RESUMEN
OBJECTIVES: Spinal cord ischaemia (SCI) following endovascular thoracoabdominal aortic aneurysm (TAAA) repair is a devastating and unpredictable complication. This study describes a single unit's experience of SCI in patients who have had endovascular TAAA repair. METHODS: A prospectively maintained database of patients having endovascular TAAA repair using branched and fenestrated stent grafts between 2008 and 2014 at a single high volume centre was reviewed. Patients who developed neurological symptoms and signs related to SCI were identified and factors associated with onset and recovery of neurology were analysed. RESULTS: Sixty-nine patients (median age 73 years, 52 male; Crawford classification type I [n = 4], type II [n = 11], type III [n = 33], type IV [n = 14], type V [n = 7]) underwent endovascular TAAA repair. Twelve patients developed neurological symptoms/signs related to SCI but this was successfully reversed in eight patients, leaving four (5.8%) with permanent paraplegia. The median length of aorta covered was not significantly different in the 12 patients who developed SCI compared with the cohort that did not. Eleven of the patients who developed SCI had an intraoperative mean arterial pressure (MAP) below 80 mmHg. Cutaneous atheroemboli were noted in half of the patients in the SCI group compared with 11% of the non-SCI group (p < .05). Strategies used to reverse SCI included raising MAP, cerebrospinal fluid drainage, angioplasty of stenosed internal iliac arteries, and restoring perfusion to the aneurysm sac. CONCLUSIONS: This series highlights some of the risk factors associated with the development of SCI after endovascular repair of TAAAs. It also illustrates the importance of a dedicated institutional protocol aimed at ensuring the early diagnosis of SCI and prompt intervention to reverse permanent paraplegia in the majority of cases.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Paraplejía/prevención & control , Isquemia de la Médula Espinal/etiología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paraplejía/etiología , Estudios Retrospectivos , Isquemia de la Médula Espinal/complicacionesRESUMEN
OBJECTIVES/BACKGROUND: The increased complexity of endovascular aortic repair necessitates longer procedural time and higher radiation exposure to the operator, particularly to exposed body parts. The aims were to measure directly exposure to radiation of the bodies and heads of the operating team during endovascular repair of thoracoabdominal aortic aneurysms (TAAA), and to identify factors that may increase exposure. METHODS: This was a single-centre prospective study. Between October 2013 and July 2014, consecutive elective branched and fenestrated TAAA repairs performed in a hybrid operating room were studied. Electronic dosimeters were used to measure directly radiation exposure to the primary (PO) and assistant (AO) operator in three different areas (under-lead, over-lead, and head). Fluoroscopy and digital subtraction angiography (DSA) acquisition times, C-arm angulation, and PO/AO height were recorded. RESULTS: Seventeen cases were analysed (Crawford II-IV), with a median operating time of 280 minutes (interquartile range 200-330 minutes). Median age was 76 years (range 71-81 years); median body mass index was 28 kg/m(2) (25-32 kg/m(2)). Stent-grafts incorporated branches only, fenestrations only, or a mixture of branches and fenestrations. A total of 21 branches and 38 fenestrations were cannulated and stented. Head dose was significantly higher in the PO compared with the AO (median 54 µSv [range 24-130 µSv] vs. 15 µSv [range 7-43 µSv], respectively; p = .022), as was over-lead body dose (median 80 µSv [range 37-163 µSv] vs. 32 µSv [range 6-48 µSv], respectively; p = .003). Corresponding under-lead doses were similar between operators (median 4 µSv [range 1-17 µSv] vs. 1 µSv [range 1-3 µSv], respectively; p = .222). Primary operator height, DSA acquisition time in left anterior oblique (LAO) position, and degrees of LAO angulation were independent predictors of PO head dose (p < .05). CONCLUSIONS: The head is an unprotected area receiving a significant radiation dose during complex endovascular aortic repair. The deleterious effects of exposure to this area are not fully understood. Vascular interventionalists should be cognisant of head exposure increasing with C-arm angulation, and limit this manoeuvre.
