RESUMO
OBJECTIVES: Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. METHODS: The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. RESULTS: Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). CONCLUSIONS: Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.
Assuntos
Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Doença Aguda , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Stents , Resultado do TratamentoRESUMO
This paper presents the description of the author's experience with bifurcated endovascular stent graft in a patient affected by spontaneous infrarenal acute aortic dissection (SIAAD). The authors report a case of SIAAD occurring in the normal aorta of a patient who presented with severe lower back pain radiated to the abdomen, not responding to common pain-killers. A complete exclusion of the dissected aorta was accomplished with a bifurcated endovascular graft using a simple technique. SIAAD is a rare event. Endovascular therapy is a safe option and can be considered the treatment of choice even for dissection extending into one or both iliac.
Assuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Stents , Doença Aguda , Dissecção Aórtica/diagnóstico , Aorta Abdominal/cirurgia , Aneurisma Aórtico/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Artéria Renal , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
BACKGROUND: Structural alterations of aortic wall resulting from degradation of matrix proteins by matrix metalloproteinases (MMPs) characterize abdominal aortic aneurysms (AAAs). No studies have compared circulating levels of MMPs after endovascular graft (EVG) exclusion in comparison with open surgical repair (OSR) in patients affected by AAA. METHODS AND RESULTS: An abdominal angiography and CT scan were performed in all patients at the time of enrollment. A spiral CT scan was performed at 6 months to detect presence of endoleaks. MMP-3 and MMP-9 levels were measured before EVG (n=30) and OSR (n=15) treatments and at 1, 3, and 6 months of follow-up by a sandwich ELISA technique. Healthy volunteers (n=10) were used as control subjects. Immunohistochemical staining for MMP-9 and MMP-3 was performed on tissue samples from surgical cases. Both MMP-9 and MMP-3 mean basal levels were significantly higher in patients affected by AAA than in control subjects (32.3+/-20.7 ng/mL for EVG and 28+/-9.9 ng/mL for OSR versus 8.9+/-2.5 ng/mL, 2P<0.05; 18.3+/-9.7 ng/mL and 26.7+/-10.8 ng/mL versus 8.2+/-5.3 ng/mL, 2P<0.001). In the OSR group, both MMP-9 and MMP-3 mean levels decreased after surgery (28+/-9.9 ng/mL at basal versus 14.7+/-6.6 ng/mL at 6 months, 2P<0.001; 26.7+/-10.8 versus 12+/-5.3 ng/mL; 2P<0.001). In the EVG group, a statistically significant difference at 6-month follow-up in MMP-9 and MMP-3 mean plasma values was detected in patients who had endoleakage in comparison with patients without endoleakage (44.3+/-20.7 versus 14.6+/-7.0 ng/mL, 2P<0.005; 25+/-11.5 versus 10.3+/-5.4 ng/mL, 2P<0.005). CONCLUSIONS: After EVG exclusion, MMP-9 and MMP-3 levels decreased to a level similar to that of patients undergoing OSR. In addition, a lack of decrease in MMP levels after EVG exclusion may help in identifying patients who will have endoleakage and consequent aneurysm expansion caused by continuous sac pressurization during follow-up.
Assuntos
Aneurisma da Aorta Abdominal/sangue , Metaloproteinase 3 da Matriz/sangue , Procedimentos Cirúrgicos Vasculares , Idoso , Aneurisma da Aorta Abdominal/patologia , Aneurisma da Aorta Abdominal/cirurgia , Aortografia , Biomarcadores/sangue , Implante de Prótese Vascular/efeitos adversos , Cateterismo , Feminino , Seguimentos , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Falha de Prótese , Valores de Referência , Stents/efeitos adversos , Inibidor Tecidual de Metaloproteinase-1/sangue , Inibidor Tecidual de Metaloproteinase-2/sangue , Tomografia Computadorizada por Raios X , Procedimentos Cirúrgicos Vasculares/efeitos adversosRESUMO
Between 1974 and 1989, 42 patients have been operated on at the Istituto di Chirurgia Generale e Cardiovascolare of University of Milan, for traumatic pathology of the thoracic aorta: in 14 cases it occurred an acute rupture at the level of aortic isthmus and in 28 cases a posttraumatic fals aneurysm. We had an operative mortality of 28% (4 cases) in the acute rupture: 3 patients died for neurological complications which were present at hospitalization. In one case appeared a serious ARDS. We had no surgical deaths in patients operated on for the posttraumatic false aneurysm. In 15 cases, the patients suffered for a postoperative paraplegia. Surgical indications are discussed, overall for the posttraumatic false aneurysms. The authors consider the advantage and the risks of the use of ECC and of total heparinization of the patients.
