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1.
Ann Thorac Surg ; 109(3): 959-981, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32000979

RESUMO

This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/normas , Consenso , Procedimentos Endovasculares/normas , Sociedades Médicas , Cirurgia Torácica , Humanos
2.
Medicina (Kaunas) ; 55(8)2019 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-31349723

RESUMO

Background and objectives: Abdominal aortic aneurysm (AAA) growth is unpredictable after the endovascular aneurysm repair (EVAR). Continuing aortic wall degradation and weakening due to hypoxia may have a role in post-EVAR aneurysm sac growth. We aimed to assess the association of aortic wall density on computed tomography angiography (CTA) with aneurysm growth following EVAR. Materials and Methods: A total of 78 patients were included in the study. The control group consisted of 39 randomly assigned patients without aortic pathology. Post-EVAR aneurysm sac volumes on CTA were measured twice during the follow-up period to estimate aneurysm sac behavior. A maximum AAA sac diameter, aortic wall and lumen densities in Hounsfield units (HU) on CTA were measured. A relative aortic wall density (the ratio of aortic wall to lumen densities) was calculated. A statistical data analysis was performed using standard methods. Results: An increase in the AAA sac volume was observed in 12 (30.8%) cases. Median relative aortic wall density on CTA scores in both the patient and the control group at the level of the diaphragm were similar: 0.15 (interquartile range (IQR), 0.11-0.18) and 0.16 (IQR 0.11-0.18), p = 0.5378, respectively. The median (IQR) relative aortic wall density score at the level of the maximum AAA diameter in the patient group was lower than at the level below renal arteries in the control group: 0.10 (0.07-0.12) and 0.17 (0.12-0.23), p < 0.0001, respectively. The median (IQR) relative growing AAA sac wall density score was lower than a relative stable/shrinking AAA sac wall density score: 0.09 (0.06-0.10) and 0.11 (0.09-0.13), p = 0.0096, respectively. Conclusions: A lower aortic aneurysm wall density on CTA may be associated with AAA growth after EVAR.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Gravidade Específica , Procedimentos Cirúrgicos Vasculares/normas , Idoso , Aorta Abdominal/fisiopatologia , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/fisiopatologia , Estudos de Coortes , Angiografia por Tomografia Computadorizada/métodos , Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos
3.
J Neurointerv Surg ; 11(10): 1024-1025, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31197026

RESUMO

Endosaccular flow disruption is an innovative method of treating wide-necked complex aneurysms. Currently four types of devices have obtained the CE mark for use within Europe. These are the Woven EndoBridge device (WEB), the Luna Aneurysm Embolization System, the Medina Embolic Device (Medtronic), and the Contour Neurovascular System. The aim of this article is to provide an overview of these devices and to summarize the evidence in the literature pertaining to the treatment of intracranial aneurysms with them.


Assuntos
Aneurisma/diagnóstico por imagem , Aneurisma/cirurgia , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/normas , Desenho de Prótese/normas , Sistemas de Liberação de Medicamentos/métodos , Sistemas de Liberação de Medicamentos/normas , Embolização Terapêutica/instrumentação , Embolização Terapêutica/normas , Europa (Continente) , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Resultado do Tratamento
4.
J Neurointerv Surg ; 11(10): 1055-1062, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31103994

RESUMO

BACKGROUND: The aim of this publication is to provide a detailed update on the diagnosis, treatment, and endovascular techniques for posterior circulation emergent large vessel occlusion (pc-ELVO). METHODS: We performed a review of the literature to specifically evaluate this disease and its treatments. RESULTS: Data were analyzed, and recommendations were reported based on the strength of the published evidence and expert consensus. CONCLUSION: While many questions about pc-ELVO remain to be studied, there is evidence to support particular practices in its evaluation and treatment.


