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1.
JBJS Rev ; 12(7)2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38968379

RESUMO

BACKGROUND: Total femur replacement (TFR) has become increasingly significant as a salvage procedure for both oncologic reconstruction and complex nononcologic conditions such as revision arthroplasty. Despite its effectiveness in limb salvage, TFR is associated with high complication and failure rates, which vary depending on the underlying indication. METHODS: This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was conducted, focusing on studies that reported outcomes of TFR in oncologic and nononcologic cases. Primary outcomes included failure mode and rates according to the Henderson classification, functional outcomes scores, and mobility status. Data were analyzed using random-effects models and generalized linear mixed models. RESULTS: A total of 35 studies involving 1,002 patients were included. The majority of TFRs were performed for oncologic reasons (63.7%). The mean Musculoskeletal Tumor Society (MSTS) score was 66%, with a limb salvage rate of 89%. The meta-analysis revealed a combined failure rate of 34%. For type 4 failures (infection), nononcologic patients exhibited a significantly higher rate at 18% (95% confidence interval [CI], 12%-26%, I2 = 46%, p < 0.01) compared with 8% in oncologic patients (95% CI, 6%-12%, I2 = 0%). Regarding combined types 1 to 4 failures, oncologic patients had a rate of 20% (95% CI, 25%-52%, I2 = 60%), whereas nononcologic patients faced a higher rate of 37% (95% CI, 12%-26%, I2 = 63%) (p < 0.05), indicating a significant difference. There were no significant differences in the MSTS score. In addition, there were no notable differences when comparing failure modes 1, 2, and 3 independently. Mobility analysis showed that approximately 70% of patients required walking aids after surgery. CONCLUSION: TFR offers a valuable limb salvage option in both oncologic and nononcologic scenarios, despite its high failure rates. Although functional outcomes were similar between groups, the higher failure rate in nononcologic cases and the poor overall quality of evidence warrant further comprehensive assessments into predictors of outcomes to optimize results. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Fêmur , Humanos , Fêmur/cirurgia , Salvamento de Membro/métodos , Resultado do Tratamento , Masculino , Feminino , Neoplasias Femorais/cirurgia , Falha de Tratamento
2.
Am J Case Rep ; 25: e944121, 2024 Jun 30.
Artigo em Inglês | MEDLINE | ID: mdl-38944681

RESUMO

BACKGROUND Heparin-induced thrombocytopenia (HIT) is a disease in which the immune response elicited by heparin results in a state of hypercoagulability and platelet activation, leading to thrombocytopenia and thromboembolism. Gustilo-Anderson type IIIC open fractures of the extremities are defined as open fractures presenting with arterial injuries that require repair and result in treatment challenges and complications. The diagnosis of HIT can be difficult in patients with severe trauma with consumptive thrombocytopenia associated with heavy bleeding and the use of heparin after vascular anastomosis. CASE REPORT A 48-year-old man was injured in a car accident, pinching his right lower leg and sustaining a Gustilo-Anderson type IIIc open fracture, for which he underwent emergency revascularization surgery. Heparin was administered continuously immediately after the surgery. On postoperative day 9, ischemic changes were observed in the right foot, and we performed suture re-anastomosis; however, the blood circulation in the right lower leg did not resume, and right lower leg amputation was performed due to ischemic necrosis with the onset of HIT. Postoperatively, the patient was switched to edoxaban after the recovery of his platelet count. Thereafter, the patient experienced no new thrombus occlusion or wound trouble, and was able to walk on a prosthetic leg and return to daily life. CONCLUSIONS It is important to consider the possibility of HIT as soon as thrombocytopenia appears in patients with Gustilo-Anderson type IIIC open fracture who are receiving heparin after vascular anastomosis, as a delayed diagnosis of HIT can make it difficult to save the limb.


Assuntos
Fraturas Expostas , Heparina , Salvamento de Membro , Trombocitopenia , Humanos , Masculino , Pessoa de Meia-Idade , Heparina/efeitos adversos , Trombocitopenia/induzido quimicamente , Fraturas Expostas/cirurgia , Anticoagulantes/efeitos adversos , Isquemia/cirurgia , Isquemia/etiologia , Isquemia/induzido quimicamente
3.
Trials ; 25(1): 370, 2024 Jun 08.
Artigo em Inglês | MEDLINE | ID: mdl-38851710

