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1.
J Stroke Cerebrovasc Dis ; 29(10): 105158, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912500

RESUMO

INTRODUCTION: Intra-operative stroke (IOS) is associated with poor clinical outcome as detection is often delayed and time of symptom onset or patient's last known well (LKW) is uncertain. Intra-operative neurophysiological monitoring (IONM) is uniquely capable of detecting onset of neurological dysfunction in anesthetized patients, thereby precisely defining time last electrically well (LEW). This novel parameter may aid in the detection of large vessel occlusion (LVO) and prompt treatment with endovascular thrombectomy (EVT). METHODS: We performed a retrospective analysis of a prospectively maintained AIS and LVO database from May 2018-August 2019. Inclusion criteria required any surgical procedure under general anesthesia (GA) utilizing EEG (electroencephalography) and/or SSEP (somatosensory evoked potentials) monitoring with development of intraoperative focal persistent changes using predefined alarm criteria and who were considered for EVT. RESULT: Five cases were identified. LKW to closure time ranged from 66 to 321 minutes, while LEW to closure time ranged from 43 to 174 min. All LVOs were in the anterior circulation. Angiography was not pursued in two cases due to large established infarct (both patients expired in the hospital). EVT was pursued in two cases with successful recanalization and spontaneous recanalization was noted in one patient (mRS 0-3 at 90 days was achieved in all 3 cases). CONCLUSIONS: This study demonstrates that significant IONM changes can accurately identify patients with an acute LVO in the operative setting. Given the challenges of recognizing peri-operative stroke, LEW may be an appropriate surrogate to quickly identify and treat IOS.


Assuntos
Eletroencefalografia , Procedimentos Endovasculares , Potenciais Somatossensoriais Evocados , Monitorização Neurofisiológica Intraoperatória , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Triagem , Idoso , Anestesia Geral , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
2.
J Stroke Cerebrovasc Dis ; 29(10): 105122, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912548

RESUMO

BACKGROUND: Endovascular treatment (EVT) is merely recommended as class of recommendation IIb for patients with ASPECTS <6 according to the American Heart Association guideline 2019. In addition, the best determined imaging technique for EVT in patient with ASPECTS<6 remains unknown. The objective of this study was to define the safety and efficacy of EVT for patients with ASPECTS<6 and investigate the superiority between MRI and CT for patient selection. METHODS: A systematic search of PubMed, EMBASE, The Cochrane Library and other additional sources was performed for studies published with no publication period. Our study was conducted corresponding to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRIMA) guidelines. The analysis was performed using the Comprehensive Meta-Analysis (CMA) 2.0. RESULTS: Five studies reporting data from 844 participants were included in our analysis according to the inclusion criteria. Consequently, EVT was associated with statistically significant higher functional independence compared with MT (OR 5.401, 95% CI 3.227-9.041). Whereas EVT was found to be related to lower mortality compared with MT based on eligible data (OR 0.461, 95% CI 0.329-0.647). No significant difference was identified in sICH between EVT and MT (OR 1.075, 95% CI 0.452-2.558). CONCLUSION: According to the results of our study, we suggested that EVT is a preferred therapy in ACS patients with ASPECTS<6 in consideration of efficacy and safety. Furthermore, MRI did not show superiority over CT as no statistical difference was detected in all subgroups.


Assuntos
Isquemia Encefálica/terapia , Circulação Cerebrovascular , Procedimentos Endovasculares , Hemorragias Intracranianas/terapia , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
3.
J Stroke Cerebrovasc Dis ; 29(10): 105123, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912553

RESUMO

BACKGROUND: While patients with good grade aneurysmal subarachnoid hemorrhage are routinely admitted in intensive care units, critical care capacity in low-middle income countries (LMICs) is limited. In this study, we report the outcomes of good-grade SAH (Hunt and Hess grades I & II) patients admitted in ICU and non-ICU settings at a center in the Philippines and determine if site of care is predictive of outcome. METHODS: We performed a retrospective study of all adults diagnosed with good-grade SAH in a five-year period. Patients were analyzed according to three groups based on site of care: Group A (>50% of length of stay in ICU), Group B (>50% of LOS in non-ICU), and Group C (100% of LOS in non-ICU). The primary outcome measures were in-hospital mortality and mRS score at discharge. The secondary outcome measures were complication rate and LOS. RESULTS: A total of 242 patients was included in the cohort, which had a mean age of 51.16 years and a female predilection (64%). The rates of in-hospital mortality and favorable functional outcome at discharge were 0.82% and 93.8%, respectively, with no difference across groups. Delayed cerebral ischemia and infection were more frequently diagnosed in ICUs (p < 0.001), while rebleeding occurred more commonly in non-ICUs (p = 0.02). The median LOS was significantly longer in patients who developed complications. CONCLUSIONS: Admission of good-grade aneurysmal SAH patients in non-ICU settings did not adversely affect both in-hospital mortality and functional outcome at discharge. Prospective, randomized studies may lead to changes in pattern of ICU utilization which are critical for LMICs.


