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1.
J Trauma Acute Care Surg ; 88(2): 298-304, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31996655

RESUMO

BACKGROUND: Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) and intermittent REBOA (iREBOA) are techniques to extend the therapeutic duration of REBOA by balloon titration for distal flow or cyclical balloon inflation/deflation to allow transient distal flow, respectively. We hypothesized that manually titrated pREBOA would reduce blood losses and ischemic burden when compared with iREBOA. METHODS: Following 20% blood volume controlled hemorrhage, 10 anesthetized pigs underwent uncontrolled hemorrhage from the right iliac artery and vein. Once in hemorrhagic shock, animals underwent 15 minutes of complete zone 1 REBOA followed by 75 minutes of either pREBOA or iREBOA (n = 5/group). After 90 minutes, definitive hemorrhage control was obtained, animals were resuscitated with the remaining collected blood, and then received 2 hours of critical care. RESULTS: There were no differences in mortality. Animals randomized to iREBOA spent a larger portion of the time at full occlusion when compared with pREBOA (median, 70 minutes; interquartile range [IQR], 70-80 vs. median, 20 minutes; IQR, 20-40, respectively; p = 0.008). While the average blood pressure during the intervention period was equivalent between groups, this was offset by large fluctuations in blood pressure and significantly more rescue occlusions for hypotension with iREBOA. Despite lower maximum aortic flow rates, the pREBOA group tolerated a greater total amount of distal aortic flow during the intervention period (median, 20.9 L; IQR, 20.1-23.0 vs. median, 9.8 L; IQR, 6.8-10.3; p = 0.03) with equivalent abdominal blood losses. Final plasma lactate and creatinine concentrations were equivalent, although iREBOA animals had increased duodenal edema on histology. CONCLUSION: Compared with iREBOA, pREBOA reduced the time spent at full occlusion and the number of precipitous drops in proximal mean arterial pressure while delivering more distal aortic flow but not increasing total blood loss in this highly lethal injury model. Neither technique demonstrated a survival benefit. Further refinement of these techniques is necessary before clinical guidelines are issued.


Assuntos
Oclusão com Balão/métodos , Procedimentos Endovasculares/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Animais , Aorta/cirurgia , Oclusão com Balão/efeitos adversos , Oclusão com Balão/instrumentação , Modelos Animais de Doenças , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Ressuscitação/efeitos adversos , Ressuscitação/instrumentação , Choque Hemorrágico/etiologia , Choque Hemorrágico/mortalidade , Análise de Sobrevida , Sus scrofa , Fatores de Tempo , Índices de Gravidade do Trauma , Resultado do Tratamento , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico
2.
Br J Radiol ; 93(1106): 20190017, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31899661

RESUMO

Paediatric aortic trauma is a rare injury which can be fatal if not identified and managed appropriately. Surgical repair remains the gold-standard in moderate to severe aortic injuries. In the last decade however, endovascular treatment has gained popularity in children who have suitable vascular anatomy for intervention and are either not fit for surgery or in whom, endovascular intervention is the only alternative that will make a difference in the clinical outcome. Children pose a unique set of challenges to endovascular therapy. In this article, we aim to illustrate the different endovascular options that are available for the treatment of acute traumatic aortic injury and visceral thromboembolisation through pictorial representation. We will also demonstrate the feasibility and the limitation of this technique.


Assuntos
Aorta Abdominal/lesões , Aorta Torácica/lesões , Procedimentos Endovasculares , Ferimentos não Penetrantes/cirurgia , Ferimentos Perfurantes/cirurgia , Acidentes de Trânsito , Adolescente , Aorta Abdominal/cirurgia , Aorta Torácica/cirurgia , Criança , Pré-Escolar , Angiografia por Tomografia Computadorizada , Estudos de Viabilidade , Humanos , Angiografia por Ressonância Magnética , Masculino , Ferimentos não Penetrantes/diagnóstico , Ferimentos Perfurantes/diagnóstico
3.
Medicine (Baltimore) ; 99(2): e18665, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914055

