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1.
Angiol Sosud Khir ; 26(3): 116-121, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33063758

RESUMO

Presented herein is original experience in using a technique of arterialization in patients with critical lower limb ischaemia on the background of diffuse multilevel occlusive lesions of femoral, crural arteries and arteries of the foot in 214 patients. We used a new method of treatment by means of oxygenation of the sural group of muscles and the foot through the small saphenous vein and indirect communicating veins. This method does not require destruction of the valvular apparatus of the communicants themselves, promoting opening of previously not functioning ones, as well as appears to be a powerful stimulus for the development of collateral circulation of the extremity. Alterations introduced into the design characteristics of a valvulotome make it possible to avoid lateral injury of the venous wall in the area of confluence of tributaries, preventing incomplete resection of the valve. The method expands the boundaries of operability of patients with the absence of the receiving arterial bed of the calf and foot. It may be combined with arterial primary and repeat reconstructions in patients with depleted receiving channel of the calf as an effective additional path of outflow. It also makes it possible to lower the level of amputation in the developed necrosis of the distal part of the foot. Based on clinical laboratory and instrumental findings, the patients were diagnosed by the aetiological factor of the occlusive process and its extension, substantiating the indications for operative treatment with the use of one or another venous basin. Comparative assessment of reversion of arterial blood flow through the great saphenous vein, small saphenous vein, and posterior tibial vein, according to the findings of bioelectromagnetic diagnosis of reactivity of tissues demonstrated that the most effective method was that of arterialization thought the small saphenous vein. With the help of the questionnaire of quality of life in patients with performed arterialization of the calf and foot through the small saphenous vein for critical lower limb ischaemia we obtained 5-year remote results. Upon completion of this period, 87.3% of the limbs were saved and composite measures of the patients' quality of life proved to be high, ranging from 53 to 69 points.


Assuntos
Doenças Vasculares Periféricas , Qualidade de Vida , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Isquemia/cirurgia , Perna (Membro) , Veia Safena
2.
Khirurgiia (Mosk) ; (8): 55-60, 2020.
Artigo em Russo | MEDLINE | ID: mdl-32869616

RESUMO

OBJECTIVE: To study the immediate results of therapy and indirect revascularization in patients with critical ischemia of the lower limbs. MATERIAL AND METHODS: The results of medication and surgical treatment were analyzed in 210 patients with critical ischemia of the lower limbs. Atherosclerosis obliterans was diagnosed in 142 patients, thromboangiitis obliterans - in 68 patients. Lesion of femoropopliteal segment was observed in 32 (15.2%) cases, popliteal-tibial segment - 68 (32.8%) patients, tibial and foot segment - 62 (29.5%) cases, foot - 31 (14.8%) cases, multiple-level lesion - 17 (8.1%) cases. Survey consisted of Doppler ultrasound, CT angiography, rheovasography with analysis of rheographic index (RI) and pulse oximetry. Circulatory parameters were compared with identical values in 48 almost healthy persons ("reference group"). The results of medication and surgical treatment were evaluated by using of the scale of Rutherford R.B. et al. (1997). RESULTS: Conservative treatment was performed in 48 patients (control group). The following types of indirect revascularization operations were performed to stimulate regional circulation: bone trepanation in 42 patients, lumbar sympathectomy in 51 patients, bone trepanation + lumbar sympathectomy in 38 patients, bone trepanation with intraosseous irradiation in 31 cases. CONCLUSION: Indirect revascularization improves early postoperative outcomes, ensures maintaining support function of the limb and active lifestyle in patients with critical ischemia of the lower limbs. Technical simplicity of these procedures facilitates widespread introduction of indirect revascularization in multi-field hospitals.