Assuntos
Aorta Torácica/lesões , Adulto , Ruptura Aórtica/patologia , Ruptura Aórtica/cirurgia , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Extension into vena cava and right atrium of tumor thrombus from a renal cell carcinoma presents a surgical challenge. The use of cardiopulmonary by-pass, hypothermia and cardiac arrest with temporary exsanguination has allowed the successful surgical excision of this tumor. During 1986 and 1987 3 patients with cancer of kidney invading the vena cava were operated on with this surgical technique. No deaths occurred. The possibility of curing this type of cancer with minimal operative risk and good results is discussed.
Assuntos
Carcinoma de Células Renais/complicações , Cardiopatias/etiologia , Neoplasias Renais/complicações , Trombose/etiologia , Veia Cava Inferior/diagnóstico por imagem , Idoso , Carcinoma de Células Renais/diagnóstico por imagem , Carcinoma de Células Renais/cirurgia , Feminino , Cardiopatias/diagnóstico por imagem , Cardiopatias/cirurgia , Humanos , Neoplasias Renais/diagnóstico por imagem , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Trombose/diagnóstico por imagem , Trombose/cirurgia , Tomografia Computadorizada por Raios X , Veia Cava Inferior/cirurgiaRESUMO
The paper reports a consecutive series of 523 patients undergoing abdominal aortic aneurysm surgery, paying particular attention to the cardiological risk factor. Coronary disease was present in 167 (31.9%) cases and the overall mortality rate was 1.7%: 5 cases (3%) in the group of coronary disease patients; 4 cases (1.2%) in the group of noncoronary disease patients. All fatal cardiac complications during the postoperative period occurred in those patients who presented coronary cardiopathies before surgery. The preoperative cardiological risk was therefore much greater and more significant in this group of patients. This risk factor should therefore be assessed prior to the operation in order to prepare the necessary medical or even surgical therapeutic measures.
Assuntos
Aneurisma Aórtico/cirurgia , Cardiopatias/etiologia , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Abdominal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
Fifteen cases of ruptured thoracoabdominal aneurysm (-TAA) were encountered in 1987-July 1994. These patients included 13 males (86.6%), 2 females (13.4%) with a mean age of 66.3 years (range 58-78). Surgery was performed on 13 patients of whom 6 (46.1%) died within 30 days. The two other patients had died of heart failure prior to surgery. In 8 of these patients (53.4%) the condition was not diagnosed until clear symptoms had appeared. The ruptured aneurysms were thoracic in 9 cases (60%), abdominal in 6 (40%). The maximum aneurysm diameter in the most frequently ruptured group was 6.1-8 cm (in 9 patients-60%)./ For 5 cases (33.4%) the maximum diameter of ruptured aneurysms included dorsolumbar pain. In one patient a concomitant aortobronchial fistula had produced rupture. Low blood pressure was found in 9 cases (60%). In 5 cases (38.4%) curative surgery was performed within 24 hours of the onset of symptoms. In this group, the mortality rate was 40% (2 patients). In the remaining 8 cases, on whom surgery could not be performed within 24 hours (range 25 hours-4 months) the mortality rate was 50% (4 cases). All four cases of paraplegia (30.7%) were encountered among patients in the second group, 2 of whom died. Follow-up revealed a 5-year mortality rate of 71.4%.
Assuntos
Aneurisma Roto , Aorta Abdominal , Aorta Torácica , Idoso , Aneurisma Roto/mortalidade , Aneurisma Roto/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Doenças do Sistema Nervoso/etiologia , Complicações Pós-Operatórias , Análise de Sobrevida , Fatores de TempoRESUMO
The authors' experience of surgical management of abdominal aortic aneurysms (AAA), in 1725 consecutive patients, operated on in a ten years period (1980-1989) is presented. Surgical indications, operative technique, and outcome of elective and emergency procedures are analyzed. A ten years follow-up period is also presented. This shows a significantly better survival rate in surgically treated patients than in nonoperated cases.
Assuntos
Aneurisma Aórtico/cirurgia , Adulto , Idoso , Aorta Abdominal , Emergências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The paper describes the Authors' experience of abdominal aortic aneurysm surgery in over 75-year-old patients. One hundred and forty-two cases were operated over a 10-year period (1980-89). Seventy-two patients were treated electively and 70 underwent emergency surgery following rupture of the aneurysm. Operative mortality during elective surgery was comparable to that in younger patients, whereas the mortality rate during emergency surgery was notably higher than that in under 75-year-old patients. Follow-up confirmed that the life expectancy of operated patients is significantly better than that of patients with untreated abdominal aortic aneurysms.
