Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 862
Filtrar
1.
Medicine (Baltimore) ; 99(6): e18996, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32028410

RESUMO

Upper extremity vein thrombosis (UE-VT) are more and more frequent pathologies and yet little studied. The aim is to describe the clinical and ultrasound features, UE-VT-related diseases, and the prevalence of pulmonary embolism (PE) and associated deaths.All UE-VT patients diagnosed by Doppler-ultrasound in Nantes University Hospital, from January 2015 to December 2017, were included retrospectively. UE-VT suspicion patterns, clinical features, UE-VT topography, and prevalence of PE and death were analyzed.Seven hundred and fifty-five UE-VT were analyzed, including 427 deep thrombosis (UE-DVT) and 328 superficial thrombosis (UE-SVT). In 86.2% (n = 651) UE-VT were related to endovascular devices. Among these thrombosis, one third is in connection with a PICC LINE and one quarter with a peripheral venous line. Forty nine percent (n = 370) of the patients had solid neoplasia or hematological malignancies. An inflammatory or systemic infectious context was found in 40.8% (n = 308) of the cases. The most frequently observed clinical sign at the UE-VT diagnosis was edema (28.6%). Among the UE-SVT it was the presence of an indurated cord (33.2%) and among the UE-DVT the indication of the Doppler-ultrasound was mainly a suspicion of infection on endovascular device (35.1%). In 10.6% (n = 80) of the cases the UE-VT were asymptomatic. The most frequently thrombosed veins were brachial basilic veins (16.7% of all thrombosed segments) followed by jugular (13%) and subclavian (12.3%) veins; 61.3% (n = 463) of UE-VT were in the right upper extremity; 63.3% (n = 478) UE-VT were occlusive. The occurrence of PE is 4% and the death rate is 10.2%, mainly related to the severe comorbidities of patients with UE-VT.UE-VT occurs in particular clinical contexts (hematological malignancies, solid cancers, systemic infections) and in the majority of endovascular devices (86.2%). The occurrence of PE is low.


Assuntos
Braço/irrigação sanguínea , Trombose/diagnóstico , Trombose Venosa/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Trombose/complicações , Trombose/diagnóstico por imagem , Trombose/mortalidade , Ultrassonografia , Trombose Venosa/complicações , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/mortalidade
2.
Ann Hematol ; 99(1): 49-55, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31853702

RESUMO

Immune thrombocytopenia (ITP) has been reported to be associated with thrombotic events. The incidence of thrombosis in 303 newly diagnosed ITP patients in our institute between 2000 and 2016 was retrospectively reviewed. During a median follow-up of 3.6 years, 16 thrombotic events (12 arterial and four venous) occurred. The median platelet count at thrombotic events was 102 × 109/l. At 10 years, the cumulative thrombosis incidence was 10%. A univariate analysis showed that smoking, hypertension, male gender, a history of thrombosis, and atrial fibrillation (Af) were significantly associated with the occurrence of thrombosis, and a multivariate analysis identified smoking and Af as independent risk factors. The thrombotic risk was not increased by lupus anticoagulant positivity or ITP treatment. At 5 years, the cumulative incidence of bleeding and overall survival probability was 5.6% and 92%, respectively. This study demonstrates that smoking and Af were associated with an increased risk of thrombosis. Previously identified risk factors were not confirmed in these Japanese ITP patients.


Assuntos
Púrpura Trombocitopênica Idiopática , Trombose , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Púrpura Trombocitopênica Idiopática/complicações , Púrpura Trombocitopênica Idiopática/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida , Trombose/etiologia , Trombose/mortalidade
4.
J Cardiovasc Surg (Torino) ; 60(5): 624-632, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31486613