Assuntos
Transtornos Cerebrovasculares/cirurgia , Procedimentos Endovasculares/normas , Procedimentos Neurocirúrgicos/normas , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas/normas , Acidente Vascular Cerebral/cirurgia , Transtornos Cerebrovasculares/diagnóstico por imagem , Procedimentos Endovasculares/métodos , Humanos , Procedimentos Neurocirúrgicos/métodos , Relatório de Pesquisa , Acidente Vascular Cerebral/diagnóstico por imagem
5.
Ann Vasc Surg ; 59: 248-258, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31132446

RESUMO

BACKGROUND: Ambulatory hospitalization for endovascular repair of lower extremity peripheral arterial disease (PAD) could be a real opportunity to respond to the burden of PAD, to reduce costs, and to improve patients' empowerment. The French Society of Vascular and Endovascular Surgery (SCVE) established guidelines to facilitate the development of ambulatory hospitalization in France. METHODS: In 2017, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and MEDLINE database to conduct a systematic review of available literature. A total of 448 relevant articles were found. Twelve articles, all published after the year 2000, were included and reviewed by two independent investigators. The SCVE mandated a scientific committee to collectively establish these guidelines. RESULTS: Eligibility for ambulatory management shall be based on the assessment of the triad: (1) patient, (2) procedure, and (3) structure. Comprehensive information and a detailed procedural pathway should be provided for the patient. No age limit is recommended. American Society of Anesthesiologists I, II, and III stable patients are eligible for ambulatory intervention. Specific comorbidities such as severe obesity, sleep apnea, and/or chronic kidney failure should be assessed preoperatively. Critical limb ischemia and complex lesions have not been considered as exclusion criteria. Antiplatelet drug use (aspirin and/or clopidogrel) has not been considered as a contraindication. Femoral ultrasound-guided puncture is recommended. Manual compression or closure devices have been recommended for 7F sheath or less. A minimum of 4 hours of monitoring after percutaneous femoral access is required before discharge. CONCLUSIONS: The SCVE guidelines aim to frame the practice of ambulatory endovascular procedures for lower extremity peripheral artery disease and to give vascular interventionalists help in their routine practice.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/normas , Procedimentos Endovasculares/normas , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Padrões de Prática Médica/normas , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Tomada de Decisão Clínica , Consenso , Procedimentos Endovasculares/efeitos adversos , França , Fidelidade a Diretrizes/normas , Humanos , Resultado do Tratamento
6.
J Neurointerv Surg ; 11(8): 781-784, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31088943

RESUMO

BACKGROUND AND PURPOSE: Despite numerous optimization attempts, time delays are still a relevant problem in endovascular stroke treatment. We hypothesized that public display of the fastest procedural times in our institution would raise awareness, which would result in improved procedural times. METHODS: We established a competition, which lasted 6 months, in which the fastest neurovascular team in terms of procedural times (image to reperfusion) was displayed on a public board in our institution and rewarded with public praise. During this time no other relevant procedural or infrastructural means for improvement of procedural times were introduced in our institution. We prospectively evaluated procedural times in 496 patients who received endovascular stroke treatment 9 months before the competition, during the competition, and during the four 6-month time periods for 2 years after the competition. RESULTS: Median image-to-reperfusion times improved significantly from 98 min before the competition to 85 min during the competition (p=0.005) and remained stable with a median of 81 min 2 years after the competition (p=0.837). CONCLUSION: We were able to improve our procedural times significantly with a simple and cost-efficient competition. This effect was sustained 2 years after the competition was completed, implying that the improvement in procedural times was probably due to raised awareness.


Assuntos
Comportamento Competitivo , Procedimentos Endovasculares/tendências , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Tempo para o Tratamento/tendências , Idoso , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reperfusão/métodos , Trombectomia/métodos , Trombectomia/normas , Trombectomia/tendências , Fatores de Tempo , Tempo para o Tratamento/normas , Resultado do Tratamento
8.
J Neurointerv Surg ; 11(11): 1070-1072, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30926686