Assuntos
Procedimentos Endovasculares , Unidades de Terapia Intensiva , Admissão do Paciente , Hemorragia Subaracnóidea/terapia , Adulto , Idoso , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Filipinas , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/mortalidade , Hemorragia Subaracnóidea/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
4.
Vasc Health Risk Manag ; 16: 285-297, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32764949

RESUMO

Purpose: To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography. Patients and Methods: A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes. Results: All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG. Conclusion: Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Procedimentos Endovasculares , Intervenção Coronária Percutânea , Idoso , Fármacos Cardiovasculares/efeitos adversos , Causas de Morte , Doença Crônica , Doença da Artéria Coronariana/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Estudos Prospectivos , Encaminhamento e Consulta , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo , Resultado do Tratamento
6.
Eur J Vasc Endovasc Surg ; 60(4): 549-558, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32807674

RESUMO

OBJECTIVE: Endovascular revascularisation has become a standard approach for below knee lesions and paclitaxel coated devices have been widely used in patients with chronic limb threatening ischaemia. A recent meta-analysis reported higher mortality in paclitaxel coated devices compared with uncoated devices in femoropopliteal lesions. This study aimed to determine long term outcomes in below the knee interventions using paclitaxel coated devices in routine vascular care using a large and contemporary cohort. METHODS: A large cohort was created using all inclusive health insurance claims data of patients covered by the second largest insurance fund in Germany. The cohort included patients with index revascularisation of arteries below the knee performed from 1 January 2010, to 31 December 2018. Only patients with first paclitaxel coated device exposure were included. The study cohort was stratified into balloon vs. stent treatment and patients with paclitaxel coated devices were matched with uncoated devices using propensity score. Outcomes were evaluated using the Kaplan-Meier method and Cox regression. RESULTS: There were 14 738 patients (mean age 77.6 years, 43.6% female) and 6 568 matched patients included in the study. Increasing use of paclitaxel coated devices was observed during the study period (6% in 2010 vs. 31% in 2018, p < .001), and a total of 2 611 (39.8%) deaths occurred within five years of follow up. In the propensity score matched Cox model, a paclitaxel related reduction of five year mortality (hazards ratio, HR 0.84, 95% confidence interval, CI 0.78-0.91), amputation or death (HR 0.87, 95% CI 0.81-0.94), and cardiovascular event or death (HR 0.86, 95% CI 0.80-0.92) were observed. CONCLUSION: In this propensity score matched cohort, reduced long term all cause mortality, reduced rates of amputation or death and cardiovascular event or death were observed at five years after the use of paclitaxel coated devices when compared with uncoated devices for the treatment of chronic limb threatening ischaemia.


Assuntos
Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Stents Farmacológicos , Procedimentos Endovasculares/instrumentação , Isquemia/terapia , Perna (Membro)/irrigação sanguínea , Paclitaxel/administração & dosagem , Doença Arterial Periférica/terapia , Demandas Administrativas em Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Amputação , Fármacos Cardiovasculares/efeitos adversos , Doença Crônica , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Alemanha , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Paclitaxel/efeitos adversos , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
7.
J Stroke Cerebrovasc Dis ; 29(9): 105039, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807451