RESUMO

INTRODUCTION: Recently transcatheter aortic valve replacement (TAVR) has emerged as a feasible alternative for traditional surgical aortic valve replacement (SAVR) in patients with intermediate to high risk. There is currently no clear consensus regarding the optimal antiplatelet strategy after TAVR. The primary objective of this updated meta-analyses was to compare the outcomes of dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT) following TAVR. EVIDENCE ACQUISITION: A meta-analysis of eligible studies of patients undergoing TAVR which reported our outcomes of postoperative DAPT in comparison with SAPT, was carried out. The outcomes included the all-cause mortality, stroke, major/life-threatening bleeding, myocardial infarction and a composite endpoint of mortality, stroke, bleeding and myocardial infarction. EVIDENCE SYNTHESIS: Three randomized controlled trials (RCTs, N.=421) and 5 observational studies (N.=6683) were included in this updated meta-analysis. All-cause mortality was comparable between the two groups (OR 1.13 [95% CI: 0.70-1.81], P=0.619). Besides, DAPT resulted in an augmented risk of major/life-threatening bleeding (OR 2.45 [95% CI: 1.08-5.59], P=0.032). No statistically significant difference was found between the two groups in the rates of stroke (OR 0.83 [95% CI: 0.62-1.10], P=0.212) and myocardial infarction (OR 1.17 [95% CI: 0.47-2.91], P=0.728). And DAPT led to an increased rate of the composite endpoint (OR 2.39 [95% CI: 1.63-3.50], P<0.0001). CONCLUSIONSː The updated meta-analysis presents the evidence that post-TAVR DAPT increases bleeding events, with no benefit in survival and ischemic events, in comparison with SAPT. Nevertheless, it is currently difficult to evaluate by a meta-analysis the effectiveness of DAPT versus SAPT to prevent the valve thrombosis resulting in leaflet dysfunction, due to a limited number of existing publications. Additional RCTs are needed to determine the optimal antiplatelet strategy after TAVR.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Inibidores da Agregação de Plaquetas/administração & dosagem , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Esquema de Medicação , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Masculino , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Inibidores da Agregação de Plaquetas/efeitos adversos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Trombose/mortalidade , Trombose/prevenção & controle , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
5.
Blood Cells Mol Dis ; 79: 102351, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31400712

RESUMO

Acute promyelocytic leukemia (APL) is often accompanied by a potentially devastating coagulopathy. Predictors of thrombohemorrhagic early death (TH-ED)/early bleeding death are not well characterized. In this retrospective study, eleven baseline clinical variables that can be assessed easily and promptly were chosen for evaluation in a cohort of 364 patients with APL who were administered arsenic trioxide (ATO) alone as remission induction therapy. TH-ED was defined as death from bleeding or thrombosis within 30 days after hospital admission. Cox proportional hazards regression model was used for both the univariate and multivariate analyses. Totally, 53 patients died from severe bleeding (51 cases) or thrombosis (2 cases), and at 30 days the cumulative incidences of TH-ED were 14.6%. Six independent risk factors for TH-ED were identified, including relapse, male, white blood cell (WBC) count above 10 × 109/L, fibrinogen level below 1 g/L, D-dimer level above 4 mg/L and increased creatinine level. Increased creatinine level was the most powerful risk factor, followed by WBC count > 10 × 109/L. This study identified risk factors for TH-ED in a large cohort of patients with APL, which enriched clinical information on identifying patients at high risk of TH-ED.


Assuntos
Trióxido de Arsênio/uso terapêutico , Hemorragia/mortalidade , Leucemia Promielocítica Aguda/mortalidade , Trombose/mortalidade , Adulto , Estudos de Coortes , Hemorragia/etiologia , Humanos , Leucemia Promielocítica Aguda/complicações , Leucemia Promielocítica Aguda/tratamento farmacológico , Leucemia Promielocítica Aguda/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Trombose/etiologia
6.
Biomarkers ; 24(6): 517-523, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31215825

RESUMO

To evaluate whether genotype-guided antiplatelet therapy reduces the rates of cardiovascular events and bleeding events in patients with acute coronary syndrome (ACS). We systematically searched Pubmed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) (searched in September 2018) for controlled studies evaluating genotype-guided antiplatelet therapy in ACS with percutaneous coronary intervention (PCI) or without PCI. The primary endpoint was a composite of death, myocardial infarction (MI), stroke, targeted vessel revascularization and/or major bleeding. A total of five studies involving 2900 patients were included. Compared with the conventional group, the genotype-guided group had a decreased risk of primary composite outcomes (RR= 0.54; 95% CI: 0.41-0.72; I2 = 30%), death (RR = 0.54; 95% CI: 0.32-0.94; I2 = 21%), MI (RR = 0.52; 95% CI: 0.31-0.88; I2 = 49%), targeted vessel revascularization (RR = 0.59; 95% CI: 0.35-0.98; I2 = 0%), but not for stroke (RR = 0.53; 95% CI: 0.22-1.24; I2 = 0%) and bleeding events (RR = 0.80; 95% CI: 0.51-1.25; I2 = 33%). Genotype-guided strategies could reduce the rates of cardiovascular events without increasing bleeding events compared with conventional treatment in ACS. Future multi-centre genotype-based randomized control trials are required to confirm these findings.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Citocromo P-450 CYP2C19/genética , Hemorragia/tratamento farmacológico , Infarto do Miocárdio/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Trombose/tratamento farmacológico , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/genética , Síndrome Coronariana Aguda/mortalidade , Aspirina/uso terapêutico , Plaquetas , Revascularização Cerebral/métodos , Clopidogrel/uso terapêutico , Expressão Gênica , Genótipo , Hemorragia/etiologia , Hemorragia/genética , Hemorragia/mortalidade , Humanos , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/genética , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/métodos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/genética , Acidente Vascular Cerebral/mortalidade , Análise de Sobrevida , Trombose/complicações , Trombose/genética , Trombose/mortalidade
7.
BMJ ; 365: l2222, 2019 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-31253632