RESUMO

BACKGROUND: The "General or Local Anesthesia in Intra-Arterial Therapy" (GOLIATH) trial compared infarct growth and outcome in patients undergoing endovascular therapy (EVT) under either general anesthesia (GA) or conscious sedation (CS). The results were the same for the primary outcome (infarct growth) but successful reperfusion was higher in the GA arm. OBJECTIVE: To further examine differences in the quality and safety of EVT with the two anesthetic regimens in a post hoc analysis of GOLIATH. METHODS: In GOLIATH, 128 subjects with anterior circulation large vessel occlusion stroke within 6 hours of onset were randomized to either GA or CS (1:1 allocation). We compared the quality of reperfusion, treatment delay, use of catheters, and contrast and radiation dosage between the trial arms. RESULTS: Sixty-five subjects were randomized to GA. Baseline demographic and clinical variables were similar between the treatment arms. We found no difference in procedure time, contrast dose, or radiation dose between the two arms. Tandem occlusions were associated with a longer procedure time, but there was no difference between the two arms. There was no difference in reperfusion rates between the direct aspiration technique and a stent retriever (86% vs 79%, respectively, p=0.54), but aspiration was associated with a shorter procedure time (28 min vs 42 min for a stent retriever), p=0.03. CONCLUSION: Safety and quality of EVT under either GA and CS are comparable. TRIAL REGISTRATION: Unique identifier: NCT02317237;Post-results.


Assuntos
Anestesia Geral/métodos , Isquemia Encefálica/terapia , Sedação Consciente/métodos , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/normas , Isquemia Encefálica/diagnóstico por imagem , Sedação Consciente/normas , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/normas , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Acidente Vascular Cerebral/diagnóstico por imagem , Trombectomia/métodos , Resultado do Tratamento
10.
J Neurointerv Surg ; 11(8): 847-851, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30712013

RESUMO

BACKGROUND: Endovascular thrombectomy (ET) is the standard of care for treatment of acute ischemic stroke (AIS) secondary to large vessel occlusion. The elderly population has been under-represented in clinical trials on ET, and recent studies have reported higher morbidity and mortality in elderly patients than in their younger counterparts. OBJECTIVE: To use machine learning algorithms to develop a clinical decision support tool that can be used to select elderly patients for ET. METHODS: We used a retrospectively identified cohort of 110 patients undergoing ET for AIS at our institution to train a regression tree model that can predict 90-day modified Rankin Scale (mRS) scores. The identified algorithm, termed SPOT, was compared with other decision trees and regression models, and then validated using a prospective cohort of 36 patients. RESULTS: When predicting rates of functional independence at 90 days, SPOT showed a sensitivity of 89.36% and a specificity of 89.66% with an area under the receiver operating characteristic curve of 0.952. Performance of SPOT was significantly better than results obtained using National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT score, or patients' baseline deficits. The negative predictive value for SPOT was >95%, and in patients who were SPOT-negative, we observed higher rates of symptomatic intracerebral hemorrhage after thrombectomy. With mRS scores prediction, the mean absolute error for SPOT was 0.82. CONCLUSIONS: SPOT is designed to aid clinical decision of whether to undergo ET in elderly patients. Our data show that SPOT is a useful tool to determine which patients to exclude from ET, and has been implemented in an online calculator for public use.


Assuntos
Procedimentos Endovasculares/normas , Aprendizado de Máquina/normas , Seleção de Pacientes , Trombectomia/normas , Idoso de 80 Anos ou mais , Estudos de Coortes , Procedimentos Endovasculares/métodos , Feminino , Humanos , Masculino , Estudos Prospectivos , Estudos Retrospectivos , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Resultado do Tratamento
11.
Crit Care ; 23(1): 61, 2019 Feb 22.
Artigo em Inglês | MEDLINE | ID: mdl-30795782