Assuntos
Arteriopatias Oclusivas/cirurgia , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/cirurgia , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/tratamento farmacológico , Arteriosclerose Obliterante/diagnóstico por imagem , Arteriosclerose Obliterante/tratamento farmacológico , Arteriosclerose Obliterante/cirurgia , Osso e Ossos/cirurgia , Tratamento Conservador , Humanos , Isquemia/diagnóstico por imagem , Isquemia/tratamento farmacológico , Salvamento de Membro/métodos , Extremidade Inferior/diagnóstico por imagem , Estudos Retrospectivos , Simpatectomia , Tromboangiite Obliterante/diagnóstico por imagem , Tromboangiite Obliterante/tratamento farmacológico , Tromboangiite Obliterante/cirurgia , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodos
3.
J Med Vasc ; 45(5): 241-247, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32862980

RESUMO

OBJECTIVE: The persistent sciatic artery (PSA) is a rare congenital anomaly with a high rate of aneurysm formation, occlusion and stenosis. It may lead to severe complications including thrombosis, distal embolisation, or aneurysm rupture. We reported herein our experience in the management of PSA and its complications, and discuss the therapeutic options. METHODS: Eight patients with 10 PSA were managed in our institutions between 1985 and 2017. An analysis was done for the clinical data, surgical technique, and results. RESULTS: The series included six women and two men. The median age of the patients was 66,5 years (37-80 years). Physical examination found a pulsatile gluteal mass in five patients, sciatic neuropathy in two cases. Four patients had an acute ischemia of the lower limb. Cowie's sign was described in only two patients (diminished or absent femoral pulse but presence of popliteal pulse). Digital subtraction angiography was performed in all patients, and was completed with a computed tomography angiography (CTA) with a diagnosis of PSA, associated with a symptomatic aneurysmal lesion in seven cases and with an occlusion in one case. The treatment was surgical in all cases: bipolar exclusion of the aneurysm and bypass between the iliac artery and the PSA distal to the aneurysm was performed in four cases, only proximal and distal ligation was done in 2 other cases. A Chopart amputation was necessary in 2 cases. CONCLUSION: We consider that the treatment of PSA is usually surgical in symptomatic cases. Surgical techniques depend on symptoms and classification describing anatomy of the PSA. However, future studies should compare the open versus the endovascular approach to optimize patient selection criteria and identify the most safe and effective strategy. In an asymptomatic patient, PSA does not require any intervention; continued follow-up is required because of the high incidence of aneurysmal formation and the risk of thromboembolic events.


Assuntos
Artérias/anormalidades , Isquemia/etiologia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/etiologia , Malformações Vasculares/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação , Artérias/diagnóstico por imagem , Artérias/cirurgia , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/cirurgia , Ligadura , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular , Malformações Vasculares/diagnóstico por imagem
4.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi ; 34(8): 994-999, 2020 Aug 15.
Artigo em Chinês | MEDLINE | ID: mdl-32794668

RESUMO

Objective: To summarize the research progress of tibial transverse transport (TTT) in treatment of chronic ischemic diseases of the lower extremities. Methods: The related literature was systematically searched and the mechanisms, clinical treatment methods, clinical efficacy, indications, contraindications, and complications of TTT were discussed. Results: Based on the law of tension-stress, TTT is a new method in the treatment of chronic ischemic diseases of the lower extremities. It can relieve the ischemic symptoms, promote the wound healing, and increase the limb salvage rate. The clinical application in recent years has shown good effectiveness, and the scope of application is expanding. Conclusion: Due to the current limited clinical application, the sample size of the TTT for the chronic ischemic diseases of the lower extremities is relatively small, and the follow-up time is limited. So its validity, long-term effectiveness, and bone transport standards are need further research.