RESUMO

We assessed the value of fluid-attenuated inversion recovery vascular hyperintensity (FVH)-diffusion-weighted imaging (DWI) mismatch in predicting revascularization and functional outcome in stroke patients with large vessel occlusion (LVO) after endovascular thrombectomy (EVT).Seventy-two acute stroke patients within 6 hour of stroke onset who received EVT were enrolled. FVH-DWI mismatch, revascularization (mTICI score), functional outcome (mRS at 3 months) and other clinical data were collected. Statistical analysis was performed to predict revascularization and functional outcome after stroke.Twenty-nine patients (60.42%) had FVH-DWI mismatch in patients with complete revascularization and 8 patients (33.33%) had FVH-DWI mismatch in patients with no/partial revascularization, and there was significant difference in 2 groups (t = 4.698; P = .045). The good functional outcome group (37/72; 51.39%) had higher FVH score (4.38 ±â€Š1.53 vs 3.49 ±â€Š1.52; t = 2.478; P = .016), higher FVH-DWI mismatch ratio (81.25% vs 48.15%; t = 10.862; P = .002), higher complete revascularization ratio (83.78% vs 48.57%; t = 10.036; P = .002) than the poor functional outcome group (35/72; 48.61%). Spearman's rank correlation analysis revealed that FVH-DWI mismatch was positively correlated with complete revascularization (r = 0.255; P = .030) and good functional outcome (r = 0.417; P = .000). Multivariable logistic regression analysis demonstrated that FVH-DWI mismatch was independently associated with complete revascularization (OR, 0.328; 95% CI, 0.117-0.915; P = .033) and good functional outcome (OR, 0.169; 95% CI, 0.061-0.468; P = .001).Assessments of FVH-DWI mismatch before thrombectomy therapy might be useful for predicting revascularization and functional outcome in stroke patients with LVO.


Assuntos
Revascularização Cerebral/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Imagem de Difusão por Ressonância Magnética , Procedimentos Endovasculares/métodos , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/tratamento farmacológico , Fatores de Tempo , Ativador de Plasminogênio Tecidual/uso terapêutico
4.
Isr Med Assoc J ; 22(1): 17-21, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31927800

RESUMO

BACKGROUND: Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) is associated with decreased perioperative morbidity and mortality. OBJECTIVES: To report the outcomes of EVAR among patients older than 80 years of age. METHODS: In this retrospective study, we reviewed patients older than 80 years of age who underwent elective EVAR at our institution between 2007 and 2017. The demographics, perioperative morbidity and mortality, and long-term results are reported. RESULTS: During the study period, 444 patients underwent elective EVAR for AAAs. Among them 128 patients (29%) were > 80 years of age. Mean age was 84 ± 3.4 (range 80-96) years, and 110 patients (86%) were male. The EVAR was technically successful in 127 patients (99%) and there were intraoperative mortalities. Within 30 days of the surgery, nine patients (7%) died. Major and minor adverse events occurred in 26 (20%) and 59 (46%) patients, respectively. Factors associated with increased risk of perioperative morbidity and mortality included chronic kidney disease, peripheral artery disease, and the existence of three or more co-morbidities. CONCLUSIONS: EVAR in the elderly can be performed with a high rate of success; however, it is associated with a substantial rate of morbidity and mortality, particularly when patients present with multiple co-morbidities. When performing EVAR in this population group, the risk of rupture must be considered opposed to the life expectancy of these patients and the risk of perioperative morbidity and mortality.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/efeitos adversos , Fatores Etários , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
5.
Vasc Endovascular Surg ; 54(2): 162-164, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31707948

RESUMO

Hybrid thoracic endovascular aortic repair with surgical arch debranching is an accepted method for total arch reconstruction. Although off-pump arch debranching is increasingly used as a prophylactic adjunct to endovascular arch repair extending into landing zone 0, this technique is seldom performed with a ministernotomy due to a steep learning curve among surgeons. Herein, we report our standard technique for off-pump hybrid total aortic arch repair using a ministernotomy.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Esternotomia/métodos , Aneurisma Dissecante/diagnóstico por imagem , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
6.
Vasc Endovascular Surg ; 54(2): 165-168, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31707973

