RESUMO
OBJECTIVE: The objective of this study was to determine whether long-term follow-up after endovascular aneurysm repair (EVAR) is justified in octogenarians. METHODS: Between September 1996 and October 2011, all patients, including octogenarians, treated for an abdominal aortic aneurysm (AAA) by EVAR were included in a prospective database. Patients older than 80 years and with a nonruptured infrarenal aneurysm treated electively or urgently were included in the study (study group [SG]). Patients with ruptured aneurysms and patients who died during surgery or within the first postoperative month were excluded from further analysis. The control group (CG) consisted of patients younger than 80 years, matched for gender and AAA diameter. All patients were evaluated 4 to 8 weeks after EVAR and then annually thereafter. Follow-up data were complemented by review of the computerized hospital registry and charts and by contact of the patient's general practitioner or referring hospital. Primary outcomes were stent- or aneurysm-related complications and interventions. Secondary outcomes were additional surgical complications and patient survival. RESULTS: A total number of 193 patients (SG, n = 97; CG, n = 96) were included for analysis. Median age was 80 years, and 88.6% were male. Median follow-up time was 33.6 months (interquartile range [IQR], 12.9-68.3). Stent- and procedure-related postoperative complications were comparable between groups (SG, 41.2%; CG, 39.6%; P = .82). Median time to complication was 2.3 months (IQR, 0.2-19.4) in the SG compared with 18.1 months (IQR, 6.8-50.5) in the CG. The 2-year complication-free survival rates were 58% (SG) and 60% (CG). Interventions were performed significantly less frequently in octogenarians (SG, 8.2%; CG, 19.8%; P < .05). Median time to intervention was 11.1 months (IQR, 2.0-31.0) in the SG compared with 54.3 months (IQR, 15.0-93.2) in the CG. The 2-year intervention-free survival rates were 90% (SG) and 92% (CG). During follow-up, 98 patients died (SG, n = 54; CG, n = 44); median time to death was 31.8 months (IQR, 13.3-66.0) in the SG compared with 44.4 months (IQR, 15.0-77.7) in the CG. One aneurysm-related death occurred in the CG. The 2- and 5-year survival rates were 71% and 32% for the SG compared with 77% and 66% for the CG (P < .05). CONCLUSIONS: Because of the low incidence of secondary procedures and AAA-related deaths in octogenarians, long-term and frequent follow-up after EVAR seems questionable. An adapted and shortened follow-up seems warranted in this patient group.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Continuidade da Assistência ao Paciente , Procedimentos Endovasculares , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Causas de Morte , Intervalo Livre de Doença , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: To evaluate the outcome of carotid endarterectomy (CEA) in octogenarians. METHOD: Between January 2005 and July 2010, all CEA patients were prospectively recorded. Patients were categorized into those <80 and ≥80 years of age. Primary outcome measures were hospital duration of stay (HDOS), mortality, any stroke, and postprocedural complications. RESULTS: In total, 477 patients with carotid artery stenosis were treated with CEA. Seventy-one patients (13%) were ≥80 years of age and 477 (87%) patients were <80 years of age. Median HDOS was 3.0 days (interquartile range [IQR], 2-5) for the entire cohort with a median of 3 days (IQR, 2-4) for patients <80 years of age and 4 days (IQR, 2-7) for patients ≥80 years of age (P = 0.0001). Fifteen patients (3%) had an early adverse neurologic event, with 7 patients (1.3%) developing a transient ischemic attack, 2 patients (0.3%) a minor stroke with full neurologic recovery, and 6 patients (1.1%) had a major stroke. Forty patients (6.8%) had a postoperative nerve injury. No statistical differences were observed between the younger (<80 years of age) and older (≥80 years of age) group despite a significant difference in postoperative delirium (P < 0.0001). During follow-up, more fatal cardiac events occurred in the octogenarians group (4.2% vs. 0.4%; P = 0.02). Kaplan-Meier analysis revealed a significantly better survival for the younger patients (log rank test; P = 0.04). CONCLUSIONS: Octogenarians who suffer from carotid artery stenosis can be safely treated by CEA. The increased incidence of postoperative delirium is an important finding and requires extra attention in this vulnerable group.
Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Ataque Isquêmico Transitório/epidemiologia , Medição de Risco/métodos , Acidente Vascular Cerebral/epidemiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Eletroencefalografia , Feminino , Seguimentos , Humanos , Incidência , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Estimativa de Kaplan-Meier , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Complicações Pós-Operatórias , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
BACKGROUND: Vascular prosthetic graft infection is a severe complication after open aortic aneurysm repair. Reports of infected endografts are scarce. General treatment consensus with infected graft material is that it should be removed completely. The objective of this study was to describe the incidence of endograft infection after endovascular repair of abdominal (EVAR) and thoracic aortic aneurysm (TEVAR) and to report treatment options and their outcome. METHODS: A retrospective cohort study was performed of patients endovascularly operated for abdominal and thoracic aortic aneurysm in two large hospitals (one tertiary referral center and one large community hospital) between March 1996 and June 2009. Diagnosis of infected endograft was made based on clinical findings, blood tests and cultures, imaging studies (computed tomography, fludeoxyglucose positron emission tomography), and intraoperative findings at reoperation. RESULTS: Eleven patients with an infected endograft were identified in 1431 endovascular procedures. One other patient was referred from another hospital. Patients were aged 68 ± 9 years, and all but one were male. The median time from initial TEVAR/EVAR to the diagnosis of infection was 115 days (range, 7-3748 days), with 42% of patients presenting within 3 months after TEVAR/EVAR. Seven patients were diagnosed with endograft infection after elective TEVAR/EVAR and five after emergency TEVAR/EVAR. The incidence was significantly higher in patients that were treated in an emergency setting (0.56% vs 2.79%; P = .002), while there was no significant difference between TEVAR and EVAR procedures (1.37% vs 0.77%). All patients were initially treated with antibiotic therapy, which was complemented with surgical intervention in six patients. In four patients, the infected graft material was completely explanted. Isolated microorganisms included Staphylococcus species (n = 4), Streptococcus species (n = 4), Enterobacter cloacae (n = 1), Escherichia coli (n = 1), Pseudomonas aeruginosa (n = 1), and Listeria monocytogenes (n = 1). Median time of follow-up was 201 days (range, 6-2023 days). During the study period, three out of 12 patients died, of which two were treated conservatively (P = ns). At their last follow-up visit, seven of nine patients still used antimicrobial therapy. CONCLUSIONS: The incidence of endograft infection is below 1%, with a mortality rate of 25%. Although consensus is that infected graft material should always be removed, this study shows no significant difference in mortality between the conservatively- and the surgically-managed group, possibly related to the small sample size. There may be a role for conservative treatment in selected cases of patients with an infected endograft.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Infecções Relacionadas à Prótese/etiologia , Centros Médicos Acadêmicos , Idoso , Antibacterianos/uso terapêutico , Aortografia/métodos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Distribuição de Qui-Quadrado , Remoção de Dispositivo , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Fluordesoxiglucose F18 , Hospitais Comunitários , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Países Baixos , Tomografia por Emissão de Pósitrons , Valor Preditivo dos Testes , Desenho de Prótese , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Infecções Relacionadas à Prótese/cirurgia , Compostos Radiofarmacêuticos , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
OBJECTIVE: To investigate whether advanced age may be a reason to refrain from treatment in patients with an acute abdominal aortic aneurysm (AAAA). METHODS: This was a retrospective cohort study that took place in a tertiary care university hospital with a 45-bed intensive care unit. Two hundred seventy-one patients with manifest AAAA, admitted and treated between January 2000 and February 2008, were included. Six patients died during operation and were included in the final analysis to ensure an intention-to-treat protocol, resulting in 234 men and 37 women with a mean age of 72 ± 7.8 years (range, 54-88 years). Forty-six patients (17%) were 80 years or older. Interventions involved open or endovascular