Assuntos
Técnica de Ilizarov , Fraturas da Tíbia/cirurgia , Humanos , Isquemia/cirurgia , Salvamento de Membro , Extremidade Inferior , Tíbia/cirurgia , Resultado do Tratamento
5.
Eur J Vasc Endovasc Surg ; 60(4): 560-566, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32778492

RESUMO

OBJECTIVE: Although high quality epidemiological data are lacking, the global increase in chronic limb threatening ischaemia may be disproportionately affecting low and LMICs. All available data for outcomes from bypass for limb salvage are from high income countries, with none from LMIC settings where the challenge is greatest. This study aimed to assess the clinical outcomes following vein lower extremity bypass for chronic limb threatening ischaemia at the University of Colombo, Sri Lanka, and to compare patients and outcomes with those described in the Society for Vascular Surgery (SVS) Objective Performance Goals (OPG) and United States National Surgical Quality Improvement Program (NSQIP). METHODS: Consecutive patients (n = 367) undergoing SVS-OPG eligible lower extremity bypass between 2015 and 2017 were studied. Thirty day major adverse cardiovascular events (MACE), major adverse limb events (MALE), deaths, and amputations are reported, along with one year overall survival, limb salvage, and amputation free survival. RESULTS: Patients at University of Colombo had more diabetes mellitus (80% vs. SVS 57% vs. NSQIP 50%, p < .001) and tissue loss (100% vs. SVS 74% vs. NSQIP 59%, p < .001). The 30 day MALE was 7.6%, which is not a statistically significant difference from the SVS (6.1%) or NSQIP (9%). The 30 day MACE was 8.2%, statistically significantly higher than NSQIP (4.2%, p < .001) but not SVS (6.2%, p = .20). At 12 months, the overall survival (82%) was within the OPG threshold, but limb salvage (81.8%) and amputation free survival (64.5%) were just outside. CONCLUSION: Outcomes following vein bypass for ischaemic necrosis at the University of Colombo, Sri Lanka, are acceptable and similar to those reported from high income countries despite greater limb threat severity and resource limitations. Further real world data from similar settings on outcomes following revascularisation are required. These data suggest that a vein bypass first strategy for advanced ischaemic necrosis is feasible and effective even in resource limited settings.


Assuntos
Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Enxerto Vascular , Veias/transplante , Idoso , Idoso de 80 Anos ou mais , Amputação , Doença Crônica , Bases de Dados Factuais , Estudos de Viabilidade , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Intervalo Livre de Progressão , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Sri Lanka , Fatores de Tempo , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
6.
Proc Natl Acad Sci U S A ; 117(32): 19033-19044, 2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32709748

RESUMO

Therapeutic factors secreted by mesenchymal stem cells (MSCs) promote angiogenesis in vivo. However, delivery of MSCs in the absence of a cytoprotective environment offers limited efficacy due to low cell retention, poor graft survival, and the nonmaintenance of a physiologically relevant dose of growth factors at the injury site. The delivery of stem cells on an extracellular matrix (ECM)-based platform alters cell behavior, including migration, proliferation, and paracrine activity, which are essential for angiogenesis. We demonstrate the biophysical and biochemical effects of preconditioning human MSCs (hMSCs) for 96 h on a three-dimensional (3D) ECM-based microgel platform. By altering the macromolecular concentration surrounding cells in the microgels, the proangiogenic phenotype of hMSCs can be tuned in a controlled manner through cell-driven changes in extracellular stiffness and "outside-in" integrin signaling. The softest microgels were tested at a low cell dose (5 × 104 cells) in a preclinical hindlimb ischemia model showing accelerated formation of new blood vessels with a reduced inflammatory response impeding progression of tissue damage. Molecular analysis revealed that several key mediators of angiogenesis were up-regulated in the low-cell-dose microgel group, providing a mechanistic insight of pathways modulated in vivo. Our research adds to current knowledge in cell-encapsulation strategies by highlighting the importance of preconditioning or priming the capacity of biomaterials through cell-material interactions. Obtaining therapeutic efficacy at a low cell dose in the microgel platform is a promising clinical route that would aid faster tissue repair and reperfusion in "no-option" patients suffering from peripheral arterial diseases, such as critical limb ischemia (CLI).