RESUMO

BACKGROUND: Pseudoaneurysm developing after repair of a patent ductus arteriosus (PDA) is uncommon, with only a handful of cases reported in the literature. While older literature cites infection, recent series suggest that formation of pseudoaneurysm off of a ligated PDA attributed to breakdown in the suture line. Thoracic endovascular aortic repair (TEVAR) for this rare pathology has been demonstrated in selected case reports. METHODS/RESULTS: A 61-year-old woman presented with enlarging left chest mass and shortness of breath. The patient reported a history of a PDA with 2 attempts at closure. At age 6, she had undergone an attempt at endovascular closure of the PDA; this subsequently resulted in right lower extremity limb ischemia with resultant below-knee amputation. At age 12, she underwent open thoracotomy with ligation of the PDA; at this procedure, she had injury to her recurrent laryngeal nerve, resulting in permanent hoarseness of voice. A computed tomography angiogram of the chest was obtained, which demonstrated a saccular 4.5 × 3.8 cm pseudoaneurysm in the region of the PDA with calcific wall changes. Recommendation was made to proceed with operative repair and she agreed. A TEVAR was performed using a commercially available stent graft. During the procedure, intravascular ultrasound was performed; however, the connection between the PDA pseudoaneurysm and the aorta was not visualized. She had an uncomplicated operative and postoperative course. Follow-up imaging showed complete thrombosis of the pseudoaneurysm. CONCLUSIONS: Pseudoaneurysm from previous PDA repair is a rare pathology. We present a unique case in which the patient had undergone attempts at both endovascular and open surgical repair. Open repair for PDA is still advocated; however, TEVAR appears to be a safe treatment in adults with this pathology following failed open closure.


Assuntos
Falso Aneurisma/cirurgia , Implante de Prótese Vascular , Permeabilidade do Canal Arterial/cirurgia , Procedimentos Endovasculares , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Permeabilidade do Canal Arterial/diagnóstico por imagem , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Ligadura/efeitos adversos , Pessoa de Meia-Idade , Stents , Resultado do Tratamento
7.
Vasc Endovascular Surg ; 54(2): 118-125, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31690248

RESUMO

BACKGROUND: Expanded applications and increasing volumes of complex endovascular procedures have increased the risk of unintended intraoperative fragmentation and retention of catheters and sheaths. We describe a series of retained or fragmented endovascular devices, a quality improvement program to address this unmet need for improved detection of catheter fragmentation, and the results of this program. METHODS: Cases utilizing endovascular devices that resulted in a retained catheter fragment were identified and analyzed during divisional quality improvement review. One consistent area of concern was operating room (OR) staff unfamiliarity with verifying the integrity of an endovascular device. In response, a slide-based training protocol of focused, endovascular nursing education was implemented. Following perceived lack of improvement after this approach, we developed a handheld visual reference display of the tips of common catheters and sheaths. Staff was surveyed before and after intervention to assess the educational value of the display and the impact on staff device familiarity. RESULTS: All 4 described cases resulted in an unplanned return to the OR for retrieval of the fragmented catheter or sheath. No thromboembolic complications were observed, although associated intra-arterial thrombus was noted in 2 cases. Thirty-four OR nurses were polled to trial the visual reference display initiative, with 70% of those reporting primary surgical assignments outside of cardiovascular ORs. Introduction of the new visual reference display improved staff confidence in their ability to identify a broken device (2.4-3.7, P < .001). This improvement was most significant in OR staff with primary assignments in noncardiovascular services. CONCLUSION: Current OR standard operating procedures fail to address the potential for unintentionally retained catheters and wires during endovascular procedures. Our novel visual reference display of common endovascular items rather than conventional in-service training improved the ability of staff to identify device fragmentation at the time of the index procedure.


Assuntos
Remoção de Dispositivo , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Falha de Equipamento , Corpos Estranhos/cirurgia , Dispositivos de Acesso Vascular , Adulto , Idoso , Atitude do Pessoal de Saúde , Competência Clínica , Desenho de Equipamento , Feminino , Corpos Estranhos/diagnóstico por imagem , Corpos Estranhos/etiologia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem no Hospital , Enfermagem de Centro Cirúrgico , Reoperação , Resultado do Tratamento
8.
Vasc Endovascular Surg ; 54(2): 172-174, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31714184

RESUMO

Axillary artery blowout is a rare life- and limb-threatening condition. The traditional surgical approach of ligation and extra-anatomic bypass is associated with a high morbidity and mortality. We present a case report of a 65-year-old male with axillary artery hemorrhage secondary to an irradiated squamous cell cancer. We propose a staged hybrid approach for the treatment of this unusual clinical entity consisting of emergent stent grafting followed by planned elective extra-anatomic bypass, debridement, and a course of specific antimicrobial therapy.


