RESUMEN
High exposure of the internal carotid artery is a challenging procedure even for experienced surgeons. Access to the distal internal carotid artery is impeded by progressive encroachment of the mastoid process and the angle of the mandible and furthermore at this level the artery is intimately associated with the hypoglossal and glossopharyngeal nerves. If high exposure is needed we prefer preparation of the distal internal carotid artery by dissection of the venter posterior of the digastric muscle and the styloid process including the stylohyoid and stylopharyngeus muscles. This procedure can be advantageously carried out without additional preoperative requirements. The need for high access to the internal carotid artery depends strongly on the underlying pathology: in atherosclerotic disease the rate of high access in our patients is approximately 4.4%, whereas in carotid aneurysms the rate is considerably higher and averages about 15%.
Asunto(s)
Trombosis de las Arterias Carótidas/cirugía , Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Disección/métodos , Endarterectomía Carotidea/métodos , Músculos del Cuello/cirugía , Nervio Glosofaríngeo/patología , Traumatismos del Nervio Glosofaríngeo , Humanos , Nervio Hipogloso/patología , Traumatismos del Nervio Hipogloso , Complicaciones Posoperatorias/prevención & control , Factores de RiesgoRESUMEN
OBJECTIVE: To report the collaborative data of 3 major European Vascular Units using the 'visceral hybrid' procedure for thoraco-abdominal aortic aneurysms and dissections. METHODS: A consecutive series of 107 urgent and elective high-risk patients were included in a prospectively collected database. RESULTS: All stents involved the entire thoracic and abdominal aorta with left subclavian coverage in 19 and revascularisation in 12. The distal landing zone was in the infra-renal aorta in 75% and in the iliac artery in 25%. The 30-day mortality rate was 16/107 (14.95%). 13/107 (12.1%) of the patients suffered spinal cord ischaemia which was complete and permanent in 9/12 (8.4%). 4 patients (3.7%) required long term dialysis and a segment of gut infarction requiring resection occurred in 3 (2.8%). Most patients had visceral bypass grafting and aortic stent-grafting performed in one stage. In 18 patients the stenting was performed later. Three of these patients ruptured before the stenting procedure was undertaken. CONCLUSION: These early results of visceral hybrid repair for high-risk patients with complex thoraco-abdominal aortic aneurysms are encouraging, in a group of patients in whom fenestrated/branched stent-grafting is not an option and open surgery hazardous.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Conducta Cooperativa , Bases de Datos como Asunto , Femenino , Alemania , Mortalidad Hospitalaria , Humanos , Cooperación Internacional , Londres , Masculino , Persona de Mediana Edad , Paraplejía/etiología , Estudios Prospectivos , Falla de Prótesis , Insuficiencia Renal/etiología , Medición de Riesgo , Isquemia de la Médula Espinal/etiología , Stents , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: To evaluate long-term results of surgical therapy of extracranial carotid artery aneurysms (ECCA) and to provide a morphologic classification for individual surgical reconstruction techniques. PATIENT AND METHODS: This retrospective analysis includes 57 patients (43 male, mean age 61.9 years.) with 64 carotid reconstructions for ECCA between 1980 and 2004. In 29 (50.9%) of the patients there was found a cerebral ischemic event as an initial symptom (18 transient ischemic attacks, 11 strokes). In patients without cerebral events, the presenting symptom was pulsatile cervical mass in 19 and cranial nerve dysfunction in 3 cases. ECCA was morphologically stratified in Type I=isolated aneurysms of the internal carotid artery (n=25), Type II=aneurysms of the complete internal carotid artery with involvement of the bifurcation (n=8), Type III=aneurysms of the carotid bifurcation (n=20), Type IV=combined aneurysm of the internal and common carotid artery (n=5) and Type V=isolated aneurysm of the common carotid artery (n=6). RESULTS: Perioperative stroke rate was 1.6%. 4 patients suffered from transient ischemic attacks (6.3%). Permanent and transient cranial nerve injury rate was 6.3% and 20.3% respectively. After 5, 10, 15 and 20 years the actuarial survival was 90%, 77%, 65% and 57%. The ipsilateral stroke-free time was 96%, 96%, 93% and 87%, respectively. CONCLUSIONS: Surgical reconstruction of extracranial carotid aneurysms is a safe procedure with good long-term results. The risk of a permanent, perioperative cerebral neurological deficit is low, but there is a considerable risk of cranial nerve injury.