Assuntos
Células-Tronco Mesenquimais/química , Células-Tronco Mesenquimais/citologia , Microgéis/química , Neovascularização Fisiológica , Animais , Proliferação de Células , Células Imobilizadas/química , Células Imobilizadas/citologia , Células Imobilizadas/metabolismo , Matriz Extracelular/genética , Matriz Extracelular/metabolismo , Membro Posterior/irrigação sanguínea , Membro Posterior/metabolismo , Membro Posterior/cirurgia , Humanos , Integrinas/genética , Integrinas/metabolismo , Isquemia/fisiopatologia , Isquemia/cirurgia , Isquemia/terapia , Transplante de Células-Tronco Mesenquimais , Células-Tronco Mesenquimais/metabolismo , Camundongos , Camundongos Nus
7.
Eur J Vasc Endovasc Surg ; 60(2): 231-241, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32709468

RESUMO

OBJECTIVE: The aim of this systematic review and meta-analysis was to assess the clinical outcomes after revascularisation in octogenarians with chronic limb threatening ischaemia (CLTI). METHODS: This was a systematic review and meta-analysis, in which the Medline, Embase, and Cochrane Library databases were searched systematically by two independent researchers. Meta-analyses were performed to analyse one year mortality, one year major amputation, and one year amputation free survival (AFS) after revascularisation. Pooled outcome estimates were reported as percentages and odds ratio (OR) with 95% confidence intervals (CI). In addition, sensitivity and subgroup analyses were performed and the quality of evidence was determined according to the GRADE system. RESULTS: The review includes 21 observational studies with patients who were treated for CLTI. Meta-analysis of 12 studies with a total of 17 118 patients was performed. A mortality rate of 32% was found in octogenarians (95% CI 27-37%), which was significantly higher than in the non-octogenarians (17%, 95% CI 11-22%/OR 2.52, 95% CI 1.93-3.29; GRADE: "low"). No significant difference in amputation rate was found (octogenarians 15%, 95% CI 11-18%; non-octogenarians 12%, 95% CI 7-14%; GRADE: "very low"). AFS was significantly lower in the octogenarian group (OR 1.55, 95% CI 1.03-2.43; GRADE: "very low"). In a subgroup analysis differentiating between endovascular and surgical revascularisation, amputation rates were comparable. For octogenarians, those treated conservatively had a mortality rate significantly higher than those treated by revascularisation (OR 1.76, 95% CI 1.19-2.60; GRADE: "very low"). No significant difference in mortality rate was found between primary amputation and revascularisation in octogenarians (OR 0.70, 95% CI 0.24-2.03; GRADE: "very low"). CONCLUSION: In octogenarians with CLTI, a substantial one year mortality rate of 32% was found after revascularisation. The amputation rates were comparable between both age groups. However, only low quality evidence could be obtained supporting the results of this meta-analysis because only observational studies were available for inclusion.


Assuntos
Amputação/mortalidade , Isquemia/cirurgia , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Idoso de 80 Anos ou mais , Amputação/efeitos adversos , Doença Crônica , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Masculino , Estudos Observacionais como Assunto , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Intervalo Livre de Progressão , Medição de Risco , Fatores de Risco , Fatores de Tempo , Procedimentos Cirúrgicos Vasculares/efeitos adversos
8.
J Rehabil Med ; 52(9): jrm00094, 2020 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-32720698

RESUMO

OBJECTIVE: To evaluate the clinical characteristics and rehabilitation management of patients who undergo amputation for COVID-19-associated coagulopathy. METHODS: Clinical and laboratory data for 3 patients were analysed and their rehabilitative management discussed. RESULTS: The medical records of 3 patients who had undergone amputation due to acute lower extremity ischaemia and who were provided with rehabilitation in our COVID-19 unit were reviewed. CONCLUSION: Coagulation changes related to SARS-CoV-2 may complicate recovery from this devastating disease. The rehabilitation management of amputated patients for COVID-19 acute lower extremity ischaemia is based on a multilevel approach for clinical, functional, nutritional and neuropsychological needs. Based on this limited experience, a dedicated programme for this specific group of patients seems advantageous to warrant the best functional outcome and quality of life.