Assuntos
Artéria Axilar/efeitos da radiação , Artéria Axilar/cirurgia , Implante de Prótese Vascular , Carcinoma de Células Escamosas/radioterapia , Procedimentos Endovasculares , Hemorragia/cirurgia , Lesões por Radiação/terapia , Neoplasias Cutâneas/radioterapia , Idoso , Anti-Infecciosos/administração & dosagem , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Carcinoma de Células Escamosas/patologia , Desbridamento , Procedimentos Endovasculares/instrumentação , Hemorragia/diagnóstico , Hemorragia/etiologia , Humanos , Masculino , Lesões por Radiação/diagnóstico , Lesões por Radiação/etiologia , Radioterapia Adjuvante/efeitos adversos , Neoplasias Cutâneas/patologia , Stents , Resultado do Tratamento
9.
World Neurosurg ; 133: e796-e803, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31605852

RESUMO

BACKGROUND: Techniques for endovascular management of carotid-cavernous fistulas (CCFs) have evolved over the years. Current strategies include transarterial or transvenous approaches and direct puncture or exposure of the cavernous sinus. Rarely, complex CCFs may require multiple approaches or procedures. We describe our experience managing CCFs, reporting on outcomes and technical nuances. METHODS: A retrospective review of institutional records was conducted to identify consecutive cases of CCF treated between July 2005 and July 2016. Pertinent technical details and outcomes were recorded. RESULTS: In 44 patients, 51 procedures were performed. There were 13 direct CCFs and 31 indirect CCFs: 13 (30%) type A, 3 (7%) type B, 5 (11%) type C, and 23 (52%) type D. A transarterial approach was selected in 39% of cases (n = 20), resulting in a long-term successful embolization rate of 60% (n = 12). Transvenous methods via the inferior petrosal sinus or superior ophthalmic vein were used in 49% of cases (n = 25), resulting in a long-term obliteration rate of 88% (n = 22). Multimodal management was required in 5 patients, including 1 patient in whom a craniotomy was performed to facilitate coil embolization of the cavernous sinus under direct vision. A 7% complication rate (n = 3) was observed, with significant morbidity in 1 patient. CONCLUSIONS: CCFs are complex vascular lesions that require facility with various endovascular and surgical approaches. High-flow, direct-type fistulas may harbor a significant risk of recurrence after transarterial embolization. Partial or unsuccessful embolization may necessitate an open surgical approach to the superior ophthalmic vein or cavernous sinus.


Assuntos
Fístula Carotidocavernosa/terapia , Seio Cavernoso/cirurgia , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
10.
World Neurosurg ; 133: e739-e744, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31606499

RESUMO

OBJECTIVE: To carry out surgery safely in vessels with stents, it is essential to have knowledge of what would happen if the stents were clamped or cut. Using all stents that are permitted in Japan, we recorded with a surgical microscope the behavior of stents when they were clamped or cut and discussed the morphologic changes along with image findings. METHODS: We classified carotid artery and intracranial stents as group 1A and 1B or group 2A and 2B according to the structure of stent eye: laser cut or blade. Each stent was clamped using a Yasargil aneurysm clip, bulldog forceps, and vascular forceps. Degree of closure and presence or absence of stent deformation after declamping were recorded using a surgical microscope. Furthermore, we performed morphologic evaluations using high-resolution cone-beam computed tomography. Lastly, each stent was cut; the behavior of the cut stent was recorded, and differences between stents were examined. RESULTS: Complete clamping was confirmed both visually and based on image evaluations with bulldog forceps and vascular forceps in the groups of carotid artery stents, with the Yasargil aneurysm clip in the intracranial stents. In the blade-type stents, we found that the stents elongated during clamping, and the component wire scattered at the time of stent cutting. Furthermore, the stents could be easily separated by holding with forceps. CONCLUSIONS: Knowing the properties of each stent is essential to conduct safe surgery in response to complications. Special care must be taken when clamping and cutting blade-type stents.


Assuntos
Procedimentos Endovasculares/instrumentação , Teste de Materiais , Stents , Artérias Carótidas/cirurgia , Humanos , Técnicas In Vitro , Aneurisma Intracraniano/cirurgia
11.
Vasc Endovascular Surg ; 54(2): 111-117, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31607232