Asunto(s)
Aneurisma/cirugía , Enfermedades de las Arterias Carótidas/cirugía , Arteria Carótida Común/cirugía , Arteria Carótida Interna/cirugía , Procedimientos Quirúrgicos Vasculares , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma/complicaciones , Aneurisma/mortalidad , Aneurisma/patología , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/mortalidad , Enfermedades de las Arterias Carótidas/patología , Arteria Carótida Común/patología , Arteria Carótida Interna/patología , Traumatismos del Nervio Craneal/etiología , Femenino , Humanos , Ataque Isquémico Transitorio/etiología , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND AND OBJECTIVE: Diabetes mellitus (DM) and peripheral arterial disease (PAD) are both coronary artery disease equivalents ("coronary equivalents"). It was the aim of this study to ascertain (1) to what extent each of these diseases differs from the other in respect of early death, (2) how frequently DM and PAD occur together in elderly patients seen in general practice and (3) what risk patients with DM and concomitant PAD carry. PATIENTS AND METHODS: In the prospective non-interventional study--"German Epidemiological Trial on Ankle Brachial Index"--6,880 unselected patients, aged 65 years or more, from 344 general medical practices were followed over five years and the incidence of deaths and of cardiovascular events recorded. DM was defined according to the medical diagnosis and/or if the HbA1c was > or = 6.5% and the ankle brachial index (ABI), determined by Doppler sonography. PAD was defined as an ABI of < 0.9 or the presence of intermittent claudication or state after peripheral revascularization/amputation. Survival rates were obtained using Kaplan-Meier estimate curves and Cox's proportional hazard model. 59 patients with an ABI > 1.5 were excluded from the study. Hazard ratios (HR with 95% confidence intervals [CI]) were adjusted according to known risk factors. RESULTS: The overall observation period for all the patients amounted to nearly 33000 patient-years (PY). The risk of death of patients with DM but no PAD (n = 1,220; 17.9%) was 1.5 times the risk of death (HR, 95% CI 1.2-1.8) of persons with neither disease (n = 4 172; 61.2%) and the risk of those with PAD but no DM (n = 918, 13;5%) was 1.7 times of those persons without either disease (HR, 95% CI 1.4-2.0). The risk for persons with DM and PAD (n = 511; 7.5%) was nearly 3 times that of persons without either disease, after adjustment for other cardiovascular risk factors (HR 2.8, 95% CI 2.3-3.4). The lower the ABI in persons with or without DM the greater the number of deaths per 1000 PY. CONCLUSIONS: These results confirm that diabetics and patients with PAD have a clearly increased risk of early death. These patients need intensive treatment of the risk factors. This is especially true for patients who have DM and PAD concomitantly.
Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Diabetes Mellitus/epidemiología , Enfermedades Vasculares Periféricas/epidemiología , Anciano , Femenino , Alemania/epidemiología , Humanos , Masculino , Enfermedades Vasculares Periféricas/complicaciones , Prevalencia , Estudios Prospectivos , Factores de RiesgoRESUMEN
AIM: The aim of this study was to analyse the incidence and aetiology of paraplegia secondary to endovascular repair of the thoracic and thoracoabdominal aorta (TEVAR). METHODS: A retrospective study was conducted in the patients treated at our facility between March 1997 and April 2007. During this interval, 173 patients (163 men; median age: 62 years) underwent endovascular repair of the thoracic aorta. Indications for treatment were thoracic aortic aneurysms in 36 patients, thoracoabdominal aortic aneurysms in 33 patients, type B dissections in 43 patients, type A dissections in 5 patients, penetrating aortic ulcers in 31 patients, traumatic aortic transections in 9 patients, post-traumatic aortic aneurysms in 5 patients, aortobronchial fistulas in 8 patients, aortic patch ruptures in 2 patients, and an anastomotic aortic aneurysm in 1 patient. 101 procedures (58%) were conducted as emergency interventions while 72 were elective. Device design and implant strategy were chosen on the basis of an evaluation of morphology from a computed tomographic scan. Clinical assessment and imaging of the aorta (CT or magnetic resonance imaging) during follow up were performed prior to discharge, at 6 and 12 months, and then annually. RESULTS: A primary technical success was achieved in 170 patients (98%). The overall 30-day mortality rate was 9.2%. Length of follow-up ranged from 1 to 96 months, with a mean of 52 months. Paraplegia or paraparesis developed in 3 patients (1.7%). Two of these patients had a thoracoabdominal aortic aneurysm and the third a chronic expanding type B dissection, being treated with hybrid procedures. CONCLUSIONS: Endovascular repair of the thoracic and thoracoabdominal aorta is associated with a relatively low risk for postoperative paraplegia or paraparesis. Patients requiring long segment aortic coverage, and with prior aortic replacement are especially at risk.
Asunto(s)
Angioplastia , Aorta Abdominal/cirugía , Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Paraplejía/etiología , Complicaciones Posoperatorias/etiología , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Disección Aórtica/cirugía , Aorta Abdominal/diagnóstico por imagen , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Aortografía , Implantación de Prótesis Vascular , Estudios Transversales , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Imagenología Tridimensional , Incidencia , Masculino , Persona de Mediana Edad , Paraplejía/diagnóstico por imagen , Paraplejía/mortalidad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
OBJECTIVES: Spinal cord ischemia remains a devastating complication after thoracic aortic surgery. The aim of this study was to investigate the pathophysiology of spinal cord ischemia after thoracic aortic endografting and the role of intercostal artery blood supply for the spinal cord in a standardized animal model. METHODS: Female merino sheep were randomized to either I, open thoracotomy with cross-clamping of the descending aorta for 50 min (n=7), II, endograft implantation (TAG, WL Gore & Ass.), (n=6) or III open thoracotomy with clipping of all intercostal arteries (n=5) . CT-angiography was used to assess completion of surgical protocol and assess the fate of intercostal arteries. Tarloy score was used for daily neurological examination for up to 7 days post-operatively. Histological cross sections of the lumbar, thoracic and cervical spinal cords were scored for ischemic damage after stained with Hematoxylin-Eosin, Klüver-Barrrera and antibodies. Exact Kruskall-Wallis-Test was used for statistical assessment (p<0.05). RESULTS: Incidence of paraplegia was 100% in group I and 0% in group II (p=0.0004). When compared to the endovascular group, there was a higher rate of histological changes associated with spinal cord ischemia in the animals of the control group (p=0.0096). Group III animals showed no permanent neurological deficit and only 20% infarction rate (p=0.0318 compared to group I). CONCLUSIONS: In sheep, incidence of histological and clinical ischemic injury of the spinal cord following endografting was very low. Complete thoracic aortic stent-grafting was feasible without permanent neurologic deficit. Following endovascular coverage or clipping of their origins, there is retrograde filling of the intercostal arteries which remain patent.
Asunto(s)
Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Isquemia de la Médula Espinal/etiología , Animales , Aorta Torácica/diagnóstico por imagen , Arterias/cirugía , Femenino , Inmunohistoquímica , Infarto/etiología , Modelos Animales , Examen Neurológico , Paraplejía/etiología , Distribución Aleatoria , Ovinos , Médula Espinal/irrigación sanguínea , Médula Espinal/patología , Toracotomía , Tomografía Computarizada por Rayos XRESUMEN
Intraluminal mobile thrombus of the descending aorta are rare disorders. They are at high risk for peripheral embolism and therefore indication for treatment is mandatory. We report on a 54-year-old patient with peripheral arterial embolization who was treated by surgical thrombus removement by thoracotomy and staged peripheral bypass grafting. New diagnostic tools are presented, therapy and prognosis are discussed.
Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Isquemia/cirugía , Pierna/irrigación sanguínea , Arteria Poplítea , Tromboembolia/cirugía , Trombosis/cirugía , Angiografía de Substracción Digital , Aorta Torácica/diagnóstico por imagen , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/diagnóstico por imagen , Aortografía , Derivación Arteriovenosa Quirúrgica , Humanos , Procesamiento de Imagen Asistido por Computador , Imagenología Tridimensional , Isquemia/diagnóstico por imagen , Isquemia/etiología , Masculino , Persona de Mediana Edad , Arteria Poplítea/diagnóstico por imagen , Reoperación , Toracotomía , Tromboembolia/diagnóstico por imagen , Tromboembolia/etiología , Trombosis/complicaciones , Trombosis/diagnóstico por imagenRESUMEN
Arteriovenous fistula (AVF) formation is a recognized complication of arterial trauma. A 63-year-old man with no known risk factors for atheroma and a history of a 20-year delay in the diagnosis and treatment of a traumatic AVF presented with right calf claudication (maximal walking distance = 150 m). A duplex ultrasound scan and a magnetic resonance angiography showed an aneurysmatic dilatation and partial thrombosis of the infrarenal aorta and the right leg feeding arteries. Selective angiography revealed a complete occlusion of the right popliteal artery in the segment 2 and the infrapopliteal arteries with good collateral formation in the lower leg. At this time, there is no indication for infragenual arterial revascularisation in this patient. Instead, therapy consists of exercise training and antiplatelet therapy. We concluded, that peripheral microembolism from the aneurysmatic aorta, iliac or femoral arteries is most probably the reason for the popliteal occlusion in this patient, representing a rare, nonatherosclerotic cause of claudication.
Asunto(s)
Aneurisma Falso/complicaciones , Aneurisma de la Aorta Abdominal/complicaciones , Fístula Arteriovenosa/complicaciones , Embolia/complicaciones , Arteria Femoral/lesiones , Aneurisma Ilíaco/complicaciones , Claudicación Intermitente/etiología , Arteria Poplítea , Heridas Penetrantes/complicaciones , Aneurisma Falso/diagnóstico , Angiografía , Aneurisma de la Aorta Abdominal/diagnóstico , Fístula Arteriovenosa/diagnóstico , Diagnóstico Diferencial , Embolia/diagnóstico , Humanos , Aneurisma Ilíaco/diagnóstico , Claudicación Intermitente/diagnóstico , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Arteria Poplítea/patologíaRESUMEN
BACKGROUND AND AIMS: The usefulness of the metabolic syndrome (MetS) or a low ankle brachial index (ABI), respectively, to identify patients with high risk for cardiovascular events has repeatedly been postulated. However, robust data on the prevalence and prognosis of such patients are missing in the primary care setting. PATIENTS AND METHODS: In the prospective, non-interventional "German epidemiological trial on Ankle Brachial Index (getABI) at total of 6880 unselected patients > or = 65 years were observed by their General Practitioners over 3 years. Death and cardiovascular events were recorded. The definition of MetS was similar to the one of NCEP ATP III (National Cholesterol Education Program--Adult Treatment Panel III). ABI (ratio of the systolic blood pressures measured at the distal part of the calf and at the upper arm) was measured with Doppler sonography. Peripheral arterial disease (PAD) was defined as ABI <0.9 or peripheral revascularization/amputation owing to PAD. Survival analyses were conducted with a Cox proportional hazard model. Hazard rate ratios (HRR, 95 % confidence intervals, CI) were multvariate adjusted. RESULTS: The observation time for the total cohort was more than 20,000 patient years (PY). Cardiovascular mortality in patients with MetS (n = 3040, 44 %) compared to patients without MetS (n = 3795; 55 %) was doubled (8.5 vs. 4.0 per 1,000 PY; HRR: 2.0; CI 1.3 - 2.9). Concomitant presence of MetS and PAD (n = 651; 9.5 %) increased the mortality risk compared to patients without both conditions (n = 3194; 46.4 %) drastically (21.1 vs. 3.0 per 1000 PY; HRR: 5.7; CI: 3.5 - 9.4). Similar significant risk increases also were noted for all-cause mortality or a combined endpoint of mortality and vascular morbidity. Further, in lower ABI categories cardiovascular event rates increased. CONCLUSIONS: Patients with MetS carry a substantially increased risk of premature death, especially cardiovascular death, and therefore require intensive treatment of their risk factors. This holds especially true if concomitant PAD is present.
