associated with high morbidity and mortality. Endovascular therapy has rapidly evolved and has replaced surgery as the first choice of treatment in CMI. Bare-metal stents (BMS) are standard care currently, although retrospective studies suggested significantly higher patency rates for covered stents (CS). The Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI) trial is designed to prospectively assess the patency of CS versus BMS in patients with atherosclerotic CMI. METHODS/DESIGN: The CoBaGI trial is a randomized controlled, parallel-group, patient- and investigator-blinded, superiority, multicenter trial conducted in six centers of the Dutch Mesenteric Ischemia Study group (DMIS). Eighty-four patients with a consensus diagnosis of atherosclerotic CMI are 1:1 randomized to either a balloon-expandable BMS (Palmaz Blue with rapid-exchange delivery system, Cordis Corporation, Bridgewater, NJ, USA) or a balloon-expandable CS (Advanta V12 over-the-wire, Atrium Maquet Getinge Group, Hudson, NH, USA). The primary endpoint is the primary stent-patency rate at 24 months assessed with CT angiography. Secondary endpoints are primary stent patency at 6 and 12 months and secondary patency rates, freedom from restenosis, freedom from symptom recurrence, freedom from re-intervention, quality of life according the EQ-5D-5 L and SF-36 and cost-effectiveness at 6, 12 and 24 months. DISCUSSION: The CoBaGI trial is designed to assess the patency rates of CS versus BMS in patients treated for CMI caused by atherosclerotic mesenteric stenosis. Furthermore, the CoBaGI trial should provide insights in the quality of life of these patients before and after stenting and its cost-effectiveness. The CoBaGI trial is the first randomized controlled trial performed in CMI caused by atherosclerotic mesenteric artery stenosis. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02428582 . Registered on 29 April 2015.


Assuntos
Angioplastia com Balão/instrumentação , Aterosclerose/terapia , Materiais Revestidos Biocompatíveis , Isquemia Mesentérica/terapia , Oclusão Vascular Mesentérica/terapia , Metais , Stents , Angioplastia com Balão/efeitos adversos , Aterosclerose/diagnóstico por imagem , Aterosclerose/fisiopatologia , Doença Crônica , Método Duplo-Cego , Estudos de Equivalência como Asunto , Humanos , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Estudos Multicêntricos como Assunto , Países Baixos , Placa Aterosclerótica , Intervalo Livre de Progressão , Desenho de Prótese , Recidiva , Circulação Esplâncnica , Fatores de Tempo , Grau de Desobstrução Vascular
7.
Emerg Radiol ; 26(5): 523-529, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31240505

