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2.
Eur J Vasc Endovasc Surg ; 61(5): 810-818, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33810975

RESUMO

OBJECTIVE: The benefit of preventive treatment for superior mesenteric artery (SMA) stenosis remains uncertain. The latest European Society for Vascular Surgery (ESVS) guidelines remain unclear given the lack of data in the literature. The aim of this study was to evaluate asymptomatic SMA stenosis prognosis according to the presence of associated coeliac artery (CA) and/or inferior mesenteric artery (IMA) stenosis. METHODS: This was a single academic centre retrospective study. The entire computed tomography (CT) database of a single tertiary hospital was reviewed from 2009 to 2016. Two groups were defined: patients with isolated > 70% SMA stenosis (group A) and patients with both SMA and CA and/or IMA > 70% stenosis (group B). Patient medical histories were reviewed to determine the occurrence of mesenteric disease (MD) defined as development of acute mesenteric ischaemia (AMI) or chronic mesenteric ischaemia (CMI). RESULTS: Seventy-seven patients were included. Median follow up was 39 months. There were 24 patients in group A and 53 patients in group B. In group B, eight (10.4%) patients developed MD with a median onset of 50 months. AMI occurred in five patients with a median of 33 months and CMI in three patients with a median of 88 months. Patients of group B developed more MD (0% vs. 15.1%; p = .052). The five year survival rate was 45% without significant difference between groups. CONCLUSION: Patients with SMA stenosis associated with CA and/or IMA seem to have a higher risk of developing mesenteric ischaemia than patients with isolated SMA stenosis. Considering the low life expectancy of these patients, cardiovascular risk factor assessment and optimisation of medical treatment is essential. Preventive endovascular revascularisation could be discussed for patients with non-isolated > 70% SMA stenosis, taking into account life expectancy.


Assuntos
Procedimentos Endovasculares/efeitos adversos , Isquemia Mesentérica/epidemiologia , Oclusão Vascular Mesentérica/complicações , Adulto , Idoso , Doenças Assintomáticas/mortalidade , Doenças Assintomáticas/terapia , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/patologia , Angiografia por Tomografia Computadorizada , Constrição Patológica/complicações , Constrição Patológica/diagnóstico , Constrição Patológica/mortalidade , Constrição Patológica/patologia , Procedimentos Endovasculares/normas , Seguimentos , Fatores de Risco de Doenças Cardíacas , Humanos , Masculino , Artéria Mesentérica Inferior/diagnóstico por imagem , Artéria Mesentérica Inferior/patologia , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/patologia , Isquemia Mesentérica/etiologia , Isquemia Mesentérica/prevenção & controle , Oclusão Vascular Mesentérica/diagnóstico , Oclusão Vascular Mesentérica/mortalidade , Oclusão Vascular Mesentérica/patologia , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Prognóstico , Estudos Retrospectivos , Medição de Risco/estatística & dados numéricos , Taxa de Sobrevida
5.
Int J Med Sci ; 18(4): 944-952, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33456352

RESUMO

The extracranial internal carotid artery (ICA) refers to the anatomic location that reaches from the common carotid artery proximally to the skull base distally. The extracranial ICA belongs to the C1 segment of the Bouthillier classification and is at considerable risk for injury. Currently, the understanding of endovascular treatment (EVT) for blunt injury of the extracranial ICA is limited, and a comprehensive review is therefore important. In this review, we found that extracranial ICA blunt injury should be identified in patients presenting after blunt trauma, including classical dissection, pseudoaneurysm, and stenosis/occlusion. Computed tomography angiography (CTA) is the first-line method for screening for extracranial ICA blunt injury, although digital subtraction angiography (DSA) remains the "gold standard" in imaging. Antithrombotic treatment is effective for stroke prevention. However, routine EVT in the form of stenting should be reserved for patients with prolonged neurological symptoms from arterial stenosis or considerably enlarged pseudoaneurysm. Endovascular repair is now emerging as a favored therapeutic option given its demonstrated safety and positive clinical and radiographic outcomes.