RESUMO

OBJECTIVE: To evaluate the efficacy and safety of standard term (12 months) or long term (>12 months) dual antiplatelet therapy (DAPT) versus short term (<6 months) DAPT after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Relevant studies published between June 1983 and April 2018 from Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, ClinicalTrials.gov, and Clinicaltrialsregister.eu. REVIEW METHODS: Randomised controlled trials comparing two of the three durations of DAPT (short term, standard term, and long term) after PCI with DES were included. The primary study outcomes were cardiac or non-cardiac death, all cause mortality, myocardial infarction, stent thrombosis, and all bleeding events. RESULTS: 17 studies (n=46 864) were included. Compared with short term DAPT, network meta-analysis showed that long term DAPT resulted in higher rates of major bleeding (odds ratio 1.78, 95% confidence interval 1.27 to 2.49) and non-cardiac death (1.63, 1.03 to 2.59); standard term DAPT was associated with higher rates of any bleeding (1.39, 1.01 to 1.92). No noticeable difference was observed in other primary endpoints. The sensitivity analysis revealed that the risks of non-cardiac death and bleeding were further increased for ≥18 months of DAPT compared with short term or standard term DAPT. In the subgroup analysis, long term DAPT led to higher all cause mortality than short term DAPT in patients implanted with newer-generation DES (1.99, 1.04 to 3.81); short term DAPT presented similar efficacy and safety to standard term DAPT with acute coronary syndrome (ACS) presentation and newer-generation DES placement. The heterogeneity of pooled trials was low, providing more confidence in the interpretation of results. CONCLUSIONS: In patients with all clinical presentations, compared with short term DAPT (clopidogrel), long term DAPT led to higher rates of major bleeding and non-cardiac death, and standard term DAPT was associated with an increased risk of any bleeding. For patients with ACS, short term DAPT presented similar efficacy and safety with standard term DAPT. For patients implanted with newer-generation DES, long term DAPT resulted in more all cause mortality than short term DAPT. Although the optimal duration of DAPT should take personal ischaemic and bleeding risks into account, this study suggested short term DAPT could be considered for most patients after PCI with DES, combining evidence from both direct and indirect comparisons. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018099519.


Assuntos
Clopidogrel/uso terapêutico , Stents Farmacológicos/normas , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/cirurgia , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Humanos , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombose/epidemiologia , Trombose/mortalidade
8.
Int Angiol ; 38(3): 173-184, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31112023

RESUMO

BACKGROUND: Proper risk stratification of patients for early mortality after cancer-associated thrombosis may lead to personalized anticoagulation protocols. Therefore, we aimed to derive and validate a scoring system to predict early mortality in this population. To this end, we selected patients with active cancer and thrombosis from the Computerized Registry of Patients with Venous Thromboembolism database. METHODS: The main outcome was all cause mortality within the month following a thrombotic event. We used a simple random selection to split are data in a derivation and a validation cohort. In the derivation cohort, we used recursive partitioning and binary logistic regression to identify groups at risk and to determine the likelihood of the primary outcome. The risk score was developed based on odds ratios from the final multivariate model, and then tested in the validation cohort. RESULTS: In 10,025 eligible patients, we identified 6 predictors of 30-day mortality: leukocytosis ≥11.5x109/L; platelet count ≤160x109/L, metastasis, recent immobility, initial presentation as pulmonary embolism and Body Mass Index <18.5. The model divided the population into 3 risk categories: low (score 0-3), moderate (score 4-6), and high (score ≥7). The AUC for the overall score was 0.74, and using a cutoff ≥7 points, the model had a negative predictive value of 94.4%, a positive predictive value of 23.1%, a sensitivity of 73.3%, and a specificity of 64.6% in the validation cohort. CONCLUSIONS: Our validated risk model may assist physicians in the selection of patients for outpatient management, and perhaps anticoagulant, considering expanding anticoagulation options.