RESUMO

PURPOSE: To retrospectively evaluate the utility of biphasic multi-detector computed tomography (MDCT) with arterial and portal venous phases for the detection of suspected acute mesenteric ischemia (AMI) in emergency department (ED) patients compared to limited surgical confirmation. METHODS: A research ethics board (REB)-approved retrospective review of all consecutive adult patients who underwent an emergency biphasic 64-MDCT examination of the abdomen and pelvis due to clinical suspicion for AMI over a 5-year period at a single tertiary-care institution was performed. Patients who underwent biphasic 64-MDCT scans performed for any clinical concern other than suspected acute mesenteric ischemia were excluded. Specifically, reported vascular and bowel findings were used to establish occlusive arterial, venous, and non-occlusive MDCT findings of AMI. Correlation was made with surgical findings in operatively managed patients and with serum lactate values preceding imaging assessment. Diagnostic yield and positive predictive value calculations were performed. RESULTS: Two hundred and twenty-five patients underwent MDCT for suspected occlusive AMI between 10 Jan 2011 and 31Jul 2016. Of these, 200 patients were negative for AMI and 25 patients (mean age 73.5 years; age range 48 to 94 years; 13 men and 12 women) had MDCT findings positive for bowel ischemia (yield of 11.1%). On MDCT, 18/25 (72%) had an occlusive arterial etiology for AMI, 2/25 (8%) had an occlusive venous etiology, and 5/25 (20%) had non-occlusive AMI. Twenty of 25 (80%) patients with positive MDCT findings of AMI also had an elevated serum lactate level, including 14/18 (77.8%) patients with arterial occlusive AMI on MDCT, 2/2 (100%) with venous-occlusive AMI on MDCT, and 4/5 (80%) with non-occlusive AMI on MDCT. Correlation with surgical findings led to a positive predictive value (PPV) of biphasic MDCT for surgically proven all-cause occlusive ischemia of 92.9%. Further substratification revealed PPVs of arterial and venous-occlusive ischemia of 85.7% and 7.1%, respectively. Of the 225 patients MDCT-positive for AMI, 213 had pre-imaging serum lactate assessments. Of 188 patients MDCT-negative for AMI, 85 patients had elevated serum lactate (45.2%). Twenty of the 25 patients with positive MDCT findings of AMI (80%) also had an elevated serum lactate level, including 14/18 (77.8%) patients with arterial occlusive AMI on MDCT, 2/2 (100%) with venous-occlusive AMI on MDCT, and 4/5 (80%) with non-occlusive AMI on MDCT. CONCLUSION: Emergent biphasic MDCT demonstrated low but non-trivial yield (11.1%) for the depiction of suspected acute mesenteric ischemia but was particularly low for occlusive venous AMI (0.9%). The relationship between serum lactate elevation and positive MDCT findings of AMI in our study conforms to prior work and cautiously suggests value in routine serum lactate assessment preceding imaging for patient prioritization.


Assuntos
Serviço Hospitalar de Emergência , Isquemia Mesentérica/diagnóstico por imagem , Tomografia Computadorizada Multidetectores , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
8.
Emerg Radiol ; 26(5): 515-521, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31209593

RESUMO

OBJECTIVES: To assess the usefulness of the neutrophil-to-lymphocyte ratio (NLR) as a predictive factor of acute mesenteric ischemia (AMI) in patients presenting at the emergency department (ED) with acute abdominal pain. METHODS: This is a retrospective case-control study of patients older than 16 years admitted to the ED with acute abdominal pain with CT and histologic confirmation. The study group corresponded to patients with abdominal CT with radiological signs of AMI. The control group corresponded to patients with non-AMI findings in abdominal CT. Association measurements of NLR with radiological signs were compared with a paired-sample t test, and multivariate regression performed to analyze potential correlations. To assess the diagnosis capacity of NLR, ROC curves were calculated. RESULTS: A total of 61 patients were included (32 cases and 29 controls). The cases of AMI showed higher mortality (43.8% vs 6.9%, p < 0.01) and higher NLR on the limit of statistical significance (13.8 vs 8.7, p = 0.053). Patients with AMI due to occlusion of the superior mesenteric artery (SMA) showed a higher NLR (8.3 vs 22.3, p < 0.001). The area under the curve (AUC) of the NLR for AMI due to occlusion of the SMA was 0.88 (95% CI 0.7-1.0, p = 0.001). No patient with NLR < 5 presented AMI due to occlusion of the SMA. An NLR of 12.8 showed a sensitivity of 92% and a specificity of 74% for AMI due to occlusion of SMA. CONCLUSIONS: The NLR is a useful parameter of AMI of arterial origin due to occlusion of the SMA; it can help the clinician to raise suspicion of this diagnosis and the interpreting radiologist in the acquisition protocol for the CT study and would alert for an early surgical treatment.


Assuntos
Abdome Agudo/diagnóstico por imagem , Linfócitos/patologia , Isquemia Mesentérica/sangue , Isquemia Mesentérica/diagnóstico por imagem , Neutrófilos/patologia , Tomografia Computadorizada por Raios X/métodos , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
9.
J Med Case Rep ; 13(1): 171, 2019 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-31159864