Assuntos
Amputação/reabilitação , Betacoronavirus , Transtornos da Coagulação Sanguínea/virologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/reabilitação , Isquemia/virologia , Extremidade Inferior/irrigação sanguínea , Pneumonia Viral/complicações , Pneumonia Viral/reabilitação , Idoso , Transtornos da Coagulação Sanguínea/reabilitação , Transtornos da Coagulação Sanguínea/cirurgia , Humanos , Isquemia/reabilitação , Isquemia/cirurgia , Itália , Extremidade Inferior/cirurgia , Masculino , Pessoa de Meia-Idade , Pandemias , Qualidade de Vida
9.
Am J Case Rep ; 21: e925753, 2020 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-32724028

RESUMO

BACKGROUND The novel COVID-19 disease caused by the SARS-CoV-2 virus is a highly infectious disease that originated in Wuhan, China, and has rapidly spread throughout the world. In addition to respiratory complications, the virus has also been implicated in damage to other organ systems as well as coagulopathy. The present report describes the first presumptive case of COVID-19-associated acute superior mesenteric artery thrombosis and acute intestinal ischemia. CASE REPORT A 55-year old man presented to the emergency department with nausea, generalized abdominal pain and diarrhea; he denied having a fever or any respiratory symptoms. Computed tomography (CT) of the abdomen and pelvis revealed bilateral pulmonary ground-glass opacities. He tested positive for SARS-CoV-2, and was treated with hydroxychloroquine, azithromycin and ceftriaxone, and was discharged home after five days of inpatient treatment. One week later, the patient returned with recurrent nausea, vomiting and worsening diffuse abdominal pain. A CT scan of the abdomen showed a 1.6-cm clot, causing high grade narrowing of the proximal superior mesenteric artery and bowel ischemia. The patient emergently underwent exploratory laparotomy, thromboembolectomy and resection of the ischemic small bowel. A post-operative complete hypercoagulable workup was unrevealing. CONCLUSIONS Despite the absence of respiratory symptoms, patients infected with SARS-CoV-2 may show atypical presentations, such as gastrointestinal symptoms. Clinicians managing patients with suspected or confirmed SARS-CoV-2 infection during the COVID-19 pandemic should monitor these patients for potential complications that may arise from this disease.


Assuntos
Infecções por Coronavirus/complicações , Intestinos/irrigação sanguínea , Isquemia/virologia , Oclusão Vascular Mesentérica/virologia , Pneumonia Viral/complicações , Trombose/virologia , Dor Abdominal/etiologia , Betacoronavirus , Diarreia/etiologia , Embolectomia , Humanos , Infarto/diagnóstico , Infarto/cirurgia , Infarto/virologia , Intestinos/diagnóstico por imagem , Intestinos/cirurgia , Isquemia/diagnóstico por imagem , Isquemia/cirurgia , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/cirurgia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/cirurgia , Pessoa de Meia-Idade , Pandemias , Trombectomia , Trombose/diagnóstico por imagem , Trombose/cirurgia , Tomografia Computadorizada por Raios X
10.
Am Heart J ; 227: 100-106, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32730905