RESUMO

BACKGROUND: Data comparing the effect of age on outcomes of patients who underwent either endovascular coiling (EVC) or neurosurgical clipping (NSC) for ruptured intracranial aneurysms remains limited. OBJECTIVE: To better elucidate the preferred intervention for ruptured aneurysm management by presenting the results of our systematic review of the literature that evaluated the potential advantages of the two interventions between different age groups. METHODS: Systematic review of PubMed and Embase was performed (2002 - June 10, 2019) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2013 guidelines. Median ages of EVC and NSC cohorts were 54 and 56, respectively. Ages below the median were used in our "younger" cohort; ages above the median were used in our "older" cohort. RESULTS: We reviewed 13 studies on 7,137 patients. In the younger cohort, there were 2840 (EVC: 1412, NSC: 1428) patients. In the older cohort, there were 4297 (EVC: 2552, NSC: 1745) patients. Overall, there was a significant difference in functionality between EVC (77.70%) and NSC (69.23%) (OR=1.69; 95% C.I.: 1.10-2.60, p = 0.0212). In our younger cohort, functionality was significantly different between EVC (77%) and NSC (69%) (OR=1.54; 95% C.I.: 1.29-1.84, p < 0.001). For the older cohort, there was no significant difference in functionality, complications, or efficacy. CONCLUSIONS: We have highlighted the importance of considering age prior to deciding which intervention is most appropriate for ruptured aneurysms, with higher morbidity and mortality with NSC versus EVC in the younger population.


Assuntos
Aneurisma Roto/terapia , Procedimentos Endovasculares , Aneurisma Intracraniano/terapia , Procedimentos Neurocirúrgicos , Fatores Etários , Idoso , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/mortalidade , Aneurisma Roto/fisiopatologia , Tomada de Decisão Clínica , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/mortalidade , Aneurisma Intracraniano/fisiopatologia , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/instrumentação , Procedimentos Neurocirúrgicos/mortalidade , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Resultado do Tratamento
8.
J Stroke Cerebrovasc Dis ; 29(9): 105049, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807457

RESUMO

BACKGROUND: Patients with large-vessel occlusion (LVO) who initially present to a non-thrombectomy-capable center ("spoke") have worse outcomes than those presenting directly to a thrombectomy-capable center ("hub"). Furthermore, patients who suffer in-hospital strokes (IHS) suffer worse outcomes than those suffering strokes in the community. Data on patients who suffer IHS at a spoke hospital is lacking. We aim to characterize this particularly vulnerable population, define their outcomes, and compare them to patients who develop IHS at a hub institution. METHODS: We retrospectively reviewed prospectively collected data from patients suffering an IHS at a spoke hospital who were then transferred to the hub hospital for endovascular therapy (EVT). We then compared outcomes of these patients under EVT after developing IHS at the hub institution. RESULTS: A total of 108 IHS patients met inclusion criteria: 91 (84%) at a spoke facility and 17 (16%) at the hub facility. Baseline characteristics and reason for hospital admission were comparable between the two groups. Time from imaging to IV-tPA administration (17 vs. 70 min, p = 0.01) and time to EVT (120 vs. 247 min, p = 0.001) were significantly shorter in the hub group. More patients had a 90 day-mRS of 0-3 in the hub group than the spoke group (57% vs 22%, p < 0.05). CONCLUSION: Patients undergoing EVT after suffering IHS at a spoke hospital have significantly higher rates of poor outcomes compared to patients who suffer IHS at a hub hospital. Prolonged time delays in the initiation of IV-tPA and EVT represent areas of improvement.


Assuntos
Procedimentos Endovasculares , Fibrinolíticos/administração & dosagem , Pacientes Internados , Transferência de Pacientes , Acidente Vascular Cerebral/terapia , Trombectomia , Terapia Trombolítica , Tempo para o Tratamento , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
9.
J Stroke Cerebrovasc Dis ; 29(9): 105018, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807433

