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1.
Br J Radiol ; 93(1109): 20190505, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32101462

RESUMO

OBJECTIVE: Percutaneous transluminal balloon angioplasty (PTA) is recommended as the first choice to treat stenosis of Brescia-Cimino arteriovenous fistulas (B-C AVFs). The ability to predict which B-C AVFs are at risk for recurrent stenosis post-PTA would allow closer monitoring of patients, and possibly result in surgical intervention rather than repeat PTA. The purpose of this study was to identify predictive factors of primary patency after PTA in B-C AVFs. METHODS: Patients diagnosed with B-C AVF primary stenosis and treated by PTA between November 2013 and March 2018 were included in the study. Patient and stenotic lesion characteristics and PTA procedure factors were included in the analysis. The Kaplan-Meier method was used to analyze the primary patency rate. Cox proportional hazard regression analysis was used to identify factors predictive of decreased primary patency. RESULTS: 74 patients (35 males, 39 females) with a mean age of 61.68 ± 11.44 years (range, 36-84 years) were included in the study. The mean B-C AVF age was 16.34 ± 12.93 months (range, 2-84 months), and the median primary patency time was 7.79 ± 0.48 months. Cox proportional hazard regression analysis revealed stenosis location at the inflow artery [hazard ratio (HR)=3.83, 95% confidence interval (CI): 1.46-10.09] or anastomosis (HR = 1.90, 95% CI: 1.09-3.32), dilation >2 times during PTA (HR = 2.30, 95% CI: 1.22-4.34), and residual stenosis >30% (HR = 2.42, 95% CI: 1.26-4.63) were significantly associated with decreased patency. CONCLUSION: In conclusion, the primary patency rate of PTA for B-C AVF dysfunction is reduced by dilation >2 times, residual stenosis >30%, and stenosis located at the inflow artery or anastomosis. These results may help in tailoring surveillance programs, multiple PTA, or a proximal re-anastomosis surgery in patients with AVF dysfunction. ADVANCES IN KNOWLEDGE: A number of studies have been conducted to examine the predictors of primary patency after PTA, however, no definitive conclusions have been reached. Our study revealed that stenosis location at the inflow artery or anastomosis, dilation >2 times during PTA, and residual stenosis >30% were the predictors of primary patency after PTA, which may help in tailoring surveillance programs, multiple PTA, or a proximal re-anastomosis surgery in patients with arteriovenous fistulas dysfunction.


Assuntos
Angioplastia com Balão/métodos , Derivação Arteriovenosa Cirúrgica , Oclusão de Enxerto Vascular/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Constrição Patológica/terapia , Procedimentos Endovasculares/métodos , Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/instrumentação , Resultado do Tratamento , Grau de Desobstrução Vascular/fisiologia
2.
J Vasc Access ; 21(1): 60-65, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31203718

RESUMO

BACKGROUND: Radiologic justification for endovascular treatment of a dialysis arteriovenous fistula circuit stenosis is currently based on ⩾50% severity. However, the clinical significance of any given stenosis is not always clear. The minimum luminal diameter of any stenotic lesion in the arteriovenous fistula circuit might exert a more predictive effect on the arteriovenous fistula blood flow rate (Qa). METHODS: To investigate relationships between anatomic parameters of stenosis and Qa, this study was conducted in a cohort of patients with a variety of arteriovenous fistula stenotic lesions. The goals were to determine (1) the degree of correlation between arteriovenous fistula stenosis estimated during the procedure, and that which is measured, and (2) the correlations between two anatomic stenosis parameters (percent stenosis and stenosis minimum luminal diameter) and Qa. RESULTS: The cohort comprised 113 patients. Only a moderate correlation between estimated and measured stenosis was seen. A correlation between measured stenosis and Qa for the whole cohort was not seen, but a weak correlation between estimated stenosis and Qa was seen. Correlations between stenosis minimum luminal diameter and Qa were superior. The superiority of stenosis minimum luminal diameter to percent stenosis in correlating with a Qa of <500 mL/h was also demonstrated by receiver operating characteristics curve analysis. Stenosis minimum luminal diameter cutoffs of ⩽2.5 mm or >4 mm seemed to have a good predictive value of Qa. CONCLUSIONS: Percent stenosis determination is fraught with uncertainty and exhibits a weak correlation with Qa. Compared with percent stenosis, the minimum luminal diameter of the stenosis demonstrates a superior correlation with Qa.