RESUMO

BACKGROUND: New antithrombotic strategies that reduce primary thrombosis and restenosis might improve vascular outcomes in patients with peripheral artery disease (PAD) undergoing arterial angioplasty. The study objective is to evaluate the potential benefit of apixaban plus aspirin compared with standard of care dual antiplatelet therapy (DAPT) in reducing thrombotic restenosis and artery re-occlusion in patients undergoing endovascular infrapopliteal revascularization. STUDY DESIGN: This multicenter, parallel-group, prospective, randomized, open-label, blinded-endpoint adjudication, proof-of-concept, exploratory trial aims to randomize 200 patients 72 hours after successful infrapopliteal angioplasty for critical limb ischemia (CLI). Patients will be randomly assigned in a 1:1 ratio to receive oral apixaban (2.5 mg twice daily) plus aspirin (100 mg once daily) for 12 months or clopidogrel (75 mg daily) for at least 3 months on a background of aspirin (100 mg once daily) for 12 months. The primary endpoint is the composite of target lesion revascularization (TLR), major amputation, or restenosis/occlusion (RAS) in addition to major adverse cardiovascular events - MACE (myocardial infarction, stroke or cardiovascular death) at 12 months. The primary safety endpoint is the composite of major bleeding or clinically relevant non-major bleeding at 12 months. SUMMARY: This study will evaluate the efficacy and safety of apixaban 2.5 mg twice daily plus aspirin compared with DAPT (clopidogrel plus aspirin) in patients with CLI undergoing endovascular infrapopliteal revascularization and might prove the concept of an alternative antithrombotic regimen for these patients to be tested in a future large randomized clinical trial.


Assuntos
Angioplastia , Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Inibidores da Agregação de Plaquetas/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Trombose/prevenção & controle , Angioplastia/métodos , Estado Terminal , Inibidores do Fator Xa , Humanos , Estudos Multicêntricos como Assunto , Artéria Poplítea , Estudo de Prova de Conceito , Estudos Prospectivos
11.
PLoS One ; 15(6): e0234271, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32525925

RESUMO

OBJECTIVES: Antiplatelet therapy following peripheral arterial endovascular intervention lacks high quality evidence to guide practice. The aim of this study was to assess the effect of three months of dual antiplatelet therapy on amputation-free survival following peripheral arterial endovascular intervention in patients with chronic limb threatening ischemia. METHODS: A retrospective review of symptomatic patients undergoing primary peripheral arterial endovascular intervention over a seven-year period was performed. The primary outcome measure was amputation-free survival. A sample size calculation based on previous cohort studies suggested that 629 limbs would be required to show a difference between single and dual therapy. Kaplan-Meier estimates and multivariate logistic regression analysis of recorded baseline characteristics was performed to determine predictors of amputation-free survival. Dual antiplatelet therapy was routinely given for 3 months. RESULTS: 754 limbs were treated with primary angioplasty and/or stenting over a 7-year period, 508 of these for chronic limb threatening ischemia. There was no difference in unadjusted amputation-free survival between patients with chronic limb threatening ischaemia taking single vs. dual antiplatelet therapy (69% vs. 74% respectively Log rank Chi2 = 0.1, p = .72). After adjusting for confounders, at 1 year there was also no significant difference in amputation-free survival between patients taking single vs. dual antiplatelet therapy [OR 0.8, 95% CI 0.5-1.2, p = .3]. There was no difference in rates of major bleeding between single and dual antiplatelet therapy. CONCLUSIONS: There was no clear evidence of reduced amputation-free survival in patients with chronic limb threatening ischemia undergoing peripheral arterial endovascular intervention being treated with dual antiplatelet therapy for 3 months. This is at odds with other retrospective case series and highlights the limitations in basing clinical practice on such data. There is a need for an adequately powered, independent randomised trial to definitively answer the question.


Assuntos
Procedimentos Endovasculares , Isquemia/tratamento farmacológico , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Inibidores da Agregação de Plaquetas/farmacologia , Idoso , Estudos de Coortes , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Inibidores da Agregação de Plaquetas/uso terapêutico , Estudos Retrospectivos , Análise de Sobrevida
15.
Vasa ; 49(5): 395-402, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32597320