Assuntos
Lesões das Artérias Carótidas/cirurgia , Procedimentos Endovasculares/normas , Guias de Prática Clínica como Assunto , Ferimentos não Penetrantes/cirurgia , Angiografia Digital , Lesões das Artérias Carótidas/diagnóstico , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Tomada de Decisão Clínica , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Humanos , Seleção de Pacientes , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico
6.
J Vasc Surg Venous Lymphat Disord ; 9(2): 346-351, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-32721587

RESUMO

OBJECTIVE: The Intersocietal Accreditation Commission of vein centers was instituted in 2014, yet data regarding impact of accreditation on patients undergoing superficial vein interventions are lacking. This study was undertaken to identify differences in patient outcomes and utilization index as a measure of appropriate use in accredited compared with nonaccredited centers. METHODS: This study was performed with a matched control design using prospectively collected data from two major U.S.-based venous registries: the Society for Vascular Surgery Vascular Quality Initiative Varicose Vein Registry and the American Vein & Lymphatic Society PRO Venous Registry. RESULTS: A total of 39,001 patients treated between 2015 and 2018 in 192 centers were included in the study. The Vascular Quality Initiative Varicose Vein Registry provided information on 19,810 (50.8%) patients, and the American Vein & Lymphatic Society PRO Venous Registry provided information on 19,191 (49.2%) patients. Accredited centers were significantly more likely to treat patients with advanced venous disease as characterized by trophic skin changes (C4-C6, 38.1% vs 25.2%; P < .001). Percentage of patients treated 2 standard deviations above the Medicare-reported mean (3.4 utilization index) was significantly higher among patients treated at nonaccredited centers (3.3% vs 0.1%; P < .001). Venous Clinical Severity Score of those who were assessed between 1 month and 1 year after ablation decreased by 4.98 ± 4.01 in nonaccredited centers compared with 5.61 ± 3.64 in accredited centers (P < .001). Complications were low in both cohorts (nonaccredited centers, 71 [0.4%]; accredited centers, 17 [0.1%]; P < .001). One-year clinical follow-up was higher in nonaccredited centers (76.4% vs 31.5%; P < .001). CONCLUSIONS: Venous registries are a powerful tool for capturing and identifying significant variations in procedure utilization and complications in low-risk procedures. Intersocietal Accreditation Commission accreditation was associated with reduced use of endovenous therapies, slightly lower complication rates, lower 1-year follow up, and greater improvement in Venous Clinical Severity Score.


Assuntos
Técnicas de Ablação/normas , Acreditação/normas , Procedimentos Endovasculares/normas , Instalações de Saúde/normas , Disparidades em Assistência à Saúde/normas , Veia Safena/cirurgia , Sociedades Médicas/normas , Varizes/cirurgia , Insuficiência Venosa/cirurgia , Técnicas de Ablação/efeitos adversos , Doença Crônica , Procedimentos Endovasculares/efeitos adversos , Humanos , Complicações Pós-Operatórias/etiologia , Indicadores de Qualidade em Assistência à Saúde/normas , Sistema de Registros , Veia Safena/diagnóstico por imagem , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Varizes/diagnóstico por imagem , Insuficiência Venosa/diagnóstico por imagem
7.
J Neurointerv Surg ; 13(3): 251-254, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32669397

RESUMO

BACKGROUND: Simulation training has been used in the aviation industry and surgical specialties for many years, but integration into neurointerventional practice is lagging behind. OBJECTIVE: To investigate how neurointerventionalists perceive the usefulness and limitations of simulation tools for the treatment of unruptured intracranial aneurysms (UIAs), and to identify simulation applications that were perceived to be most valuable for endovascular UIA treatment. METHODS: A web-based international multidisciplinary survey was conducted among neurointerventionalists. Participants were asked for their perceptions on the usefulness of current simulation tools and the potential impact of future simulation tools in endovascular UIA treatment. They identified simulation applications that could add most value to endovascular UIA treatment and help to specifically reduce endovascular UIA treatment complications. RESULTS: 233 neurointerventionalists from 38 countries completed the survey, most of whom (157/233 (67.4%)) had access to a simulator as a trainee, but only 15.3% used it frequently. Most participants (117/233 (50.2%)) considered currently available simulation tools relatively useful for endovascular UIA treatment, with greater value for trainees than for staff. Simulation of new devices (147/233 (63.1%)) and virtual practice runs in individual patient anatomy (119/233 (51.1%)) were considered most valuable for reducing endovascular UIA treatment complications. CONCLUSION: Although neurointerventionalists perceived currently available simulation tools relatively useful, they did not use them regularly during their training. A priori testing of new devices and practice runs in individual patient anatomy in a virtual environment were thought to have the greatest potential for reducing endovascular UIA treatment complications.