Assuntos
Angiografia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Diálise Renal , Ultrassonografia Doppler , Adulto , Idoso , Idoso de 80 Anos ou mais , Velocidade do Fluxo Sanguíneo , Feminino , Fluoroscopia , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fluxo Sanguíneo Regional , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Resultado do Tratamento , Adulto Jovem
3.
J Vasc Access ; 21(1): 55-59, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31188045

RESUMO

OBJECTIVE: The aim of this study was to compare two complex vascular access techniques that utilize the axillary artery as inflow and accesses were created with early cannulation grafts: the axillary-atrial arteriovenous graft versus axillary-iliac arteriovenous graft. METHODS: This is a retrospective study of end-stage renal disease patients with occluded intrathoracic central veins that underwent complex hemodialysis access creation in our institution after failed endovascular recanalization attempts. Patients' demographics, comorbidities, number and types of previous accesses, intraoperative variables, and clinical outcomes were collected and compared. RESULTS: Four patients underwent axillary-atrial arteriovenous graft creation with Flixene™ (Atrium™, Hudson, NH, USA) grafts, through a midline sternotomy to expose the right atrium; all were successfully implanted and used for hemodialysis within the first 72 h; one patient developed a pseudoaneurysm in the mid-graft portion, requiring surgical repair, and it is currently functional. Eight axillary-iliac arteriovenous grafts were created; all grafts were patent and were utilized within 96 h after placement. At 6 months of follow-up period, five (62 %) of our patients underwent graft thrombectomy, one (12 %) balloon angioplasty at the vein anastomosis secondary to stenosis, and two (25 %) grafts were removed due to infectious complications. Axillary-atrial arteriovenous graft and axillary-iliac arteriovenous graft primary patency rates at 6 months were 75% and 48%, respectively; 6-month secondary patency of the axillary-atrial arteriovenous graft compares favorably against that of axillary-iliac arteriovenous graft (100% vs 75%, respectively). CONCLUSION: Despite the invasiveness, direct atrial outflow procedures remain a valid alternative in carefully selected patients with adequate cardiopulmonary reserve.


Assuntos
Derivação Arteriovenosa Cirúrgica , Apêndice Atrial/cirurgia , Artéria Axilar/cirurgia , Implante de Prótese Vascular , Veia Ilíaca/cirurgia , Falência Renal Crônica/terapia , Diálise Renal , Adulto , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/instrumentação , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
4.
Cardiovasc Pathol ; 44: 107151, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31760241

RESUMO

Intramyocardial dissection or intramyocardial dissecting hematoma is uncommon complication either of myocardial infarction or severe thoracic injury. Intramyocardial dissecting hematoma is caused by intersecting bleeding between the layers of myocardial fibers. In contrast to cardiac rupture, the myocardial wall maintains its integrity. In this paper, we present a case of patient suffering with ischemic heart disease, reporting worsening chest pain and dyspnea 2 months after autovenous graft bypass surgery. The coronary angiography revealed severe stenosis of the autovenous graft, which was treated by stent implantation. Three hours after intervention, the patient showed signs of cardiogenic shock with clinical suspicion of heart tamponade because of ventricular wall rupture. The patient died despite the surgical drainage of the hematoma and blood transfusions. In the necropsy, the large intramyocardial dissecting hematoma in the very superficial layer of the left ventricular myocardium was found, accompanied with very small extent of necrotic myocardium in the neighborhood of the intramyocardial dissecting hematoma. The prevailing majority of the left ventricle thickness was vital. The lack of developed transmural infarction in our case leads us to hypothesis that the increased intravascular pressure during the reperfusion is the main contributor to the intramyocardial dissecting hematoma development, together with reduced biomechanical resistance of the capillaries affected by chronic ischemia.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Oclusão de Enxerto Vascular/terapia , Hematoma/etiologia , Infarto do Miocárdio/cirurgia , Traumatismo por Reperfusão Miocárdica/etiologia , Miocárdio/patologia , Intervenção Coronária Percutânea/efeitos adversos , Idoso de 80 Anos ou mais , Autopsia , Causas de Morte , Evolução Fatal , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Hematoma/patologia , Humanos , Masculino , Traumatismo por Reperfusão Miocárdica/patologia , Intervenção Coronária Percutânea/instrumentação , Stents
5.
Pediatr Surg Int ; 35(11): 1185-1195, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31535198