RESUMO

BACKGROUND: Endovascular therapy has become established as a first-line therapy in most arterial regions. However, open vascular surgery (endarterectomy) remains the treatment of choice for common femoral artery (CFA) lesions. The aim of this study is to investigate the acute and mid-term results of directional atherectomy plus drug-coated balloon (DCB) in comparison to endarterectomy in treatment of de novo arteriosclerotic CFA lesions. METHODS: This prospective, randomized, multicenter non-inferiority study will enroll 306 participants with symptomatic (Rutherford category 1 to 5) de novo stenosis of the CFA including the bifurcation. Patients eligible for both treatment groups could be included in this 1:1 randomized trial. Primary efficacy endpoint is patency of the target lesion at 12 months defined as restenosis < 50% without the need of clinically driven target lesion revascularization (cdTLR). Primary safety endpoint is a combined endpoint including death, myocardial infarction, major or minor amputation of the target limb, and peri-procedural complications at 30 days. Secondary endpoints include primary patency of the target lesion at 6 and 24 months, secondary patency, cdTLR 6, 12, and 24 months, change in ankle-brachial index, and Rutherford-Becker class at 6, 12, and 24 months. Limb salvage, change in quality of life measured by Walking Impairment Questionnaire, and major adverse events including death, myocardial infarction, and minor or major amputation of the target limb will be determined at 6, 12, 24, and 36 months. DISCUSSION: Endovascular treatment of CFA lesions is still a matter of debate. Few studies compared modern endovascular therapy methods against the so-called gold standard surgical endarterectomy so far. Based on recent positive results, this study aims to confirm non-inferiority of a "leaving nothing behind" endovascular approach combining directional atherectomy and DCB compared to surgical therapy. TRIAL REGISTRATION: ClinicalTrials.gov NCT02517827.


Assuntos
Endarterectomia , Artéria Femoral , Doença Arterial Periférica , Grau de Desobstrução Vascular , Humanos , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/métodos , Angioplastia com Balão/instrumentação , Aterectomia/efeitos adversos , Aterectomia/métodos , Materiais Revestidos Biocompatíveis , Endarterectomia/efeitos adversos , Endarterectomia/métodos , Estudos de Equivalência como Asunto , Artéria Femoral/cirurgia , Salvamento de Membro , Estudos Multicêntricos como Assunto , Doença Arterial Periférica/terapia , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/fisiopatologia , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Resultado do Tratamento , Dispositivos de Acesso Vascular
4.
BJS Open ; 8(3)2024 May 08.
Artigo em Inglês | MEDLINE | ID: mdl-38761111

RESUMO

BACKGROUND: Octogenarians are regarded as one of the frailest patient groups among the chronic limb-threatening ischaemia population with high perioperative morbidity and mortality rates. As a result, alternative vein bypass surgery in the absence of sufficient great saphenous vein is often not considered as a potential treatment option. The aim of this study was to compare the results of octogenarians undergoing alternative vein bypass surgery due to chronic limb-threatening ischaemia to younger patients. METHODS: A single-centre retrospective analysis of patients undergoing bypass surgery for chronic limb-threatening ischaemia with alternative autologous vein grafts between 1997 and 2018 was performed. Patients aged over 80 years were compared with those under 80 years. Graft patency rates were assessed and a risk factor analysis for limb loss was performed. RESULTS: In total, 592 patients underwent bypass surgery during the study interval. Twenty-one per cent (n = 126) of patients were 80 years or older. At 4 years, primary, primary-assisted and secondary patency as well as limb salvage rates were not significantly different between the two groups (46% versus 50%, 60% versus 66%, 69% versus 72%, 72% versus 77%, for octogenarians versus non-octogenarians respectively). Major amputations were performed in 27 (21%) octogenarians and 91 (20%) non-octogenarians (P = 0.190). No higher 30-day and long-term mortality rates nor morbidity rates were detected in the octogenarian group with a median follow-up time of 27 (interquartile range 12-56) months. Minor amputation, the reason for alternative vein grafts, as well as the profunda femoris artery as proximal origin of the bypass were risk factors for limb loss in the postoperative course. CONCLUSION: Alternative vein bypass surgery in octogenarians with chronic limb-threatening ischaemia is safe and effective in terms of patency rates, limb salvage and survival compared with younger patients in the absence of sufficient great saphenous vein. Age alone should not be a deterrent from performing bypass surgery.


Assuntos
Amputação Cirúrgica , Salvamento de Membro , Grau de Desobstrução Vascular , Humanos , Estudos Retrospectivos , Masculino , Idoso de 80 Anos ou mais , Feminino , Salvamento de Membro/métodos , Idoso , Amputação Cirúrgica/estatística & dados numéricos , Isquemia Crônica Crítica de Membro/cirurgia , Veia Safena/transplante , Enxerto Vascular/métodos , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade , Fatores de Risco , Fatores Etários , Pessoa de Meia-Idade , Isquemia/cirurgia , Resultado do Tratamento , Doença Crônica
5.
Clin Podiatr Med Surg ; 41(3): 593-606, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38789172

RESUMO

Lower extremity trauma can result in extensive soft tissue loss, which can require a staged multispecialty approach. Flaps can be an excellent choice for significant soft tissue loss. A variety of variables goes into the selection of a flap including understanding what the recipient site needs, available donor sites, nature of trauma, and utilization of indices to predict limb salvageability in order to strategically select the correct flap option.