RESUMO

INTRODUCTION: Recent clinical comparisons of M1 and M2 segment endovascular thrombectomy have reached incongruous results in rates of complication and functional outcomes. This study aims to clarify the controversy surrounding this rapidly advancing technique through literature review and meta-analysis. METHODS: A Pubmed search was performed (January 2015-September 2019) using the following keywords: "M2 AND ("stroke" OR "occlusion") AND ("thrombectomy" OR "endovascular")". Safety and clinical outcomes were compared between segments via weighted Student's t-test, Chi-square and odds ratio while study heterogeneity was analyzed using Cochran Q and I2 tests. RESULTS: Pubmed identified 208 articles and eleven studies were included after full-text analysis, comprising 2,548 M1 and 758 M2 mechanical thrombectomy segment cases. Baseline National Institutes of Health Stroke Scale scores were comparatively lower in patients experiencing an M2 occlusion (16 ± 1.25 vs 13.6 ± 0.96, p < 0.01). Patients who underwent M2 mechanical thrombectomy were more likely to experience both good clinical outcomes (modified Rankin Scale 0-2) (48.6% vs 43.5% respectively, OR 1.24; CI 1.05-1.47, p = 0.01) and excellent clinical outcomes (modified Rankin Scale 0-1) (34.7% vs. 26.5%%, OR 1.6; CI 1.28-1.99, p < 0.01) at 90 days compared to M1 mechanical thrombectomy. Neither recanalization rates (75.3% vs 72.8%, OR 0.92, CI 0.75-1.13, p = 0.44) nor symptomatic intracranial hemorrhage rates (5.6% vs 4.9%, OR 0.92; CI 0.61-1.39, p= 0.7) were significantly different between M1 and M2 cohorts. Mortality was less frequent in the M2 cohort compared to M1 (16.3% vs 20.7%, OR 0.73; CI 0.57-0.94, p = 0.01). M1 and M2 cohorts did not differ in symptom onset-to-puncture (238.1 ± 46.7 vs 239.8 ± 43.9 min respectively, p=0.488) nor symptom onset-to recanalization times (318.7 ± 46.6 vs 317.7 ± 71.1 min respectively, p = 0.772), though mean operative duration was shorter in the M2 cohort (61.8 ± 25.5 vs 54.6 ± 24 min, p < 0.01). CONCLUSIONS: Patients who underwent M2 mechanical thrombectomy had a higher prevalence of good and excellent clinical outcomes compared to the M1 mechanical thrombectomy cohorts. Additionally, our data suggest lower mortality rates in the M2 cohort and symptomatic intracranial hemorrhage rates that are similar to the M1 cohort. Therefore, M2 segment thrombectomy likely does not pose a significantly elevated operative risk and may have a positive impact on patient outcomes.


Assuntos
Procedimentos Endovasculares/efeitos adversos , Infarto da Artéria Cerebral Média/terapia , Trombectomia/efeitos adversos , Idoso , Avaliação da Deficiência , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/fisiopatologia , Masculino , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
11.
Vasc Endovascular Surg ; 54(7): 565-572, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32677549

RESUMO

OBJECTIVES: To investigate the safety and efficacy of a stent combined with a linear strand of 125I seeds to treat malignant cancer-associated venous obstruction. METHODS: We retrospectively analyzed the data of 57 patients with malignant cancer-associated venous obstruction. Nineteen patients underwent the placement of a stent combined with a linear strand of 125I seeds (group A), and 38 patients underwent the placement of a bare stent (group B). The following parameters were compared between the 2 groups of patients: symptom relief rate, duration of venous patency, survival time, quality of life, and adverse events. RESULTS: A total of 34 stents and 527 seeds were implanted in group A, while a total of 57 stents were implanted in group B. The surgery success rate was 96.5%, and no serious complication related to the surgery was reported. Symptoms of venous obstruction improved significantly after surgery. The score of group A decreased from 14.74 ± 0.562 points before surgery to 2.79 ± 1.357 points after surgery(P < .001), and the score of group B decreased from 13.79 ± 1.398 points before surgery to 5.55 ± 3.674 points after surgery (P < .001). The patency rate of group A was significantly higher than that of group B at 1 to 6 months after surgery (100%, 84.2%, 68.4%, 63.2%, 36.8%, 21.1% vs 68.4%, 23.7%, 18.4%, 7.9%, 5.3%, 2.6%, respectively; P < .05). Before treatment, there was no statistically significant difference in the Karnofsky Performance Status (KPS) score between the groups (P = .791). After 1 to 6 months of treatment, the KPS score was significantly higher in group A than in group B (P = .013). The median patency duration in groups A and B was 125 days (95% CI: 80.018-169.982) and 35 days (95% CI: 20.501-49.499), respectively (P < .001). The median survival time of group A was 155 days (95% CI: 110.406-199.594), and that of group B was 98 days (95% CI: 55.712-140.288; P = .325). Multivariate analysis showed that the implantation of a stent combined with a linear strand of 125I seeds and the KPS score (≥80 points) were independent factors of long-term patency after stent placement. CONCLUSIONS: The placement of a stent combined with a linear strand of 125I seeds is a safe and effective treatment for venous obstruction caused by malignant tumors. This treatment provides prolonged patency compared with the placement of bare stent, and while it does not significantly improve the survival time of patients, it can improve their quality of life.