Assuntos
Neoplasias/complicações , Medição de Risco , Trombose/diagnóstico , Tromboembolia Venosa/diagnóstico , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Recém-Nascido , Internacionalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Neoplasias/mortalidade , Valor Preditivo dos Testes , Sistema de Registros , Fatores de Risco , Trombose/mortalidade , Tromboembolia Venosa/mortalidade , Adulto Jovem
9.
Immunity ; 50(6): 1401-1411.e4, 2019 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-31076358

RESUMO

Inflammasome activation and subsequent pyroptosis are critical defense mechanisms against microbes. However, overactivation of inflammasome leads to death of the host. Although recent studies have uncovered the mechanism of pyroptosis following inflammasome activation, how pyroptotic cell death drives pathogenesis, eventually leading to death of the host, is unknown. Here, we identified inflammasome activation as a trigger for blood clotting through pyroptosis. We have shown that canonical inflammasome activation by the conserved type III secretion system (T3SS) rod proteins from Gram-negative bacteria or noncanonical inflammasome activation by lipopolysaccharide (LPS) induced systemic blood clotting and massive thrombosis in tissues. Following inflammasome activation, pyroptotic macrophages released tissue factor (TF), an essential initiator of coagulation cascades. Genetic or pharmacological inhibition of TF abolishes inflammasome-mediated blood clotting and protects against death. Our data reveal that blood clotting is the major cause of host death following inflammasome activation and demonstrate that inflammasome bridges inflammation with thrombosis.


Assuntos
Coagulação Sanguínea , Inflamassomos/metabolismo , Piroptose , Trombose/etiologia , Trombose/metabolismo , Animais , Infecções Bacterianas/complicações , Infecções Bacterianas/microbiologia , Biomarcadores , Caspases/metabolismo , Micropartículas Derivadas de Células/imunologia , Micropartículas Derivadas de Células/metabolismo , Modelos Animais de Doenças , Humanos , Lipopolissacarídeos/imunologia , Macrófagos/imunologia , Macrófagos/metabolismo , Camundongos , Monócitos/imunologia , Monócitos/metabolismo , Transdução de Sinais , Tromboplastina/metabolismo , Trombose/sangue , Trombose/mortalidade
10.
Biomed Res Int ; 2019: 7105084, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31061825

RESUMO

Background: The results of kidney transplantation are impacted by the categories of events responsible for patient death and graft failure. The objective of this study was to evaluate the causes of death and graft failure and outcomes after graft failure among kidney transplant recipients. Methodology: A retrospective cohort study was conducted with 944 patients who underwent kidney transplantation. Outcomes were categorized in a managed and hierarchical manner. Results: The crude mortality rate was 10.8% (n=102): in 35.3% cause of death was infection, in 30.4% cardiovascular disease, and in 15.7% neoplasia and in 6.8%, it was not possible to determine the cause of death. The rate of graft loss was 10.6%. The main causes of graft failure were chronic rejection (40%), acute rejection (18.3%), thrombosis (17.3%), and recurrence of primary disease (16.5%). Failures due to an acute rejection occurred earlier than those due to chronic rejection and recurrence (p<0.0001). As late causes of graft loss, death with the functioning kidney occurred earlier than recurrence and chronic rejection (p=0.008). The outcomes after graft failure were retransplantation in 26.1% and death in 21.4%, at a mean of 25.5 and 21.4 months, respectively. Conclusion: It was possible to identify more than 90% of the events responsible for the deaths of transplanted patients, predominantly infectious and cardiovascular diseases. Among the causes of graft failure, chronic and acute rejections and recurrence were the main causes of graft failure which were followed more frequently by retransplantation than by death on dialysis.


Assuntos
Rejeição de Enxerto/mortalidade , Transplante de Rim/mortalidade , Trombose/mortalidade , Doença Aguda , Adulto , Idoso , Doença Crônica , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Retratamento , Estudos Retrospectivos , Trombose/etiologia
12.
Eur Respir Rev ; 28(151)2019 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-30918022

RESUMO

Cancer-associated thrombosis (CAT) is a condition in which relevance has been increasingly recognised both for physicians that deal with venous thromboembolism (VTE) and for oncologists. It is currently estimated that the annual incidence of VTE in patients with cancer is 0.5% compared to 0.1% in the general population. Active cancer accounts for 20% of the overall incidence of VTE. Of note, VTE is the second most prevalent cause of death in cancer, second only to the progression of the disease, and cancer is the most prevalent cause of deaths in VTE patients. Nevertheless, CAT presents several peculiarities that distinguish it from other VTE, both in pathophysiology mechanisms, risk factors and especially in treatment, which need to be considered. CAT data will be reviewed in this review.