RESUMO

BACKGROUND: Vascular complications of acute pancreatitis are common. Splanchnic thrombosis accounts for 11% of these complications, whereas extrasplanchnic thrombosis remains a rare entity. These complications are associated with high morbidity and mortality. Diagnosis is established on the basis of clinical and radiological evaluation, especially computed tomography. Renal vein thrombosis has been reported previously, but only in association with thrombosis of the inferior vena cava. To our knowledge, renal vein thrombosis without inferior vena cava thrombosis has never been reported in the literature. We report a case of a woman who developed acute pancreatitis complicated with splanchnic thrombosis and renal vein thrombosis with a patent inferior vena cava. CASE PRESENTATION: A 48-year-old Moroccan woman with no significant past medical history presented to our emergency department with worsening epigastric pain and vomiting. Her physical examination was notable only for moderate epigastric tenderness. She was apyrexic and had no jaundice or any features of liver failure. An initial computed tomographic scan showed Balthazar grade C pancreatitis with multiple splanchnic thromboses involving the portal vein, superior mesenteric vein, and left renal vein and enteromesenteric venous infarct with no signs of bowel perforation. The inferior vena cava was patent. Therapeutic anticoagulation and analgesia were started with resumption of enteral feeding 72 h later. The result of a thrombophilia screen was negative. Two months later, the patient was admitted to the intensive care unit with acute liver failure. Computed tomography of the abdomen showed worsening ischemic liver lesions and no signs of bowel perforation. Biochemical analysis showed acute hepatitis with hepatocellular insufficiency. The clinical evolution was unfavorable, and the patient died 48 h later. CONCLUSIONS: Association of splanchnic and renal vein thrombosis without inferior vena cava thrombosis as a complication of acute pancreatitis has never been reported before. There are no specific aspects of management of this complication; therapeutic anticoagulation and symptomatic treatment are the main measures used owing to the lack of available organs for liver transplant. The prognosis depends on the consequences of splanchnic thrombosis and their complications.


Assuntos
Isquemia Mesentérica/etiologia , Pancreatite/complicações , Trombose Venosa/etiologia , Anticoagulantes/uso terapêutico , Evolução Fatal , Feminino , Insuficiência Hepática/etiologia , Humanos , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Hepatopatias/diagnóstico por imagem , Hepatopatias/etiologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/tratamento farmacológico , Pessoa de Meia-Idade , Pancreatite/diagnóstico , Veia Porta/diagnóstico por imagem , Veias Renais/diagnóstico por imagem , Circulação Esplâncnica , Tomografia Computadorizada por Raios X , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/tratamento farmacológico
10.
Vasc Endovascular Surg ; 53(6): 497-500, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31043138

RESUMO

We present a case of an 18-year-old female with neurofibromatosis type 1 who presented with abdominal pain and weight loss secondary to chronic mesenteric ischemia due to celiac axis occlusion and was subsequently found to have multiple visceral artery aneurysms. Of clinical significance, 2 aneurysms of the right renal artery were noted at the hilum, with the larger one having a diameter of 2.4 cm. After initial endovascular treatment with stenting of a concurrent pancreaticoduodenal artery pseudoaneurysm, staged aorto-hepatic bypass and right nephrectomy with renal autotransplantation after back table resection of the aneurysmal segments were successfully completed.


Assuntos
Aneurisma/cirurgia , Artéria Celíaca/cirurgia , Procedimentos Endovasculares/métodos , Transplante de Rim/métodos , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Neurofibromatose 1/complicações , Artéria Renal/cirurgia , Enxerto Vascular/métodos , Adolescente , Aneurisma/diagnóstico por imagem , Aneurisma/etiologia , Aneurisma/fisiopatologia , Angiografia Digital , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Feminino , Humanos , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/etiologia , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/etiologia , Oclusão Vascular Mesentérica/fisiopatologia , Neurofibromatose 1/diagnóstico , Artéria Renal/diagnóstico por imagem , Artéria Renal/fisiopatologia , Circulação Renal , Circulação Esplâncnica , Transplante Autólogo , Resultado do Tratamento
11.
Ann Vasc Surg ; 59: 306.e11-306.e15, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31075449

RESUMO

Ostial stenosis of the superior mesenteric artery (SMA) is usually a benign finding due to the significant collateralization inherent with visceral vessels. There is a subset of patients, however, with significant atherosclerotic disease leading to in situ thrombosis and subsequent mesenteric ischemia requiring intervention. Over the last 20 years, management of mesenteric ischemia-acute or chronic-has transitioned from an open embolectomy or bypass to an endovascular-first approach involving angioplasty and stenting. We are reporting a unique case of recurrent SMA stent fracture with imaging demonstrating diaphragmatic compression of the SMA during the respiratory cycle, subsequent management, and recommendations for future intervention.