Assuntos
Procedimentos Endovasculares/instrumentação , Radioisótopos do Iodo/administração & dosagem , Neoplasias/terapia , Células Neoplásicas Circulantes/patologia , Compostos Radiofarmacêuticos/administração & dosagem , Stents , Doenças Vasculares/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Radioisótopos do Iodo/efeitos adversos , Masculino , Pessoa de Meia-Idade , Neoplasias/complicações , Neoplasias/mortalidade , Neoplasias/patologia , Desenho de Prótese , Qualidade de Vida , Compostos Radiofarmacêuticos/efeitos adversos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Doenças Vasculares/etiologia , Doenças Vasculares/mortalidade , Doenças Vasculares/patologia , Grau de Desobstrução Vascular
12.
Eur J Vasc Endovasc Surg ; 60(2): 181-191, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32709467

RESUMO

OBJECTIVE: The aim was to describe the outcomes of the Anaconda™ Fenestrated endograft Italian Registry for complex aortic aneurysms (AAAs), unsuitable for standard endovascular aneurysm repair (EVAR). METHODS: Between 2012 and 2018 patients with a proximal neck unsuitable for standard EVAR, treated with the fenestrated Anaconda™ endograft, were prospectively enrolled in a dedicated database. Endpoints were peri-operative technical success (TS) and evaluation of type Ia/b or 3 endoleaks (T1/3 EL), target visceral vessel (TVV) occlusion, re-interventions, and AAA related mortality at 30 days, six months, and later follow up. RESULTS: One hundred twenty seven patients (74 ± 7 years, American Society Anesthesiology (ASA) II/III/IV: 12/85/30) were included in the study in 49 Italian Vascular Surgery Units (83 juxta/para-renal AAA, 13 type IV thoraco-abdominal AAA, 16 T1aEL post EVAR, and 15 short neck AAA). Configurations with one, two, three, and four fenestrations were used in 5, 56, 39, and 27 cases, respectively, for a total of 342 visceral vessels. One hundred and eight (85%) bifurcated and 19 (15%) tube endografts were implanted. In 35% (44/127) of cases the endograft was repositioned during the procedure, and 37% (128/342) of TVV were cannulated from brachial access. TS was 87% (111/127): five T1EL, six T3EL (between fenestration and vessel stent), and six loss of visceral vessels (one patient with a Type Ia EL had also a TVV loss) occurred. Thirty day mortality was 4% (5/127). Two of the five T1EL resolved spontaneously at 30 days. The overall median follow up was 21 ± 16 months; one T1EL (5%) occurred at six months and one T3EL (4%) at the three year follow up. Another two (3%) TVV occlusions occurred at six months and five (3%) at three years. The re-intervention rate at the 30 days, six months, and three year follow up was 5%, 7%, and 18 ± 5%, respectively. CONCLUSION: The fenestrated Anaconda™ endograft is effective in the treatment of complex AAA. Some structure properties, such as the re-positionability and the possibility of cannulation from above, are specific characteristics helpful for the treatment of some complex anatomies.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Endoleak/etiologia , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Itália , Masculino , Estudos Prospectivos , Desenho de Prótese , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
13.
J Stroke Cerebrovasc Dis ; 29(8): 104932, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689619

RESUMO

BACKGROUND: Inflammation and malnutrition play a critical role in the outcomes of patients undergoing carotid artery stenting (CAS). Prognostic nutritional index (PNI) is commonly utilized to evaluate the peri-operative immune-nutritional status of patients undergoing colorectal cancer surgery and is independently associated with survival. We assessed the association between immune-nutritional status, indexed by PNI, and outcomes in CAS patients. METHODS: A total of 615 patients hospitalized for CAS in a tertiary heart center were enrolled in the study. PNI was calculated using the following formula: 10× serum albumin value (g/dL) + 0.005 × total lymphocyte count in the peripheral blood (per mm3). In-hospital and 5-year outcomes (ipsilateral stroke, major stroke, transient ischemic attack, myocardial infarction, and mortality) were compared between the tertiles of PNI. RESULTS: In-hospital outcomes were similar between the groups except the increased mortality in decreasing tertiles of PNI. During a mean follow-up duration of 51.1 months, the lower PNI tertile was related to unfavorable outcomes. After adjusting for multi-model Cox regression analysis, PNI persisted as an independent prognostic factor for mortality and major stroke. CONCLUSION: PNI was independently associated with long-term mortality and major stroke in CAS patients. Malnutrition and inflammation, which can be assessed easily and quickly using PNI, have an important prognostic value in the patients undergoing CAS.