RESUMO

PURPOSE: Advances in interventional radiology (IVR) treatment have notably improved the prognosis of hepatic vein (HV) and portal vein (PV) complications following pediatric living donor liver transplantation (LDLT); however, graft failure may develop in refractory cases. Although endovascular stent placement is considered for recurrent stenosis, its indications are controversial. METHODS: We enrolled 282 patients who underwent pediatric LDLT in our department from May 2001 to September 2016. RESULTS: 22 (7.8%) HV complications occurred after LDLT. Recurrence was observed in 45.5% of the patients after the initial treatment, and 2 patients (9.1%) underwent endovascular stent placement. The stents were inserted at 8 months and 3.8 years following LDLT, respectively. After stent placement, both patients developed thrombotic obstruction and are currently being considered for re-transplantation. 40 (14.2%) PV complications occurred after LDLT. Recurrence occurred in 27.5% of the patients after the initial treatment, and 4 patients (10.0%) underwent endovascular stent treatment. The stents of all the patients remained patent, with an average patency duration of 41 months. CONCLUSION: Endovascular stent placement is an effective treatment for intractable PV complications following pediatric LDLT. However, endovascular stent placement for HV complications should be carefully performed because of the risk of intrastent thrombotic occlusion and the possibility of immunological venous injury.


Assuntos
Procedimentos Endovasculares , Oclusão de Enxerto Vascular/terapia , Transplante de Fígado/efeitos adversos , Stents , Trombose Venosa/terapia , Adolescente , Criança , Pré-Escolar , Feminino , Oclusão de Enxerto Vascular/etiologia , Humanos , Lactente , Doadores Vivos , Masculino , Reoperação , Estudos Retrospectivos , Trombose Venosa/etiologia
6.
J Vasc Surg ; 70(3): 970-979.e3, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31445651

RESUMO

BACKGROUND: Arteriovenous fistulas for patients undergoing hemodialysis (HD) are at high risk of stenosis. Despite conventional balloon angioplasty (CBA), restenosis rates are high. The use of a drug-coated balloon (DCB) may offer an alternative to reduce restenosis. METHODS: This study has been performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search on MEDLINE, Embase, and the Cochrane Library was performed to identify articles evaluating DCB angioplasty for patients with HD access stenosis. Risk ratios (RRs) of primary patency were pooled, and relevant subgroup and sensitivity analyses were conducted. RESULTS: There were 17 studies (8 randomized controlled trials [RCTs], 9 cohort studies) included, comprising a total of 1113 stenotic dialysis accesses, of which 54.7% underwent DCB angioplasty and 45.3% underwent CBA. There was a significantly superior 6-month (RR, 0.57; 95% confidence interval [CI], 0.44-0.74; P < .00001; I2 = 62%) and 12-month (RR, 0.73; 95% CI, 0.63-0.84; P < .0001; I2 = 53%) primary patency in the DCB angioplasty group in comparison to the CBA group (71.0% vs 49.2% at 6 months; 44.2% vs 20.6% at 12 months). Subgroup analyses of study design (RCTs, cohort studies) showed similar trends. Sensitivity analyses by excluding one poor-quality RCT and those employing the crossover analysis design also showed similar results. Studies investigating central venous stenosis showed significantly better 6-month (RR, 0.57; 95% CI, 0.41-0.79; P = .0009; I2 = 67%) and 12-month (RR, 0.69; 95% CI, 0.56-0.85; P = .0004; I2 = 64%) primary patency in the DCB angioplasty group in comparison to the CBA group. The pooled rate of minor complications was low in both the DCB (1.1%) and CBA (0.9%) groups. CONCLUSIONS: DCB angioplasty appears to be a better and safe alternative to CBA in treating patients with HD stenosis in terms of 6- and 12-month primary patency. However, a larger trial is warranted to establish these findings.


Assuntos
Angioplastia com Balão/instrumentação , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Oclusão de Enxerto Vascular/terapia , Diálise Renal , Dispositivos de Acesso Vascular , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Fármacos Cardiovasculares/efeitos adversos , Desenho de Equipamento , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
7.
Ann Vasc Surg ; 60: 364-370, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31200031

RESUMO

BACKGROUND: Vein graft stenosis is a critical complication of lower-limb bypass surgery. For vein graft stenosis, balloon angioplasty has been performed instead of surgical revision in recent years. We therefore investigated the effectiveness of the balloon angioplasty for vein graft stenosis. METHODS AND RESULT: We conducted a retrospective analysis of prospectively collected data for 115 vein graft stenoses performed via balloon angioplasty from August 2011 to January 2018. The rate of freedom from reintervention after balloon angioplasty was 54.3%, 44.4%, and 38.0% at 1, 2, and 3 years, respectively. The rate of freedom from graft occlusion after balloon angioplasty was 79.9%, 71.9%, and 61.3% at 1, 2, and 3 years, respectively. Predictors of freedom from graft occlusion after balloon angioplasty by a multivariate analysis were a single treated lesion (hazard ratio [HR]: 0.38; 95% confidence interval [CI]: 0.17-0.85; P = 0.0189), balloon angioplasty within 90 days after bypass surgery (HR: 3.59; 95% CI: 1.56-8.07; P = 0.0033), and using a cutting balloon (HR: 0.42; 95% CI: 0.17-0.97; P = 0.0426). CONCLUSIONS: The freedom from graft occlusion rate after balloon angioplasty remained relatively high. Furthermore, better results can be expected in single treated lesions and cases of balloon angioplasty occurring 90 days after bypass surgery or in which a cutting balloon was used. Balloon angioplasty for lower-limb bypass graft stenosis was shown to be a useful treatment.