Assuntos
Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/instrumentação , Artéria Mesentérica Superior , Isquemia Mesentérica/terapia , Oclusão Vascular Mesentérica/terapia , Falha de Prótese , Stents , Idoso , Circulação Colateral , Angiografia por Tomografia Computadorizada , Feminino , Hemodinâmica , Humanos , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Recidiva , Circulação Esplâncnica , Resultado do Tratamento , Ultrassonografia Doppler em Cores , Procedimentos Cirúrgicos Vasculares
12.
Eur J Vasc Endovasc Surg ; 57(6): 842-849, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31126834

RESUMO

OBJECTIVES: Despite modern advances in diagnosis and treatment, acute arterial mesenteric ischaemia (AMI) remains a high mortality disease. One of the key modifiable factors in AMI is the first door to operation time, but the factors attributing to this parameter are largely unknown. The aim of this study was to evaluate the factors affecting delay, with special focus on the pathways to treatment. METHODS: This was a single academic centre retrospective study. Patients undergoing intervention for AMI caused by thrombosis or embolism of the superior mesenteric artery between 2006 and 2015 were identified from electronic patient records. Patients not eligible for intervention or with chronic, subacute onset, colonic only, venous, or non-occlusive mesenteric ischaemia were excluded. Patients were divided into two groups according to the first speciality examining the patient (surgical emergency room [SER], surgeon examining the patient first or non-surgical emergency room [non-SER], internist examining the patient first). The primary endpoint was first door to operation time and secondary endpoints were length of stay and 90 day mortality. RESULTS: Eighty-one patients with AMI were included. Fifty patients (62%) died during the first 30 days and 53 (65%) within 90 days. Presenting first in non-SER (vs. SER) was independently associated with a first door to operation time of over 12 h (OR 3.7 [95% CI 1.3-10.2], median time 15.2 h [IQR 10.9-21.2] vs. 10.1 h [IQR 6.9-18.5], respectively, p = .025). The length of stay was shorter (median 6.5 days [4.0-10.3] vs. 10.8 days [7.0-22.3], p = .045) and 90 day mortality was lower in the SER group (50.0% vs. 74.5%, p = .025). CONCLUSIONS: The first specialty that the patient encounters seems to be crucial for both delayed management and early survival of AMI. Developing fast/direct pathways to a unit with both gastrointestinal and vascular surgeons offers the possibility of improving the outcome of AMI.


Assuntos
Comportamento de Escolha , Serviço Hospitalar de Emergência , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Encaminhamento e Consulta , Tempo para o Tratamento , Triagem , Centros Médicos Acadêmicos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Procedimentos Clínicos , Registros Eletrônicos de Saúde , Feminino , Humanos , Tempo de Internação , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/mortalidade , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/mortalidade , Oclusão Vascular Mesentérica/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Especialização , Fatores de Tempo , Resultado do Tratamento
13.
Vasc Endovascular Surg ; 53(5): 424-428, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30982410

RESUMO

Endovascular treatment of chronic mesenteric ischemia is currently the treatment of choice, regardless of the number of involved vessels. Unlike other anatomic areas, the hyperperfusion produced by revascularization and the consecutive reperfusion syndrome is only described in cases of acute bowel ischemia, which is usually resolved with traditional surgery. We present a case of severe hyperperfusion syndrome secondary to endovascular correction with stents of a critical ischemia affecting the celiac trunk and superior mesenteric artery.