Assuntos
Simulação por Computador/normas , Procedimentos Endovasculares/normas , Aneurisma Intracraniano/cirurgia , Neurocirurgiões/normas , Complicações Pós-Operatórias/prevenção & controle , Adulto , Simulação por Computador/tendências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/tendências , Feminino , Previsões , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Neurocirurgiões/educação , Neurocirurgiões/tendências , Complicações Pós-Operatórias/etiologia , Inquéritos e Questionários , Resultado do Tratamento , Realidade Virtual
8.
J Neurointerv Surg ; 13(3): 272-277, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32601259

RESUMO

BACKGROUND: With the recent advent of advanced technologies in the field, treatment of neurovascular diseases using endovascular techniques is rapidly evolving. Here we describe our experience with pre-surgical simulation using the Biomodex EVIAS patient-specific 3D-printed models to plan aneurysm treatment using endovascular robotics and novel flow diverter devices. METHODS: Pre-procedural rehearsals with 3D-printed patient-specific models of eight cases harboring brain aneurysms were performed before the first in-human experiences. To assess the reliability of the experimental model, the characteristics of the aneurysms were compared between the patient and 3D models. The rehearsals were used to define the patient treatment plan, including technique, device sizing, and operative working projections. RESULTS: The study included eight patients with their respective EVIAS 3D aneurysm models. Pre-operative simulation was performed for the first in-human robotic-assisted neurovascular interventions (n=2) and new generation flow-diverter stents (n=6). Aneurysms were located in both the anterior (n=5) and posterior (n=3) circulation and were on average 11.0±6.5 mm in size. We found reliable reproduction of the aneurysm features and similar dimensions of the parent vessel anatomy between the 3D models and patient anatomy. Information learned from pre-surgical in vitro simulation are described in detail, including an improved patient treatment plan, which contributed to successful first in-world procedures with no intraprocedural complications. CONCLUSIONS: Pre-procedural rehearsal using patient-specific 3D models provides precise procedure planning, which can potentially lead to greater operator confidence, decreased radiation dose and improvements in patient safety, particularly in first in-human experiences.


Assuntos
Procedimentos Endovasculares/métodos , Desenho de Equipamento/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Impressão Tridimensional , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Procedimentos Endovasculares/normas , Desenho de Equipamento/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Impressão Tridimensional/normas , Reprodutibilidade dos Testes , Procedimentos Cirúrgicos Robóticos/normas , Stents Metálicos Autoexpansíveis/normas , Resultado do Tratamento
9.
J Neurointerv Surg ; 13(2): 177-181, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32606102

RESUMO

BACKGROUND: The management of unruptured intracranial aneurysms (UIAs) has evolved significantly over the last few decades. Our objective was to evaluate the 100 most cited UIA articles by bibliometric analysis to identify nature, content and shifts over time. METHODS: Elsevier's Scopus database was interrogated for the 100 most cited articles that focused on UIA. Older versus newer articles were compared, with categorical data analyzed using Pearson's Chi-square, and continuous data analyzed using Wilcoxon's rank-sum test. RESULTS: The 100 most cited articles were published between 1975 and 2015, with the majority of these reporting patient clinical outcomes (n=69). There were 47/69 (68%) articles that described surgical intervention, with 38/47 (81%) and 18/47 (38%) including endovascular and open approaches, respectively . Publications peaked in 2004 (n=8), and the most common country of correspondence was the United States (n=59). Compared to older articles, newer articles had statistically higher citation rates (P<0.01), higher number of authors (P<0.01) with more multiple institution collaborations (P=0.01), greater disclosures of funding (P<0.01), more focus on endovascular treatments (P=0.04), in more journals with a clinical, non-surgical focus (P<0.01) published under open access policies (P<0.01). CONCLUSIONS: In the 100 most cited articles about UIAs to date, there is a distinct shift towards more co-authored efforts utilizing multi-institutional efforts focused on endovascular approaches supported by funding. The emergence of endovascular techniques has refreshed the need for more contemporary rupture risk prediction models and natural history data to validate current attitudes towards clinical management after these minimally invasive procedures for UIAs.