RESUMO

Background: Lower limb bypass occlusion in patients with chronic limb threating ischemia remains a challenge. We can choose between different treatment options: open surgery, local thrombolysis, thrombectomy/atherectomy devices. In this pilot study, we compare clinical outcomes and treatment costs between open surgery (OS) and percutaneous mechanical thrombectomy (pMTH). Patients and methods: This pilot study represents a retrospective analysis of hospital data of 48 occluded bypasses admitted from 2013 to 2018. Only patients presenting with severe ischemia and recrudescence of symptoms (Rutherford 4-6) were included in the current analysis. Two cohorts of patients were analysed: patients who underwent OS and patients that underwent pMTH. Primary clinical outcomes were one-year cumulative patency and limb salvage rates. Total cost was calculated as a sum of intra- and post-operative costs. To weigh clinical benefits against the economic consequences of OS versus pMTH a cost-effectiveness framework was adopted. Results: We analysed a series of 48 occluded bypasses 17 treated with open surgery and 31 with pMTH. Procedural success was 100% in both groups. When comparing one-year death rates (p-value = .22) and re-occlusion rates (p-value = .43), no statistically significant differences were observed between the two cohorts. Mean patency duration in the surgery cohort was significantly shorter (p-value < .05). Primary patency (OS 41.2% vs. pMTH 48.4%) and limb salvage rate (OS 88.2% vs. pMTH 90.3%) at one year are similar in both groups. The total cost of surgery was substantially higher (OS 10,159€ vs. pMTH 8,401€) Conclusions: This pilot study, although limited to 48 occluded bypasses, demonstrates that endovascular treatment with pMTH is less invasive, less time consuming and less expensive, and produces greater health benefits than traditional OS.


Assuntos
Isquemia , Humanos , Isquemia/cirurgia , Salvamento de Membro , Extremidade Inferior , Projetos Piloto , Estudos Retrospectivos , Fatores de Risco , Trombectomia , Resultado do Tratamento , Grau de Desobstrução Vascular
16.
Int J Infect Dis ; 96: 590-592, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32447121

RESUMO

Acute thromboembolic events appear to be frequent in patients with SARS-CoV-2 infection. We report a case of an intubated patient, who developed a threatening lower limb ischemia. Intra-arterial fibrinolysis and intravenous heparin infusion did not lead to complete recanalization of the tibial arteries, which were successfully treated by surgical embolectomy.


Assuntos
Infecções por Coronavirus/patologia , Isquemia/virologia , Extremidade Inferior/fisiopatologia , Pneumonia Viral/patologia , Aorta/patologia , Betacoronavirus , Fibrinolíticos/uso terapêutico , Heparina/uso terapêutico , Humanos , Isquemia/cirurgia , Extremidade Inferior/virologia , Masculino , Pessoa de Meia-Idade , Pandemias , Trombose , Tíbia/irrigação sanguínea
18.
Ann R Coll Surg Engl ; 102(6): 412-417, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32306742

RESUMO

INTRODUCTION: The national reconfiguration of vascular surgery means that arterial centres serve larger populations with increased demand on resources. Emergency general surgery ambulatory clinics facilitate timely review and intervention, avoiding admission; a critical limb ischaemia (CLI) 'hot clinic' (HC) was implemented to achieve similar for vascular patients. The aim of the study was to determine HC efficacy. METHODS: This was a prospective cohort study comparing HC patients with emergency admission (EA) patients between 1 May and 1 December 2017. Age, sex, comorbidities, CLI severity and smoking status were noted. HC patients were provided with satisfaction surveys. Primary outcome measures were freedom from reintervention and major amputation. Secondary outcome measures included time to procedure, length of stay, returns to theatre and 30-day readmission. RESULTS: A total of 147 patients (72 HC, 75 EA) were enrolled in the study. No statistical difference was found in age, sex, smoking status, severity of CLI or prevalence of comorbidities between the groups except that diabetes was more prevalent in EA patients (p=0.028). The median length of stay for the HC cohort was shorter (3 days vs 17 days, p<0.001), with no difference between time to procedure, return to theatre or 30-day readmission. HC patients were nearly 6 times more likely to experience freedom from reintervention (odds ratio: 5.824, p<0.001) and 2.5 times less likely to undergo amputation (odds ratio: 2.616, p=0.043). HC utilisation saved a total of 441 bed days. Over 90% of attendees responded with 100% positive feedback. CONCLUSIONS: A vascular HC facilitates urgent review and revascularisation. It provides comparable in-hospital outcomes and better long-term outcomes, with greater efficiency than hospital admission, demonstrating its value in treating CLI.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Isquemia/cirurgia , Salvamento de Membro/estatística & dados numéricos , Ambulatório Hospitalar/organização & administração , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos , Idoso , Amputação/estatística & dados numéricos , Estado Terminal/terapia , Eficiência Organizacional , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Humanos , Isquemia/diagnóstico , Perna (Membro)/irrigação sanguínea , Tempo de Internação/estatística & dados numéricos , Salvamento de Membro/efeitos adversos , Masculino , Ambulatório Hospitalar/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Doença Arterial Periférica/diagnóstico , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Reino Unido , Procedimentos Cirúrgicos Vasculares/efeitos adversos
19.
Plast Reconstr Surg ; 145(5): 1302-1312, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32332556