Assuntos
Traumatismos do Tornozelo , Traumatismos do Pé , Lesões dos Tecidos Moles , Retalhos Cirúrgicos , Humanos , Traumatismos do Pé/cirurgia , Lesões dos Tecidos Moles/cirurgia , Traumatismos do Tornozelo/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Salvamento de Membro/métodos
6.
Medicine (Baltimore) ; 103(20): e38137, 2024 May 17.
Artigo em Inglês | MEDLINE | ID: mdl-38758848

RESUMO

INTRODUCTION: Gout is a chronic disease characterized by deposition of monosodium urate crystals. Tophi develop in some individuals with untreated or uncontrolled gout, which leads to ulcerations, cosmetic problems, mechanical obstruction of joint movement, joint damage and musculoskeletal disability. Currently, the treatment of gouty tophi is controversial and challenging. Both surgical and internal medical treatments have limitations and require further exploration in clinical practice. PATIENT CONCERNS: In Case 1, we treated a patient with severe infection of diabetic foot ulcers with concomitant multiple gouty tophi in the same limb. A systematic management strategy was formulated to close the wound and save the limb. The ulcers healed successfully after half a year. In Case 2, a giant gouty tophi located in the first metatarsophalangeal joint of the left foot was removed by surgical treatment and vancomycin-loaded bone cement implantation. In Case 3, we present a case of gouty tophi that was resolved by standardized systemic medical management. DIAGNOSIS: Three patients were all diagnosed with gout accompanied by gouty deposition, although there were other different comorbidities. INTERVENTIONS: In case 1, we used debridement to gradually remove gouty tophi. In case 2, the giant gouty tophi was removed by surgical operation. In case 3, the gouty tophi disappeared after standardized treatment with medicine, diet and lifestyle management. OUTCOMES: Three patients underwent different treatment therapies to remove gouty tophi based on their specific conditions. LESSONS: We explored effective interventions for tophi in gout by surgical or other interventions in combination with pharmacotherapy.


Assuntos
Gota , Salvamento de Membro , Humanos , Masculino , Gota/complicações , Idoso , Salvamento de Membro/métodos , Pessoa de Meia-Idade , Desbridamento/métodos , Articulação Metatarsofalângica/cirurgia , Antibacterianos/uso terapêutico , Feminino , Vancomicina/uso terapêutico , Vancomicina/administração & dosagem , Pé Diabético/terapia , Pé Diabético/cirurgia
7.
Artigo em Inglês | MEDLINE | ID: mdl-38758674

RESUMO

BACKGROUND: Patients with diabetes and diffuse infrageniculate arterial disease who present with chronic limb-threatening ischemia require an exact anatomical plan for revascularization. Advanced pedal duplex can be used to define possible routes for revascularization. In addition, pedal acceleration time (PAT) can predict the success or failure of both medical and surgical interventions. METHODS: A retrospective review of patients who were referred to our group for unilateral limb-threatening ischemia with isolated infrageniculate disease was conducted. Pedal duplex and PAT at the base of the wound was performed before and 1 week after intervention. The primary endpoint was limb salvage at 1 year. Revascularization was defined as direct or indirect based on the angiosome concept. RESULTS: Fifty-four patients meeting inclusion criteria presented over a 5-year period (toe wound, n = 42; heel wound, n = 8; both, n = 4). At 1 year, 10 (18.5%) had required below-knee amputation, whereas the remainder had healed/improved. Limb salvage was predicted by absence of ongoing smoking, absence of dialysis, and postprocedural PAT (class I/II). Limb salvage did not correlate with direct versus indirect revascularization. CONCLUSIONS: Advanced lower-extremity duplex in conjunction with determining PAT at the area of concern is a useful technique for mapping the vasculature and identifying targets for revascularization in patients with diffuse infrageniculate disease. Target artery revascularization to the wound bed resulting in a PAT less than 180 msec is predictive of limb salvage, regardless of whether perfusion is direct or indirect.


Assuntos
Pé Diabético , Salvamento de Membro , Ultrassonografia Doppler Dupla , Humanos , Estudos Retrospectivos , Masculino , Pé Diabético/cirurgia , Feminino , Salvamento de Membro/métodos , Idoso , Pessoa de Meia-Idade , Extremidade Inferior/irrigação sanguínea , Amputação Cirúrgica , Idoso de 80 Anos ou mais , Fatores de Tempo
8.
Jt Dis Relat Surg ; 35(2): 347-353, 2024 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-38727114

RESUMO

OBJECTIVES: This study aimed to present our experiences with cross-leg flap surgery, which demonstrates successful outcomes in lower limb soft tissue defects without the necessity of microsurgical intervention. PATIENTS AND METHODS: The retrospective study included 26 patients (18 males, 8 females; mean age: 35.6±12.2 years; range, 18 to 65 years) between January 2015 and September 2019. A fasciocutaneous cross-leg flap was applied to the recipient extremity, and the extremities were immobilized by a tubular external fixator. Flap divisions were performed on the 21st postoperative day. At least two years of clinical outcomes were presented. RESULTS: Twenty-five flaps survived and recovered completely without any complication at the donor site, flaps, or the recipient area. In one diabetic patient, partial flap loss was encountered, which granulated with secondary healing. All patients demonstrated stable wound coverage, with none demanding additional soft tissue surgeries. All patients resumed normal ambulation and physical activity without any residual joint stiffness. CONCLUSION: Cross-leg flap method is an effective and respectable option for extremity salvage as a good alternative to free flaps for the management of traumatic complex lower limb defects. This method is simple, provides abundant blood supply to the wound, and does not require microsurgical experience or a good working recipient artery.