Asunto(s)
Angiografía de Substracción Digital , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Cabeza/efectos de la radiación , Anciano , Anciano de 80 o más Años , Angiografía de Substracción Digital/métodos , Implantación de Prótesis Vascular/métodos , Humanos , Exposición Profesional/análisis , Estudios Prospectivos , Dosis de Radiación , Radiografía Intervencional/métodos , Medición de RiesgoRESUMEN
OBJECTIVES: To compare the mid-term outcome and secondary intervention rate following elective open and endovascular aortic aneurysm repair (EVAR) in patients aged 65 years and younger. METHODS: A retrospective analysis of patients aged 65 years and younger who had elective abdominal aortic aneurysm repair (AAA) between 1994 and 2012. RESULTS: One hundred and sixty-five patients under the age of 65 years (mean age: 61 years ± 4; 8 women) had elective abdominal aneurysm repair (97 EVAR and 68 open). The overall 30-day mortality rate was 3.7% (2.1% EVAR and 5.9% open). Forty per cent of patients had died at a median follow up of 77 months (interquartile range, 36-140). Most deaths were not related to aneurysm. There was no difference in the long-term mortality between the EVAR and open groups (hazard ratio [HR] = 1.22; 95% confidence interval [CI] 0.75-1.98, p = .43), but there was a trend of better outcomes with the use of commercially made endografts over open repair (HR = 2.9; 95% CI 0.9-10.0, p = .08) and custom-made endografts (HR = 3.1, 95% CI 0.9-10.3; p = .07). Eleven per cent of patients who had EVAR required a further procedure compared with 13% who had open repair. All but one of the re-interventions in the EVAR group was performed on patients who had custom-made endografts. CONCLUSIONS: Young patients with AAA have significant comorbidities and do not necessarily have long lifespans. In the less fit younger patients with AAA, the results with EVAR are comparable with fit patients who had open AAA repair. The management of fitter young patients with AAA remains controversial, but improving results with EVAR over time may increase the role of EVAR in this group.
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Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares , Anciano , Aneurisma de la Aorta Abdominal/mortalidad , Comorbilidad , Femenino , Humanos , Esperanza de Vida , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Estadísticas no Paramétricas , Resultado del TratamientoRESUMEN
BACKGROUND: Recent international guidance recommends the use of catheter-directed thrombolysis (CDT) in selected patients with symptomatic iliofemoral deep vein thrombosis (DVT). The aim of this study was to estimate the potential increase in workload as a result of this recommendation. METHODS: Using the radiology database, a review was performed of all DVTs diagnosed between August 2010 and February 2012 at a large tertiary referral hospital. The National Institute for Health and Clinical Excellence and American College of Chest Physicians guidance was applied retrospectively to this cohort, using case-note review by two independent clinicians to determine which patients would have been suitable for CDT. RESULTS: Some 563 patients had DVT confirmed radiologically over the 18-month interval. Fifty-three of the 128 patients with iliofemoral DVT would have been eligible for intervention with CDT, equivalent to 4·4 patients per 100 000 per year. Only eight (15 per cent) of the 53 were actually referred to vascular services for treatment. All eight patients had successful CDT, which involved a stay in critical care for monitoring (median 2 (range 1-3) sessions). CONCLUSION: Vascular units should be prepared for a major increase in the requirement for CDT for iliofemoral DVT. This increase will affect inpatient beds, the interventional radiology suite, critical care and interhospital referrals.
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Cateterismo Periférico/métodos , Vena Femoral , Vena Ilíaca , Terapia Trombolítica/métodos , Trombosis de la Vena/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Atención Ambulatoria/estadística & datos numéricos , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Extremidad Inferior/irrigación sanguínea , Masculino , Persona de Mediana Edad , Retratamiento/estadística & datos numéricos , Estudios Retrospectivos , Trombectomía/métodos , Trombectomía/estadística & datos numéricos , Trombosis de la Vena/etiología , Carga de Trabajo , Adulto JovenRESUMEN
The case report describes a gentleman with renal transplant who presented with pulmonary tuberculosis (TB) and mycotic aneurysm of abdominal aorta. The aneurysm was successfully treated with endovascular aneurysm repair. A multidisciplinary approach with renal physicians and infectious diseases unit was necessary to treat TB and maintain immunosuppression. The technique used for deployment of the stent graft in the presence of infection and a transplanted kidney is described. The satisfactory outcome at 5 years follow-up indicates that endovascular option for TB mycotic aneurysm is durable and safe option particularly when major open surgery is associated with significant mortality and morbidity.