Assuntos
Aneurisma Aórtico/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aorta Abdominal , Aneurisma Aórtico/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Fatores de TempoRESUMO
Proximal pseudoaneurysm of ascending-abdominal aortic bypass is an uncommon surgical disease. We report a repair of complete detachment of proximal anastomosis of the ascending-abdominal aortic bypass in a 68-year-old man that underwent surgery in 1988 for chronic descending thoracic aortic aneurysm treated with thromboesclusion technique. The clinical, diagnostic, and operative aspects are discussed.
Assuntos
Falso Aneurisma/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Idoso , Falso Aneurisma/diagnóstico por imagem , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Humanos , Masculino , RadiografiaRESUMO
Acute type A aortic dissection and coarctation of the aorta is a rare associated disease. A case of two-stage repair is presented. Firstly the ascending aorta and the right hemi-arch was replaced using deep hypo-thermic circulatory arrest. Cardiopulmonary bypass was proximally instituted, in a patient with total aortic isthmus occlusion, using right axillary artery cannulation. Distally arterial perfusion was obtained cannulating the bilateral hypoplasic femoral arteries. Ten months later a left subclavian artery-descending thoracic aorta bypass was performed.
Assuntos
Aneurisma Aórtico/cirurgia , Coartação Aórtica/cirurgia , Dissecção Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos , Dissecção Aórtica/complicações , Aneurisma Aórtico/complicações , Coartação Aórtica/complicações , Implante de Prótese Vascular , Feminino , Parada Cardíaca Induzida , Humanos , Hipotermia Induzida , Pessoa de Meia-IdadeRESUMO
A 50-year-old man with Behçet's disease (BD) diagnosed ten years previously, was submitted to emergency operation of two symptomatic type IV thoracoabdominal aortic and left common iliac aneurysms repair. Despite the rarity of vascular lesions in the course of BD, the uncommon clinical situation of double symptomatic aneurysms was successfully treated with surgical management that appears more difficult because of the inflammatory process associated with obliterative endoarteritis involving all periaortic tissues.
Assuntos
Aneurisma/cirurgia , Aneurisma Aórtico/cirurgia , Síndrome de Behçet/complicações , Artéria Ilíaca , Aneurisma/diagnóstico , Aneurisma/etiologia , Angiografia , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
Aortic dissection is a catastrophic event with a high mortality rate for untreated patients. One hundred and thirteen patients with acute aortic dissection were observed in the IInd Surgical Department of Milan University from 1974 to 1985; 55 had type I and II aortic dissection and 58 had type III aortic dissection. All patients with type I and II and about 50% of patients with type III aortic dissection underwent surgical correction. In the second type III group the aortic lesion was surgically corrected only when visceral ischaemia or ischaemia of the lower limb was recognized. In the other type III cases, medical treatment was preferred. The mortality rate was lower after medical treatment (15%) than after surgical treatment (37%). Follow-up was performed for the majority of patients and was recently completed with non-invasive techniques like Magnetic Resonance. It accurately shows the residual dissection and follows, the development of occlusion of the false lumen without any risk to the patients.
Assuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Doença Aguda , Adulto , Idoso , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/mortalidade , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Ruptura Aórtica/cirurgia , Prótese Vascular , Emergências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Estudos RetrospectivosRESUMO
From 1970 to October 1991, 26 patients affected by splanchnic artery aneurysms were observed and treated at the Department of General and Cardiovascular Surgery, University of Milan, Italy. Three splanchnic artery aneurysms were operated on in emergency. Visceral artery aneurysms are often completely silent and are generally detected during diagnostic procedures performed in order to clarify some diagnostic questions. When symptomatic they present a characteristic clinical picture of the involved vascular district. Two patients affected by aneurysmal disease of the proper hepatic artery died after operation. All the other splanchnic aneurysms underwent a successful surgical procedure. This study is aimed at analyzing some characteristic clinical pictures, diagnostic methods, therapeutic procedures and postoperative results.
Assuntos
Aneurisma/cirurgia , Circulação Esplâncnica , Adulto , Idoso , Aneurisma/diagnóstico por imagem , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/cirurgia , Angiografia , Emergências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ruptura Espontânea , Tomografia Computadorizada por Raios XRESUMO
A rare case of arteriovenous fistula between an internal mammary artery and a pulmonary artery is presented. The clinical history of recurrent bronchitis and dyspnoea during exercise, the presence of right parasternal murmur with normal heart size and normal blood gases justified the execution of an arteriovenous thoracic angiography which revealed the presence of a cirsoid aneurysm supplied by the internal and external mammary arteries. Diagnostic investigation and surgical indication in patients with the rare fistulous communication between the internal mammary artery and the systemic or pulmonary circulation are analysed.