Assuntos
Angioplastia com Balão , Oclusão de Enxerto Vascular/terapia , Doenças Vasculares Periféricas/cirurgia , Enxerto Vascular/efeitos adversos , Veias/transplante , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/diagnóstico por imagem , Doenças Vasculares Periféricas/fisiopatologia , Intervalo Livre de Progressão , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Grau de Desobstrução Vascular , Veias/diagnóstico por imagem , Veias/fisiopatologia
8.
Ann Vasc Surg ; 60: 211-220, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31200038

RESUMO

BACKGROUND: The purpose of the study was to compare the access patency rates of forearm loop arteriovenous grafts (AVGs) using deep veins and superficial veins for venous outflow. METHODS: The medical records of patients on dialysis were retrospectively reviewed to identify the individual risk factors and the outcomes of forearm loop AVGs according to their outflow types. RESULTS: Overall, 170 cases were enrolled in this study. Of these, 103 cases (60.6%) used deep veins for outflow. Most patients using deep vein outflow had their venous anastomosis above the elbow (P = 0.000). Patients with venous anastomosis above the elbow were more likely to be female (P = 0.049) and have a lower albumin level (P = 0.025). The primary patency rates for superficial vein outflow and deep view outflow were 35.5% and 29.4% at 12 months and 18.9% and 4.9% at 24 months, respectively. There was a statistically significant difference between the two groups (P = 0.013). The assisted primary patency rates for superficial venous outflow and deep vein outflow were 85.5% and 79.5% at 12 months and 73.2% and 59.6% at 24 months, respectively (P = 0.139). Primary and assisted primary patency rates did not differ according to the crossing of the elbow. CONCLUSIONS: The primary patency rate of AVGs using deep veins for outflow was inferior to AVGs using superficial veins. But the assisted primary patency rate showed no difference. The use of a deep vein for outflow in the forearm loop AVG is a safe strategy for patients with exhausted superficial veins.


Assuntos
Derivação Arteriovenosa Cirúrgica/métodos , Antebraço/irrigação sanguínea , Veias/cirurgia , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Humanos , Masculino , Diálise Renal , Retratamento , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Veias/diagnóstico por imagem , Veias/fisiopatologia
9.
Ann Vasc Surg ; 60: 264-269, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31075469

RESUMO

BACKGROUND: Bypass in the upper extremity is a rare procedure mainly performed for chronic ischemia, trauma, or hemodialysis access complications. Feasibility and success of use of the arm vein and small saphenous vein (SSV) for autologous vein bypass have been reported in peripheral artery bypass procedures. There are very few reports on the use of alternative veins in upper extremity bypass. We report our experience with arm vein and SSV as a graft source in upper extremity arterial disease. METHODS: Retrospective analysis of a consecutively collected case series in an academic tertiary referral center from January 2010 to February 2018. Study end points were primary patency, secondary patency, limb salvage, and survival. RESULTS: In total, 47 patients were treated with upper extremity bypass either using the SSV (n = 17) or arm veins (n = 30). Indications were either acute (n = 12) or chronic ischemia (n = 35) caused by acute (n = 8) and chronic (n = 9) trauma, sequela of iatrogenic interventions (n = 4), peripheral artery disease (n = 14), thrombangiitis obliterans (n = 3), and dialysis-access-related complications (n = 9). An arm vein was used in 30 and the SSV in 17 patients. Primary patency after 12 months was 87% with the SSV and 75% with an arm vein (P = 0.8) and 63% and 75% after 36 months (P = 0.9). Secondary patency were 100% with an arm vein and 100% with the SSV after 36 months (P = 0.4). One patient had to undergo major amputation and 2 minor amputations. CONCLUSIONS: Arm vein revascularization using the primarily arm vein or SSV as a bypass conduit can be performed with reasonable mortality and morbidity rates and provide good results comparable with the greater saphenous vein.