Asunto(s)
Aneurisma Infectado/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Trasplante de Riñón , Tuberculosis Cardiovascular/cirugía , Aneurisma Infectado/diagnóstico por imagen , Aneurisma Infectado/microbiología , Antituberculosos/uso terapéutico , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/microbiología , Aortografía/métodos , Humanos , Huésped Inmunocomprometido , Inmunosupresores/uso terapéutico , Trasplante de Riñón/inmunología , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Tuberculosis Cardiovascular/diagnóstico por imagen , Tuberculosis Cardiovascular/microbiologíaRESUMEN
OBJECTIVES: To determine the feasibility and reliability of an online patient completed Aberdeen Varicose Vein Questionnaire (AVVQ) as a tool to guide specialist referral. METHODS: This was a prospective qualitative and quantitative study. One hundred and six patients completed an online questionnaire. Some 43 (40%) completed the AVVQ questionnaire at home and 63 (60%) did it immediately before their appointment. Venous Clinical Severity Score (VCSS) and CEAP grades were assigned by a consultant vascular surgeon. In 11 patients, the questionnaire was repeated at the time of surgery to assess reproducibility and bias. RESULTS: The AVVQ correlated with the specialist's VCSS scores (Spearman coefficient 0.795; p < 0.01) and similarly with CEAP grade (P < 0.01, ANOVA test). AVVQ was reproducible with close agreement (Spearman coefficient 0.89; p < 0.01) between both 1st AVVQ score of 21.61 (sd 10.26; range 6.12-40.14) and 2nd AVVQ score of 21.03 (sd 10.50 range 4.51-42.57). Patients' feedback about the online AVVQ was positive. CONCLUSIONS: An online questionnaire is acceptable to patients, correlates with clinical findings and using a threshold value could be used by healthcare Commissioners to guide varicose vein referrals.
Asunto(s)
Internet , Atención Primaria de Salud , Derivación y Consulta , Encuestas y Cuestionarios , Várices/diagnóstico , Análisis de Varianza , Actitud hacia los Computadores , Inglaterra , Estudios de Factibilidad , Humanos , Satisfacción del Paciente , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Várices/terapiaRESUMEN
BACKGROUND: The presence of fibrous tissue in poorly healing venous leg ulcers suggests abnormal collagen metabolism. The aim was to determine whether there were differences in collagen turnover and matrix metalloproteinase (MMP) activity between ulcers that healed, those that did not heal and normal skin. METHODS: Biopsies were taken from the ulcers of 12 patients whose venous ulcers went on to heal and 15 patients whose ulcers failed to heal despite 12 months of compression bandaging. Biopsies were taken from 15 normal controls. Collagen turnover (collagen III N-terminal propeptide (PIIINP) and degraded collagen), and total MMP, MMP-1 and MMP-3 activities were measured. RESULTS: PIIINP and degraded collagen levels were higher in ulcers that healed compared with lesions that failed to heal (P = 0.005 and P < 0.001 respectively) and normal skin (P = 0.003 and P < 0.001). MMP-1 activity was also higher in healing ulcers than resistant ulcers (P < 0.001) and normal skin (P < 0.001). Significantly more total MMP activity was present in all ulcers than in normal skin (P < 0.001), but there was no difference in total MMP (and MMP-3 activity) between ulcers that healed and those that did not. CONCLUSION: Rapidly healing venous leg ulcers had increased collagen turnover and MMP-1 activity, which appeared to differentiate them from those that failed to heal within 12 months.