Assuntos
Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Fibrinolíticos/uso terapêutico , Neoplasias/complicações , Trombose/tratamento farmacológico , Anticoagulantes/efeitos adversos , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Incidência , Neoplasias/sangue , Neoplasias/mortalidade , Prevalência , Recidiva , Medição de Risco , Fatores de Risco , Trombose/sangue , Trombose/etiologia , Trombose/mortalidade , Resultado do Tratamento
13.
J Thromb Thrombolysis ; 47(4): 495-504, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30859370

RESUMO

In patients with active cancer and acute venous thromboembolism (VTE), the low-molecular-weight-heparin (LMWH) dalteparin is more effective than vitamin K antagonist (VKA) in reducing the risk of recurrent venous thromboembolism (rVTE) without increasing the risk of bleeding. However, the relative benefit of LMWH versus VKA in patients with active cancer at high or low risk of rVTE and bleeding is unclear. This post hoc analysis used data from the CLOT study to explore the efficacy and safety of LMWH versus VKA in preventing recurrent thrombosis in high- and low-risk patients with active cancer. High-risk patients were defined by metastatic disease and/or antineoplastic treatment at baseline; low-risk patients presented with neither. Among high-risk patients, rVTE occurred in 25/318 (8%) (LMWH) versus 53/314 (17%) (VKA) (hazard ratio, 0.44; p = 0.001). No significant difference was detected in the rate of major or any bleeding. The 6-month mortality rate was 40% (LMWH) versus 41% (VKA). In low-risk patients, 2/20 (10%) (LMWH) had rVTE versus 0/24 (0%) (VKA) (hazard ratio, not estimable; p = 0.998). No significant difference was detected in the rate of major or any bleeding. The 6-month mortality rate was 20% (LMWH) versus 29% (VKA). In patients with cancer-associated thrombosis at high risk of rVTE and bleeding, the LMWH dalteparin was more effective than VKA in reducing the risk of rVTE without increasing the risk of bleeding. No difference in rate of rVTE or bleeding was observed between LMWH and VKA among low-risk patients.


Assuntos
Cumarínicos/administração & dosagem , Dalteparina/administração & dosagem , Neoplasias/tratamento farmacológico , Trombose/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológico , Idoso , Cumarínicos/efeitos adversos , Dalteparina/efeitos adversos , Intervalo Livre de Doença , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/mortalidade , Neoplasias/patologia , Taxa de Sobrevida , Trombose/mortalidade , Trombose/patologia , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/patologia
14.
J Vasc Surg ; 69(4): 1174-1179, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30777685

RESUMO

OBJECTIVE: The primary objective was to evaluate the safety of transfer, type of procedure, and factors associated with limb salvage in patients with acute limb ischemia (ALI) treated at a quaternary referral center. METHODS: A retrospective review of all patients with ALI secondary to thrombotic or embolic occlusion at a quaternary referral hospital from 2013 to 2016 was conducted. Patients were transferred from throughout Washington and Alaska by ambulance, helicopter, or fixed-wing modes of transportation. Demographics, transport and operative timing, Rutherford classification, level of occlusion, procedural information, and fasciotomy characteristics were reviewed. Outcomes measured included limb salvage rates, discharge disposition, and mortality. RESULTS: One hundred twelve patients with ALI were identified, with 82% due to thrombosis and 18% due to arterial embolization. Fifty-seven percent of patients were transferred from a referring hospital with low mean transfer times (1.9 hours for embolic, 2.7 hours for thrombotic). Although the initial operative strategy varied according to the etiology, with 50% of thrombotic occlusions treated with endovascular therapies and 80% of embolic occlusions treated with open thrombectomy, the rates of limb salvage did not vary based on operative approach (92% endovascular first, 90% open first). Further, limb salvage rates were identical between transferred and nontransferred patients (77%). Limb salvage was successful in 91% of patients with Rutherford class 1 and 2 disease, but only 8% in patients with Rutherford class 3 disease. In-hospital and 30-day mortality rates were not different based on ischemic etiology (5%), although patients with Rutherford class 3 disease had significantly higher mortality rates (15%) compared with patients with class 1 (6%), class 2a (6%), and class 2b (2%) disease. Fasciotomy was performed in 29% of patients, with 59% of fasciotomy wounds closed primarily. Predictors of amputation include multiple attempts at limb salvage, higher Rutherford class, multilevel occlusion, more proximal levels of occlusion, and nonviable muscle seen after fasciotomy, with ischemic times trending toward higher amputation rates without statistical significance. There was no difference in discharge disposition based on ischemic etiology. CONCLUSIONS: The modern treatment of patients with ALI is effective, with high rates of limb salvage and low mortality regardless of transfer status, etiology, or initial operation performed. In situations where compartment syndrome is unclear, fasciotomy should not be withheld because it provides valuable predictive information regarding limb salvage.