Assuntos
Doenças das Artérias Carótidas/terapia , Procedimentos Endovasculares/instrumentação , Inflamação/diagnóstico , Desnutrição/diagnóstico , Avaliação Nutricional , Estado Nutricional , Stents , Idoso , Biomarcadores/sangue , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Inflamação/complicações , Inflamação/mortalidade , Inflamação/fisiopatologia , Contagem de Linfócitos , Masculino , Desnutrição/complicações , Desnutrição/mortalidade , Desnutrição/fisiopatologia , Pessoa de Meia-Idade , Projetos Piloto , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Albumina Sérica Humana/metabolismo , Fatores de Tempo , Resultado do Tratamento
14.
J Endovasc Ther ; 27(4): 599-607, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32633651

RESUMO

Purpose: To report the outcomes of bypass grafting (BG) vs endovascular therapy (EVT) in patients with non-dialysis-dependent chronic kidney disease (CKD) and chronic limb-threatening ischemia (CLTI). Materials and Methods: The CRITISCH Registry is a prospective, national, interdisciplinary, multicenter registry evaluating the current practice of all available treatment options in 1200 consecutive CLTI patients. For the purposes of this analysis, only the 337 patients with non-dialysis-dependent CKD treated by either BG (n=86; median 78 years, 48 men) or EVT (n=251; median age 80 years, 135 men) were analyzed. The primary composite outcome was amputation-free survival (AFS); secondary outcomes were overall survival (OS) and amputation-free time (AFT). All outcomes were evaluated in Cox proportional hazards models; the results are reported as the hazard ratio (HR) and 95% confidence interval (CI). Results: The Cox regression analysis revealed a significantly greater hazard of amputation or death after BG (HR 1.78, 95% CI 1.05 to 3.03, p=0.028). The models for AFT and overall survival also suggested a higher hazard for BG, but the differences were not significant (AFT: HR 1.66, 95% CI 0.78 to 3.53, p=0.188; OS: HR 1.41, 95% CI 0.80 to 2.47, p=0.348). The absence of runoff vessels (HR 1.73, 95% CI 1.15 to 2.60, p=0.008) was associated with a decreased AFS. The likelihood of amputation was higher in male patients (HR 2.21, 95% CI 1.10 to 4.45, p=0.027) and was associated with a lack of runoff vessels (HR 1.95, 95% CI 0.96 to 3.95, p=0.065) and myocardial infarction (HR 3.74, 95% CI 1.23 to 11.35, p=0.020). Death was more likely in patients without runoff vessels (HR 1.76, 95% CI 1.11 to 2.80, p=0.016) and those with a higher risk score (HR 1.73, 95% CI 1.03 to 2.91, p=0.038). Conclusion: This analysis suggested that BG was associated with poorer AFS than EVT in patients with non-dialysis-dependent CKD and CLTI. Male sex, previous myocardial infarction, and the absence of runoff vessels were additionally identified as predictors of poorer outcomes.


Assuntos
Procedimentos Endovasculares , Isquemia/terapia , Doença Arterial Periférica/terapia , Insuficiência Renal Crônica/terapia , Enxerto Vascular , Idoso , Idoso de 80 Anos ou mais , Amputação , Doença Crônica , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Alemanha/epidemiologia , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Salvamento de Membro , Masculino , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Estudos Prospectivos , Sistema de Registros , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
16.
J Stroke Cerebrovasc Dis ; 29(8): 104817, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689620

RESUMO

BACKGROUND: With the increasing age of acute stroke patients being admitted to hospitals, more data are needed on indications, complications and outcome of endovascular treatment (EVT) in the very elderly. METHODS: Retrospective observational study with data collection from Belgian, Swiss, Canadian comprehensive stroke centers and Swedish EVT National database. All patients with acute ischemic stroke were eligible if aged older than or ≥90 years and treated with EVT ± pretreatment with intravenous thrombolysis (IVT). Safety assessment comprised presence of periprocedural complications, hemorrhagic transformation or other adverse events (<7days). Efficacy and outcome measures were successful recanalization (modified Treatment In Cerebral Infarction (mTICI) score ≥2b), favorable clinical outcome (modified Rankin Score (mRS) 0-2) and 3-months mortality. RESULTS: Inclusion of 112 nonagenarians (mean age 93.3 ± 2.5 years; 76.8% women; pre-mRS ≤2 in 69.4%). Pretreatment with IVT was performed in 54.7%. In 74.6% successful recanalization (mTICI ≥2b) was achieved. Favorable outcome (mRS ≤2) was seen in 16.4% and 3-months mortality was 62.3%. Multivariate logistic regression analysis showed younger age (odds ratio [OR] 2.99; 1.29-6.95; P = .011) and lower prestroke mRS (OR 13.46; 2.32-78.30; P = .004) as significant predictors for good clinical outcome at 90 days. CONCLUSIONS: Our observational study on EVT in nonagenarians demonstrates the need for careful patient selection. A substantial proportion of nonagenarians shows an unfavorable clinical outcome and high mortality, despite acceptable recanalization rates. A high prestroke disability (mRS) and advancing age predict an unfavorable outcome. Treatment decisions should be made on case-by-case evaluation, keeping in mind limited chances of favorable outcome and high risk of mortality.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares , Acidente Vascular Cerebral/terapia , Fatores Etários , Idoso de 80 Anos ou mais , Bélgica , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Canadá , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Suíça , Fatores de Tempo , Resultado do Tratamento
17.
Vasc Endovascular Surg ; 54(8): 676-680, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32729398