Assuntos
Isquemia/cirurgia , Veia Safena/transplante , Extremidade Superior/irrigação sanguínea , Enxerto Vascular/métodos , Adulto , Idoso , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Retratamento , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade , Grau de Desobstrução Vascular
10.
J Vasc Access ; 20(6): 716-724, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31084389

RESUMO

INTRODUCTION: Arteriovenous fistulas are the best form of vascular access for haemodialysis. A radiological balloon angioplasty is the standard treatment for a clinically relevant stenosis, but the recurrence rate is high. Data on factors associated with recurrence are limited. METHODS: A single centre, retrospective analysis was performed for 124 consecutive patients who had successful interventions for dysfunctional arteriovenous fistulae, to examine factors associated with post-intervention patency. Follow-up was at least 1 year for all patients. Variables associated with primary and cumulative patency were pre-specified and assessed using both un-adjusted (univariate) and adjusted Cox proportional hazards models. Analysis was repeated for a subgroup of 80 patients with a single lesion only in order to examine the potential effects of stenotic lesion characteristics on patency. RESULTS: Factors found to have a significant association with poorer outcomes (less time to loss of patency) included thrombosis at the time of intervention and a history of previous intervention. Fistula age (log days) was significantly associated with better outcomes (greater time to loss of patency). Non-white ethnicity, lesion length, and patient age were also significantly associated with accelerated loss of patency. DISCUSSION: The factors we have identified as linked to poor outcome may help to identify patients in whom a balloon angioplasty is unlikely to provide a durable outcome. This may prompt exploring alternative treatment or dialysis options at an early stage.


Assuntos
Angioplastia com Balão , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Oclusão de Enxerto Vascular/terapia , Diálise Renal , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia Intervencionista , Recidiva , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Adulto Jovem
11.
J Vasc Access ; 20(6): 733-739, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31130061

RESUMO

BACKGROUND: We evaluated the safety and technical and clinical outcomes of angioplasty with a drug-coated balloon for the management of venous stenosis in arteriovenous grafts and arteriovenous fistulas in patients undergoing haemodialysis. METHODS: Data were obtained from an ongoing prospective, non-randomised registry conducted at three Italian centres. Patients were treated with a drug-coated balloon according to standard procedures in each participating centre. Evaluation was by colour Doppler imaging every 3 months. The primary end-point was primary assisted patency. The secondary end-point was the rate of assisted patency of the vascular access. RESULTS: A total of 311 angioplasty procedures in 200 patients, (60.4% male), were analysed. The procedural success rate was 100%. A total of 192 treatments of restenosis were necessary in 81 patients during average 21 ± 8 months follow-up. Kaplan-Meier estimates indicated that 88.0%, 64.2% and 40.6% of treated lesions were free from restenosis at 6, 12 and 24 months, respectively. Including multiple angioplasty, circuit patency rates were 99.2%, 92.5% and 84.8% at 6, 12 and 24 months, respectively. Primary patency rates were highest in shunts treated de novo with drug-coated balloons. Risk of restenosis was associated with circuit age (p = 0.017), history of treatment with conventional angioplasty (p < 0.001) and the kind of balloon used during pre-dilation (p = 0.001). CONCLUSION: The results suggest that favourable long-term patency rates can be achieved with the drug-coated balloon in a varied population of patients with failing haemodialysis arteriovenous shunts treated under conditions of actual care.


Assuntos
Angioplastia com Balão/instrumentação , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Oclusão de Enxerto Vascular/terapia , Diálise Renal , Dispositivos de Acesso Vascular , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Desenho de Equipamento , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
12.
J Vasc Interv Radiol ; 30(7): 1050-1056.e3, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31133451

RESUMO

PURPOSE: To evaluate the changing use of transcatheter hemodialysis conduit procedures. METHODS: Multiple Centers for Medicare & Medicaid Services datasets were used to assess hemodialysis conduit angiography. Use was normalized per 100,000 beneficiaries and stratified by specialty and site of service. RESULTS: From 2001 to 2015, hemodialysis angiography use increased from 385 to 1,045 per 100,000 beneficiaries (compound annual growth rate [CAGR], +7.4%)]. Thrombectomy use increased from 114 to 168 (CAGR, +2.8%). Angiography and thrombectomy changed, by specialty, +1.5% and -1.3% for radiologists, +18.4% and +14.4% for surgeons, and +24.0% and +17.7% for nephrologists, respectively. By site, angiography and thrombectomy changed +29.1% and +20.7% for office settings and +0.8% and -2.4% for hospital settings, respectively. Radiologists' angiography and thrombectomy market shares decreased from 81.5% to 37.0% and from 84.2% to 47.3%, respectively. Angiography use showed the greatest growth for nephrologists in the office (from 5 to 265) and the greatest decline for radiologists in the hospital (299 to 205). Across states in 2015, there was marked variation in the use of angiography (0 [Wyoming] to 1173 [Georgia]) and thrombectomy (0 [6 states] to 275 [Rhode Island]). Radiologists' angiography and thrombectomy market shares decreased in 48 and 31 states, respectively, in some instances dramatically (eg, angiography in Nevada from 100.0% to 6.7%). CONCLUSIONS: Dialysis conduit angiography use has grown substantially, more so than thrombectomy. This growth has been accompanied by a drastic market shift from radiologists in hospitals to nephrologists and surgeons in offices. Despite wide geographic variability nationally, radiologist market share has declined in most states.