Assuntos
Angioplastia com Balão/efeitos adversos , Artéria Celíaca , Artéria Mesentérica Superior , Isquemia Mesentérica/terapia , Oclusão Vascular Mesentérica/terapia , Traumatismo por Reperfusão/etiologia , Idoso , Angioplastia com Balão/instrumentação , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Doença Crônica , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Traumatismo por Reperfusão/diagnóstico por imagem , Traumatismo por Reperfusão/terapia , Circulação Esplâncnica , Stents , Resultado do Tratamento , Grau de Desobstrução Vascular
14.
Ann Vasc Surg ; 59: 313.e5-313.e10, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31009713

RESUMO

Median arcuate ligament (MAL) syndrome usually involves the celiac artery (CA) only. Far less frequently, both the CA and superior mesenteric artery (SMA) are compressed, leading to chronic mesenteric ischemia. We report the case of a 46-year-old woman with a 4-year history of permanent nausea, postprandial abdominal pain, and asthenia. A clear epigastric bruit was observed on physical examination. Duplex ultrasound and computed tomography angiography revealed an occlusion of the CA and a highly compressed proximal SMA by the MAL, with an important collateral mesenteric network. Laparoscopic release of the MAL using a transperitoneal retrorenal approach was performed, with excellent postoperative outcomes. Compression of the SMA by the MAL is a rare cause of chronic mesenteric ischemia. Laparoscopic release of the SMA from the MAL using a transperitoneal retrorenal approach is safe and effective. Long-term outcomes need to be further assessed.


Assuntos
Artéria Celíaca/cirurgia , Descompressão Cirúrgica/métodos , Laparoscopia , Síndrome do Ligamento Arqueado Mediano/cirurgia , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Doença Crônica , Circulação Colateral , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Síndrome do Ligamento Arqueado Mediano/complicações , Síndrome do Ligamento Arqueado Mediano/diagnóstico por imagem , Síndrome do Ligamento Arqueado Mediano/fisiopatologia , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/etiologia , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/etiologia , Oclusão Vascular Mesentérica/fisiopatologia , Pessoa de Meia-Idade , Circulação Esplâncnica , Resultado do Tratamento , Grau de Desobstrução Vascular
15.
Ann Vasc Surg ; 59: 102-109, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31009717

RESUMO

BACKGROUND: Fenestrated/branched endografts for aortic repair (FB-EVAR) are valid options to treat thoracoabdominal aortic aneurysms (TAAAs). Successful repair requires manipulation of target visceral vessels (TVVs) with possible splanchnic ischemia. The aim of the study was to evaluate the clinical impact of splanchnic ischemia occurring in FB-EVAR for TAAA. METHODS: Between 2010 and 2015, patients with TAAAs undergoing FB-EVAR were prospectively enrolled. Clinical, morphological, procedural, and 30-day data were evaluated. Splanchnic ischemia was defined as the presence of splanchnic ischemic lesions (SILs) visible at perioperative computed tomography angiography. Preoperative, postoperative, and 30-day hepatic/pancreatic/renal laboratory functions were analyzed. End points were incidence of SILs, laboratory splanchnic functions worsening (≥25% of baseline), and presence of related clinical/morphological and procedural risk factors. RESULTS: Thirty-six patients (male: 78%; age: 73 ± 7 years) with 27 (75%) type I-III and 9 (25%) type IV TAAA who underwent FB-EVAR for a total of 127 TVV (branches: 47-60%; fenestrations: 53-67%). Fourteen SILs occurred in 12 (33%) patients: 4 (29%) in pancreas, 3 (21%) in spleen, 2 (14%) in bowel, 5 (36%) in kidney. The cause was embolic in 79% and thrombotic in 21%. No preoperative clinical/morphological data or procedural data were correlated with SIL. Pancreatic, hepatic, or renal function worsening occurred at 24 hr in 16 (44%), 16 (44%), and 9 (25%) cases, respectively. Overall, SILs were associated with increased values of C-reactive protein (CRP) (17.9 ± 0.4 vs. 9.9 ± 9.0 mg/dL; P = 0.03) and bilirubin (1.2 ± 2.3 vs. 1.0 ± 0.5 mg/dL; P = 0.02) at 24 hr. Specifically, SIL of the celiac trunk and superior mesenteric and renal arteries' parenchyma were associated with the significant laboratory function changes 24 hr. SIL of the superior mesenteric artery was associated with increased 30-day mortality (50% vs. 7 %; P = 0.002). Pancreatic, hepatic, or renal function worsening occurred at 30 days in 2 (6%), 0 (0%), and 4 (12%) cases, with similar laboratory tests in patients with and without SIL. CONCLUSIONS: SIL can be frequently detected after FB-EVAR for TAAA and appears mainly of embolic origin. No clinical, morphological, or procedural predictors could be identified in our series. Postoperative laboratory changes of CRP, bilirubin, activated partial thromboplastin time, and amylases are associated with SIL but disappear without clinical consequences within 30 days. However, SIL occurring in the superior mesenteric artery are associated with an increased 30-day mortality.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Embolia/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/etiologia , Oclusão Vascular Mesentérica/etiologia , Circulação Esplâncnica , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/fisiopatologia , Implante de Prótese Vascular/mortalidade , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Embolia/diagnóstico por imagem , Embolia/mortalidade , Embolia/fisiopatologia , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/mortalidade , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/mortalidade , Oclusão Vascular Mesentérica/fisiopatologia , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Trombose/etiologia , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
16.
Ann Vasc Surg ; 58: 24-31, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31009732