RESUMO

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) remains controversial in patients with connective tissue disorders given the concern for durability. We report on the largest series to date on outcomes of patients with thoracic aortic disease and connective tissue disorders treated with TEVAR. METHODS: The Vascular Quality Initiative registry identified 12 207 patients treated with TEVAR from January 2010 to December 2018, including 102 with Marfans, Ehlers-Danlos, or Loey-Dietz syndrome. Outcomes were analyzed per the Society for Vascular Surgery reporting standards. RESULTS: Median age was 50.6 years (interquartile range: 57.0-75.0), and 62 (60.7%) were male. Eighty-eight (86.3%) patients had Marfan, 9 (8.8%) had Ehlers-Danlos, and 5 (4.9%) had Loey-Dietz syndrome. Twenty-six (25.5%) patients were treated for degenerative aneurysmal disease and 76 (74.5%) patients for type B dissections (33 acute, 31 chronic). Most common indications for interventions in patients with type B dissection were pain (n = 41), aneurysmal degeneration (n = 16), and malperfusion (n = 8), with 3 patients who presented ruptured. There was no significant difference in perioperative complications between acute/chronic dissections and aneurysms (P = .14). Percutaneous access was utilized in 61.7% of patients, with a 2.9% rate of arterial injury requiring reintervention. Follow-up data were available for 75 (73.3%) patients at a mean follow-up of 15.6 months. Overall mortality was 5.3%. There were 30 patients with follow-up endoleak data, and 8 (26.7%) endoleaks were identified. All endoleaks were in patients treated for acute type B dissection, and all resolved after a mean of 2.1 reinterventions. Three patients treated for acute Type B Aortic Dissection (TBAD) had retrograde dissections requiring intervention. DISCUSSION: Thoracic endovascular aortic repair for patients with connective tissue disorders can be performed with low perioperative mortality, spinal cord ischemia, or Cerebrovascular Accident (CVA). On follow-up, acute type B aortic dissections represent a higher risk subgroup with increased rates of endoleak and retrograde dissection. Closer follow-up for these patients and early reintervention may be beneficial.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Síndrome de Ehlers-Danlos/complicações , Procedimentos Endovasculares , Síndrome de Loeys-Dietz/complicações , Síndrome de Marfan/complicações , Adulto , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/etiologia , Aneurisma Dissecante/mortalidade , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/etiologia , Aneurisma da Aorta Torácica/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/etiologia , Ruptura Aórtica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Síndrome de Ehlers-Danlos/diagnóstico , Síndrome de Ehlers-Danlos/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Síndrome de Loeys-Dietz/diagnóstico , Síndrome de Loeys-Dietz/mortalidade , Masculino , Síndrome de Marfan/diagnóstico , Síndrome de Marfan/mortalidade , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
18.
Eur J Vasc Endovasc Surg ; 60(4): 519-530, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32624387