Assuntos
Procedimentos de Cirurgia Plástica , Lesões dos Tecidos Moles , Retalhos Cirúrgicos , Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Estudos Retrospectivos , Adolescente , Adulto Jovem , Idoso , Procedimentos de Cirurgia Plástica/métodos , Lesões dos Tecidos Moles/cirurgia , Traumatismos da Perna/cirurgia , Resultado do Tratamento , Extremidade Inferior/cirurgia , Extremidade Inferior/lesões , Extremidade Inferior/irrigação sanguínea , Salvamento de Membro/métodos
9.
Port J Card Thorac Vasc Surg ; 31(1): 33-39, 2024 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-38743516

RESUMO

INTRODUCTION: Portugal has one of the highest prevalence of patients on a regular dialysis program. This population has a higher incidence of peripheral arterial disease with higher rates of postoperative morbidity and mortality. Our goal was to compare outcomes between dialysis and non-dialysis patients with chronic limb threatening ischemia (CLTI) submitted to infrapopliteal bypass. MATERIALS AND METHODS: A retrospective single-center study of infrapopliteal bypass for CLTI was performed between 2012 and 2019. Patients were divided in two groups based on dialysis status (group 1 incorporated patients on dialysis). Primary end point was 1-year freedom from CLTI. Secondary end points were limb-salvage, survival and primary (PP) and tertiary patency (TP) rates at 3 years of follow-up. RESULTS: A total of 352 infrapopliteal bypasses were performed in 310 patients with CLTI. Fourteen percent of the revascularizations were performed on dialysis patients (48/352). Median age was 73 years (interquartile range - IQR 15) and 74% (259/352) were male. Median follow-up was 26 months (IQR 42). Overall, 92% (325/352) had tissue loss and 44% (154/352) had some degree of infection. The majority of revascularization procedures were performed with vein grafts (61%, 214/352). The 30-day mortality was 4% (11/310), with no difference between groups (p = 0.627). Kaplan-Meier analysis showed no difference between groups regarding freedom from CLTI (76% vs. 79%; HR 0.96, CI 0.65-1.44, p=0.857), limb-salvage (70% vs. 82%; HR 1.40, CI 0.71-2.78, p=0.327) and survival (62% vs. 64%; HR 1.08, CI 0.60-1.94, p=0.799). PP rates were 39% in group 1 and 64% in group 2 (HR 1.71, CI 1.05-2.79, p=0.030). TP rates were not different between groups (57% and 78%; HR 1.79, CI 0.92-3.47, p=0.082). CONCLUSION: Infrapopliteal bypass for CLTI, on dialysis patients, resulted in lower PP rates. No differences were observed in freedom from CLTI, TP, limb salvage and survival.


Assuntos
Salvamento de Membro , Doença Arterial Periférica , Artéria Poplítea , Diálise Renal , Grau de Desobstrução Vascular , Humanos , Masculino , Feminino , Idoso , Estudos Retrospectivos , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/mortalidade , Artéria Poplítea/cirurgia , Portugal/epidemiologia , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Isquemia/mortalidade , Isquemia/cirurgia , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Fatores de Risco
10.
Orthopedics ; 47(3): e106-e113, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38690850

RESUMO

BACKGROUND: Total humeral endoprosthetic reconstruction (THER) is a rare reconstruction option for limb salvage surgery for large humeral neoplasms or bone destruction. MATERIALS AND METHODS: Because of the limited data and need for this procedure, we reviewed the literature surrounding THER and assessed functionality, complications, and revisions using the PubMed, Embase, Ovid, and Scopus databases. RESULTS: Among 29 articles and 175 patients, the most common indication was neoplasm (n=25, 86%), mean follow-up was 61.98 months (SD=55.25 months), and mean Musculoskeletal Tumor Society score was 73.64% (SD=10.69%). Reported complications included 26 (23%) revisions in 7 studies, 35 (36%) cases of shoulder instability in 7 studies, and 13 (13.54%) cases of deep infection in 4 studies. CONCLUSION: THER should be considered with a thorough knowledge of outcomes and potential complications to guide patient and clinician expectations. [Orthopedics. 2024;47(3):e106-e113.].


Assuntos
Úmero , Humanos , Úmero/cirurgia , Neoplasias Ósseas/cirurgia , Salvamento de Membro/métodos , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias , Reoperação
11.
JBJS Case Connect ; 14(2)2024 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-38728441

RESUMO

CASE: A 24-year-old woman presented with dedifferentiated parosteal osteosarcoma of the proximal femur and was treated with limb salvage surgery using the Compress implant. It was implanted with a technical error, was not revised, and has demonstrated no negative outcomes 29 months postoperatively. CONCLUSION: An instance of incorrect pin placement during the implantation of a Zimmer Compress implant is presented with good survivorship. This report acts as information for other surgeons who might inadvertently obtain unicortical fixation. In this patient, revision surgery was avoided and an excellent, short-term outcome was achieved while avoiding the potentially devastating complications associated with revision implantation.