Asunto(s)
Arteriopatías Oclusivas/complicaciones , Enfermedades Cardiovasculares/mortalidad , Síndrome Metabólico/complicaciones , Enfermedades Vasculares Periféricas/complicaciones , Anciano , Anciano de 80 o más Años , Determinación de la Presión Sanguínea/métodos , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Análisis de Supervivencia , Ultrasonografía DopplerRESUMEN
Leiomyosarcomas of the inferior vena cava are rare and the clinical symptoms unspecific. We report a case of leiomyosarcoma of the inferior vena cava in an 82-year-old woman presenting with weight loss and abdominal pain. Following elaborate preoperative examinations, surgical resection was performed and the inferior vena cava was reconstructed. Clinical signs, diagnosis, therapy, and prognosis are discussed.
Asunto(s)
Leiomiosarcoma/cirugía , Neoplasias Vasculares/cirugía , Vena Cava Inferior/cirugía , Anciano de 80 o más Años , Implantación de Prótesis Vascular , Diagnóstico Diferencial , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Imagenología Tridimensional , Leiomiosarcoma/diagnóstico por imagen , Flebografía , Politetrafluoroetileno , Tomografía Computarizada por Rayos X , Neoplasias Vasculares/diagnóstico por imagen , Vena Cava Inferior/diagnóstico por imagenRESUMEN
The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Prótesis Vascular , Disección Aórtica/clasificación , Disección Aórtica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/clasificación , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Humanos , Diseño de Prótesis , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Carotid endarterectomy is effective in stroke prevention for patients with severe symptomatic carotid-artery stenosis, and carotid-artery stenting has been widely used as alternative treatment. Since equivalence or superiority has not been convincingly shown for either treatment, we aimed to compare the two. METHODS: 1200 patients with symptomatic carotid-artery stenosis were randomly assigned within 180 days of transient ischaemic attack or moderate stroke (modified Rankin scale score of < or =3) carotid-artery stenting (n=605) or carotid endarterectomy (n=595). The primary endpoint of this hospital-based study was ipsilateral ischaemic stroke or death from time of randomisation to 30 days after the procedure. The non-inferiority margin was defined as less than 2.5% on the basis of an expected event rate of 5%. Analyses were on an intention-to-treat basis. This trial is registered at Current Controlled Trials with the international standard randomised controlled trial number ISRCTN57874028. FINDINGS: 1183 patients were included in the analysis. The rate of death or ipsilateral ischaemic stroke from randomisation to 30 days after the procedure was 6.84% with carotid-artery stenting and 6.34% with carotid endarterectomy (absolute difference 0.51%, 90% CI -1.89% to 2.91%). The one-sided p value for non-inferiority is 0.09. INTERPRETATION: SPACE failed to prove non-inferiority of carotid-artery stenting compared with carotid endarterectomy for the periprocedural complication rate. The results of this trial do not justify the widespread use in the short-term of carotid-artery stenting for treatment of carotid-artery stenoses. Results at 6-24 months are awaited.