RESUMO

OBJECTIVE: Hospital and surgeon operative caseload is thought to be associated with peri-operative mortality following the non-elective repair of aortic aneurysms; however, whether such an association exists within the Australian healthcare setting is unknown. METHODS: The Australasian Vascular Audit was interrogated to identify patients undergoing non-elective (emergency [EMG] or semi-urgent [URG]) aortic aneurysm repair between 2010 and 2016, as well as their treating surgeon and hospital. Hierarchal logistic regression modelling was used to assess the impact of caseload on outcomes after both endovascular (EVAR) and open surgical repair (OSR). RESULTS: Volume counts were determined from 14 262 patients (4 121 OSR and 10 141 EVAR). After exclusion of elective procedures and duplicates, 1 153 EVAR (570 EMG and 583 URG) and 1 245 OSR (946 EMG and 299 URG) non-elective cases remained for the analysis. Crude mortality was 24.0% following OSR (EMG 29.2%; URG 7.7%) and 7.5% following EVAR (EMG 12.6%; URG 2.4%). Univariable analysis demonstrated an association between OSR mortality and hospital volume (quintile [Q] 1: 25.3%, Q2: 27.8%, Q3: 23.9%, Q4: 27.0%, Q5: 16.2%; p = .030), but not surgeon (Q1: 25.2%, Q2: 27.4%, Q3: 26.0%, Q4: 21.4%, Q5: 19.5%, p = .32). Multivariable analysis confirmed this association (odds ratio (OR) [95% CI]; Q1 vs 5: 1.91 [1.13-3.21], Q2 vs. 5: 2.01[1.24-3.25], Q3 vs. 5: 1.41 [0.86-2.29], Q4 vs. 5: 1.92 [1.17-3.15]; p = .020). The difference was most pronounced in the EMG OSR group [Q1 - 3 vs. 4-5] (OR 1.63 [1.07-2.48]; p = .020). Mortality after EVAR was not associated with either hospital (Q1: 6.3%, Q2: 10%, Q3: 6.8%, Q4: 4.5%, Q5: 10%; p = .14) or surgeon volume (Q1: 9.3%, Q2: 5.7%, Q3: 8.1%, Q4: 7.0%, Q5: 7.3%; p = .67). CONCLUSION: There is an inverse correlation between hospital volume and peri-operative mortality following EMG open repair of aortic aneurysm. These data support restructuring Australian pathways of care to direct suspected ruptured aneurysm to institutions that reach a minimum volume threshold.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Procedimentos Endovasculares , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Avaliação de Processos e Resultados em Cuidados de Saúde , Cirurgiões , Procedimentos Cirúrgicos Vasculares , Carga de Trabalho , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Austrália/epidemiologia , Competência Clínica , Bases de Dados Factuais , Emergências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
19.
Eur J Vasc Endovasc Surg ; 60(3): 347-354, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32631711

RESUMO

OBJECTIVE: The objective of this study was to evaluate the outcomes of open surgery (OS) and endovascular surgery (ES) for extracranial carotid aneurysm (ECCA) in the authors' centre. METHODS: Fifty-seven consecutive patients who were diagnosed with ECCA and underwent intervention from January 2005 to July 2019 at Zhongshan Hospital, Fudan University, were reviewed retrospectively. Patient characteristics and surgical outcomes for OS and ES were analysed. ECCAs were divided into three morphological subgroups: subgroup Ⅰ, no severe tortuosity of the internal carotid artery (ICA) or common carotid artery (CCA) proximal to the aneurysm, tortuosity of the aneurysm and 1 cm of peri-aneurysmal carotid artery ≤ 90°; subgroup Ⅱ, severe ICA or CCA tortuosity proximal to the aneurysm, tortuosity of the aneurysm and 1 cm of peri-aneurysmal carotid artery ≤ 90°; subgroup Ⅲ, aneurysm tortuosity and 1 cm peri-aneurysmal carotid artery > 90°. RESULTS: 35 patients underwent OS, 20 patients underwent ES and 2 patients underwent OS after the failure of ES. Thirty-six cases were classified in subgroup Ⅰ, 11 cases in subgroup Ⅱ, and 10 cases in subgroup Ⅲ. ES was achieved successfully in all 18 cases of subgroup I, but failed in three of four cases in subgroups Ⅱ and Ⅲ. With a mean duration of 62.9 ± 44.5 months of follow up, five deaths were recorded in the OS group, two of which were caused by ipsilateral stroke and three were not neurologically related. There was no stroke or death in the ES group during follow up. One case of stroke and two cases of death occurred in symptomatic patients, while one case of stroke and three cases of death occurred in asymptomatic patients. CONCLUSION: This series demonstrates that ES may be a safe and durable option for ECCA in subgroup Ⅰ, while in subgroups Ⅱ and Ⅲ, ES alone may be difficult to apply. A 30 day stroke rate around 5% existed in ECCAs with interventions, which should be considered before the intervention.


Assuntos
Aneurisma/cirurgia , Doenças das Artérias Carótidas/cirurgia , Procedimentos Endovasculares , Procedimentos Cirúrgicos Vasculares , Adulto , Idoso , Anastomose Cirúrgica , Aneurisma/diagnóstico por imagem , Aneurisma/mortalidade , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/mortalidade , China , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Ligadura , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
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