RESUMO

BACKGROUND: Patients commonly use online materials as a source of health information. Since poor health literacy has been shown to correlate with negative outcomes, it is recommended that patient-directed materials be written at a sixth-grade reading level. This study evaluates the readability and understandability of commonly accessed online materials pertaining to both endovascular and open repair of abdominal aortic aneurysm. METHODS: Searches for "endovascular repair abdominal aortic aneurysm" and "open repair abdominal aortic aneurysm" were performed on both Google and Bing, and the top 10 websites from each search engine were identified. Relevant websites (total N = 28, endovascular n = 15, open n = 15, and 2 redundant sites) with patient-directed content were analyzed. Readability was assessed using 9 established methods, and understandability was assessed using the Patient Education Materials Assessment Tool scoring system. RESULTS: The average reading grade level for all sites was 12.8. Endovascular sites averaged a reading grade level of 13.6 with a range from 11.5 to 15.6. Open-repair websites had a grade-level average of 12.1 with a range from 9.9 to 14.1. Readability was found to be inversely related to understandability, with a Pearson correlation coefficient of -0.551 (P = .003). No website was written at or below the recommended sixth-grade reading level. CONCLUSIONS: Patient-directed online health information pertaining to open and endovascular repair of abdominal aortic aneurysm exceeds the recommended sixth-grade reading level. Increasing complexity of health literature correlates with poor understandability. Modifications such as shorter sentences, fewer words with more than 6 letters, and increasing usage of clear visual aids can increase readability and understandability.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Compreensão , Procedimentos Endovasculares , Conhecimentos, Atitudes e Prática em Saúde , Alfabetização em Saúde , Internet , Educação de Pacientes como Assunto/métodos , Procedimentos Cirúrgicos Vasculares , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Humanos , Ferramenta de Busca
12.
World Neurosurg ; 133: e666-e682, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31568908

RESUMO

BACKGROUND: Giant aneurysms at carotid arteries are typically treated with flow diverter (FD) stents in the clinic. Although the goal of an FD stent is to direct most of the blood flow into the main artery, not much is known regarding the effects of wire number an FD possesses on the hemodynamics inside the aneurysm. METHODS: In this study, 48-, 72-, and 96-wire FD stents were separately implanted into the site of aneurysm of a 45-year-old woman to evaluate the effects of the FD's number of wires on fluid flow behavior in the aneurysm sac. Time evolution of both finite-time Lyapunov exponent (FTLE) and hyperbolic time fields in the aneurysm sac were calculated by using computational fluid dynamics along with Lagrangian coherent structure (LCS) methods. RESULTS: The computations reveal that a 48-wire FD stent allows a large amount of blood to enter inside the aneurysm sac revealing scattered nonstagnant flow zones formation. Besides, time-dependent results of LCS analysis show that most of the blood flow is diverted into the main artery when 72- and 96-wire number Surpass brand FD stents are separately implanted into the site of the aneurysm, yielding a small amount of blood flow to penetrate into the aneurysm sac. CONCLUSIONS: Furthermore, FTLE and hyperbolic time field plots are in good agreement with the patient's digital subtraction angiography image captured 3.5 minutes after 72-wire Surpass brand FD stent implantation.


Assuntos
Procedimentos Endovasculares/instrumentação , Hemodinâmica/fisiologia , Aneurisma Intracraniano/cirurgia , Modelos Biológicos , Stents , Angiografia Digital , Simulação por Computador , Feminino , Humanos , Hidrodinâmica , Pessoa de Meia-Idade
13.
World Neurosurg ; 133: e600-e608, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31568912

RESUMO

BACKGROUND: Evidence is lacking regarding the role of radiologic surveillance for asymptomatic intracranial aneurysms (AIAs) in the elderly (≥65 years). We sought to establish if long-term clinical and radiologic observation is warranted for older patients with AIAs. METHODS: A retrospective cohort of 193 consecutive patients with 255 AIAs were clinically and radiologically observed between January 2011 and January 2019. The primary end points were documented aneurysm growth, subarachnoid hemorrhage, or definitive treatment with microsurgical clipping or endovascular coiling. Baseline patient and aneurysm characteristics were obtained. Univariate and multivariate comparisons were performed. RESULTS: Aneurysm growth was observed in 8 patients (4.2%) at a median follow-up of 58.2 months (interquartile range, 38.4-78.5 months). The median aneurysm size at initial diagnosis was 3.5 mm (interquartile range, 2.2-5 mm). Aneurysms larger than 7 mm selected for surveillance were noted in 37 patients (19.2%). The growth rate was estimated at 0.2 mm per person-year. At the end of the study period, 175 patients (90.7%) were alive, 6 (3.1%) were lost to follow-up, and 12 (6.2%) died of unrelated causes. During the 1025.2 person-years follow-up, no patient had experienced subarachnoid hemorrhage, and none required definitive treatment. The presence of aneurysmal bleb (odds ratio, 6.02; 95% confidence interval, 1.15-31.43; P = 0.033) and multiple intracranial aneurysms (odds ratio, 10.98; 95% confidence interval, 1.27-94.91; P = 0.029) were associated with growth. CONCLUSIONS: AIAs in older patients deemed suitable for conservative management do not require robust follow-up. The current study suggests a potential role for closer surveillance for patients with multiple intracranial aneurysms or aneurysms with bleb morphology.