Assuntos
Bibliometria , Bases de Dados Factuais/tendências , Aneurisma Intracraniano/cirurgia , Publicações Periódicas como Assunto/tendências , Bases de Dados Factuais/normas , Procedimentos Endovasculares/normas , Procedimentos Endovasculares/tendências , Humanos , Aneurisma Intracraniano/diagnóstico , Aneurisma Intracraniano/epidemiologia , Publicações Periódicas como Assunto/normas , Estados Unidos/epidemiologia
10.
J Vasc Surg ; 73(1S): 55S-83S, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32628988

RESUMO

Thoracic aortic diseases, including disease of the descending thoracic aorta (DTA), are significant causes of death in the United States. Open repair of the DTA is a physiologically impactful operation with relatively high rates of mortality, paraplegia, and renal failure. Thoracic endovascular aortic repair (TEVAR) has revolutionized treatment of the DTA and has largely supplanted open repair because of lower morbidity and mortality. These Society for Vascular Surgery Practice Guidelines are applicable to the use of TEVAR for descending thoracic aortic aneurysm (TAA) as well as for other rarer pathologic processes of the DTA. Management of aortic dissections and traumatic injuries will be discussed in separate Society for Vascular Surgery documents. In general, there is a lack of high-quality evidence across all TAA diseases, highlighting the need for better comparative effectiveness research. Yet, large single-center experiences, administrative databases, and meta-analyses have consistently reported beneficial effects of TEVAR over open repair, especially in the setting of rupture. Many of the strongest recommendations from this guideline focus on imaging before, during, or after TEVAR and include the following: In patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging, usually computed tomography angiography (CTA) because of its speed and ease of use for preoperative planning. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). If TEVAR is being considered, we recommend fine-cut (≤0.25 mm) CTA of the entire aorta as well as of the iliac and femoral arteries. CTA of the head and neck is also needed to determine the anatomy of the vertebral arteries. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). We recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). We recommend contrast-enhanced computed tomography scanning at 1 month and 12 months after TEVAR and then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is detected at 1 month. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). Finally, based on our review, in patients who could undergo either technique (within the criteria of the device's instructions for use), we recommend TEVAR as the preferred approach to treat elective DTA aneurysms, given its reduced morbidity and length of stay as well as short-term mortality. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). Given the benefits of TEVAR, treatment using a minimally invasive approach is largely based on anatomic eligibility rather than on patient-specific factors, as is the case in open TAA repair. Thus, for isolated lesions of the DTA, TEVAR should be the primary method of repair in both the elective and emergent setting based on improved short-term and midterm mortality as well as decreased morbidity.


Assuntos
Assistência ao Convalescente/normas , Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares/normas , Sociedades Médicas/normas , Especialidades Cirúrgicas/normas , Assistência ao Convalescente/métodos , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Tomada de Decisão Clínica , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/instrumentação , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/instrumentação , Tratamento de Emergência/métodos , Tratamento de Emergência/normas , Endoleak/diagnóstico , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Humanos , Tomografia Computadorizada por Raios X/normas , Resultado do Tratamento
11.
J Vasc Surg ; 73(1S): 87S-115S, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33171195

RESUMO

BACKGROUND: Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis. METHODS: The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus. RESULTS: Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion. CONCLUSIONS: These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.


Assuntos
Aterosclerose/cirurgia , Procedimentos Endovasculares/normas , Isquemia Mesentérica/cirurgia , Sociedades Médicas/normas , Especialidades Cirúrgicas/normas , Aterosclerose/complicações , Doença Crônica/terapia , Procedimentos Endovasculares/métodos , Medicina Baseada em Evidências/instrumentação , Medicina Baseada em Evidências/métodos , Medicina Baseada em Evidências/normas , Humanos , Isquemia Mesentérica/diagnóstico , Isquemia Mesentérica/etiologia , Qualidade de Vida , Recidiva , Prevenção Secundária/instrumentação , Prevenção Secundária/métodos , Prevenção Secundária/normas , Resultado do Tratamento
12.
Ann Vasc Surg ; 71: 237-248, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32771463