RESUMO

BACKGROUND: The aim of this study was to explore the performance and outcomes for intravascular (IC) versus surface cooling devices (SFC) for targeted temperature management (TTM) after out-of-hospital cardiac arrest. METHODS: A retrospective analysis of data from the Time-differentiated Therapeutic Hypothermia (TTH48) trial (NCT01689077), which compared whether TTM at 33 °C for 48 h results in better neurologic outcomes compared with standard 24-h duration. Devices were assessed for the speed of cooling and rewarming rates. Precision was assessed by measuring temperature variability (TV), i.e., the standard deviation (SD) of all temperature measurements in the cooling phase. Main outcomes were overall mortality and poor neurological outcome, including death, severe disability, or vegetative status. RESULTS: A total of 352 patients had available data and were included in the analysis; of those, 218 (62%) were managed with IC. A total of 114/218 (53%) patients with IC and 61/134 (43%) with SFC were cooled for 48 h (p = 0.22). Time to target temperature (≤ 34 °C) was significantly shorter for patients treated with endovascular devices (2.2 [1.1-4.0] vs. 4.2 [2.7-6.0] h, p < 0.001), but temperature was also lower on admission (35.0 [34.2-35.6] vs. 35.3 [34.5-35.8]°C; p = 0.02) and cooling rate was similar (0.4 [0.2-0.8] vs. 0.4 [0.2-0.6]°C/h; p = 0.14) when compared to SFC. Temperature variability was significantly lower in the endovascular device group when compared with SFC methods (0.6 [0.4-0.9] vs. 0.7 [0.5-1.0]°C; p = 0.007), as was rewarming rate (0.31 [0.22-0.44] vs. 0.37 [0.29-0.49]°C/hour; p = 0.02). There was no statistically significant difference in mortality (endovascular 65/218, 29% vs. others 43/134, 32%; p = 0.72) or poor neurological outcome (endovascular 69/218, 32% vs. others 51/134, 38%; p = 0.24) between type of devices. CONCLUSIONS: Endovascular cooling devices were more precise than SFC methods in patients cooled at 33 °C after out-of-hospital cardiac arrest. Main outcomes were similar with regard to the cooling methods.


Assuntos
Hipotermia Induzida/métodos , Parada Cardíaca Extra-Hospitalar/terapia , Idoso , Análise de Variância , Superfície Corporal , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/normas , Feminino , Humanos , Hipotermia Induzida/normas , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
12.
Ann Vasc Surg ; 59: 54-62, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30802590

RESUMO

BACKGROUND: The goals of this study were to evaluate mid-term outcome in endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) using a GORE C3 EXCLUDER and compare results between patients treated within and outside the instructions for use (IFU). METHODS: Over a 3-year period spanning October 2013 to September 2016, consecutive patients undergoing EVAR for AAA using the C3 EXCLUDER at Tokyo Medical University Hospital were registered on a prospectively maintained database. The data thus obtained were retrospectively analyzed. RESULTS: A total of 109 AAA patients underwent EVAR using the C3 EXCLUDER. The median follow-up duration was 729 days (interquartile range, 542-1,069 days). Technical success was achieved in 98.2% of cases. Adjunctive, unplanned proximal cuff-extender implantation was required in 8 patients (9.2%). Of the total number, 29 (24.8%) were categorized as being treated outside the IFU. No significant difference was observed in freedom from overall mortality or aneurysm-related mortality between patients treated within and outside the IFU. Freedom from reintervention tended to be lower in patients treated outside the IFU. There was aneurysm sac shrinkage (≥5 mm) in 30.3% and 39.1%; stable aneurysm sac in 69.7% and 56.3%; and aneurysm sac expansion (≥5 mm) in 0% and 4.7% of cases at 1 and 2 years, respectively. No significant difference was observed in aneurysm sac shrinkage between patients treated within and outside the IFU. CONCLUSIONS: The C3 EXCLUDER showed good clinical performance and aneurysm sac shrinkage, regardless of whether the patient was treated within or outside the IFU. The results suggest, however, that in those treated outside the IFU, precise planning, careful operative procedure, and subsequent follow-up are required to obtain short-term and mid- to long-term success in EVAR for AAA using the C3 EXCLUDER.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Rotulagem de Produtos , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Prótese Vascular/normas , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/normas , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/normas , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Intervalo Livre de Progressão , Desenho de Prótese , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents/normas , Fatores de Tempo , Tóquio
13.
J Neurointerv Surg ; 11(8): 757-761, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30610072