Assuntos
Neoplasias Femorais , Humanos , Feminino , Adulto Jovem , Neoplasias Femorais/cirurgia , Osteossarcoma/cirurgia , Salvamento de Membro/métodos
12.
J Am Heart Assoc ; 13(8): e031922, 2024 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-38606780

RESUMO

BACKGROUND: Peripheral artery disease is characterized by an intense inflammatory process that can be associated with a higher mortality rate, particularly in chronic limb-threatening ischemia (CLTI). This study aims to compare the evolution of inflammatory markers between patients with claudication with those with CLTI at 3, 6, and 12 months. METHODS AND RESULTS: An observational, single-center, and prospective study was conducted. A total of 119 patients with peripheral artery disease (65 with claudication and 54 with CLTI) were observed and inflammatory markers collected at admission and 3, 6, and 12 months. At admission, patients with CLTI, when compared with patients with claudication, had significantly higher serum levels of C-reactive protein and fibrinogen (positive acute-phase proteins) and lower serum level of albumin, total cholesterol, and high-density lipoprotein (negative acute-phase proteins): C-reactive protein (g/dL), 2.90 (25th-75th percentile, 2.90-4.90) versus 6.80 (25th-75th percentile, 2.90-53.26) (P=0.000); fibrinogen (mg/dL), 293.00 (25th-75th percentile, 269.25-349.00) versus 415.50 (25th-75th percentile, 312.00-615.75) (P=0.000); total cholesterol (mg/dL), 161.79±95% [152.74-170.85] versus 146.42%±95% [135.30-157.53] (P=0.034); high-density lipoprotein (mg/dL), 50.00 (25th-75th percentile, 41.00-60.00) versus 37.00 (25th-75th percentile, 30.00-45.50) (P=0.000); albumin (g/dL): 4.00 (25th-75th percentile, 3.70-4.20) versus 3.60 (25th-75th percentile, 3.10-4.00) (P=0.003). The association between CLTI and total cholesterol was lost after adjusting for confounders. Three months after the resolution of the CLTI, there was an increase in the levels of negative acute-phase proteins and a decrease in positive acute-phase proteins. These inflammatory proteins did not register an evolution in patients with claudication. The differences in the inflammatory proteins between groups disappeared at 6 months. CONCLUSIONS: CLTI has an inflammatory environment that can be partially reverted after resolution of the ischemic process, emphasizing the importance of timely intervention.


Assuntos
Isquemia Crônica Crítica de Membro , Doença Arterial Periférica , Humanos , Proteína C-Reativa , Estudos Prospectivos , Doença Arterial Periférica/diagnóstico , Claudicação Intermitente/diagnóstico , Isquemia/diagnóstico , Fibrinogênio , Lipoproteínas HDL , Colesterol , Fatores de Risco , Resultado do Tratamento , Estudos Retrospectivos , Salvamento de Membro , Doença Crônica
13.
Ann Vasc Surg ; 105: 201-208, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38604500

RESUMO

BACKGROUND: Endovascular treatment (EVT) for aortoiliac (AI) occlusive lesions is now conducted worldwide, but there are challenges in EVT for complex AI lesions. The VIABAHN VBX (W.L. Gore & Associates, Flagstaff, AZ) is a next-generation balloon-expandable covered stent designed for use with complex AI lesions. The purpose of this study is to evaluate the medium-term outcomes of VIABAHN VBX for such lesions. METHODS: Symptomatic patients who underwent EVT with VIABAHN VBX for an AI lesion from 2018 to 2020 at 7 Japanese centers were reviewed retrospectively. The primary endpoints were primary patency and freedom from target lesion revascularization (TLR). RESULTS: A total of 95 EVT procedures with VIABAHN VBX for AI occlusive lesions were performed in 71 patients. The patients had high rates of dyslipidemia (53%) and chronic kidney disease (61%), and 22% had chronic limb-threatening ischemia (CLTI). The Transatlantic Inter-Society Consensus (TASC Ⅱ) class was A in 12 patients (17%), B in 12 (17%), C in 10 (14%), and D in 37 (52%). Severe calcification (360°) of the treated lesion was present in 31 patients (33%). The median procedure time was 84 (49-158) min, with a technical success rate of 100%. The median follow-up period was 36 (32-43) months. The 3-year primary and secondary patency of VIABAHN VBX were 91% and 99%, the 3-year freedom from TLR was 92%, and the 3-year freedom from major adverse limb event (MALE) was 98%. No limbs required major amputation. Lesion severity (TASC Ⅱ C or D) and severe calcification did not affect the primary patency or freedom from TLR. CONCLUSIONS: Medium-term outcomes after EVT with VIABAHN VBX for AI lesions were acceptable regardless of lesion severity and calcification. These results suggest that VIABAHN VBX may be suitable for AI occlusive lesions with severe anatomical complexity and/or severe calcification.