Assuntos
Aneurisma Intracraniano/patologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Tratamento Conservador , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/terapia , Masculino , Estudos Retrospectivos , Fatores de Risco , Hemorragia Subaracnóidea/epidemiologia , Hemorragia Subaracnóidea/etiologia , Tempo
14.
World Neurosurg ; 133: e487-e491, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31542440

RESUMO

BACKGROUND: Stenting may be a safer alternative to endarterectomy for treating carotid artery stenosis (CAS), but its long-term efficacy is uncertain. There is a lack of long-term and noncontrolled clinical trial data that reflects "real-world" CAS. This study aimed to analyze the long-term efficacy and safety of our center's CAS procedure. METHODS: We retrospectively analyzed our database of patients who underwent CAS. Patient demographic data, previous risk factors, diagnostic and procedural information, and clinical and image follow-up data were collected from up to 1 year after treatment. RESULTS: Overall, 187 patients were analyzed. Our patient population largely comprised higher-risk patients compared with the patient populations of randomized controlled trials. We had more symptomatic (n = 145, 77.5%) than asymptomatic patients (n = 42, 22.5%), and 49% of patients had >90% stenosis. By the 30-day follow-up, there were 10 major adverse events (5.3%) observed in 8 patients (4.2%), including 7 strokes (3 ischemic and 4 hemorrhagic) and 3 deaths. By the 1-year follow-up, 6 strokes and 5 deaths occurred in 9 patients (4.8%), and color Doppler control showed that 87.6% of patients had stenosis-free stents. CONCLUSIONS: Despite our high-risk population group, there were high rates of successful stent placement, low complication rates, good clinical outcomes, and low rates of stenting restenosis.


Assuntos
Estenose das Carótidas/cirurgia , Procedimentos Endovasculares/métodos , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Stents , Resultado do Tratamento
15.
World Neurosurg ; 133: 409-412, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31421298

RESUMO

BACKGROUND: Carotid cavernous aneurysm (CCA) rupture is rare. However, it can result in various complications such as carotid cavernous fistula (CCF), epistaxis, spontaneous thrombosis, and subarachnoid hemorrhage. CASE DESCRIPTION: We report a 65-year-old woman with a history of uncontrolled diabetes who was referred with complaints of acute headache, diplopia, proptosis, and chemosis. Ophthalmic examination revealed elevated intraocular pressure in the right eye, optic disk edema, and retinal venous congestion. Canthotomy was performed based on a diagnosis of orbital compartment syndrome (OCS). Further imaging revealed a dilated superior ophthalmic vein and cavernous sinus, as well as swelling of the extraocular muscles in the right eye. Digital subtraction angiography revealed the fistulous connection between the cavernous part of the internal carotid and cavernous sinus (direct CCF) due to the large ruptured CCA, resulting in retrograde flow through the superior and inferior ophthalmic veins. Successful endovascular coiling of the aneurysm resulted in complete occlusion of the fistula. Postintervention ophthalmic examination demonstrated progressive improvement of ophthalmic signs and symptoms; however, the patient's right eye remained sightless. CONCLUSIONS: In patients with clinical manifestation of OCS with no history of any predisposing risk factors, diagnosis of ruptured cavernous sinus aneurysm and resulting direct CCF should be considered. In such cases, emergent imaging along with early endovascular intervention can resolve OCS and prevent permanent ocular injury and vision loss.


Assuntos
Aneurisma Roto/complicações , Fístula Carotidocavernosa/complicações , Síndromes Compartimentais/etiologia , Oftalmopatias/etiologia , Idoso , Aneurisma Roto/terapia , Fístula Carotidocavernosa/terapia , Síndromes Compartimentais/terapia , Procedimentos Endovasculares , Oftalmopatias/terapia , Feminino , Humanos , Resultado do Tratamento
16.
World Neurosurg ; 133: e576-e582, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31561042