Assuntos
Angiografia/tendências , Derivação Arteriovenosa Cirúrgica/tendências , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/terapia , Medicare/tendências , Padrões de Prática Médica/tendências , Radiografia Intervencionista/tendências , Diálise Renal/tendências , Trombectomia/tendências , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Oclusão de Enxerto Vascular/epidemiologia , Disparidades em Assistência à Saúde/tendências , Humanos , Nefrologistas/tendências , Radiologistas/tendências , Estudos Retrospectivos , Cirurgiões/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
14.
J Vasc Access ; 20(6): 725-732, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31094648

RESUMO

PURPOSE: To evaluate the technical and clinical results of endovascular recanalization of thrombosed native hemodialysis fistula and the factors influencing patency. METHODS: A retrospective study was conducted with 73 patients who had thrombosed arteriovenous fistulas and were treated with endovascular methods. Patient characteristics, arteriovenous fistula-related characteristics, and endovascular procedures were analyzed. Technical and clinical results and patency rates were evaluated. The factors influencing patency were analyzed using a univariate and multivariate Cox proportional hazards model. RESULTS: Technical and clinical success rates were 93% (68/73) and 85% (62/73), respectively. At 3, 6, and 12 months, the primary patency rates were 87.9%, 73.3%, and 64.8%; assisted primary patency rates were 89.2%, 78.6%, and 70.7%; and secondary patency rates were 90.8%, 87.2%, and 83.1%, respectively. Previous intervention and cephalic arch stenosis were risk factors for lower primary and assisted primary patency (p < 0.05 for all). Cephalic arch stenosis was the only risk factor for lower secondary patency (p < 0.05). No major complications associated with the procedures were noticed. CONCLUSION: Endovascular treatment was effective for the immediate recanalization of thrombosed arteriovenous fistula. In addition, previous intervention and cephalic arch stenosis were significantly related to lower arteriovenous fistula patency.


Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Procedimentos Endovasculares , Oclusão de Enxerto Vascular/terapia , Diálise Renal , Trombose/terapia , Grau de Desobstrução Vascular , Idoso , Procedimentos Endovasculares/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
15.
Hand Clin ; 35(2): 221-229, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30928053

RESUMO

Postoperative care of amputated digits begins before replantation. Detailed informed consent should be obtained and completion amputation discussed if revascularization is not ultimately successful. Complications and failure of the replanted digit should also be addressed. Postoperative pharmacologic treatment should consist of aspirin, at minimum. Complications, such as venous congestion or occlusion, and arterial thrombosis, should be dealt with expediently. Digital motion rehabilitation should start after 5 to 7 days of digital viability and splinting of the affected digit. Early protective motion protocol is implemented to maintain digital motion with emphasis on tendon glide and joint motion.


Assuntos
Amputação Traumática/reabilitação , Amputação Traumática/cirurgia , Traumatismos dos Dedos/reabilitação , Traumatismos dos Dedos/cirurgia , Reimplante/reabilitação , Antibioticoprofilaxia , Arteriopatias Oclusivas/terapia , Fibrinolíticos/uso terapêutico , Oclusão de Enxerto Vascular/terapia , Hemorragia/terapia , Humanos , Necrose/etiologia , Modalidades de Fisioterapia , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/prevenção & controle , Contenções , Trombose/prevenção & controle , Grau de Desobstrução Vascular
16.
Ann Vasc Surg ; 59: 158-166, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31009720

RESUMO

BACKGROUND: Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. METHODS: The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, 1 year, 18 months, and 2 years. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P < 0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P = 0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P = 0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P = 0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P < 0.001), fewer complications (1.6% vs. 21.5% for AVF, P < 0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P < 0.001). CONCLUSIONS: This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.