Assuntos
Resgate Aéreo , Embolia/cirurgia , Procedimentos Endovasculares , Isquemia/cirurgia , Salvamento de Membro , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Trombectomia , Trombose/cirurgia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Amputação , Embolia/diagnóstico por imagem , Embolia/mortalidade , Embolia/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Fasciotomia , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Trombose/diagnóstico por imagem , Trombose/mortalidade , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
15.
J Vasc Surg ; 69(4): 1137-1142, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30777691

RESUMO

OBJECTIVE: Acute mesenteric ischemia (AMI) is an emergent event with a high mortality rate; survivors have high rates of intestinal failure. Restoration of blood flow using endovascular or surgical revascularization is associated with better outcome in terms of survival rate and intestinal resection. Retrograde open mesenteric stenting (ROMS), which is a hybrid technique, combines two benefits: prompt blood flow restoration with an endovascular approach and inspection and resection of the small bowel. The aim of the study was to assess the results of ROMS in thrombotic AMI in a retrospective multicenter study. METHODS: We retrospectively enrolled all consecutive patients who underwent ROMS revascularization for occlusive thrombotic AMI in three participating tertiary care centers between November 2012 and March 2017. RESULTS: Twenty-five patients (14 men and 11 women; mean age, 64.9 ± 11.6 years) were included. In two patients, ROMS was not possible because of failure of re-entry in the aortic lumen (technical success, 92%). One patient required revascularization of two visceral arteries and underwent an aortohepatic bypass. Five patients (20%) underwent endarterectomy and patch angioplasty of the superior mesenteric artery before retrograde stenting. Thirteen patients (52%) required bowel or colon resection (11 patients required both resections) during the initial procedure with a mean length of small bowel resection of 52 ± 87 cm. The 30-day operative mortality rate was 25%, and the overall 1-year survival rate was 65%. The 1-year primary patency rate was 92%. In one patient, postoperative imaging at 1 month showed stent migration in the aortic bifurcation. CONCLUSIONS: ROMS for thrombotic AMI has a high technical success rate and a high midterm primary patency rate. It could be an alternative procedure to retrograde superior mesenteric artery bypass for patients when percutaneous endovascular revascularization is not indicated or has failed.


Assuntos
Procedimentos Endovasculares/instrumentação , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Stents , Trombose/cirurgia , Idoso , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , França , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/mortalidade , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/mortalidade , Oclusão Vascular Mesentérica/fisiopatologia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de Risco , Circulação Esplâncnica , Trombose/diagnóstico por imagem , Trombose/mortalidade , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
16.
J Pediatr Hematol Oncol ; 41(1): 51-55, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30095694

RESUMO

Acute promyelocytic leukemia (APL) is characterized by a heightened risk of coagulopathy with significant morbidity and mortality. Here we report our evaluation of presenting white blood cell (WBC) and the International Society on Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC) scoring system as markers for early death and nonlethal coagulopathy in pediatric APL. We evaluated 79 pediatric patients treated on a Children's Oncology Group phase III clinical trial. There were 4 early deaths and 13 nonlethal, clinically significant (grade III to IV) coagulopathy events during induction. Elevated presenting WBC was significantly associated with early death but not with both lethal and nonlethal coagulopathy events. An ISTH DIC score of ≥5 (the original ISTH criteria for overt DIC) was not associated with either early deaths or coagulopathy events. An ISTH DIC score threshold of 6, however, was significantly associated with early death (12% score ≥6 vs. 0% score <6) and with both lethal and nonlethal coagulopathy events (35% score ≥6 vs. 11% score <6). In pediatric APL patients, the presenting WBC is a marker for risk of early death. Although the ISTH score using a cutoff of ≥6 showed improved correlation with adverse coagulation events during induction, the sensitivity was only 70.6% (95% confidence interval, 44.0%-89.7%) and the specificity was 64.5% (95% confidence interval, 51.3%-76.3%). Thus, there is a strong need to identify other biomarkers that can predict APL-associated coagulopathy.


Assuntos
Hemorragia , Leucemia Promielocítica Aguda , Trombose , Adolescente , Biomarcadores/sangue , Criança , Pré-Escolar , Intervalo Livre de Doença , Feminino , Hemorragia/sangue , Hemorragia/etiologia , Hemorragia/mortalidade , Hemorragia/terapia , Humanos , Lactente , Leucemia Promielocítica Aguda/sangue , Leucemia Promielocítica Aguda/mortalidade , Leucemia Promielocítica Aguda/terapia , Contagem de Leucócitos , Masculino , Fatores de Risco , Taxa de Sobrevida , Trombose/sangue , Trombose/etiologia , Trombose/mortalidade , Trombose/terapia
17.
J Vasc Surg ; 69(3): 651-660.e4, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30154012