RESUMO

OBJECTIVE: To investigate the factors associated with futile recanalization after stent retriever thrombectomy in patients with acute ischemic stroke due to large vessel occlusion. METHODS: We retrospectively analyzed the medical records of 56 patients with an acute anterior circulation macrovascular occlusion who underwent successful stent retriever thrombectomy. Patients were classified as successful recanalization or futile recanalization at the follow-up. Univariate analysis and binary logic regression analysis were used to explore the association between patients' demographic and clinical characteristics and futile recanalization. RESULTS: The rate of futile recanalization was significantly higher after stent retrieval thrombectomy in patients with an Alberta Stroke Program Early CT (ASPECT) score ≤7 points versus >7 points (P < 0.001), ≥5 passes with the stent retriever versus <5 passes with the stent retriever (P = 0.036), or a longer recanalization time (P = 0.008). The influence of number of stent retriever pass is foremost, followed by ASPECT and occurrence to recanalization. CONCLUSIONS: Improving technical expertise with mechanical thrombectomy and shortening the therapeutic time window may improve the prognosis of patients with acute ischemic stroke due to large vessel occlusion.


Assuntos
Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Resultado do Tratamento , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Stents
17.
Vasa ; 49(1): 39-42, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31549917

RESUMO

Background: To present a technique of sheath supported contralateral limb gate (CLG) cannulation of modular bifurcated stent-graft in endovascular abdominal aortic repair. Materials and methods: After totally percutaneous bilateral femoral access, the 9F introducer sheath is exchanged to a 30 cm 12 fr introducer sheath over a stiff wire contralateral to the intended main stent-graft insertion side and advanced into the aorta below the lowest renal artery. Parallel to the stiff wire within the sheath an additional standard J-tip guidewire with a 5 fr Pigtail angiographic catheter is advanced to the level of the renal arteries. After main body deployment, the 12 fr introducer sheath and J-tip wire with pigtail catheter are retracted until the CLG opening level, maintaining the stiff "buddy" wire in position to support the 12 fr sheath, maintaining its distal opening close to the contralateral gate opening to achieve easy cannulation. Results: Retrospective analysis of video archive from July 2016 to February 2018 evidenced 55 recorded EVAR cases. All CLG cannulations were obtained with Standard J-tip or Terumo Glidewire wires and with Pig-Tail or Berenstein catheters. Technical success was 100 %. Mean fluoroscopy time to accomplish CLG cannulation was 37.6 33 (range 1-105) seconds. The aortic carrefour angulation on coronal axis strongly correlates with cannulation time p = <.001, with longer cannulation time for higher carrefour angulations on coronal axis (Pearson correlation coefficient 0.47). Conclusions: The use of 12 fr sheath with parallel wire introduction technique, appears to be a safe and reliable tool to facilitate CLG cannulation during EVAR procedures.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Prótese Vascular , Humanos , Estudos Retrospectivos , Stents , Resultado do Tratamento
18.
Vasc Endovascular Surg ; 54(2): 102-110, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31746273

RESUMO

OBJECTIVE: Compare technical, clinical, and economic outcomes between endovascular and open approaches in patients with type D aortoiliac occlusive disease according to the TransAtlantic Inter-Society Consensus. METHODS: Patients undergoing revascularization for type D aortoiliac lesions, either endovascular or open surgery approach, from 2 Portuguese institutions between January 2011 and October 2017 were included. The surgical technique was left to the surgeon discretion. Patients with common femoral artery affection, both obstructive and aneurysmatic, were excluded. RESULTS: Twenty-seven patients underwent aortobifemoral bypass and 32 patients were submitted to endovascular repair. The patients undergoing endovascular procedure were more likely to present with chronic heart failure (P = .001) and chronic kidney disease (P = .022) and less likely to have a history of smoking (P = .05). The mean follow-up period was 67.84 (95% confidence interval = 61.85-73.83) months. The open surgery approach resulted in a higher technical success (P = .001); however, limb salvage and patency rates were not different between groups. Endovascular approach was associated with a shorter length-of-stay, both inpatient (6 vs 9 days; P = .041) and patients admitted in the intensive care unit (0 vs 3.81 days; P = .001) as well as lower hospital expenses (US$9281 vs US$23 038; P = .001) with a similar procedure cost (US$2316 vs US$1173; P = .6). No differences were found in the postsurgical quality of life. CONCLUSION: Endovascular approach is, at least, clinically equivalent to open surgery approach and is more cost-efficient. The "endovascular-first" approach should be considered for type D occlusive aortoiliac lesions.