AAAA repair. RESULTS: Mean follow-up was 33 ± 30.4 months (including early deaths). Mean hospital length of stay was 16.9 ± 20 days for patients younger than 80 and 13 ± 16.7 days for patients older than 80 years of age. Kaplan-Meier survival analysis revealed a significantly better survival for the younger patients (P < .05). Stratification based on urgency or type of treatment did not change the difference. Two-year actuarial survival was 70% for patients younger than 80 and 52% for those older than 80. At 5-year follow-up, these figures were 62% and 29%, respectively. Mean survival in patients older than 80 was 39.8 ± 6.8 months versus 64.5 ± 3.0 months in those younger than 80. CONCLUSIONS: For octogenarians, our liberal strategy of treating patients with AAAA was associated with satisfactory short- and long-term outcome, with no difference with regard to disease- or procedure-related morbidity between the younger and older group. Assuming an integrated system for managing AAAA is in place, advanced age is not a reason to deny patients surgery.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares , Procedimentos Cirúrgicos Vasculares , Doença Aguda , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Distribuição de Qui-Quadrado , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Hospitais Universitários , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Países Baixos , Seleção de Pacientes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidadeRESUMO
OBJECTIVE: During the last decade, endovascular repair of popliteal artery aneurysms (PAAs) has become a valid alternative to open repair. This study analyzes the incidence and origin of stent graft fractures after endovascular repair, its impact on patency, and strategies to prevent fractures. METHODS: Data of 78 atherosclerotic PAAs in 64 patients were gathered in a prospectively-held database from 1998 to 2009. All x-rays were reviewed to detect stent fractures. Only circumferential fractures were included for analysis; localized strut fractures were excluded. Clinical endpoints were circumferential stent fracture, occlusion, and clinical status of the patient. RESULTS: Mean follow-up time was 50 months (range, 1-127 months). Fifteen circumferential stent fractures occurred in 13 (16.7%) patients. The majority of stent fractures (93.3%) were associated with the use of multiple stent grafts. At univariate analysis, younger age was identified as the only significant predictor for stent fracture (P = .007). The cumulative stent fracture-free survival was estimated at 78% and 73% at 5- and 10-year follow-up, respectively. The cumulative primary patency rate, defined as time to occlusion, was not different for the fracture group compared with the nonfracture group (P = .284). CONCLUSIONS: The incidence of stent fractures after endovascular PAA repair is probably underreported in the literature. Stent graft fractures mainly occur at overlap zones and are associated with younger age of the patient. Fracture of the stent did not significantly influence patency of the stent graft.
Assuntos
Aneurisma/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Artéria Poplítea/cirurgia , Falha de Prótese , Stents , Fatores Etários , Idoso , Aneurisma/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Distribuição de Qui-Quadrado , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Razão de Chances , Artéria Poplítea/fisiopatologia , Desenho de Prótese , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularAssuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/complicações , Dissecção Aórtica/complicações , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Falha de Prótese , Stents , Doença Aguda , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/fisiopatologia , Dissecção Aórtica/cirurgia , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/cirurgia , Aortografia/métodos , Hemodinâmica , Humanos , Masculino , Reoperação , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
The iliac branched device (IBD) is the only totally endovascular option to preserve flow to the internal iliac artery for the treatment of aorto-iliac or solitary iliac artery aneurysms. This technique involves the use of two parallel guide wires, including the indwelling through-and-through wire and a wire to introduce the bridging stent-graft. We describe a technique which uses "tromboned" sheaths (ie, a 7F ANL 1 inside a 10F Balkin sheath) for increased cross-over stability and avoids problems associated with the use of parallel wires inside one sheath. In addition, reduction of the gap between the IBD and the origin of the internal iliac artery may result in a more stable position of the device.