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Colágeno/metabolismo , Metaloproteinasas de la Matriz/metabolismo , Piel/metabolismo , Úlcera Varicosa/enzimología , Cicatrización de Heridas/fisiología , Anciano , Femenino , Humanos , Masculino , Fragmentos de Péptidos/metabolismo , Procolágeno/metabolismoRESUMEN
BACKGROUND: The aim of this study was to examine the effect of statin treatment on the activity of proteases in the wall of abdominal aortic aneurysms (AAAs). METHODS: The activities of matrix metalloproteinases (MMPs) 9 and 3, cathepsins B, H, K, L and S, and the cystatin C level were measured in extracts of AAA wall taken from 82 patients undergoing AAA repair; 21 patients were receiving statin treatment before surgery. All values were standardized against soluble protein (SP) concentration in the extract, and reported as median (interquartile range) or mean(s.e.m.). RESULTS: The two groups had similar demographics. Reduced activity of MMP-9 (43 (34-56) versus 80 (62-110) pg per mg SP; P < 0.001), cathepsin H (183 (117-366) versus 321 (172-644) nmol 4-methylcoumarin-7-amide released per mg SP; P = 0.016) and cathepsin L (102 (51-372) versus 287 (112-816) micromol 7-amino-4-trifluoromethylcoumarin released per mg SP; P = 0.020) was found in the statin-treated aortas compared with AAAs from patients not taking a statin. The statin-treated group had lower MMP-3 activity, but this did not reach statistical significance (P = 0.053). Cystatin C levels were higher in statin-treated aortas than in controls (41.3(3.1) versus 28.9(2.1) ng per mg SP; P = 0.003). CONCLUSION: Statins decreased the activity of proteases that have been implicated in aneurysm disease.
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Aorta Abdominal/enzimología , Aneurisma de la Aorta Abdominal/enzimología , Inhibidores de Hidroximetilglutaril-CoA Reductasas/farmacología , Metaloproteinasa 3 de la Matriz/metabolismo , Metaloproteinasa 9 de la Matriz/metabolismo , Anciano , Catepsinas/metabolismo , Cistatina C , Cistatinas/metabolismo , Femenino , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , MasculinoRESUMEN
OBJECTIVE: The aim of this study was to assess the relationship between urinary and tissue haemosiderin in chronic leg ulcers, and its value as a diagnostic test for venous ulceration. METHODS: 45 patients with chronic leg ulcers were recruited to the study (24 venous, 6 ischaemic, 6 lymphoedematous, 5 rheumatoid and 4 sickle cell). Punch biopsy of the ulcer edge was taken and early morning urine samples were collected. Positive Prussian-blue urinary haemosiderin granules were measured with a haemocytometer following Perls' staining. The percentage area of histological section staining positively with Perls' was measured using image analysis. RESULTS: 84 urine samples and 46 ulcer biopsies were collected. Urinary haemosiderin was present in 92% of venous ulcer patients, but was absent in the ischaemic ulcer patients (p<0.0001). Significantly more urinary haemosiderin granules were detected in venous ulcer patients compared with patients who had lymphoedema (p<0.05). Tissue haemosiderin was detected in all ulcer types investigated. No correlation was found between the amounts of haemosiderin deposited in the tissue and the amount found in urine (r(2)=0.06). CONCLUSIONS: Haemosiderin is present in the urine of most patients with venous ulcers but not in ischaemia ulcers.