RESUMO

BACKGROUND: Patients suffering from chronic mesenteric ischemia are at risk of malnutrition due to the fear of food and weight loss. However, the impact of malnutrition on the morbidity and mortality at the time of surgery is not studied extensively, just as its prevalence. The main objective of this study was to evaluate the influence of malnutrition on the survival of the patients operated for chronic mesenteric ischemia. The secondary objectives were to evaluate the prevalence of malnutrition in this population and to evaluate the early complications after surgery according to the nutritional condition of the patients. METHODS: We conducted a monocentric retrospective observational study including consecutively all the patients operated for chronic mesenteric ischemia between 2005 and 2016. The nutritional status was determined a posteriori according to the criteria of the French High Health Authority using body mass index, the percentage of weight loss, and albumin. We thus divided the patients into 2 groups, "malnourished" and "non-malnourished." We compared the survival of the patients of the 2 groups with a log-rank test. RESULTS: We enrolled 54 patients including 35 men (65%), with a mean age of 68.1 years (±12.3). The prevalence of malnutrition was 70% (38 patients), including 9 severely malnourished patients (23.6%). Twenty-nine patients (53.7%) were treated by endovascular technique, and twenty-five had conventional surgery (46.3%). The type of management was not different between the 2 groups: 20 patients of the malnourished group (52.6%) and 9 patients of the non-malnourished group (56.3%) were treated by endovascular technique (P = 0.8). The 30-day mortality was null in the non-malnourished group, whereas ten patients (26.3%) died in the malnourished group (P = 0.02). The short-term complications were not significantly different between the malnourished and the non-malnourished groups (37% vs. 19%, P = 0.32). The mean duration of follow-up was 639 days (±660). The 3-year survival was not different between the endovascular group and the open surgery group (43% vs. 52%, P = 0.7). The 3-year survival was statistically higher in the non-malnourished group (87%) than in the malnourished group (49.6%) (P = 0.01). CONCLUSIONS: In our experience, preoperative malnutrition is a factor significantly decreasing the survival of the patients treated with open surgery or with endovascular technique for chronic mesenteric ischemia. A more optimal preoperative management of this malnutrition could improve the results of these procedures.