Assuntos
Implante de Prótese Vascular/métodos , Prótese Vascular , Aneurisma Ilíaco/cirurgia , Angiografia , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Desenho de Prótese , Resultado do TratamentoRESUMO
A 70-year-old man was successfully treated for an aortoduodenal fistula originating from a Q fever-related abdominal aortic aneurysm. He had no known history of contact with cattle or sheep. Although the combination of abdominal aortic aneurysm and aortoduodenal fistula is rare, one should be suspicious of Q fever infection as the causative agent, and additional medical treatment should be initiated.
RESUMO
INTRODUCTION: Mortality from ruptured abdominal aortic aneurysms (RAAA) remains high. Severe systemic inflammation, leading to multi-organ failure, often occurs in these patients. In this study we describe the level of HLA-DR expression in a consecutive group of patients following surgery for RAAA and compare results between survivors and non-survivors. A similar comparison is made for IL-6, IL-10 levels and SOFA-scores. METHODS: This is a prospective observational study. Patients with RAAA were prospectively analyzed. Blood samples were collected on day 1, 3, 5, 7, 10 and 14. The fraction of CD-14 positive monocytes expressing HLA-DR was measured by flow-cytometry. Interleukin-6 and interleukin-10 levels were measured by ELISA. RESULTS: Thirty patients with a median age of 70 years were included. There were 27 (90%) men. Six patients died from multiple organ failure, all other patients survived. The Sequential Organ Failure Assessment (SOFA) scores were significantly higher in non-survivors on day 1 through 14. HLA-DR expression on monocytes was significantly lower on day 3, 5, 7, 10 and 14 in non-survivors. Interleukin-6 and IL-10 levels were significantly higher in non-survivors on day 1 and day 1 and 3 respectively. CONCLUSIONS: HLA-DR expression on monocytes was decreased, especially in non-survivors. All patients with RAAA displayed a severe inflammatory and anti-inflammatory response with an increased production of IL-6 and IL-10. Poor outcome is associated with high levels of IL-6 and IL-10 and a high SOFA score in the first three days after surgery, while low levels of HLA-DR expression are observed from day three after RAAA repair.
Assuntos
Aneurisma da Aorta Abdominal/metabolismo , Ruptura Aórtica/metabolismo , Antígenos HLA-DR/biossíntese , Monócitos/metabolismo , Síndrome de Resposta Inflamatória Sistêmica/metabolismo , Idoso , Aneurisma da Aorta Abdominal/imunologia , Ruptura Aórtica/imunologia , Feminino , Regulação da Expressão Gênica/fisiologia , Antígenos HLA-DR/imunologia , Humanos , Masculino , Pessoa de Meia-Idade , Monócitos/imunologia , Estudos Prospectivos , Síndrome de Resposta Inflamatória Sistêmica/imunologiaRESUMO
The Anastoclip Vessel Closure System (VCS) (LeMaitre Vascular, Burlington, MA, USA), introduced primarily to facilitate microvascular anastomoses performed during neurosurgical extra-intracranial bypasses, has been used for several other applications as well. The relatively new anastomotic technique includes a clip applier, clip remover, and everting forceps. With the applier, tiny nonpenetrating titanium clips were installed on everted walls of tubular structures. The technical ease of application, reduced anastomotic time, superior hemodynamics, and an improved healing pattern at the anastomosis have been recognized as major advantages compared to conventional suturing. This chapter describes the various indications for use of the system and categorizes them by specific surgical specialties, which include neurosurgery, urology, and gynecology, as well as plastic and reconstructive, vascular, thoracic, transplantation, hepatopancreaticobiliary, and orthopedic and trauma surgery. The largest clinical experience with clips is in vascular access surgery for hemodialysis purposes, both in autologous constructs and with prosthetic grafts. Promising clinical results also have been achieved in neurosurgical cases (both for microvascular anastomoses and with closure of dura mater), microvascular free-tissue transfer, and renal and liver transplantations. Future clinical applications include the use of clips for nerve repair and closure of various types of tubular structures using a laparoscopic approach.