RESUMO

BACKGROUND: Outcomes of endovascular treatment for acute ischemic stroke depend on the time interval from onset to reperfusion. Although the centralized 'mothership' method is considered preferable, the required transportation time increases the risk that a patient with a stroke may not receive intravenous or endovascular therapy. In contrast, 'drive and retrieve' describes a system wherein doctors from comprehensive stroke centers travel to primary stroke centers and provide endovascular treatment for acute ischemic stroke. OBJECTIVE: To describe the drive and retrieve system and verify the effects of this new collaboration on outcomes in patients with acute ischemic stroke among facilities. METHODS: This non-randomized, single-arm study retrospectively analyzed patients who met the inclusion criteria for endovascular treatment provided through a drive and retrieve system. Among the 122 patients treated by this system, we analyzed the time of onset to recanalization as the primary outcome. We also analyzed the efficacy of the drive and retrieve system using geographic information system analysis. RESULTS: The median time from onset to recanalization was 229 min (IQR 170-307 min, 95% CI 201 to 252 min). The upper limit of the 95% CI for the time from onset to recanalization was shorter than the median times reported in two previous trials. Geographic information system analysis revealed an upward trend in the population coverage rate in each secondary medical area after the drive and retrieve method was introduced. CONCLUSION: The drive and retrieve method may be an effective form of cooperation between facilities located within 1 hour of a comprehensive stroke center.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Tempo para o Tratamento , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reperfusão , Estudos Retrospectivos , Trombectomia/métodos , Trombectomia/normas , Tempo para o Tratamento/normas , Resultado do Tratamento
15.
J Cardiothorac Vasc Anesth ; 33(5): 1197-1204, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30655202

RESUMO

OBJECTIVE: To compare myocardial protection with retrograde cardioplegia alone with antegrade and retrograde cardioplegia in minimally invasive mitral valve surgery (MIMS). DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: The authors studied 97 MIMS patients using retrograde cardioplegia alone and 118 MIMS patients using antegrade and retrograde cardioplegia. INTERVENTIONS: The data from patients admitted for MIMS using retrograde cardioplegia (MIMS retro) between 2009 to 2012 were compared with the data from patients undergoing MIMS with antegrade and retrograde cardioplegia (MIMS ante-retro) between 2006 and 2010 (control group). Cardioplegia in the MIMS retro group was delivered solely through an endovascular coronary sinus (CS) catheter positioned under echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia was used in the MIMS ante-retro group. Data regarding myocardial infarction (MI; creatine kinase Mb, troponin T, electrocardiogram), myocardial function, and hemodynamic stability were collected for comparison. MEASUREMENTS AND MAIN RESULTS: Adequate cardioplegia administration (CS pressure >30 mmHg and asystole) was attained in 74.2% of the patients with retrograde cardioplegia alone. In 23.7% of the patients, the addition of an antegrade cardioplegia was necessary. No difference was observed in the incidence of MI (0 MIMS retro v 1 for MIMS ante-retro, p = 0.3623), difficult separation from cardiopulmonary bypass, and postoperative malignant arrhythmia. No difference was found for maximal creatine kinase Mb (39.1 [28.0-49.1] v 37.9 [28.6-50.9]; p = 0.8299) and for maximal troponin T levels (0.39 [0.27-0.70] v 0.47 [0.32-0.79]; p = 0.1231) for MIMS retro and MIMS ante-retro, respectively. However, lactate levels in the MIMS retro group were significantly lower than in the MIMS ante-retro group (2.1 [1.4-3.05] v 2.4 [1.8-3.3], respectively; p = 0.0453). No difference was observed in duration of intensive care unit stay and death. MIMS retro patients had a shorter hospital stay (7.0 [6.0-8.0] v 8.0 [7.0-9.0] days; p = 0.0003). CONCLUSION: Retrograde cardioplegia administration alone provided comparable myocardial protection to antegrade and retrograde cardioplegia during MIMS, but was not sufficient to achieve asystole in one-fifth of patients.