Assuntos
Desnutrição/epidemiologia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Estado Nutricional , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Feminino , França/epidemiologia , Humanos , Masculino , Desnutrição/diagnóstico , Desnutrição/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/epidemiologia , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/epidemiologia , Oclusão Vascular Mesentérica/fisiopatologia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Prevalência , Estudos Retrospectivos , Fatores de Risco , Circulação Esplâncnica , Stents , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/instrumentação
17.
Semin Thorac Cardiovasc Surg ; 31(4): 668-673, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30980930

RESUMO

Malperfusion syndrome results from end-organ ischemia in the setting of an aortic dissection. Malperfusion syndrome can affect any vascular bed with mesenteric malperfusion (MMP) being the most challenging associated with a 3- to 4-fold increase in mortality in both acute type A and B aortic dissections. The incidence MMP is between 66% and 100% in different literature. The insidious onset of MMP, among the different ischemic end-organ complications, makes it a challenge for diagnosis and management. The management of MMP is still a polemic, as to whether initially the aortic repair to be done or to restore the mesenteric perfusion. The approach for acute type A aortic dissection with MMP includes initial central repair, endovascular repair followed by central repair or simultaneous repair. Endovascular remains the main mode of treatment for acute type B aortic dissection with MMP. With respect to the variation in presentation and degree of ischemia, a patient-specific approach is required for treating this condition.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma Aórtico/cirurgia , Hemodinâmica , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Circulação Esplâncnica , Procedimentos Cirúrgicos Vasculares , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/fisiopatologia , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/mortalidade , Aneurisma Aórtico/fisiopatologia , Humanos , Incidência , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/mortalidade , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/mortalidade , Oclusão Vascular Mesentérica/fisiopatologia , Sistema de Registros , Medição de Risco , Fatores de Risco , Síndrome , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
18.
World J Gastroenterol ; 25(9): 1100-1115, 2019 Mar 07.
Artigo em Inglês | MEDLINE | ID: mdl-30862998

RESUMO

BACKGROUND: Axial and coronal reformations have been a widely used image post-processing protocol for the ordinary multidetector computed tomography (MDCT) examination of patients with small bowel obstruction (SBO) or other abdominal diseases. The diagnostic accuracy of MDCT for assessing SBO is expected to be further improved through the use of multiple post-processing techniques. AIM: To systemically evaluate the diagnostic accuracy and efficiency of an optimized protocol using multiple post-processing techniques for MDCT assessment of SBO and secondary bowel ischemia. METHODS: This retrospective cross-sectional study included 106 patients with clinically suspected SBO. Two readers applied three protocols to image post-processing and interpretation of patients' MDCT volume data. We compared the three protocols based on time spent, number of images, diagnostic self-confidence, agreement, detection rate, and accuracy of detection of SBO and secondary bowel ischemia. RESULTS: Protocol 2 resulted in more time spent and number of images than protocols 1 and 3 (P < 0.01), but the results of the two readers using the same protocol were not different (P > 0.05). Using protocol 3, both readers added multiple post-processing techniques at frequencies of 29.2% and 34.9%, respectively, for obstruction cause, and 32.1% and 30.2%, respectively, for secondary bowel ischemia. Protocols 2 and 3 had higher total detection rates of obstruction cause and secondary bowel ischemia than protocol 1 (P < 0.01), but no difference was detected between protocols 2 and 3 (P > 0.05). The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of protocols 2 and 3 were superior to those of protocol 1 for evaluating obstruction cause and secondary bowel ischemia. CONCLUSION: Our optimized protocol of multiple post-processing techniques can both guarantee efficiency and improve diagnostic accuracy of MDCT for assessing SBO and secondary bowel ischemia.


Assuntos
Processamento de Imagem Assistida por Computador/métodos , Obstrução Intestinal/diagnóstico por imagem , Intestino Delgado/diagnóstico por imagem , Isquemia Mesentérica/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Meios de Contraste , Estudos Transversais , Feminino , Humanos , Processamento de Imagem Assistida por Computador/estatística & dados numéricos , Obstrução Intestinal/complicações , Intestino Delgado/irrigação sanguínea , Masculino , Isquemia Mesentérica/etiologia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Radiologistas/estatística & dados numéricos , Estudos Retrospectivos , Sensibilidade e Especificidade , Fatores de Tempo , Carga de Trabalho/estatística & dados numéricos , Adulto Jovem
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