Assuntos
Doenças da Aorta , Artéria Ilíaca , Doença Arterial Periférica , Desenho de Prótese , Stents , Grau de Desobstrução Vascular , Humanos , Masculino , Feminino , Idoso , Estudos Retrospectivos , Artéria Ilíaca/fisiopatologia , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/cirurgia , Fatores de Tempo , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/terapia , Pessoa de Meia-Idade , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/fisiopatologia , Doenças da Aorta/cirurgia , Japão , Resultado do Tratamento , Idoso de 80 Anos ou mais , Angioplastia com Balão/instrumentação , Angioplastia com Balão/efeitos adversos , Fatores de Risco , Salvamento de Membro
14.
World J Surg ; 48(1): 240-249, 2024 01.
Artigo em Inglês | MEDLINE | ID: mdl-38686799

RESUMO

BACKGROUND: The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision-making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians. MATERIALS AND METHODS: Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1-year limb salvage and survival rates. RESULTS: A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One-month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10 days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n = 8, 9.1%), primary major amputation (n = 1, 1.1%) or revascularization (n = 78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One-year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR = 1.81, p = 0.014) and ALI severity (HR = 1.73, p = 0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1-year survival rate significantly below that of a similar matched population. CONCLUSION: Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery.


Assuntos
Isquemia , Salvamento de Membro , Humanos , Feminino , Masculino , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Isquemia/mortalidade , Isquemia/cirurgia , Salvamento de Membro/métodos , Doença Aguda , Resultado do Tratamento , Amputação Cirúrgica/estatística & dados numéricos , Taxa de Sobrevida
15.
Ann Vasc Surg ; 104: 276-281, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38588950

RESUMO

BACKGROUND: Chronic limb-threatening ischemia (CLTI) is characterized by rest pain and tissue loss, with an annual mortality rate of 20% and amputation rate of 40%, if not treated. Open bypass surgery is recommended in CLTI, depending on the availability of good quality venous material, outflow artery patency, and surgical expertise. The aim of the study is to analyze primary patency, limb salvage, and survival rate in patients undergoing popliteal-to-distal bypass. METHODS: All consecutive patients who underwent popliteal-to-distal bypass surgery between January 2016 and December 2021 were enrolled in the study. Primary outcomes were primary patency, limb salvage, and overall survival. Secondary outcomes included amputation-free survival and secondary patency. RESULTS: Forty-nine patients were included during the study. Technical success was achieved in 100% of cases. Target outflow artery was in 27% (n. 13) of cases the anterior tibial artery, in 27% (n. 13) the dorsalis pedis, in 2% (n. 1) the peroneal artery, in 30% (n. 15) the retromalleolar tibial artery, in 10% (n. 5) the medial plantar artery, and in 4% (n. 2) the tarsal artery. Two-year primary patency was 85% ± 5. Secondary patency rates were 86% ± 3 at 2 years. The overall survival was 81% ± 6 at 2 years, the amputation-free survival was 70% ± 9, and the limb salvage rate was 81% ± 6. CONCLUSIONS: Popliteal-to-distal bypass requires high technical expertise to be performed. When a good autologous vein and adequate outflow artery are present, they can be feasible with good patency rates and overall survival.


Assuntos
Amputação Cirúrgica , Isquemia , Salvamento de Membro , Doença Arterial Periférica , Artéria Poplítea , Grau de Desobstrução Vascular , Humanos , Masculino , Feminino , Idoso , Artéria Poplítea/cirurgia , Artéria Poplítea/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Fatores de Tempo , Estudos Retrospectivos , Isquemia/cirurgia , Isquemia/fisiopatologia , Isquemia/mortalidade , Isquemia/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/diagnóstico por imagem , Pessoa de Meia-Idade , Fatores de Risco , Idoso de 80 Anos ou mais , Intervalo Livre de Progressão , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Doença Crônica , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/instrumentação
16.
J Am Heart Assoc ; 13(9): e033194, 2024 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-38639373

RESUMO

BACKGROUND: Lower extremity endovascular revascularization for peripheral artery disease carries nonnegligible perioperative risks; however, outcome prediction tools remain limited. Using machine learning, we developed automated algorithms that predict 30-day outcomes following lower extremity endovascular revascularization. METHODS AND RESULTS: The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent lower extremity endovascular revascularization (angioplasty, stent, or atherectomy) for peripheral artery disease between 2011 and 2021. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30-day postprocedural major adverse limb event (composite of major reintervention, untreated loss of patency, or major amputation) or death. Data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 machine learning models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Overall, 21 886 patients were included, and 30-day major adverse limb event/death occurred in 1964 (9.0%) individuals. The best performing model for predicting 30-day major adverse limb event/death was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.93 (95% CI, 0.92-0.94). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.70-0.74). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.09. The top 3 predictive features in our algorithm were (1) chronic limb-threatening ischemia, (2) tibial intervention, and (3) congestive heart failure. CONCLUSIONS: Our machine learning models accurately predict 30-day outcomes following lower extremity endovascular revascularization using preoperative data with good discrimination and calibration. Prospective validation is warranted to assess for generalizability and external validity.


Assuntos
Procedimentos Endovasculares , Extremidade Inferior , Aprendizado de Máquina , Doença Arterial Periférica , Humanos , Masculino , Feminino , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/diagnóstico , Idoso , Extremidade Inferior/irrigação sanguínea , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Medição de Risco/métodos , Pessoa de Meia-Idade , Resultado do Tratamento , Amputação Cirúrgica , Fatores de Risco , Estudos Retrospectivos , Bases de Dados Factuais , Fatores de Tempo , Stents , Salvamento de Membro/métodos
17.
J Am Heart Assoc ; 13(9): e033898, 2024 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-38639376

RESUMO

BACKGROUND: The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI. METHODS AND RESULTS: In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis. We described the risk-adjusted association between D2L time and clinical outcomes. Among 1 130 065 patients aged between 66 and 86 years with CLTI, 99 221 (8.8%) underwent outpatient endovascular lower extremity revascularization within 180 days of their CLTI diagnosis. Among patients with D2L time <30 days, there was no association between D2L time and all-cause death or major lower extremity amputation. However, among patients with D2L time >30 days, each additional 10-day increase in D2L time was associated with a 2.5% greater risk of major amputation (hazard ratio, 1.025 [95% CI, 1.014-1.036]). There was no association between D2L time and all-cause death. CONCLUSIONS: A delay of >30 days from CLTI diagnosis to lower extremity endovascular revascularization was associated with an increased risk of major lower extremity amputation among patients undergoing outpatient endovascular revascularization. Improving systems of care to reduce D2L time could reduce amputations.


Assuntos
Amputação Cirúrgica , Isquemia Crônica Crítica de Membro , Procedimentos Endovasculares , Tempo para o Tratamento , Humanos , Idoso , Masculino , Feminino , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/efeitos adversos , Isquemia Crônica Crítica de Membro/cirurgia , Isquemia Crônica Crítica de Membro/complicações , Estados Unidos/epidemiologia , Amputação Cirúrgica/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Salvamento de Membro , Estudos Retrospectivos , Medicare , Extremidade Inferior/irrigação sanguínea , Fatores de Risco , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/complicações , Pacientes Ambulatoriais , Medição de Risco , Isquemia/cirurgia , Isquemia/diagnóstico
18.
J Orthop Surg Res ; 19(1): 258, 2024 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-38654343

RESUMO

BACKGROUND: Debates persist over optimal pelvic girdle reconstruction after acetabular tumor resection, with surgeons grappling between modular and 3D-printed hemipelvic endoprostheses. We hypothesize superior outcomes with 3D-printed versions, yet scarce comparative research exists. This study fills the gap, examining biomechanics and clinical results retrospectively. METHODS: From February 2017 to June 2021, we retrospectively assessed 32 patients undergoing en bloc resection for malignant periacetabular tumors at a single institution. PRIMARY OUTCOME: limb function. SECONDARY OUTCOMES: implant precision, hip joint rotation center restoration, prosthesis-bone osteointegration, and complications. Biomechanical characteristics were evaluated through finite element analysis on pelvic defect models. RESULTS: In the 3D-printed group, stress distribution mirrored a normal pelvis, contrasting the modular group with elevated overall stress, unstable transitions, and higher stress peaks. The 3D-printed group exhibited superior functional scores (MSTS: 24.3 ± 1.8 vs. 21.8 ± 2.0, p < 0.05; HHS: 79.8 ± 5.2 vs. 75.3 ± 3.5, p < 0.05). Prosthetic-bone interface osteointegration, measured by T-SMART, favored 3D-printed prostheses, but surgery time (426.2 ± 67.0 vs. 301.7 ± 48.6 min, p < 0.05) and blood loss (2121.1 ± 686.8 vs. 1600.0 ± 505.0 ml, p < 0.05) were higher. CONCLUSIONS: The 3D-printed hemipelvic endoprosthesis offers precise pelvic ring defect matching, superior stress transmission, and function compared to modular endoprostheses. However, complexity, fabrication expertise, and challenging surgical implantation result in prolonged operation times and increased blood loss. A nuanced consideration of functional outcomes, complexity, and patient conditions is crucial for informed treatment decisions. LEVEL OF EVIDENCE: Level III, therapeutic study (Retrospective comparative study).


Assuntos
Acetábulo , Neoplasias Ósseas , Salvamento de Membro , Procedimentos de Cirurgia Plástica , Impressão Tridimensional , Humanos , Estudos Retrospectivos , Feminino , Masculino , Acetábulo/cirurgia , Pessoa de Meia-Idade , Neoplasias Ósseas/cirurgia , Adulto , Fenômenos Biomecânicos , Salvamento de Membro/métodos , Salvamento de Membro/instrumentação , Resultado do Tratamento , Procedimentos de Cirurgia Plástica/métodos , Procedimentos de Cirurgia Plástica/instrumentação , Desenho de Prótese , Estudos de Coortes , Idoso , Adulto Jovem , Fatores de Tempo
19.
J Orthop Traumatol ; 25(1): 18, 2024 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-38637478

RESUMO

BACKGROUND: Osteosarcoma is the most common primary bone malignancy in skeletally immature patients. The proximal humerus is the third most common site of osteosarcoma. The literature shows a paucity of published data concerning the outcome of proximal humerus osteosarcoma managed by limb salvage. The purpose of this study was to answer the following questions: (1) do patients with proximal humerus osteosarcoma managed by limb salvage and neoadjuvant chemotherapy show good functional and oncological outcomes, and (2) are there any prognostic factors that are associated with better oncological and functional outcomes? MATERIALS AND METHODS: The study was a retrospective case series study assessing the overall outcome of 34 patients with proximal humerus osteosarcoma. Eighteen patients were males (53%) while 16 were females. Biological reconstruction was done in 15 patients (44%), while nonbiological reconstruction was done in 19 patients. Resections were mainly intraarticular (82%). Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score, while oncological outcome was assessed based on local recurrence and development of chest metastasis. Comparisons between quantitative variables were done using the nonparametric Mann-Whitney test. To compare categorical data, the chi-square (χ2) test was performed. The exact test was used instead when the expected frequency was less than 5. Correlations between quantitative variables were examined using the Spearman correlation coefficient. RESULTS: The mean MSTS score was 25.5 (range 23-29). A younger age was statistically correlated with a poorer MSTS score (P = 0.0016). Six patients out of 34 (17.6%) had local recurrence and four of them (67%) were treated by forequarter amputation. 41% of patients developed chest metastasis, and the majority of them were treated by chemotherapy (71%). In comparison with patients with osteosarcoma at other sites who were also managed in our institution, proximal humerus osteosarcoma patients showed higher incidence rates of local recurrence and chest metastasis along with lower 5-year patient and limb survivorships compared to distal femur, proximal tibia and proximal femur osteosarcoma patients. CONCLUSION: Treatment of osteosarcoma of the proximal humerus by limb salvage and chemotherapy yields a good functional outcome. The method of reconstruction does not impact the resultant function. The 5-year survivorship of these patients is 65%. Younger patients have a better oncological outcome and an inferior functional outcome. LEVEL OF EVIDENCE: Level IV therapeutic study.


Assuntos
Neoplasias Ósseas , Osteossarcoma , Masculino , Feminino , Humanos , Salvamento de Membro/métodos , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias Ósseas/cirurgia , Neoplasias Ósseas/patologia , Úmero/cirurgia , Osteossarcoma/cirurgia , Osteossarcoma/patologia
20.
Ann Vasc Surg ; 105: 89-98, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38579910

RESUMO

BACKGROUND: Endovascular deep vein arteriaization (DVA) is a novel technique aimed at salvaging peripheral arterial disease unamenable to conventional surgical intervention. This study aims to review contemporary literature on the efficacy, safety, and durability of DVA on patients with no-option critical limb ischemia (NO-CLI). METHODS: The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using predefined search terms of "percutaneous deep vein arterialization" or "percutaneous deep venous arterialization" in PubMed, Web of Sciences, OvidSP, and Embase. Only studies with 5 or more patients were included, and studies involving open or hybrid DVA were excluded. The primary outcomes included technical success and primary amputation rates. Secondary outcomes included rates of wound healing, complication, reintervention, and all-cause mortality. RESULTS: Ten studies encompassing a total of 233 patients were included. Patients were primarily those deemed to have NO-CLI. The median follow-up period was 12 months (range 1-63 months). The technical success rate was 97% (95% confidence interval [CI] 96.2%-97.9%) and the major amputation rate was 21.8% (95% 21.1%-22.4%). The wound healing rate was 69.5% (95% CI 67.9-71.0%), complication rate was 13.8% (95% CI 11.7%-15.9%), reintervention rate was 37.4% (95% CI 34.9%-39.9%), and all-cause mortality rate was 15.7% (95% CI 14.1%-17.2%). CONCLUSIONS: Our study showed that endovascular DVA is safe for patients with NO-CLI. Nonetheless, studies were small with follow-up period of less than 1 year. There is currently lack of level 1 evidence to recommend routine use in patients with NO-CLI.


Assuntos
Amputação Cirúrgica , Procedimentos Endovasculares , Salvamento de Membro , Doença Arterial Periférica , Humanos , Resultado do Tratamento , Fatores de Risco , Fatores de Tempo , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Idoso , Feminino , Masculino , Veias/cirurgia , Veias/fisiopatologia , Pessoa de Meia-Idade , Cicatrização , Estado Terminal , Idoso de 80 Anos ou mais , Isquemia/cirurgia , Isquemia/fisiopatologia , Isquemia/mortalidade , Isquemia/diagnóstico por imagem
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