RESUMO

BACKGROUND: The aim of the present study is to develop relevant quality indicators (QI) to monitor and improve quality of care in vascular surgery. METHODS: The Delphi method was used to incorporate expert opinion to reach consensus on a set of QI. A national expert panel consisting of 52 vascular surgeons was installed on a voluntary basis and endorsed by the Belgian Society of Vascular Surgery and the Flemish Hospital Network KU Leuven. A task force team consisting of 12 surgeons was created to serve as a delegation of the expert panel to discuss and filter the obtained data from the different Delphi rounds. RESULTS: A total of 3 Delphi rounds were needed to reach consensus on a set of 20 QI. Each QI had a content validity index (using a 7-point Likert scale), a feasibility index, and a target level. Twelve outcome indicators and 8 process indicators on several vascular topics were selected: overall for all vascular treatments (n = 1), arterial occlusive disease in general (n = 3), arterial occlusive disease of the lower limbs (n = 4), arterial occlusive disease of the carotid arteries (n = 5), arterial aneurysm disease in general (n = 2), arterial aneurysm disease with endovascular treatment (n = 1), and venous disease (n = 4). CONCLUSIONS: This resulted in the successful identification of 20 validated and relevant vascular QI, focusing on arterial occlusive disease, arterial aneurysm disease, and venous disease. The next step in this project will be the performance of an implementation study.


Assuntos
Procedimentos Endovasculares/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Doenças Vasculares/cirurgia , Procedimentos Cirúrgicos Vasculares/normas , Bélgica , Consenso , Técnica Delfos , Procedimentos Endovasculares/efeitos adversos , Humanos , Complicações Pós-Operatórias/terapia , Melhoria de Qualidade/normas , Retratamento/normas , Resultado do Tratamento , Doenças Vasculares/diagnóstico por imagem , Procedimentos Cirúrgicos Vasculares/efeitos adversos
13.
Ann Vasc Surg ; 72: 1-56, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33359707

RESUMO

Several international guidelines concerning lower extremity arterial disease (LEAD) have been published recently, in particular, by the American Heart Association the European Society of Cardiology/European Society for Vascular Surgery, the European Society for Vascular Medicine and the Society for Vascular Surgery. These guidelines differ in some respects and certain issues are not addressed. The objective of this consensus driven by the French Societies of vascular Medicine and surgery was to analyze the disparities between the different guidelines, as well as certain issues not covered, and develop proposals with regard to these points. The following fields of LEAD have been explored: 1) classifications, 2) clinical evaluation, 3) diagnostic criteria, 4) quantification of arterial stenosis using duplex ultrasound, 5) detection of asymptomatic multisite lesions, 6) screening for LEAD in the context of cardiac disease, 7) medical treatment, 8) supervised exercise therapy, 9) revascularization and revascularization of the internal artery stenosis, 10) management of chronic limb ischemia, 11) longitudinal follow-up, and 12) diet.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Procedimentos Endovasculares/normas , Terapia por Exercício/normas , Disparidades em Assistência à Saúde , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Procedimentos Cirúrgicos Vasculares/normas , Fármacos Cardiovasculares/efeitos adversos , Consenso , Técnica Delfos , Dieta Saudável , Procedimentos Endovasculares/efeitos adversos , Medicina Baseada em Evidências/normas , Terapia por Exercício/efeitos adversos , Humanos , Doença Arterial Periférica/diagnóstico por imagem , Comportamento de Redução do Risco , Sociedades Médicas , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
14.
J Vasc Surg ; 74(1): 195-202, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33340696