Assuntos
Procedimentos Cirúrgicos Operatórios , Grampeamento Cirúrgico/instrumentação , Anastomose Cirúrgica/instrumentação , Materiais Biocompatíveis/uso terapêutico , Humanos , Microcirurgia/instrumentação , Suturas , TitânioRESUMO
BACKGROUND: Surgical site infections (SSI) after vascular surgery are related to substantial morbidity. Restriction of bacterial access to the site of surgery with a cyanoacrylate sealant is a new concept. We performed a randomized clinical trial to assess the effect of the sealing of skin with a cyanoacrylate preparation at the site of surgery on the incidence of SSI after arterial reconstruction. METHODS: Patients scheduled for vascular reconstruction in or distal to the groin were randomized into a treatment and a control group. Standard measures for preventing contamination of the surgical field were taken in the control group, whereas cyanoacrylate was used as a skin sealant at the surgical site in the patients in the treatment group. We hypothesized that the incidence of SSI with the use of cyanoacrylate would be two-thirds (67%) lower than that with standard preparation of the surgical site, and performed an interim analysis of 50 patients to assess this. RESULTS: Risk factors among the 50 patients in the study included smoking (28%), hypertension (77%), diabetes mellitus (36%), and hypercholesterolemia (74%). Indications for surgery were invalidating claudication (Fontaine IIb), pain at rest, or tissue necrosis. The overall incidence of SSI was 3/47 (6%), without differences between groups; 9% SSIs in the control group versus 4% SSIs in the intervention group. CONCLUSION: We could not confirm a reduction in the incidence of SSI after inguinal vascular surgery with the use of a cyanoacrylate skin sealant as compared with conventional means for preparing the surgical site.
Assuntos
Cianoacrilatos/uso terapêutico , Infecção da Ferida Cirúrgica/prevenção & controle , Triagem/métodos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Técnicas de Fechamento de Ferimentos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infecção da Ferida Cirúrgica/epidemiologiaRESUMO
The early postoperative phase after transtibial amputation is characterized by rapid residual limb volume reduction. Accurate measurement of residual limb volume is important for the timing of fitting a prosthesis. The aim of this study is to analyze the reduction of residual limb volume in people with transtibial amputation and to correlate residual limb volume with residual limb circumference. In a longitudinal cohort study of 21 people who had a transtibial amputation, residual limb volume was measured using a laser scanner and circumference was measured using a tape measure 1 wk postamputation and every 3 wk thereafter until 24 wk postamputation. A linear mixed model analysis was performed with weeks postamputation transformed according to the natural logarithm as predictor. Residual limb volume decreased significantly over time, with a large variation between patients. Residual limb volume does not correlate well with circumference. On average, residual limb volume decreased 200.5 mL (9.7% of the initial volume) per natural logarithm of the weeks postamputation. The decrease in residual limb volume following a transtibial amputation is substantial in the early postamputation phase, followed by a leveling off. It was not possible to determine a specific moment when the residual limb volume had stabilized.
Assuntos
Cotos de Amputação/anatomia & histologia , Membros Artificiais , Perna (Membro) , Ajuste de Prótese , Adulto , Idoso , Antropometria , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Tamanho do Órgão , Desenho de PróteseRESUMO
Biomaterials-associated infection incidence represents an increasing clinical challenge as more people gain access to medical device technologies worldwide and microbial resistance to current approaches mounts. Few reported antimicrobial approaches to implanted biomaterials ever get commercialized for physician use and patient benefit. This is not for lack of ideas since many thousands of claims to new approaches to antimicrobial efficacy are reported. Lack of translation of reported ideas into medical products approved for use, results from conflicting goals and purposes between the various participants involved in conception, validation, development, commercialization, safety and regulatory oversight, insurance reimbursement, and legal aspects of medical device innovation. The scientific causes, problems and impressive costs of the limiting clinical options for combating biomaterials-associated infection are well recognized. Demands for improved antimicrobial technologies constantly appear. Yet, the actual human, ethical and social costs and consequences of their occurrence are less articulated. Here, we describe several clinical cases of biomaterials-associated infections to illustrate the often-missing human elements of these infections. We identify the current societal forces at play in translating antimicrobial research concepts into clinical implant use and their often-orthogonal constituencies, missions and policies. We assert that in the current complex environment between researchers, funding agencies, physicians, patients, providers, producers, payers, regulatory agencies and litigators, opportunities for translatable successes are minimized under the various risks assumed in the translation process. This argues for an alternative approach to more effectively introduce new biomaterials and device technologies that can address the clinical issues by providing patients and medical practitioners new options for desperate clinical conditions ineffectively addressed by biomedical innovation.