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Anemia de Células Falciformes/diagnóstico , Artritis Reumatoide/diagnóstico , Hemosiderina/metabolismo , Isquemia/diagnóstico , Úlcera de la Pierna/etiología , Linfedema/diagnóstico , Piel/metabolismo , Insuficiencia Venosa/diagnóstico , Anemia de Células Falciformes/complicaciones , Anemia de Células Falciformes/metabolismo , Anemia de Células Falciformes/orina , Artritis Reumatoide/complicaciones , Artritis Reumatoide/metabolismo , Artritis Reumatoide/orina , Biomarcadores/metabolismo , Biomarcadores/orina , Biopsia , Enfermedad Crónica , Diagnóstico Diferencial , Hemosiderina/orina , Humanos , Isquemia/complicaciones , Isquemia/metabolismo , Isquemia/orina , Úlcera de la Pierna/metabolismo , Úlcera de la Pierna/patología , Úlcera de la Pierna/orina , Linfedema/complicaciones , Linfedema/metabolismo , Linfedema/orina , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Piel/patología , Insuficiencia Venosa/complicaciones , Insuficiencia Venosa/metabolismo , Insuficiencia Venosa/orinaRESUMEN
OBJECTIVES: Devitalized tissue in a recalcitrant leg ulcer is common and may impede healing. The aim of this study was to evaluate the use of a non-invasive low frequency ultrasound device to debride chronic leg ulcers as an adjunct to compression bandages therapy. METHODS: 19 patients with leg ulceration of at least 6 months were recruited. Low frequency ultrasound at 25kHz was delivered by a portable Sonaca--180 via a handheld probe, using normal saline as the irrigation/coupling medium. The ultrasound was applied for 10-20 seconds per probe head area onto the ulcer. Each leg underwent treatment at an interval of 2-3 weeks with compression bandages reapplied at the end of the treatment. Serial colour photographs were taken to evaluate the response at each visit. RESULTS: Each patient received on average 5.7 treatments each ranged from 5-20 minutes depending on the ulcer size. Symptomatic relief (pain and odour reduction) was achieved in 6 patients. 7 patients achieved complete ulcer healing (mean ulcer size=4.72+/-SD 1.872cm(2)) but no response was observed in 8 patients. There were no major complications of the treatment which was relatively painless. CONCLUSIONS: The application of low frequency ultrasound debridement may heal some recalcitrant ulcers when standard compression regimens have failed. It is cheap and does not require admission. The role of simple wound cleansing requires further investigation.
Asunto(s)
Desbridamiento/métodos , Úlcera de la Pierna/cirugía , Terapia por Ultrasonido , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Femenino , Humanos , Úlcera de la Pierna/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Proyectos Piloto , Resultado del Tratamiento , UltrasonografíaRESUMEN
BACKGROUND: The aim of this study was to determine the success of excision and meshed skin grafting for chronic leg ulcers. The effects of different ulcer aetiology and ulcer size on outcome were also assessed. METHODS: All patients who had excision and mesh grafting for chronic leg ulceration between January 1996 and December 2004 at St Thomas' Hospital were reviewed. Recurrence was classified as any breakdown of the ulcer during follow-up. RESULTS: Sixty-two patients with 100 chronic leg ulcers underwent operation. Seventy-two of the ulcers were venous and the median ulcer size was 36 (range 1.5-192) cm2. Only three patients left the hospital with their ulcers unhealed, but ulcers had recurred in 28 (28 per cent) by 2 months. A further 17 ulcers recurred later, with just over half (55 per cent) remaining healed by 5 years. There was no difference between the recurrence rates of venous ulcers and ulcers of other aetiologies (P=0.980), or large (more than 10 cm2) and small ulcers (P=0.686). CONCLUSION: Wide local excision and meshed skin grafting benefitted over half of these patients with refractory leg ulcers. Recurrence was most likely to occur in the first 2 months and, provided that ulcers were healed at this time, there was a low rate of further breakdown.
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Úlcera de la Pierna/cirugía , Trasplante de Piel/métodos , Mallas Quirúrgicas , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Úlcera de la Pierna/etiología , Tiempo de Internación , Masculino , Persona de Mediana Edad , Recurrencia , Medias de Compresión , Resultado del TratamientoRESUMEN
Ultrasound-guided compression and thrombin injections are reliable for the management of small and medium-sized false aneurysms. However, owing to technical limitations, large false aneurysms often necessitate surgical intervention, which is associated with significant postoperative morbidity and mortality. Endovascular coil embolization is an evolving minimally invasive technique that can be used as a safe option for large false femoral aneurysms. We report our experience with 2 cases of large false femoral aneurysms treated by using coils to occlude the aneurysm's feeding tract successfully.
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Aneurisma Falso/terapia , Angioplastia , Embolización Terapéutica , Arteria Femoral , Adulto , Anciano de 80 o más Años , Aneurisma Falso/cirugía , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/cirugía , Humanos , Masculino , Tomografía Computarizada por Rayos XRESUMEN
Unlike in Japan, autoimmune pancreatitis is uncommon in the Western world, particularly in Europe. We report the first case of a Caucasian male with typical features of autoimmune pancreatitis in the UK. Recognizing autoimmune pancreatitis as a new clinical entity in Europe will change the management of many patients who have been labelled as having acute or chronic pancreatitis.