RESUMO

OBJECTIVE: The current Society for Vascular Surgery practice guidelines recommend carotid revascularization for asymptomatic disease in patients with at least a 3-year life expectancy and stenosis >60% when the expected perioperative stroke and death rate is <3%. Based on this recommendation, it was previously determined that asymptomatic patients who require dialysis would not meet the perioperative stroke and death thresholds nor the long-term survival benchmarks to justify carotid surgery. To determine whether carotid surgery for patients requiring dialysis is appropriate, the present study compared the perioperative outcomes after carotid revascularization for dialysis-dependent patients relative to nondialysis patients in a contemporary, national cohort. METHODS: The targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who undergone carotid endarterectomy or carotid artery stenting for asymptomatic carotid disease from 2011 to 2018. The cohort was categorized as requiring or not requiring dialysis. The primary 30-day outcomes included mortality and the composite of stroke/death and stroke/death/myocardial infarction (MI). Univariate analyses were performed using the Fisher exact test and Wilcoxon rank sum test. Multivariable analyses were used to assess the independent associations of the estimated glomerular filtration rate and dialysis dependence with the stroke/death rate. RESULTS: A total of 17,579 patients met the inclusion criteria. Of these patients, 226 (1.3%) required dialysis at revascularization. No difference was found in the degree of severe stenosis (80%-99%) demonstrated by 69% of the dialysis cohort and 72% of the nondialysis cohort (P = .9). Of the dialysis and nondialysis cohorts, 5% and 3.6% underwent carotid artery stenting (P = .3). The dialysis-dependent patients were younger (68 vs 71 years; P < .001) and were more likely to have insulin-dependent diabetes (47% vs 12%; P < .001), congestive heart failure (8.4% vs 1.4%; P < .001), and severe chronic obstructive pulmonary disease (15% vs 10%; P = .03). In the dialysis and nondialysis cohort, 2 (0.9%) and 88 (0.5%) patients died (P = .3); 4 (1.8%) and 247 (1.4%) experienced strokes (P = .6); and 3 (1.3%) and 185 (1.1%) patients experienced MI (P = .5), respectively. The composite outcomes of stroke/death and stroke/death/MI was 2.2% (n = 5) and 1.8% (n = 319; P = .6) and 3.5% (n = 8) and 2.8% (n = 479; P = .4) in the dialysis and nondialysis cohorts, respectively. After multivariable analysis, neither the estimated glomerular filtration rate (adjusted odds ratio, 1.0; 95% confidence interval, 1.00-1.01; P = .26) nor dialysis dependence (adjusted odds ratio, 0.21; 95% confidence interval, 0.03-1.57; P = .13) was independently associated with the composite outcome of stroke/death. CONCLUSIONS: The 30-day carotid revascularization outcomes for asymptomatic disease in dialysis-dependent patients met the Society for Vascular Surgery guidelines in this national cohort and might be better than previously surmised. Hence, vascular surgeons could consider carotid revascularization for select dialysis-dependent patients with the appropriate expected longevity and perioperative risk.


Assuntos
Estenose das Carótidas/terapia , Endarterectomia das Carótidas , Procedimentos Endovasculares , Falência Renal Crônica/terapia , Guias de Prática Clínica como Assunto , Diálise Renal , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Tomada de Decisão Clínica , Bases de Dados Factuais , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Endarterectomia das Carótidas/normas , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/normas , Feminino , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto/normas , Diálise Renal/efeitos adversos , Diálise Renal/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Stents , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
15.
J Am Coll Surg ; 232(4): 416-422, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33348014

RESUMO

BACKGROUND: Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset. STUDY DESIGN: Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients. RESULTS: 17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p = 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001). CONCLUSIONS: TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Procedimentos Endovasculares/estatística & dados numéricos , Traumatismo Múltiplo/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Aorta Torácica/lesões , Aorta Torácica/cirurgia , Implante de Prótese Vascular/normas , Implante de Prótese Vascular/estatística & dados numéricos , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/mortalidade , Conjuntos de Dados como Assunto , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/normas , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/mortalidade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Sociedades Médicas/normas , Fatores de Tempo , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Resultado do Tratamento , Lesões do Sistema Vascular/complicações , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade
16.
Vasc Endovascular Surg ; 55(1): 33-38, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33030116