Assuntos
Antibacterianos/uso terapêutico , Materiais Biocompatíveis/efeitos adversos , Próteses e Implantes/efeitos adversos , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/etiologia , Adolescente , Idoso , Ruptura Aórtica/complicações , Ruptura Aórtica/cirurgia , Artroplastia de Quadril/efeitos adversos , Prótese Vascular/efeitos adversos , Prótese Vascular/microbiologia , Pinos Ortopédicos/microbiologia , Endocardite/tratamento farmacológico , Endocardite/etiologia , Endocardite/microbiologia , Feminino , Fraturas Ósseas/complicações , Fraturas Ósseas/microbiologia , Próteses Valvulares Cardíacas/efeitos adversos , Próteses Valvulares Cardíacas/microbiologia , Prótese de Quadril/efeitos adversos , Prótese de Quadril/microbiologia , Humanos , Laringe Artificial/efeitos adversos , Laringe Artificial/microbiologia , Traumatismos da Perna/complicações , Traumatismos da Perna/microbiologia , Masculino , Pessoa de Meia-Idade , Próteses e Implantes/microbiologia , Infecções Relacionadas à Prótese/microbiologiaRESUMO
Biomaterial-associated infections occur on both permanent implants and temporary devices for restoration or support of human functions. Despite increasing use of biomaterials in an aging society, comparatively few biomaterials have been designed that effectively reduce the incidence of biomaterial-associated infections. This review provides design guidelines for infection-reducing strategies based on the concept that the fate of biomaterial implants or devices is a competition between host tissue cell integration and bacterial colonization at their surfaces.
Assuntos
Materiais Biocompatíveis/efeitos adversos , Infecções Relacionadas à Prótese/prevenção & controle , Animais , Interações Hospedeiro-Patógeno , Humanos , Implantes Experimentais/efeitos adversos , Desenho de Prótese , Infecções Relacionadas à Prótese/microbiologia , Engenharia TecidualRESUMO
OBJECTIVE: The aim of this study was to investigate a possible overestimation of the degree of contralateral carotid artery stenosis by duplex in patients with significant bilateral carotid stenoses who are to undergo carotid endarterectomy (CEA). METHODS: A retrospective analysis was performed of all patients undergoing CEA in our center over a period of 11 years. Pre- and postoperative duplex ultrasonography measurements of peak systolic velocity (PSV) and end diastolic velocity (EDV) were compared and used to classify the degree of stenosis. Univariate analysis was performed to indicate possible predictors for contralateral stenosis overestimation. RESULTS: A total of 384 CEA procedures in 357 patients were performed in our hospital. Pre- and postoperative bilateral duplex measurements were available in 135 patients. Forty-four out of 135 patients (33%) were preoperatively identified as having significant stenosis (>60%) of the internal carotid artery on both sides. In these patients, postoperative duplex measurements of the contralateral carotid showed a decrease in mean (SD) PSV from 2.53 (1.11) m s(-1) to 1.97 (0.87) m s(-1) (P<0.01) and a decrease in EDV from 0.87 (0.60) m s(-1) to 0.60 (0.36) m s(-1) (P<0.01). The absolute changes in contralateral PSV and EDV after CEA were larger among patients with a higher degree of stenosis preoperatively. These changes led to reclassification of stenosis to a lesser degree in 24 (55%) patients. In 16 cases (36%), this resulted in a measured stenosis on the contralateral side of less than 60%. CONCLUSIONS: One-third of the patients with duplex measurements consistent with bilateral significant carotid stenosis did not have a significant contralateral stenosis by duplex after CEA. Therefore, additional postoperative duplex measurement is advisable before planning contralateral CEA.