RESUMO

BACKGROUND: Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors' preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates. METHODS: A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.). RESULTS: One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years. CONCLUSIONS: This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Artérias/cirurgia , Retalhos de Tecido Biológico/transplante , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Salvamento de Membro/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Anastomose Cirúrgica/estatística & dados numéricos , Doença Crônica/terapia , Estado Terminal/terapia , Pé Diabético/complicações , Pé Diabético/epidemiologia , Feminino , Retalhos de Tecido Biológico/efeitos adversos , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Perna (Membro)/cirurgia , Salvamento de Membro/efeitos adversos , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Osteomielite/complicações , Osteomielite/epidemiologia , Doenças Vasculares Periféricas/complicações , Doenças Vasculares Periféricas/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fumar/efeitos adversos , Fumar/epidemiologia , Resultado do Tratamento , Adulto Jovem
20.
Eur J Vasc Endovasc Surg ; 60(1): 68-75, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32312663

RESUMO

OBJECTIVE: In the presence of long lesions, in patients with chronic limb threatening ischaemia, a femorodistal bypass is often the only option to avoid major amputation. This study investigated whether targeted bypass to the affected angiosome, according to the angiosome concept definition of direct (DR) and indirect revascularisation (IR), has an impact on wound healing, major amputation rate, and mortality. METHODS: A retrospective analysis was performed at Ghent University Hospital of 201 non-healing ischaemic wounds (Rutherford categories 5 and 6) requiring femorodistal bypass surgery in 177 patients (61% male, median age 69 years) with a follow up of 36 months. For every patient, the site of the ulcer, the type of bypass, and material were identified. Based on ulcer location and distal anastomosis, the legs were divided into DR and IR. Kaplan-Meier univariable analysis was used to estimate cumulative ulcer healing, leg salvage, survival, and patency. RESULTS: DR was performed in 103 legs (51%) and IR in 98 legs (49%), with no difference in comorbidity. The mean wound healing time was seven months. DR did not lead to a higher healing rate. The fastest healing rate was obtained when opting for a DR with an autologous greater saphenous vein (GSV; 90% at 12 months). Cryopreserved allografts also yielded good results, especially for wound healing after IR (85% at 12 months). Major amputation was performed in 28.5% after IR vs. 17.3% after DR (p = .071). There was no difference in mortality rate (36.8% [DR] vs. 41.3% [IR]) (p = .088). Autologous GSV had a longer primary patency, primary assisted patency, and secondary patency (26, 34, and 38 months, respectively) than cryopreserved GSV (12.5, 18, and 24 months, respectively) (p = .002, p = .003, and p = .018, respectively), with no difference between DR and IR. CONCLUSION: Direct or indirect revascularisation performed according to the angiosome concept definition yields similar results with regard to healing rates, limb salvage, and mortality.


Assuntos
Artéria Femoral/cirurgia , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Cicatrização , Adulto , Idoso , Idoso de 80 Anos ou mais , Artéria Femoral/transplante , Humanos , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/cirurgia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
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