Assuntos
Cateterismo Cardíaco/métodos , Seio Coronário/cirurgia , Procedimentos Endovasculares/métodos , Parada Cardíaca Induzida/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Valva Mitral/cirurgia , Adulto , Idoso , Cateterismo Cardíaco/normas , Soluções Cardioplégicas/administração & dosagem , Terapia Combinada/métodos , Terapia Combinada/normas , Procedimentos Endovasculares/normas , Feminino , Parada Cardíaca Induzida/normas , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Estudos Retrospectivos
16.
Can J Surg ; 62(1): 66-69, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30693748

RESUMO

The Vascular Quality Initiative (VQI) is a national cooperative quality-improvement initiative designed to evaluate processes of care and outcomes in vascular surgery. The purpose of this report is to show the utility of such a database to provide insight into the standard of care provided, to highlight areas of local quality improvement, to benchmark our data against local, regional and national trends, and to ultimately improve safety in Canadian patients undergoing vascular surgery. We present the history of the database, its spread in the Canadian health care system and examples of quality improvements achieved from analyses of data recorded and retrieved from the VQI. Using the VQI, our institution was able to decrease the length of stay after endovascular aneurysm repair, decrease the contrast volume in endovascular aneurysm repair, save on costs, and provide medium-term outcome data on peripheral vascular interventions and smoking cessation strategies. The VQI is a powerful tool to improve patient safety and quality in vascular surgery. Its ability to create local regional improvement groups fosters a quality-focused culture and is important for Canadian patients.


Assuntos
Segurança do Paciente , Melhoria de Qualidade/normas , Procedimentos Cirúrgicos Vasculares/normas , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/normas , Canadá , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/normas , Feminino , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Medição de Risco , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
17.
Circ Cardiovasc Interv ; 12(1): e007244, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30608884

RESUMO

BACKGROUND: The objective of this study was to evaluate the evidence-base supporting the American Heart Association and American College of Cardiology guidelines on peripheral vascular interventions. METHODS AND RESULTS: American Heart Association/American College of Cardiology guideline documents available as of May 2018 were abstracted for both endovascular and surgical peripheral vascular intervention. The number of recommendations, class of recommendations (I, II, and III) and the distribution of their respective level of evidence (LOE; A, B, and C) were determined for each procedure. Guidelines were also evaluated for changes in recommendations over time. Of 5 current guidelines reporting 134 recommendations, only 13% were supported by LOE A and 39% were supported by LOE C. Overall, most recommendations were class II (54%), while 35% were class I. Lower LOEs were observed for interventions for pulmonary embolism/deep vein thrombosis (A 0%, B 24%, C 76%), inferior vena cava filter (A 0%, B 31%, C 69%), and renal artery stenosis (A 0%, B 67%, C 33%). Comparatively higher LOE A was observed for endovascular stroke therapy (24%). Compared with previous versions, total number of recommendations for lower extremity peripheral artery disease in the current guideline, decreased from 49 to 26, without an improvement in high-quality evidence. CONCLUSIONS: There is significant variation in the LOE supporting various peripheral vascular intervention in the current American Heart Association/American College of Cardiology guidelines. Overall, the availability of high-quality evidence remains low and the LOE appears insufficient to support many guideline recommendations for peripheral vascular intervention. These findings highlight the need for more objective and comparative evidence to support the use of endovascular and surgical therapy and in some areas, for updated guidelines.


Assuntos
American Heart Association , Procedimentos Endovasculares/normas , Medicina Baseada em Evidências/normas , Doenças Vasculares Periféricas/terapia , Guias de Prática Clínica como Assunto/normas , Procedimentos Cirúrgicos Vasculares/normas , Tomada de Decisão Clínica , Procedimentos Endovasculares/efeitos adversos , Humanos , Doenças Vasculares Periféricas/diagnóstico , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos
18.
Ann Vasc Surg ; 55: 104-111, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30287288