Assuntos
Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/epidemiologia , Erros de Diagnóstico/estatística & dados numéricos , Endarterectomia das Carótidas/estatística & dados numéricos , Ultrassonografia/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New Hampshire/epidemiologia , Cuidados Pré-Operatórios/estatística & dados numéricos , Prevalência , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: The aim of this study was to identify patient-related and/or disease-related factors that influence outcomes in patients with vascular prosthetic graft infections. METHODS: Through the hospital patient administration system, between January 1997 and December 2007, a total of 44 patients were diagnosed with central prosthetic graft infections. Univariate and multivariate analyses were performed to define factors predictive of mortality. RESULTS: Thirty-three men and 11 women (mean age, 71 years) were included. There was considerable comorbidity. Coagulase-negative Staphylococcus and S aureus were isolated in almost 50% of the patients. The mean follow-up duration was 5 years, during which 20 patients (46%) died. The main causes of death were related to vascular disease. Conservative treatment with antibiotics was the only variable with significant predictive value on multivariate analysis (hazard ratio, 3.62; 95% confidence interval, 1.17-11.24; P = .02). CONCLUSIONS: Conservative treatment of prosthetic graft infections was associated with high mortality; therefore, it should be limited to a specific group. Patients who are not capable of undergoing open repair may benefit from conservative management. Otherwise, aggressive open treatment seems indicated.
Assuntos
Antibacterianos/uso terapêutico , Prótese Vascular/efeitos adversos , Infecções Relacionadas à Prótese/mortalidade , Infecções Relacionadas à Prótese/terapia , Idoso , Idoso de 80 Anos ou mais , Aneurisma/complicações , Aneurisma/mortalidade , Aneurisma/terapia , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/mortalidade , Arteriopatias Oclusivas/terapia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polietilenotereftalatos , Politetrafluoretileno , Infecções Relacionadas à Prótese/diagnóstico , Reoperação , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
The diagnosis Complex Regional Pain Syndrome type I (CRPS-I) is based on clinical symptoms, including motor symptoms. Histological changes in muscle tissue may be present in the chronic phase of CRPS-I. Aim of this study was to analyze skeletal muscle tissue from amputated limbs of patients with CRPS-I, in order to gain more insight in factors that may play a role in changes in muscles in CRPS-I. These changes may be helpful in clarifying the pathophysiology of CRPS-I. Fourteen patients with therapy resistant and longstanding CRPS-I, underwent an amputation of the affected limb. In all patients histological analysis showed extensive changes in muscle tissue, such as fatty degeneration, fibre atrophy and nuclear clumping, which was not related to duration of CRPS-I prior to amputation. In all muscles affected, both type 1 and type 2 fibre atrophy was found, without selective type 2 fibre atrophy. In four patients, type grouping was observed, indicating a sequence of denervation and reinnervation of muscle tissue. In two patients even large group atrophy was present, suggesting new denervation after reinnervation. Comparison between subgroups in arms and legs showed no difference in the number of changes in muscle tissue. Intrinsic and extrinsic muscles were affected equally. Our findings show that in the chronic phase of CRPS-I extensive changes can be seen in muscle tissue, not related to duration of CRPS-I symptoms. Signs of neurogenic myopathy were present in five patients.
Assuntos
Doenças Musculares/etiologia , Transtornos Musculares Atróficos/complicações , Distrofia Simpática Reflexa/complicações , Adulto , Amputação Cirúrgica , Denervação , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Imuno-Histoquímica , Perna (Membro) , Masculino , Pessoa de Meia-Idade , Fibras Musculares Esqueléticas/patologia , Músculo Esquelético/patologia , Doenças Musculares/patologia , Transtornos Musculares Atróficos/patologia , Distrofia Simpática Reflexa/patologia , Distrofia Simpática Reflexa/cirurgiaRESUMO
We report a case in which conventional and endovascular exclusion techniques were used to treat ongoing mycotic aortic aneurysmal disease. A 51-year-old man presented with an infrarenal mycotic aortic aneurysm that was excluded and reconstructed with a superficial femoral vein. Two years later, he developed a symptomatic mycotic aneurysm of the descending thoracic aorta, which required emergent treatment with a stent graft. The patient died 5 months later of massive bleeding owing to an aortobronchial fistula deriving from a new thoracic aneurysm proximal to the stent graft. Choices and different modes of treatment are discussed. Endovascular treatment of symptomatic mycotic aortic aneurysm might provide a valid alternative to open repair but may be unsuccessful owing to ongoing infection. In situ replacement using autologous material seems appealing whenever feasible.