RESUMO

OBJECTIVE: Renal function deterioration is an important determinant of mortality in patients treated for complex aortic aneurysms. We have previously determined that catheter and guidewire manipulation in diseased aortas during fenestrated-branched endovascular aneurysm repair (F-BEVAR) is associated with risk of renal function deterioration. The aim of this study was to describe the impact of atherothrombotic aortic wall thrombus (AWT) on renal function deterioration among patients treated by F-BEVAR for pararenal and extent IV thoracoabdominal aortic aneurysms. METHODS: Clinical data of 212 patients treated for complex aortic aneurysms with F-BEVAR were entered into a prospectively maintained database (2007-2015). AWT was evaluated by computed tomography angiography using volumetric measurements in nonaneurysmal aortic segments. AWT was classified as mild, moderate, or severe using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Acute kidney injury (AKI) was defined using Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease (RIFLE) criteria, and renal function deterioration was defined by a decline in estimated glomerular filtration rate (eGFR) >30% from baseline. Patient survival and renal outcomes were assessed at dismissal, at 6 to 8 weeks, at 6 months, and annually, including AKI, serum creatinine concentration, eGFR, chronic kidney disease stage, need for renal replacement therapy, and presence of kidney infarction. RESULTS: There were 169 male (80%) and 43 female (20%) patients with a mean age of 75 ± 7 years. Aneurysm extent was pararenal in 157 patients and extent IV thoracoabdominal aortic aneurysm in 55 patients. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%), moderate in 75 (35%), and severe in 39 (19%). At 30 days, 45 patients (21%) developed AKI. Decline in eGFR and kidney infarction were associated with higher AWT volume index and severe AWT classification (P < .05). There was no association of AWT with 30-day mortality, which was 0.5% for the entire cohort. Mean follow-up was 29 ± 23 months. Freedom from renal function deterioration was 73% ± 6% for mild, 81% ± 6% for moderate, and 66% ± 8% for severe AWT patients at 3 years (P = .012) and 46% ± 9% and 82% ± 4% for those with or without AKI after the initial procedure (P < .001). Overall, 41 patients (19%) had progression of chronic kidney disease stage, but none of the patients required renal replacement therapy. Survival was 73% ± 5% for mild, 72% ± 6% for moderate, and 69% ± 10% for severe AWT patients at 3 years (P = .67). CONCLUSIONS: AWT is a significant predictor of AKI and continued decline in renal function after the initial F-BEVAR procedure. Longer follow-up time is needed to determine the actual impact of AWT on survival.


Assuntos
Lesão Renal Aguda/etiologia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Taxa de Filtração Glomerular , Rim/fisiopatologia , Trombose/complicações , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/fisiopatologia , Lesão Renal Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/mortalidade , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Trombose/mortalidade , Fatores de Tempo , Resultado do Tratamento
18.
Ann Cardiol Angeiol (Paris) ; 68(2): 65-70, 2019 Apr.
Artigo em Francês | MEDLINE | ID: mdl-30292445

RESUMO

OBJECTIVE: To describe the management and evolution of high risk of death pulmonary embolism associated with right heart thrombi. MATERIAL AND METHODS: We conducted a prospective cohort survey over a 54 month-period, from March 1st, 2012 to September 30th 2015. Were included all patients with pulmonary embolism and having high or intermediate-high risk of death. Patients were divided into two groups according to whether cardiac Doppler-echography found a thrombus in the right chambers or not (ICT+ vs. ICT-). The survival curves for the patients were obtained using the software STATA. RESULTS: The prevalence of pulmonary embolism associated with right heart thrombi was 4% in our study. Thrombi were mobile, straight localization in all cases. The ICT+group was characterized by a significantly higher proportion of congestive heart and chronic lung disease. The proportion of patients' thrombolysis was significantly higher in the ICT-group. In the ICT+group, thrombolysis significantly reduced mortality giving a 30-day survival of 80% against 20% among patients receiving only heparin. CONCLUSION: Pulmonary embolism associated with right heart thrombi including the atrium are not exceptional. These patients are at high risk of early death. Thrombolysis is significantly improving the mortality of pulmonary embolism associated with right-sided heart thrombi.


Assuntos
Cardiopatias/complicações , Embolia Pulmonar/complicações , Trombose/complicações , Burkina Faso , Distribuição de Qui-Quadrado , Ecocardiografia , Feminino , Fibrinolíticos/uso terapêutico , Átrios do Coração/diagnóstico por imagem , Cardiopatias/diagnóstico por imagem , Cardiopatias/mortalidade , Cardiopatias/terapia , Heparina/uso terapêutico , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Embolia Pulmonar/terapia , Risco , Estreptoquinase/uso terapêutico , Terapia Trombolítica/métodos , Terapia Trombolítica/mortalidade , Trombose/diagnóstico por imagem , Trombose/mortalidade , Trombose/terapia
19.
Ann Vasc Surg ; 56: 280-286, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30496900