Assuntos
Fístula Artério-Arterial/diagnóstico , Artéria Torácica Interna , Artéria Pulmonar , Artérias Torácicas , Adulto , Aneurisma/etiologia , Fístula Artério-Arterial/cirurgia , Feminino , Humanos , Ligadura , Artéria Torácica Interna/cirurgia , Artéria Pulmonar/cirurgia , Artérias Torácicas/cirurgiaRESUMO
A series of 262 observed cases of aneurysm of the thoracic aorta is examined in which 216 cases of surgical correction were performed between 1974 and 1987. Dissecting aneurysms and post-traumatic pseudoaneurysms, although of different aetiology and morbid anatomy, are also included since the surgical technique adopted is similar in all groups. Clinically different aspects of acute and chronic lesions are analyzed. Of all preoperative examinations, angiography is preferred as it gives the most precise definition of the aortic lesion. This is especially necessary in the case of acute dissection or rupture of thoracic aorta although the role of CAT scan is becoming progressively more important. In cases of aortic dissection with massive aortic valve insufficiency, the substitution of the ascending aorta and aortic valve with reimplantation of coronary arteries, in accordance with Bentall's technique is also indicated. The improvement in surgical results is emphasized, since surgical mortality has decreased from 30.6% to 22% in the last eight years. This is due to improvement in surgical technique, to extra corporeal circulation and myocardial protection.
Assuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Ruptura Aórtica/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/mortalidade , Aorta/cirurgia , Aorta Torácica/lesões , Aorta Torácica/cirurgia , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/mortalidade , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/mortalidade , Prótese Vascular , Circulação Extracorpórea , Seguimentos , Humanos , Pessoa de Meia-IdadeRESUMO
The statistical incidence, etiopathogenesis, diagnostics and surgical treatment of acute ruptures of the thoracic aorta are described. A personal series of 7 cases is reported; surgical techniques, benefits and risks of extracorporeal circulation during surgical treatments are analysed and discussed.
Assuntos
Ruptura Aórtica/etiologia , Acidentes de Trânsito , Doença Aguda , Adolescente , Adulto , Aorta Torácica/lesões , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/cirurgia , Feminino , Humanos , MasculinoRESUMO
Peripheral arterial aneurysms present characteristic locations. In the lower limbs, atherosclerotic aneurysms of the deep femoral artery are very rare. Authors report an interesting case of arteriosclerotic aneurysm of a branch of the profunda femoris artery observed in a 80 year-old man, and associated with an abdominal aortic aneurysm. Endo-aneurysmectomy was performed with a dacron patch interposition. Surgical treatment of this rate disease is discussed.
Assuntos
Aneurisma , Arteriosclerose , Artéria Femoral , Idoso , Idoso de 80 Anos ou mais , Aneurisma/diagnóstico , Aneurisma/cirurgia , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/cirurgia , Prótese Vascular , Artéria Femoral/cirurgia , Humanos , Masculino , PolietilenotereftalatosRESUMO
Chronic renal insufficiency is one of the most important factors governing the immediate and long-term outcome after aneurysm repair. A total of 484 patients with abdominal aortic aneurysm (A.A.A.) have undergone elective surgical treatment in our Institution during the last 5 years. Of these, we selected 60 patients; 30 with a normal serum creatinine concentration and 30 with preoperative renal insufficiency (serum creatinine concentration greater than 2 mg/dl). In this second group, 23 patients (76.6%) were affected by slight or median renal insufficiency, 5 patients (16.6%) were affected by severe renal insufficiency (creatinine concentration greater than 4.5 mg/dl), and 2 patients (6.6%) had complete renal failure with dialytic treatment from 1.5 and 2 years respectively. We analyzed postoperative renal function in all 60 patients. In the first group, only 6 patients (20%) showed a transient renal insufficiency, without mortality and morbidity. In the second group, postoperative complications and mortality tended to occur more frequently in patients with a severe renal insufficiency than in patients with slight or median insufficiency or complete renal failure. The present data suggest that dialytic treatment might be necessary in patients with severe renal insufficiency before aneurysm repair.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Falência Renal Crônica/complicações , Aneurisma da Aorta Abdominal/complicações , Feminino , Humanos , Masculino , PrognósticoRESUMO
Inflammatory abdominal aneurysms (AIAA) represent a clearly defined clinical entity with an incidence ranging between 1.2% and 15%. In spite of the increasing number of observations reported in recent years, the etiopatholgenesis and natural history have not been defined. The lesion can present in an acute, subacute or chronic manner and the histopathological studies reveal prevalently two components: an inflammatory infiltrate and a diffuse fibrosis, in varying degree. This study aimed to analyze the more recent imaging procedures in order to correctly diagnose this lesion. In our experience the incidence of AIAA is about 2.5%. On the basis of macro microscopic pictures the authors divided patients into two groups: one constituted by the acute or subacute inflammatory forms, the other by chronic clear inflammatory aneurysms. All patients underwent on operative treatment. The surgical adopted techniques and the obtained results are reported.