Assuntos
Derivação Arteriovenosa Cirúrgica , Cateterismo , Falência Renal Crônica/terapia , Diálise Renal , Enxerto Vascular , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Derivação Arteriovenosa Cirúrgica/mortalidade , Derivação Arteriovenosa Cirúrgica/normas , Cateterismo/efeitos adversos , Cateterismo/economia , Cateterismo/mortalidade , Cateterismo/normas , Redução de Custos , Análise Custo-Benefício , Feminino , Oclusão de Enxerto Vascular/economia , Oclusão de Enxerto Vascular/terapia , Custos de Cuidados de Saúde , Mortalidade Hospitalar , Hospitalização , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , /normas , Indicadores de Qualidade em Assistência à Saúde , Diálise Renal/efeitos adversos , Diálise Renal/economia , Diálise Renal/mortalidade , Diálise Renal/normas , Retratamento , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/economia , Enxerto Vascular/mortalidade , Enxerto Vascular/normas
17.
J Vasc Interv Radiol ; 30(4): 483-494.e1, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30857987

RESUMO

PURPOSE: To perform a systematic review and meta-analysis assessing patency outcomes following drug-coated balloon angioplasty (DCBA) in hemodialysis circuits. MATERIALS AND METHODS: MEDLINE and EMBASE systematic searches were performed from inception to November 2018 to identify comparative studies assessing DCBA vs plain old balloon angioplasty (POBA) in hemodialysis circuits. Abstract selection, data extraction, and quality assessment were performed by 2 independent reviewers. Primary outcome was loss of target lesion patency at 3, 6, 12, and 24 months for autogenous arteriovenous fistula (AVF), prosthetic arteriovenous graft (AVG), and hemodialysis-related central venous stenosis. RESULTS: Twelve studies comprising 908 patients were included. There was a significant improvement in patency among AVF after DCBA vs POBA at 3, 6, 12, and 24 months (odds ratio 0.58 [95% confidence interval, 0.36-0.94]; odds ratio 0.40 [95% confidence interval 0.23-0.70]; odds ratio 0.39 [95% confidence interval, 0.25-0.61]; and odds ratio 0.20 [95% confidence interval, 0.07-0.62]). This benefit persisted on subgroup analysis of randomized controlled trials (RCTs) only. Meta-analysis of results specific to AVG could not be performed, as only 1 RCT was identified that favored DCBA. Hemodialysis-associated central vein stenosis did not demonstrate a significant difference in patency rates between DCBA and POBA on meta-analysis. Twelve-month mortality and same-day complication rates did not differ between arms. CONCLUSIONS: Significant improvement in patency was identified with DCBA in AVF at 3, 6, 12, and 24 months. A single comparative study identified benefit of DCBA use in the AVG group. No significant benefit was identified with DCBA for central stenosis.


Assuntos
Angioplastia com Balão/instrumentação , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Oclusão de Enxerto Vascular/terapia , Diálise Renal , Dispositivos de Acesso Vascular , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Derivação Arteriovenosa Cirúrgica/mortalidade , Implante de Prótese Vascular/mortalidade , Fármacos Cardiovasculares/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/mortalidade , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
18.
J Vasc Surg ; 70(3): 748-755, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30850288

RESUMO

OBJECTIVE: Hypogastric artery aneurysms (HAAs) are rare but life-threatening in cases of rupture. Open or endovascular techniques traditionally aimed at occluding the hypogastric artery (HA) have considerable risk of pelvic ischemia. Iliac branch devices (IBDs) are indicated for aortoiliac aneurysms; however, they have also been used lately for HAAs. Currently, there are no reports about patient outcomes focusing on HAA therapy using IBDs. We retrospectively analyzed early and midterm outcomes using IBDs for HAAs. METHODS: Patients who received IBDs for HAAs at our department from January 1, 2012, through March 1, 2018, were included. Exclusion criteria were as follows: no HA involvement, emergency procedures, and HA stent grafting without IBD. Perioperative and follow-up data were collected from medical records. RESULTS: There were 18 IBDs (only IBD, n = 4; IBD + endovascular aneurysm repair [EVAR], n = 7; IBD ± EVAR + side branch occlusion, n = 7) implanted into 14 male patients (76 ± 4 [70-83] years). There were no intraoperative complications, and the technical success rate was 100%. After 19 ± 11 (2-39) months of follow-up, two hybrid (external iliac artery occlusion, n = 1; EVAR graft kinking, n = 1) and four endovascular reinterventions due to two type IB (side branch coiling + stent graft extension) and two type IIIB (stent grafting) endoleaks were required. One IBD-related type II endoleak revealed constant aneurysm diameters during follow-up. One small type IB endoleak was self-limited. Estimated freedom from reintervention was 31% ± 23% at 2.7 years. The clinical success and patency rate was 100%. The IBD-related mortality was 0%. CONCLUSIONS: The IBD for HAA shows good early and midterm results. Adequate sealing of HA landing zones and side branch occlusion are technically challenging but crucial to prevent type IB and type II endoleaks.