RESUMO

BACKGROUND: Based on prospective vein bypass trials for lower leg ischemia, objective performance goals (OPG) were established by the Society for Vascular Surgery (SVS) and are used as a benchmark tool for open and endovascular treatments. This study aims to analyze OPG of all patients with critical limb ischemia (CLI) treated by open revascularization techniques at a tertiary care facility in routine practice. METHODS: From January 2005 to March 2013, 315 patients (mean age 72 years) with CLI were retrospectively included in this study. Inclusion criteria were patients with Fontaine stage III and IV, realized revascularization with open surgical procedures (bypass grafting or endarterectomy), or hybrid method (open + endovascular). Exclusion criteria were primary major amputations, patients with revascularization treatments of the index leg within the last 3 months, and missing aftercare. Primary end point was "amputation-free survival" (AFS), and secondary end point was "freedom from major adverse limb event + perioperative death (30 days)" (MALE + POD) according to the SVS. The technical end point was primary patency. Mean follow-up was 34 months. The following variables were studied: clinical stage (Fontaine), previous interventions, bypass material used, and site of the distal anastomosis. The statistical evaluation and preparation was carried out using the Kaplan-Meier estimator and the log-rank test. A multivariate analysis was performed using the Cox proportional hazards model. A P value ≤0.05 was considered to be statistically significant. RESULTS: A total of 128 patients (31%) fulfilling the adjusted SVS OPG criteria showed significantly better results for AFS, MALE + POD, and primary patency (P = 0.013, P = 0.015, P = 0.002, respectively). Regarding the AFS (1 year: 74%), multivariate analysis displayed significant worse results for patients with end-stage renal disease (hazard ratio [HR] 2.90, 95% confidence interval [CI] 1.83-4.60, P < 0.001) and Fontaine stage IV (HR 1.69, 95% CI 1.11-2.57, P = 0.015). Regarding MALE + POD (1 year: 64%), male patients (HR 0.64, 95% CI 0.46-0.90, P = 0.011) showed a significantly better outcome and patients without previous interventions of the index leg (HR 1.51, 95% CI 1.09-2.09, P = 0.013) showed a significantly worse outcome. CONCLUSIONS: In this study, we were able to show that it is possible to reach the efficacy of OPGs set by SVS in a surgically treated all-comers cohort of CLI patients. Nevertheless, patients who did not fulfill the SVS OPG criteria showed significantly worse results for AFS and MALE + POD.


Assuntos
Procedimentos Endovasculares/normas , Isquemia/cirurgia , Doenças Vasculares Periféricas/cirurgia , Padrões de Prática Médica/normas , Cirurgiões/normas , Enxerto Vascular/normas , Idoso , Idoso de 80 Anos ou mais , Amputação/normas , Competência Clínica/normas , Estado Terminal , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fidelidade a Diretrizes/normas , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/diagnóstico , Doenças Vasculares Periféricas/mortalidade , Doenças Vasculares Periféricas/fisiopatologia , Guias de Prática Clínica como Assunto/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
20.
J Emerg Med ; 56(3): 258-266, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30528709

RESUMO

BACKGROUND: In the past three years, there have been several major studies published on the use of endovascular therapy (EVT) in large vessel occlusion (LVO) acute ischemic stroke. With multiple publications in such a short amount of time, it is difficult to keep up with the evolving landscape of ischemic stroke therapy. OBJECTIVE: This narrative review discusses recent randomized controlled trials evaluating EVT and its effects on acute ischemic stroke management. DISCUSSION: Ischemic stroke is the most common type of stroke overall, and recanalization is the predominant focus in stroke therapy to improve outcomes. Treatment first focused on systemic thrombolysis for ischemic stroke, followed by studies evaluating the use of thrombolysis with EVT. Early research did not find a benefit to EVT; however, recent studies using current devices and with narrow selection criteria demonstrate significant benefit to EVT in LVOs. In patients with LVOs and perfusion mismatches, reperfusion rates are higher with EVT compared with systemic thrombolysis alone. Recognition of patients with small infarct cores and large areas of ischemic but salvageable brain tissue up to 24 h after symptom onset stresses the need for advanced imaging to recognize the target group. CONCLUSIONS: EVT technology for acute ischemic stroke has now become more efficient, minimizing complications and improving the efficacy of EVT. Several viable interventions for a small subgroup of patients with ischemic stroke up to 24 h after symptoms onset can significantly improve patient outcomes.


Assuntos
Arteriopatias Oclusivas/terapia , Procedimentos Endovasculares/normas , Acidente Vascular Cerebral/terapia , Arteriopatias Oclusivas/tratamento farmacológico , Procedimentos Endovasculares/métodos , Humanos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Terapia Trombolítica/normas , Terapia Trombolítica/tendências , Resultado do Tratamento
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