RESUMO

BACKGROUND: Postoperative subtherapeutic low-dose heparin infusion (LDHI) is sometimes administered in patients undergoing extremity arterial revascularization to maintain graft patency and decrease the risk of thrombosis. However, the safety of this management strategy is unknown. METHODS: From 2013 to 2015, we retrospectively reviewed all patients undergoing upper and lower extremity arterial revascularization at a single university-affiliated medical center. Patients were grouped by receipt of LDHI within the first 24-hour postoperative period. Preoperative demographics, comorbidities, intraoperative measures, 30-day postoperative complications, arterial patency rates, and amputation rates were analyzed for each group. RESULTS: We identified 379 patients who received extremity revascularization, and 56 (14.8%) of them had received LDHI. Patients who received LDHI were less likely to have an elective admission on presentation (26.8% vs. 56%, P < 0.001) or an admission from home (69.6% vs. 81.7%, P = 0.04). They were more likely to have preoperative bleeding (44.6% vs. 22%, P < 0.01) and need for emergent operation (23.2% vs. 11.8%, P = 0.04). Postoperatively, although patients who received LDHI demonstrated a trend toward increased bleeding (48.2% vs. 33.7%, P = 0.053), they did not demonstrate an increase in 30-day mortality (1.79% vs. 1.24%, P = 0.55) or reoperation (19.7% vs. 12.4%, P = 0.21). Multivariable analysis demonstrated that LDHI did not have a significant association with immediate postoperative bleeding (P = 0.99), survival (P = 0.13), primary patency (P = 0.872), and amputation-free survival (P = 0.387). CONCLUSIONS: Although LDHI was more likely to be administered in patients who received emergent operations, risk-adjusted analysis demonstrated that it was not associated with increased postoperative bleeding, mortality, short-term need for reintervention, or amputation after extremity arterial revascularization.


Assuntos
Anticoagulantes/administração & dosagem , Heparina/administração & dosagem , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Cuidados Pós-Operatórios/métodos , Trombose/prevenção & controle , Extremidade Superior/irrigação sanguínea , Procedimentos Cirúrgicos Vasculares , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação , Anticoagulantes/efeitos adversos , Bases de Dados Factuais , Esquema de Medicação , Feminino , Heparina/efeitos adversos , Humanos , Infusões Intravenosas , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Cuidados Pós-Operatórios/efeitos adversos , Cuidados Pós-Operatórios/mortalidade , Hemorragia Pós-Operatória/induzido quimicamente , Estudos Retrospectivos , Fatores de Risco , Trombose/etiologia , Trombose/mortalidade , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
20.
Eur J Vasc Endovasc Surg ; 57(3): 393-398, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30393064

RESUMO

OBJECTIVE: Acute ischaemia due to thrombosed popliteal artery aneurysm (PAA) is associated with a high risk of limb loss. The aim of this study was to analyse the outcome, in particular the limb salvage rate in patients undergoing urgent open surgery for acute ischaemia due to thrombosed PAA. METHODS: This was a retrospective analysis of consecutive patients undergoing urgent open surgery for acute limb ischaemia (Rutherford category ≥ II) due to thrombosed popliteal artery aneurysm between January 2007 and December 2016 at a tertiary referral centre. RESULTS: Fifty-one patients (92% male), median age 75 years (range 46-97 years), were identified. Twenty patients (39%) presented with category IIa acute limb ischaemia, 20 (39%) with category IIb, and 11 (22%) with category III. Four patients (8%) underwent primary major amputation. Forty-seven (92%) underwent bypass surgery, 43/47 (91%) using great saphenous vein. One vessel runoff was present in 27/47 patients (57%). Thirty day mortality was 4% (n = 2). Four patients needed major amputation within 30 days, resulting in an overall 30 day major amputation rate of 16% (8/51, 95% confidence interval 7.0-28.6). No further major amputations were necessary during a median follow up of 41 months (range 4-114 months) resulting in an estimated 4 year limb salvage of 84%. The one year primary assisted and secondary bypass patency rates were 90% and 95%, respectively. The estimated four year primary assisted and secondary patency rates were 82% and 87%, respectively. CONCLUSION: Rapid open surgical revascularisation in patients with acute limb ischaemia due to a thrombosed popliteal artery aneurysm results in good long-term limb salvage rates, especially Rutherford category IIa and IIb acute ischaemia. Revascularisation may be attempted in clinically severe cases not fulfilling all criteria to be classified as category III. Such patients may, in fact, be borderline between IIb and III. Despite poor runoff, good bypass patency rates and low rates of claudication can be achieved.


Assuntos
Aneurisma/cirurgia , Isquemia/cirurgia , Salvamento de Membro , Artéria Poplítea/cirurgia , Veia Safena/transplante , Trombose/cirurgia , Enxerto Vascular/métodos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Amputação , Aneurisma/diagnóstico por imagem , Aneurisma/mortalidade , Aneurisma/fisiopatologia , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Trombose/diagnóstico por imagem , Trombose/mortalidade , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade , Grau de Desobstrução Vascular
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA