RESUMO
OBJECTIVE: Current guidelines recommend intervention in subjects with severe symptomatic aortic stenosis (AS), even though any degree of AS is associated with a higher risk of mortality. We investigated the association between the degree of AS, delineated by transvalvular flow velocity, and patient morbidity and mortality. METHODS: Medically managed patients aged 40-95 years with maximum flow velocity (Vmax ) by echocardiography between 2013 and 2018 were stratified into five groups (A-E) based on the 75th, 90th, 97.5th, and the 99th percentiles of Vmax distribution. Patient characteristics, cardiac structural changes, and end-organ disease were compared using Kruskal-Wallis and Cochran-Armitage tests. Mortality over a median of 2.8 (1.52-4.8) years was compared using Kaplan-Meier curves and risk estimates were derived from the Cox model. RESULTS: The Vmax was reported in 37,131 patients. There was a steady increase (from Group A towards E) in age, Caucasian race, structural cardiac changes, end-organ morbidities, and all-cause mortality. In reference to Group A, there as an increased risk of mortality in Groups B (hazard ratio [HR] = 1.3; confidence interval [CI]: 1.2-1.35; p < .0001), C (HR = 1.5; CI: 1.4-1.6; p < .0001), and D (HR = 1.8; CI: 1.6-2; p < .0001), with an exponential increase in Group E (HR = 2.5; CI: 2.2-2.8; p < .0001). CONCLUSIONS: A direct, strong correlation exists between the degree of AS and cardiac structural changes and mortality. Patients with Vmax ≥ 97.5th percentile (≥3.2 m/s) might benefit from early intervention.
Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Humanos , Resultado do Tratamento , Estenose da Valva Aórtica/complicações , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Ecocardiografia , Índice de Gravidade de Doença , Volume SistólicoRESUMO
BACKGROUND: Thoracic aortic aneurysm (TAA) is a significant risk factor for aortic dissection and rupture. Guidelines recommend referral of patients to a cardiovascular specialist for periodic surveillance imaging with surgical intervention determined primarily by aneurysm size. We investigated the association between socioeconomic status (SES) and surveillance practices in patients with ascending aortic aneurysms. METHODS: We retrospectively reviewed records of 465 consecutive patients diagnosed between 2013 and 2016 with ascending aortic aneurysm ≥4 cm on computed tomography scans. Primary outcomes were clinical follow-up with a cardiovascular specialist and aortic surveillance imaging within 2 years following index scan. We stratified patients into quartiles using the area deprivation index (ADI), a validated percentile measure of 17 variables characterizing SES at the census block group level. Competing risks analysis was used to determine interquartile differences in risk of death before follow up with a cardiovascular specialist. RESULTS: Lower SES was associated with significantly lower rates of surveillance imaging and referral to a cardiovascular specialist. On competing risks regression, the ADI quartile with lowest SES had lower hazard of follow-up with a cardiologist or cardiac surgeon before death (hazard ratio: 0.46 [0.34, 0.62], p < .001). Though there were no differences in aneurysm size at time of surgical repair, patients in the lowest socioeconomic quartile were more frequently symptomatic at surgery than other quartiles (92% vs. 23%-38%, p < .001). CONCLUSION: Patients with lower SES receive less timely follow-up imaging and specialist referral for TAAs, resulting in surgical intervention only when alarming symptoms are already present.
Assuntos
Aneurisma da Aorta Torácica , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/epidemiologia , Aneurisma da Aorta Torácica/cirurgia , Seguimentos , Humanos , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. In LDS patients with normal arch morphology, whether the arch should be prophylactically replaced at the time of proximal aortic replacement remains unknown. We evaluated the risk of long-term arch complications in genetically confirmed LDS patients who underwent proximal ascending aortic replacement. METHODS: We retrospectively reviewed the records of patients with LDS who have been followed at our institution between 1994 and 2020. Patients were only included if whole exome genetic testing confirmed a mutation in an LDS-causing gene (TGFBR1, TGFBR2, SMAD3, TGFB2, or TGFB3). Mutations were categorized as pathogenic, benign, or of unknown significance. We collected demographic information, aortic dimensions, comorbidities, mortality, and operative course from patients' charts. Descriptive statistics and freedom from reoperation plots were generated. RESULTS: Of the 18 patients with a mutation in an LDS-causing gene, 15 had known pathogenic variants, two had mutations of unknown significance, and one had a benign genetic variant. For the 15 patients with confirmed pathogenic variants of LDS the median follow-up duration was 5 years (interquartile range [IQR]: 4-8). Eleven patients underwent ascending aortic replacements (AAR) ± aortic valve replacement. Two patients required an additional operation; one required arch and staged elephant trunk for a dissection 18 years post-AAR and the other patient required an isolated descending aortic replacement for dissection 5 years post-AAR. Among patients who underwent surgery, the median ascending aortic diameter at intervention was 5.0 cm (IQR: 4.3-5.3). There was no surgical or late follow-up mortality observed for any of the 18 patients in the study. CONCLUSION: LDS patients who underwent proximal aortic replacement appeared to have low long-term risk of arch complications. While our study is somewhat limited by its sample size and follow-up duration, it suggests that routine prophylactic total arch replacement may not be warranted in LDS patients with nonaneurysmal aortic arches.
Assuntos
Síndrome de Loeys-Dietz , Humanos , Síndrome de Loeys-Dietz/complicações , Síndrome de Loeys-Dietz/genética , Síndrome de Loeys-Dietz/cirurgia , Receptor do Fator de Crescimento Transformador beta Tipo I , Receptor do Fator de Crescimento Transformador beta Tipo II/genética , Estudos Retrospectivos , Fator de Crescimento Transformador beta3RESUMO
BACKGROUND: It is unknown how high and low-risk cases are distributed among cardiac surgeons of different experience levels. The purpose of this study was to determine if high and low-risk coronary artery bypass grafting (CABG) cases are distributed among surgeons in such a way that would optimize outcomes in light of recent studies that show mid-career surgeons may obtain better patient outcomes on more complex cases. METHODS: We performed a cross-sectional study using aggregated New York (NY) and California (CA) statewide surgeon-level outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. The surgeon observed and expected mortality rates (OMR and EMR) were collected and the number of years-in-practice was determined by searching for surgeon training history on online registries. Loess and linear regression models were used to characterize the relationship between surgeon EMR and surgeon years-in-practice. RESULTS: The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with a median annual case volume of 46 (IQR 19, 70.25). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Median EMR for CA surgeons was 2.42% and 1.44% for NY surgeons. Linear regression models showed EMR was similar across years in practice. Regression models also showed surgeon O:E ratios were similar across years-in-practice. CONCLUSION: High and low-risk CABG cases are relatively equally distributed among surgeons of differing experience levels. This equal distribution of high and low-risk cases does not reflect a triaging of more complex cases to more experienced surgeons, which prior research shows may optimize patient outcomes.
Assuntos
Ponte de Artéria Coronária , Cirurgiões , Estudos Transversais , Humanos , New York/epidemiologia , Medição de Risco , Cirurgiões/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: The Coronavirus 19 (COVID-19) pandemic forced an unprecedented shift of postoperative care for cardiac surgery patients to telemedicine. How patients and surgeons perceive telemedicine is unknown. We examined patient and provider satisfaction with postoperative telehealth visits following cardiac surgery. METHODS: Between April 2020 and September 2020, patients who underwent open cardiac surgery and had a postoperative appointment via telemedicine were administered a patient satisfaction survey over the phone. Time of survey administration ranged from 1 to 4 weeks following their appointment. Surgeons also completed a satisfaction survey following each telemedicine appointment they conducted. RESULTS: Fifty patients were surveyed. Of these, 36 (72%) had a postoperative appointment over the telephone, and 14 (28%) had a postoperative appointment via video-chat. Overall, patients expressed satisfaction with the care that they received via our two telemedicine modalities (mean Likert scale agreement 4.8, SD 0.5). Despite this, 46% of patients said they would prefer their next postoperative appointment to be via telemedicine even if there was not a stay-at-home order in place. All surgeons surveyed reported (agree/strongly agree) that they would prefer to see their postoperative patients using telemedicine. CONCLUSIONS: These findings highlight acceptability of continuing telemedicine use in the postoperative care of cardiac surgery patients.
Assuntos
COVID-19 , Procedimentos Cirúrgicos Cardíacos , Telemedicina , Humanos , Satisfação do Paciente , Cuidados Pós-Operatórios , SARS-CoV-2RESUMO
BACKGROUND: Query a single institution computed tomography (CT) database to assess the prevalence of aortic arch anomalies in general adult population and their potential association with thoracic aortopathies. METHODS: CT chest scan reports of patients aged 50-85 years old performed for any indication at a single health system between 2013 and 2016 were included in the analysis. Characteristics of patients with and without aortic arch anomalies were compared by t test and Fisher exact tests. Logistic regression analysis was performed to assess for independent risk factors of thoracic aortic aneurysm (TAA). RESULTS: Of 21,336 CT scans, 603 (2.8%) described arch anomalies. Bovine arch (n = 354, 58.7%) was the most common diagnosis. Patients with arch anomalies were more likely to be female (p < .001), non-Caucasian(p < .001), and hypertensive (p < .001). Prevalence of TAA in arch anomalies group was 10.8% (n = 65) compared to 4.1% (n = 844) in the nonarch anomaly cohort (p < .001). The highest prevalence of thoracic aneurysm was associated with right-sided arch combined with aberrant left subclavian configuration (33%), followed by bovine arch (13%), and aberrant right subclavian artery (8.2%). On binary logistic regression, arch anomaly (OR = 2.85 [2.16-3.75]), aortic valve pathology (OR 2.93 [2.31-3.73]), male sex (OR 2.38 [2.01-2.80]), and hypertension (OR 1.47 [1.25-1.73]) were significantly associated with increased risk of thoracic aneurysm disease. CONCLUSIONS: Reported prevalence of aortic arch anomalies by CT imaging in the older adult population is approximately 3%, with high association of TAA (OR = 2.85) incidence in this subgroup. This may warrant a more tailored surveillance strategy for aneurysm disease in this subpopulation.
Assuntos
Aneurisma , Aneurisma da Aorta Torácica , Anormalidades Cardiovasculares , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria SubcláviaRESUMO
BACKGROUND: Physicians are frequently called on to make medical decisions despite being uncertain about the outcomes of these choices. The psychological stress associated with these dilemmas, known as "Uncertainty Intolerance" (UI), can significantly impact the quality of a physician's practice as well as their own mental health. Coping with uncertainty is an important competency that all residents must master, and some residency programs are introducing new education initiatives aimed at improving UI. However, currently there is no standard protocol for measuring UI or the effectiveness of such interventions and there are no established methods for identifying the residents who would most benefit from the training. In this study, we aim to use the Physician Reaction to Uncertainty (PRU) and Physician Risk Attitude (PRA) scales as assessments for UI in surgical residents, and to determine if Myers-Briggs Type Indicator (MBTI) personality factors are associated with PRU and PRA scores and can be used to identify residents who are more likely to have higher UI. MATERIALS AND METHODS: The PRU and PRA scales, and the MBTI assessment were administered to a total pool of 71 general surgery residents. In addition to the survey questions, residents provided information regarding their gender (male or female), and stage of training (junior or senior). RESULTS: In total, 45 male residents and 25 female residents completed the PRA and PRU scales (98.6%). There were no statistically significant differences when comparisons were made between junior and senior residents or male and female residents. Thirty seven male residents and 18 female residents also completed the MBTI assessment (80.4% and 72%, respectively). PRU and PRA scores were analyzed with respect to personality factors to determine if certain dichotomies are associated with increased UI. There was a trend toward higher UI in individuals identifying with Judging. CONCLUSIONS: In this study, we have conducted a pilot study using the PRU and PRA scales to measuring the success of our new education initiatives aimed at improving uncertainty tolerance. We found that the PRU and PRA assessments were simple to administer and had a high completion rate. Our findings also suggest that individuals who identify with Judging may better tolerate the uncertainties associated with surgical practice, although larger studies will be required to determine if MBTI factors are linked to UI in surgical residents.
Assuntos
Internato e Residência/estatística & dados numéricos , Inventário de Personalidade/normas , Personalidade , Cirurgiões/psicologia , Incerteza , Adaptação Psicológica , Tomada de Decisão Clínica , Estudos de Viabilidade , Feminino , Humanos , Masculino , Inventário de Personalidade/estatística & dados numéricos , Projetos Piloto , Cirurgiões/educação , Cirurgiões/estatística & dados numéricosRESUMO
We report an emergent complex hybrid repair of a type A intramural hematoma with a tear of the aortic arch at the site of Kommerell's diverticulum and an aberrant right subclavian artery. We identified a type IA endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.
Assuntos
Implante de Prótese Vascular , Anormalidades Cardiovasculares , Divertículo , Procedimentos Endovasculares , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Anormalidades Cardiovasculares/complicações , Anormalidades Cardiovasculares/diagnóstico por imagem , Anormalidades Cardiovasculares/cirurgia , Divertículo/complicações , Divertículo/diagnóstico por imagem , Divertículo/cirurgia , Endoleak/diagnóstico por imagem , Endoleak/cirurgia , Humanos , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgiaRESUMO
The nuance of operative decision making for those in need of emergent operation during coronavirus disease 2019 (COVID-19) pandemic is increasingly complex in the absence of robust data or guidelines. We present two cases of thoracic aortic emergencies with COVID-19 disease who survived high-risk operations to highlight the potential for successful outcomes even in situations compounding patient disease, morbid operation, and the added risk associated with virulent disease in the pandemic time.
Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Emergências , Pneumonia Viral/epidemiologia , Procedimentos Cirúrgicos Vasculares/métodos , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/epidemiologia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/epidemiologia , COVID-19 , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Período Pós-Operatório , Período Pré-Operatório , SARS-CoV-2 , Tomografia Computadorizada por Raios XRESUMO
We have previously shown that bone marrow-derived mesenchymal stem cells (BMSC) accelerate wound healing in a diabetic mouse model. In this study, we hypothesized that adipose tissue-derived stem cells (ADSC), cells of greater translational potential to human therapy, improve diabetic wound healing to a similar extent as BMSC. In vitro, the characterization and function of murine ADSC and BMSC as well as human diabetic and nondiabetic ADSC were evaluated by flow cytometry, cell viability, and VEGF expression. In vivo, biomimetic collagen scaffolds containing murine ADSC or BMSC were used to treat splinted full-thickness excisional back wounds on diabetic C57BL/6 mice, and human healthy and diabetic ADSC were used to treat back wounds on nude mice. Wound healing was evaluated by wound area, local VEGF-A expression, and count of CD31-positive cells. Delivery of murine ADSC or BMSC accelerated wound healing in diabetic mice to a similar extent, compared with acellular controls ( P < 0.0001). Histological analysis showed similarly increased cellular proliferation ( P < 0.0001), VEGF-A expression ( P = 0.0002), endothelial cell density ( P < 0.0001), numbers of macrophages ( P < 0.0001), and smooth muscle cells ( P < 0.0001) with ADSC and BMSC treatment, compared with controls. Cell survival and migration of ADSC and BMSC within the scaffolds were similar ( P = 0.781). Notch signaling was upregulated to a similar degree by both ADSC and BMSC. Diabetic and nondiabetic human ADSC expressed similar levels of VEGF-A ( P = 0.836) in vitro, as well as in scaffolds ( P = 1.000). Delivery of human diabetic and nondiabetic ADSC enhanced wound healing to a similar extent in a nude mouse wound model. Murine ADSC and BMSC delivered in a biomimetic-collagen scaffold are equivalent at enhancing diabetic wound healing. Human diabetic ADSC are not inferior to nondiabetic ADSC at accelerating wound healing in a nude mouse model. This data suggests that ADSC are a reasonable choice to evaluate for translational therapy in the treatment of human diabetic wounds.
Assuntos
Tecido Adiposo/transplante , Diabetes Mellitus Experimental/terapia , Transplante de Células-Tronco Mesenquimais , Cicatrização/fisiologia , Tecido Adiposo/citologia , Animais , Células da Medula Óssea/citologia , Proliferação de Células/genética , Sobrevivência Celular/genética , Diabetes Mellitus Experimental/patologia , Regulação da Expressão Gênica no Desenvolvimento , Humanos , Células-Tronco Mesenquimais/citologia , Camundongos , Neovascularização Fisiológica/genética , Molécula-1 de Adesão Celular Endotelial a Plaquetas/genética , Fator A de Crescimento do Endotélio Vascular/genéticaRESUMO
OBJECTIVE: Arteriovenous fistulae (AVF) remain the optimal conduit for hemodialysis access but continue to demonstrate poor patency and poor rates of maturation. We hypothesized that CD44, a widely expressed cellular adhesion molecule that serves as a major receptor for extracellular matrix components, promotes wall thickening and extracellular matrix deposition during AVF maturation. APPROACH AND RESULTS: AVF were created via needle puncture in wild-type C57BL/6J and CD44 knockout mice. CD44 mRNA and protein expression was increased in wild-type AVF. CD44 knockout mice showed no increase in AVF wall thickness (8.9 versus 26.8 µm; P=0.0114), collagen density, and hyaluronic acid density, but similar elastin density when compared with control AVF. CD44 knockout mice also showed no increase in vascular cell adhesion molecule-1 expression, intercellular adhesion molecule-1 expression, and monocyte chemoattractant protein-1 expression in the AVF compared with controls; there were also no increased M2 macrophage markers (transglutaminase-2: 81.5-fold, P=0.0015; interleukin-10: 7.6-fold, P=0.0450) in CD44 knockout mice. Delivery of monocyte chemoattractant protein-1 to CD44 knockout mice rescued the phenotype with thicker AVF walls (27.2 versus 14.7 µm; P=0.0306), increased collagen density (2.4-fold; P=0.0432), and increased number of M2 macrophages (2.1-fold; P=0.0335). CONCLUSIONS: CD44 promotes accumulation of M2 macrophages, extracellular matrix deposition, and wall thickening during AVF maturation. These data show the association of M2 macrophages with wall thickening during AVF maturation and suggest that enhancing CD44 activity may be a strategy to increase AVF maturation.
Assuntos
Aorta Abdominal/cirurgia , Derivação Arteriovenosa Cirúrgica , Matriz Extracelular/metabolismo , Receptores de Hialuronatos/metabolismo , Inflamação/metabolismo , Macrófagos/metabolismo , Veia Cava Inferior/cirurgia , Animais , Aorta Abdominal/efeitos dos fármacos , Aorta Abdominal/metabolismo , Aorta Abdominal/patologia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Quimiocina CCL2/farmacologia , Colágeno/metabolismo , Elastina/metabolismo , Matriz Extracelular/efeitos dos fármacos , Matriz Extracelular/patologia , Genótipo , Receptores de Hialuronatos/genética , Ácido Hialurônico/metabolismo , Inflamação/genética , Inflamação/patologia , Inflamação/prevenção & controle , Macrófagos/efeitos dos fármacos , Masculino , Camundongos Endogâmicos C57BL , Camundongos Knockout , Fenótipo , Transdução de Sinais , Fatores de Tempo , Veia Cava Inferior/efeitos dos fármacos , Veia Cava Inferior/metabolismo , Veia Cava Inferior/patologiaRESUMO
We performed a retrospective analysis of histoplasmosis cases diagnosed at our institution in New Haven, Connecticut, from 2005 to 2015. Among 12 cases of active histoplasmosis, seven were immunosuppressed and five had human immunodeficiency virus (HIV). Eleven patients reported travel to potentially endemic areas at a median of 105 days prior to presentation; travel to the Caribbean was most common (n = 6). Median time to diagnosis from symptom onset and first Histoplasma antigen testing were 41 and 28 days, respectively. Consistent with reports from other non-endemic areas, our findings suggest that the epidemiology of histoplasmosis may differ in Connecticut, potentially contributing to delayed diagnoses.
Assuntos
Histoplasmose/epidemiologia , Histoplasmose/patologia , Adulto , Idoso , Connecticut/epidemiologia , Feminino , Infecções por HIV/complicações , Humanos , Hospedeiro Imunocomprometido , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Doença Relacionada a ViagensRESUMO
OBJECTIVES: Patients sustaining multisystem trauma are at risk for oral and maxillofacial fractures. Although the University of Wisconsin established criteria to help guide the clinician in obtaining additional cross-sectional imaging to evaluate possible facial fractures, it has not been externally validated. Our aim was to evaluate whether the University of Wisconsin's Criteria is generalizable to external institutions through validation and to report modern practice patterns at a level 1 trauma center. METHODS: A retrospective case study was performed of all patients who had computed tomography of the facial bones (CT face) at a tertiary, academic, Level 1 trauma center over the 6-month period ending on June 30, 2015. The electronic medical record was reviewed for the 5 University of Wisconsin criteria (bony step off or instability, periorbital ecchymosis, malocclusion, tooth absence, and glasgow coma scale). Final interpretation of CT face findings by board-certified radiologists (facial fractures, intracranial hemorrhage, and cervical spine injury) were also captured. Our modeling was similar to that described by the reference study, the internal validation study. Sensitivity, specificity, negative, and positive predictive values with 95% confidence intervals were evaluated. A Pâ<â0.05 was considered significant. RESULTS: The presence of any ≥1 of the 5 criteria identified on physical examination resulted in 81% sensitivity for any facial fracture, which is lower than the sensitivity initially described (98%) and subsequently internally validated (97%). The absence of all 5 physical examination criteria had a negative predictive value of 60%, again lower than that initially described (87%) and then internally validated (81%). CONCLUSION: We were unable to validate the University of Wisconsin criteria for predicting facial fractures. These criteria may be institutionally specific and not generalizable to other trauma centers. Further research to refine the criteria for CT of the face is needed to improve resource allocation.
Assuntos
Ossos Faciais/diagnóstico por imagem , Ossos Faciais/lesões , Guias de Prática Clínica como Assunto , Fraturas Cranianas/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Equimose/diagnóstico , Traumatismos Faciais/diagnóstico , Feminino , Escala de Coma de Glasgow , Hospitais Universitários/organização & administração , Humanos , Masculino , Má Oclusão/diagnóstico , Pessoa de Meia-Idade , Exame Físico , Valor Preditivo dos Testes , Estudos Retrospectivos , Perda de Dente/diagnóstico , Centros de Traumatologia/organização & administração , WisconsinRESUMO
In immunocompromised patients, invasive molds such as Aspergillus and Mucor can lead to locally aggressive angioinvasive infections that are often life-threatening. A particularly devastating complication is the development of a fungal mycotic aneurysm resulting from invasion of the arterial wall. Due to anatomic contiguity, the sphenoid sinus provides potential access for these fungi, which often colonize the respiratory sinuses, into the cavernous sinus and internal carotid artery (ICA), thus leading to the formation of ICA aneurysms. The ideal treatment of fungal ICA aneurysms includes a combination of surgical debridement and long-term effective antifungal therapy, but the role of endoscopic resection and the duration of antimicrobials are poorly defined. Here, we present the case of a 71-year-old immunocompromised patient who developed an ICA mycotic aneurysm, associated with a proven invasive fungal infection (presumptively Mucorales) of the sphenoid sinuses, as defined by EORTC/MSG criteria, and who survived after undergoing coil embolization with parent vessel sacrifice of the aneurysm in combination with liposomal amphotericin B. We also review the literature for published cases of invasive fungal sphenoid sinusitis associated with mycotic aneurysms of the ICA and provide a comparative analysis .
Assuntos
Aneurisma Infectado/complicações , Aneurisma Infectado/diagnóstico , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico , Mucorales/isolamento & purificação , Sinusite Esfenoidal/complicações , Sinusite Esfenoidal/diagnóstico , Idoso , Anfotericina B/administração & dosagem , Aneurisma Infectado/microbiologia , Aneurisma Infectado/patologia , Antifúngicos/administração & dosagem , Doenças das Artérias Carótidas/microbiologia , Doenças das Artérias Carótidas/patologia , Artéria Carótida Interna/patologia , Embolização Terapêutica , Feminino , Humanos , Hospedeiro Imunocomprometido , Seio Esfenoidal/patologia , Sinusite Esfenoidal/microbiologia , Sinusite Esfenoidal/patologia , Resultado do TratamentoRESUMO
BACKGROUND: Endovascular angioplasty and stent placement is currently the most frequent treatment for iliac artery occlusive disease. However, despite a successful endovascular procedure, some patients do not experience symptomatic improvement and satisfaction with their care. This study seeks to identify patient-related factors associated with lack of symptomatic improvement after endovascular iliac artery treatment in male veterans. METHODS: Retrospective review of patients treated with endovascular methods for iliac artery occlusive disease between January 2008 and July 2012 at VA Connecticut Healthcare System. Symptomatic improvement on the first post-operative visit was evaluated, with bilateral treatments counted separately. RESULTS: Sixty-two patients had 91 iliac arteries treated with angioplasty and stent placement. Forty-seven (52 percent) legs had critical limb ischemia, and 77 (85 percent) had at least two-vessel distal runoff. Angiographic success was 100 percent. Patient-reported symptomatic improvement at the first post-operative visit was 55 percent (50/91). Lack of symptomatic improvement correlated with older age (OR 1.09 [1.03-1.17], p = 0.008), presence of critical limb ischemia (OR 3.03 [1.09-8.65], p = 0.034), and need for additional surgical intervention (OR 5.61 [1.65-17.36], p = 0.006). Survival, primary and secondary patency, and freedom from restenosis were comparable between patients who reported symptomatic improvement and those who did not. CONCLUSIONS: Despite angiographically successful revascularization, patients who are older or have critical limb ischemia who are treated with isolated endovascular iliac artery intervention are more likely to require additional interventions and less likely to experience symptomatic improvement. These patients may need more extensive infra-inguinal revascularization than isolated iliac angioplasty and stent placement, despite a preserved ankle-brachial index. Quality of life needs to be measured with formal instruments after iliac artery endovascular treatment, especially to determine long term outcomes.
Assuntos
Envelhecimento , Progressão da Doença , Procedimentos Endovasculares , Artéria Ilíaca/cirurgia , Veteranos , Fatores Etários , Idoso , Demografia , Humanos , Artéria Ilíaca/fisiopatologia , Masculino , Prognóstico , Fatores de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
OBJECTIVE: Type II endoleak is usually a benign finding after endovascular abdominal aortic aneurysm repair (EVAR). In some patients, however, type II endoleak leads to aneurysm sac expansion and the need for further intervention. We examined which factors, in particular the components of metabolic syndrome (MetS), would lead to an increase risk of endoleak after EVAR. METHODS: The medical records of all patients who underwent EVAR between 2002 and 2011 at the Veterans Affairs Connecticut Healthcare System were reviewed. MetS was defined as the presence of three or more of the following: hypertension (blood pressure ≥130 mm Hg/≥90 mm Hg), serum triglycerides ≥150 mg/dL, serum high-density lipoproteins ≤50 mg/dL for women and ≤40 mg/dL for men, body mass index ≥30 kg/m(2), and fasting blood glucose ≥110 mg/dL. Development of endoleak, including specific endoleak type, was determined by review of standard radiologic surveillance. RESULTS: During a 9-year period, 79 male patients (mean age, 73.5 years), underwent EVAR for infrarenal abdominal aortic aneurysm (mean 6.2 cm maximal transverse diameter). MetS was present in 52 patients (66%). The distribution of MetS factors among all patients was hypertension in 86%, hypertriglyceridemia in 72%, decreased high-density lipoprotein in 68%, diabetes in 37%, and a body mass index of ≥30 kg/m(2) in 30%. No survival difference was found between the MetS and non-MetS groups (P = .66). There was no difference in perioperative myocardial infarction or visceral ischemia immediately postoperatively between the two groups. Patients with MetS had a significant increase in acute kidney injury (n = 7, P = .0128). Endoleaks of all types were detected in 26% (n = 20) of all patients; patients with MetS had more endoleaks than patients without MetS (35% vs 7.4%, P = .0039). Of the 19 type II endoleaks, 79% were present at the time of EVAR and only 21% developed during surveillance; 95% had MetS (P = .0007). CONCLUSIONS: Type II endoleak after EVAR for abdominal aortic aneurysm is associated with MetS. Whether these patients are subject to more subsequent intervention due to sac expansion is unclear. MetS may be a factor to consider in the treatment of type II endoleak.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Síndrome Metabólica/complicações , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Síndrome Metabólica/diagnóstico , Síndrome Metabólica/mortalidade , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Department of Veterans AffairsRESUMO
Veins are exposed to the arterial environment during two common surgical procedures, creation of vein grafts and arteriovenous fistulae (AVF). In both cases, veins adapt to the arterial environment that is characterized by different hemodynamic conditions and increased oxygen tension compared with the venous environment. Successful venous adaptation to the arterial environment is critical for long-term success of the vein graft or AVF and, in both cases, is generally characterized by venous dilation and wall thickening. However, AVF are exposed to a high flow, high shear stress, low-pressure arterial environment and adapt mainly via outward dilation with less intimal thickening. Vein grafts are exposed to a moderate flow, moderate shear stress, high-pressure arterial environment and adapt mainly via increased wall thickening with less outward dilation. We review the data that describe these differences, as well as the underlying molecular mechanisms that mediate these processes. Despite extensive research, there are few differences in the molecular pathways that regulate cell proliferation and migration or matrix synthesis, secretion, or degradation currently identified between vein graft adaptation and AVF maturation that account for the different types of venous adaptation to arterial environments.
Assuntos
Adaptação Fisiológica , Derivação Arteriovenosa Cirúrgica , Veias/fisiologia , Animais , Artérias/fisiologia , Velocidade do Fluxo Sanguíneo , Pressão Sanguínea , Humanos , Veias/transplanteRESUMO
Stenosis or occlusion of the brachiocephalic artery represents an uncommon cause of cerebrovascular insufficiency. We report a patient with combined brachiocephalic and left subclavian obstruction with clinical manifestations of lightheadedness, syncope, and left-sided weakness who remained misdiagnosed essentially because of symmetrical pressures in the upper extremities. Aortic valve replacement for aortic stenosis failed to provide symptomatic relief. Eventual stenting of the brachiocephalic trunk resolved the patient's symptoms. Our report highlights the diagnostic challenges in this case of bilateral supraaortic vessel disease and shows that equal upper extremity pressures do not rule out brachiocephalic artery obstruction.
Assuntos
Estenose da Valva Aórtica/complicações , Arteriopatias Oclusivas/complicações , Tronco Braquiocefálico , Síndrome do Roubo Subclávio/etiologia , Idoso , Angioplastia com Balão/instrumentação , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Arteriopatias Oclusivas/diagnóstico , Arteriopatias Oclusivas/fisiopatologia , Arteriopatias Oclusivas/terapia , Tronco Braquiocefálico/fisiopatologia , Constrição Patológica , Erros de Diagnóstico , Tontura/etiologia , Feminino , Implante de Prótese de Valva Cardíaca , Hemodinâmica , Humanos , Debilidade Muscular/etiologia , Valor Preditivo dos Testes , Stents , Síndrome do Roubo Subclávio/diagnóstico , Síndrome do Roubo Subclávio/fisiopatologia , Síndrome do Roubo Subclávio/terapia , Síncope/etiologia , Resultado do Tratamento , Ultrassonografia Doppler em CoresRESUMO
BACKGROUND: Despite its potential advantages, the right internal thoracic artery (RITA) is used as a conduit in only 4% of coronary revascularizations. To broaden its application, we frequently use the RITA as a free graft. In this study, we review our experience with the RITA as an in situ and free graft. METHODS: We reviewed the perioperative outcomes and angiographic patency rates of 479 consecutive patients who underwent RITA grafting between January 1987 and December 2011. RESULTS: The RITA was harvested free (FRITA) in 380 patients (79%) and in situ in 99 (21%). The predominant target for the in situ RITA was the right coronary system (79%). The predominant targets for the FRITA were divided between the right (54%) and left coronary systems (46%). There was no perioperative mortality. Mean follow-up was 10 years. Perioperative complications included myocardial infarction (0.4%), sternal nonunions (0.4%), and reoperation for hemorrhage (0.6%). Coronary angiograms were performed in symptomatic patients (17%) after a median of seven years. FRITA patency rates at five, 10, and 15 years were 100%, 95%, and 95%, respectively, comparable to the left internal thoracic artery patency rates and superior to those of saphenous vein graft. Survival rates of FRITA patients at 10, 15, and 20 years were 92%, 89%, and 76%, respectively. CONCLUSION: The FRITA graft reaches all distal coronary vessels and is associated with excellent patency and survival rates. Its application in coronary revascularization vastly expands the benefits of internal thoracic artery grafting.