Assuntos
Doenças da Aorta/cirurgia , Arteriopatias Oclusivas/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Femoral/cirurgia , Artéria Ilíaca/cirurgia , Idoso , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/economia , Doenças da Aorta/fisiopatologia , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/economia , Arteriopatias Oclusivas/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Implante de Prótese Vascular/instrumentação , Redução de Custos , Análise Custo-Benefício , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Custos de Cuidados de Saúde , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Portugal , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Stents , Fatores de Tempo , Resultado do Tratamento
19.
Vasc Endovascular Surg ; 54(2): 97-101, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31746279

RESUMO

Preprocedural cross-sectional imaging (PCSI) for peripheral artery disease (PAD) may vary due to patient complexity, anatomical disease burden, and physician preference. The objective of this study was to determine the utility of PCSI prior to percutaneous vascular interventions (PVIs) for PAD. Patients receiving first time lower extremity angiograms from 2013 to 2015 at a single institution were evaluated for PCSI performed within 180 days, defined as computed tomography angiography (CTA) or magnetic resonance angiography (MRA) evaluating abdominal to pedal vasculature. The primary outcome was technical success defined as improving the target outflow vessels to <30% stenosis. Of the 346 patients who underwent lower extremity angiograms, 158 (45.7%) patients had PCSI, including 150 patients had CTA and 8 patients had MRA. Of these, 48% were ordered by the referring provider (84% at an outside institution). Preprocedural cross-sectional imaging was performed at a median of 26 days (interquartile range: 9-53) prior to the procedure. The analysis of the institution's 5 vascular surgeons identified PCSI rates ranging from 31% to 70%. On multivariate analysis, chronic kidney disease (odds ratio [OR] = 0.35; 95% confidence interval [CI]: 0.17-0.73) was associated with less PSCI usage, and inpatient/emergency department evaluation (OR = 3.20; 95% CI: 1.58-6.50) and aortoiliac disease (OR = 2.78; 95% CI: 1.46-5.29) were associated with higher usage. After excluding 31 diagnostic procedures, technical success was not statistically significant with PSCI (91.3%) compared to without PCSI (85.6%), P = .11. When analyzing 89 femoral-popliteal occlusions, technical success was higher with PCSI (88%) compared to procedures without (69%) P = .026. Our analysis demonstrates that routine ordering of PCSI may not be warranted when considering technical success of PVI; however, PCSI may be helpful in treatment planning. Further studies are needed to confirm these findings in another practice setting, with more prescriptive use of PCSI to improve procedural success, and thereby improve the value of PCSI.


Assuntos
Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares , Extremidade Inferior/irrigação sanguínea , Angiografia por Ressonância Magnética , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/terapia , Padrões de Prática Médica/tendências , Idoso , Tomada de Decisão Clínica , Angiografia por Tomografia Computadorizada/tendências , Bases de Dados Factuais , Procedimentos Endovasculares/tendências , Feminino , Humanos , Angiografia por Ressonância Magnética/tendências , Masculino , Variações Dependentes do Observador , Seleção de Pacientes , Doença Arterial Periférica/fisiopatologia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Resultado do Tratamento
20.
World Neurosurg ; 133: 84-89, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31574331

RESUMO

BACKGROUND: The middle meningeal artery (MMA) is an important conduit for the endovascular treatment of skull base and intracranial pathologies including, recently, subdural hematomas. A key aspect of such procedures is to perform a thorough diagnostic angiogram to detect anomalous arterial origins and "dangerous" anastomoses with branches of the internal carotid arteries. Although the most common anomaly related to the MMA is an abnormal origin from the ophthalmic artery, anomalous origin from the posterior circulation is rare. Moreover, its recognition requires a concerted effort at performing a vertebral artery angiogram irrespective of the location of the pathology (e.g., in subdural hematoma). CASE DESCRIPTION: We describe a case of anomalous origin of MMA from the basilar artery as a lateral pontine artery branch that was detected in a patient with recurrent subdural hematoma who presented for endovascular MMA embolization. CONCLUSIONS: The embryologic origin of the entity is briefly discussed, along with suggestions for managing such an anomaly during endovascular embolization.


Assuntos
Artéria Basilar/anormalidades , Hematoma Subdural Crônico/terapia , Artérias Meníngeas/anormalidades , Idoso de 80 Anos ou mais , Artéria Basilar/diagnóstico por imagem , Artéria Basilar/cirurgia , Angiografia Cerebral , Embolização Terapêutica/métodos , Procedimentos Endovasculares , Hematoma Subdural Crônico/diagnóstico por imagem , Humanos , Masculino , Artérias Meníngeas/diagnóstico por imagem , Artérias Meníngeas/cirurgia
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