RESUMO

OBJECTIVES: The Society for Vascular Surgery (SVS) created Objective Performance Goals (OPGs) for critical limb ischemia (CLI) in 2009. It was previously shown that endovascular therapy for CLI was not meeting these benchmarks. The OPG for all peripheral interventions is <8% for major adverse cardiac events (MACE), <8% for major adverse limb events (MALE), and <3% for major amputation. The goal of this study is to evaluate if outcomes have improved for CLI in recent years, specifically 2015-2018. METHODS: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify patients who underwent endovascular intervention for critical limb ischemia from 2011-2018. Cohorts were divided into 2011-2014 and 2015-2018. Primary 30-day outcomes were MACE, MALE, and major amputation. Univariate analyses were performed using the Fisher's exact test and the Wilcoxon rank-sum test. Multivariate analysis comparing groups was performed using inverse probability weights and trend over time analysis was performed using logistic regression with year of intervention as a continuous variable. RESULTS: From 2011 to 2018, 7,168 patients underwent an endovascular intervention for CLI. 28% were classified as "OPG high anatomic risk," and 17% were classified as "OPG high clinical risk." The 2015-2018 cohort vs. the 2011-14 cohort experienced MACE in 3.3% vs. 2.7% (p = .23), MALE in 9.1% vs. 8.9% (p = 0.83), and amputation in 4.0% vs. 4.2% (p = 0.71). When only high anatomic risk patients were considered (n = 1988), MACE was experienced in 2.4% vs. 2.2% (p = 0.87), MALE by 9.5% vs. 10.6% (p = 0.47) and amputation by 5.1% vs. 6.0% (p = 0.40). When only high clinical risk patients were considered (n = 1224), MACE was experienced in 5.2% vs. 3.9% (p = 0.33), MALE by 8.0% vs. 7.4% (p = 0.74) and amputation by 3.9% vs. 3.7% (p = 0.88). Comparing 2015-2018 to the reference 2011-2014, MALE adjusted odds ratio (AOR) = 0.99, 95% CI [0.83-1.18], MACE AOR = 1.19 95% CI [0.88-1.60], and major amputation AOR = 0.91 95% CI [0.70-1.17]. There were no decreases in the trend over time for MALE (AOR per year 0.97, CI [.94-1.02], major amputation (AOR per year: 0.97, CI [0.91-1.03], nor for MACE (AOR per year: 1.05, CI [.98-1.13]). CONCLUSION: Outcomes following endovascular interventions for CLI continue to underperform when compared to OPG benchmarks for MALE and amputations. There is no decrease over time for these target outcomes. Target MACE events remain acceptable despite the increasing clinical complexity of patients being treated.


Assuntos
Benchmarking/normas , Procedimentos Endovasculares/normas , Isquemia/cirurgia , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Doença Arterial Periférica/cirurgia , Guias de Prática Clínica como Assunto/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Idoso , Idoso de 80 Anos ou mais , Amputação/normas , Estado Terminal , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Salvamento de Membro/normas , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
18.
Arch Cardiovasc Dis ; 113(11): 749-759, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32978090

RESUMO

Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection.


Assuntos
Cardiologia/normas , Procedimentos Endovasculares/normas , Embolia Pulmonar/terapia , Reperfusão/normas , Trombectomia/normas , Terapia Trombolítica/normas , Tomada de Decisão Clínica , Consenso , Procedimentos Endovasculares/efeitos adversos , Oxigenação por Membrana Extracorpórea/normas , Humanos , Seleção de Pacientes , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/fisiopatologia , Reperfusão/efeitos adversos , Fatores de Risco , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Resultado do Tratamento
19.
World Neurosurg ; 143: e419-e429, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32750524

RESUMO

BACKGROUND: The number of elderly patients with subarachnoid hemorrhage is increasing. Elderly patients have been postulated to benefit more from endovascular coiling, compared with neurosurgical clipping. However, we based our therapeutic modality on the morphology and location of the aneurysms, rather than patients' age or their World Federation of Neurological Surgeons grade. The aim of this study was to investigate the validity of our therapeutic modality over earlier approaches by assessing their clinical outcomes. METHODS: The study sample included 539 patients who underwent surgical procedures between January 2010 and May 2019. Baseline characteristics, aneurysmal morphology and location, surgical and clinical complications, and clinical outcomes were compared between elderly (defined as aged 75 years or older) and young patients. RESULTS: There were 124 elderly patients (23.0%) in the sample. Eighty-five elderly patients (68.5%) received neurosurgical clipping, whereas 67.0% of the young patients (P = 0.827) received neurosurgical clipping. Of the elderly patients who had a poor World Federation of Neurological Surgeons grade, 49.4% and 48.7% underwent neurosurgical clipping and endovascular coiling, respectively (P = 1.000). Elderly patients had fewer favorable outcomes (21.8%) relative to young patients (61.8%; P < 0.001). There were no significant differences in the rate of favorable outcomes between patients undergoing neurosurgical clipping relative to endovascular coiling (21.2% vs. 23.1%; P = 0.818). CONCLUSIONS: Neurosurgical clipping and endovascular coiling yield comparable clinical outcomes in elderly and young patients with subarachnoid hemorrhage. These findings indicate that using a therapeutic modality based on aneurysmal morphology and location may be an effective treatment approach.


Assuntos
Procedimentos Endovasculares/normas , Procedimentos Neurocirúrgicos/normas , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/cirurgia , Instrumentos Cirúrgicos/normas , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/tendências , Instrumentos Cirúrgicos/tendências , Resultado do Tratamento
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