Assuntos
Aneurisma Infectado/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Aneurisma Infectado/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/etiologia , Implante de Prótese Vascular , Fístula Brônquica/etiologia , Evolução Fatal , Veia Femoral/transplante , Fístula/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Recidiva , Reoperação , StentsRESUMO
PURPOSE: Many laboratory values are abnormal after surgery for a ruptured abdominal aortic aneurysm (RAAA). However, these changes have not been comprehensively evaluated. We analyzed the changes in routine laboratory values and how these changes related to outcome in a consecutive series of RAAA patients. METHODS: All patients who underwent surgery for an RAAA between January 1990 and June 2003 at our hospital were included in this study. We analyzed laboratory data acquired during the first week for all patients and at discharge for survivors. We categorized 29 different measurements into six categories based on the related pathological process, including hematology and coagulation, metabolism, systemic inflammation, renal function, liver function, and electrolytes. RESULTS: A total of 290 patients underwent RAAA surgery, with a hospital mortality of 34%. Hemorrhage was the most common cause of early death, whereas multiple-organ failure (MOF) was the most common cause of death several days after surgery. Most laboratory values deviated from normal at multiple time points and they differed significantly between survivors and nonsurvivors. CONCLUSIONS: Both survivors and nonsurvivors of RAAA surgery displayed characteristic time-dependent laboratory abnormalities. Awareness of these responses may help us predict patients prone to complications.
Assuntos
Aneurisma Roto/sangue , Aneurisma da Aorta Abdominal/sangue , Idoso , Aneurisma Roto/mortalidade , Aneurisma da Aorta Abdominal/mortalidade , Proteína C-Reativa/análise , Causas de Morte , Feminino , Mortalidade Hospitalar , Humanos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valores de Referência , Fatores de TempoRESUMO
BACKGROUND: Isolated limb perfusion (ILP) with tumor necrosis factor alpha (TNF-alpha) and melphalan, followed by delayed surgical resection and adjuvant external-beam radiotherapy is a limb salvage treatment strategy for locally advanced soft tissue sarcomas. The long-term vascular side effects of this combined procedure were evaluated. METHODS: Thirty-two patients were treated for a locally advanced sarcoma of the upper (n = 5) or lower limb (n = 27). All patients underwent a noninvasive vascular work-up. RESULTS: Five patients underwent a leg amputation, in two cases due to critical leg ischemia 10 years after ILP. With a median follow-up of 88 (range, 17-159) months, none of the patients with a salvaged lower leg (n = 22) experienced peripheral arterial occlusive disease. Ankle-brachial index (ABI) measurements in the involved leg (median, 1.02; range, .50-1.20) showed a significant decrease compared with the contralateral leg (median, 1.09; range, .91-1.36, P = .001). Pulsatility index (PI) was decreased in the treated leg in 17 of 22 patients at the femoral level (median, 6.30; range, 2.1-23.9 vs. median, 7.35; range, 4.8-21.9; P = .011) and in 19 of 20 patients at popliteal level (median, 8.35; range, 0-21.4 vs. median, 10.95; range, 8.0-32.6; P < .0005). In patients with follow-up of >5 years, there was more often a decrease in ABI (P = .024) and PI at femoral level (P = .011). CONCLUSIONS: ILP followed by resection and external-beam radiotherapy can lead to major late vascular morbidity that requires amputation. Objective measurements show a time-related decrease of ABI and femoral PI in the treated extremity.