Assuntos
Aneurisma/cirurgia , Artérias/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Pelve/irrigação sanguínea , Idoso , Idoso de 80 Anos ou mais , Aneurisma/diagnóstico por imagem , Aneurisma/fisiopatologia , Artérias/diagnóstico por imagem , Artérias/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Endoleak/etiologia , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/terapia , Humanos , Masculino , Intervalo Livre de Progressão , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Grau de Desobstrução Vascular
19.
Cardiovasc Intervent Radiol ; 42(6): 835-840, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30927031

RESUMO

PURPOSE: To evaluate long-term primary and secondary patency results of drug-eluting balloon angioplasty for the treatment of juxta-anastomotic stenoses in distal radiocephalic arteriovenous fistulas. MATERIALS AND METHODS: Thirty-eight patients with juxta-anastomotic stenotic distal radiocephalic arteriovenous fistulas who underwent endovascular treatment with drug-eluting balloons between January 2014 and August 2016 in our interventional radiology department were included in this retrospective study. Color Doppler examination for follow-up was performed 15 days, 6 months, 12 months, 18 months, 24 months, 36 months, and 48 months after the procedure. Kaplan-Meier analysis was used to estimate primary and secondary patency rates. RESULTS: Totally, 42 angioplasty with drug-eluting balloons was performed in 38 patients (20 men and 18 women; mean age 66.42 ± 12.01). Technical and clinical success rate was 100% (42/42). The mean follow-up period was 27.71 months ± 12.98 (range, 1-54 months). The estimated primary patency rates at 6 months were 94.7% (95% CI, 80.9%-99.0%), at 12 months were 81.2% (95% CI, 64.6%-91.4%), at 24 months were 60.7% (95% CI, 43.6%-75.7%), and at 48 months were 53.1% (95% CI, 36.5%-69.1%). The estimated secondary patency rates at 6 months were 97.3% (95% CI, 84.5%-99.8%), at 12 months were 86.5% (95% CI, 70.7%-94.8%), at 24 months were 69.0% (95% CI, 51.8%-82.4%), and at 48 months were 61.7% (95% CI, 44.6%-76.5%). CONCLUSION: Drug-eluting balloon angioplasty is a useful, effective technique in dysfunctional radiocephalic fistulas due to juxta-anastomotic stenoses. We demonstrated remarkably high primary patency rates at 6, 12, 24, and 48 months.


Assuntos
Angioplastia com Balão/métodos , Fístula Arteriovenosa/terapia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Oclusão de Enxerto Vascular/terapia , Diálise Renal/efeitos adversos , Idoso , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/etiologia , Derivação Arteriovenosa Cirúrgica/métodos , Constrição Patológica , Feminino , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Ultrassonografia Doppler em Cores , Grau de Desobstrução Vascular
20.
Angiology ; 70(7): 649-661, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30704267

RESUMO

Conflicting evidence exists surrounding which conduit material is preferable in above-knee femoropopliteal bypass surgery. We performed a systemic review of electronic information sources to identify randomized controlled trials (RCTs) comparing vein versus prosthetic grafts in above-knee femoropopliteal bypasses. Eight RCTs reporting 1271 grafts (608 saphenous vein and 663 prosthetic) in 1132 patients were included. At 5 years, the vein group had significantly higher primary patency (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 1.17-2.55, P = 0.006), primary assisted patency (OR: 4.02, 95% CI: 2.84-5.70, P < 0.0001), and secondary patency (OR: 1.83, 95% CI: 1.20-2.80, P = 0.005) rates compared with the prosthetic group. The vein group required significantly fewer reinterventions (OR: 0.33, 95% CI: 0.18-0.60, P = 0.0003). There was no significant difference in 30-day mortality (risk difference: -0.01, 95% CI: -0.02 to 0.01, P = 0.34), 30-day morbidity (OR: 1.58, 95% CI: 0.61-4.06, P = 0.35), major amputation (OR: 0.71, 95% CI: 0.43-1.18, P = 0.19), or overall survival (OR: 0.95, 95% CI: 0.70-1.30, P = 0.76) when comparing vein versus prosthetic grafts. Our analysis supports the use of the saphenous vein in above-knee femoropopliteal bypass grafting owing to its superiority in primary, primary assisted, and secondary patency rates and less need for reintervention when compared with prosthetic grafts.


Assuntos
Implante de Prótese Vascular/instrumentação , Prótese Vascular , Artéria Femoral/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Artéria Poplítea/cirurgia , Veia Safena/transplante , Amputação , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Humanos , Salvamento de Membro , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
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