Asunto(s)
Angioplastia de Balón , Estenosis Carotídea/terapia , Endarterectomía Carotidea , Stents , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/cirugía , Femenino , Humanos , Masculino , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & controlAsunto(s)
Oclusión de Injerto Vascular/diagnóstico , Enfermedad Iatrogénica , Implantación de Prótesis Vascular , Arteria Femoral/cirugía , Humanos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/cirugía , UltrasonografíaRESUMEN
Isolated iliac aneurysms (IIA) are uncommon lesions that require surgical repair to prevent rupture. The aim of this article is to give an update on the current surgical management of IIA. This report also evaluates the application of endovascular repair in IIA, based on a recent Pubmed search and on our own experience in the interventional field: Open reconstruction achieves good longterm results and still represents the golden standard in surgical treatment of IIA. Transluminally placed endovascular stent grafts can be successfully used to exclude isolated iliac aneurysms in selected high risk patients with suitable anatomy. A classification based on aneurysm morphology is useful for patient selection. The value of endovascular therapy has yet to be determined.
Asunto(s)
Angioplastia de Balón , Implantación de Prótesis Vascular , Aneurisma Ilíaco/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma Roto/diagnóstico , Aneurisma Roto/cirugía , Aortografía , Femenino , Estudios de Seguimiento , Humanos , Aneurisma Ilíaco/diagnóstico , Procesamiento de Imagen Asistido por Computador , Imagenología Tridimensional , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
AIMS: Adjuncts to conventional surgical training are needed in order to address the reduction in working hours. This purpose of this study was to objectively assess the efficacy of workshop training on simulators. METHODS: Fifteen consecutive participants of the European Vascular Workshop in 2003 and 2004 were recruited to this study. Participants performed a proximal anastomosis on a commercially available abdominal aortic aneurysm simulator, were then given intensive training on sophisticated models for 3 days and re-assessed. Pre- and post-course procedures were videotaped and independently reviewed by three assessors (tapes were blinded and in random order). The operative end product was similarly assessed. Four measures of technical skill were used: generic skill, procedural skill; a five point technical rating of the anastomosis (assessed using validated rating scales) and procedure time. Non-parametric tests were used in the statistical analysis. RESULTS: The video assessment scores for aneurysm repair increased significantly following completion of the course (p=0.006 and p=0.004 for generic and procedural skill, respectively). End product assessment scores increased significantly post-course (p=0.001) and participants performed aneurysm repair faster following the course (p<0.05). Inter-observer reliability ranged from alpha=0.84-0.98 for the three rating scales pre- and post-course. CONCLUSION: Objective improvements in technical performance follow intensive workshop training. Participants' perform better, faster, and with an improved end product following the course. Such adjuncts to training play an important part in a focused integrated programme that addresses reduced work hours.
Asunto(s)
Anastomosis Quirúrgica/educación , Aneurisma de la Aorta Abdominal/cirugía , Competencia Clínica , Educación Médica , Simulación por Computador , Evaluación Educacional , Europa (Continente) , Humanos , Grabación en VideoRESUMEN
The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.
Asunto(s)
Unidades de Cuidados Coronarios , Endarterectomía Carotidea , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Complicaciones Posoperatorias , Estudios Prospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
The prevalence of vascular disease among the elderly population is high (approximately 20%). The morbidity and mortality of many vascular operations show no differences between the fit elderly and younger patients. A major problem is that the elderly are often not diagnosed and treated early enough to prevent emergency operations, which carry a much higher mortality. Many new surgical techniques, especially endovascular interventions, have made vascular surgery less invasive. These advances have increased the potential of life saving and prolonging vascular surgery that can be offered to all patients regardless of age. Risk-benefit analysis, especially in elderly patients, is a cornerstone of proper patient selection. The main goal of vascular surgery in the elderly is preservation of quality of life and independence. Surgery of a ruptured aneurysm is a life saving exception. Indications for treatment in the elderly remains an individual decision making process. Advanced age should not be considered as a limitation or contraindication for carotid, aneurysm and bypass surgery. Age is not a disease, it is just a chapter of life.
Asunto(s)
Anciano , Procedimientos Quirúrgicos Vasculares , Factores de Edad , Anciano de 80 o más Años , Angiografía de Substracción Digital , Angioplastia de Balón , Aneurisma de la Aorta/cirugía , Arteriopatías Oclusivas/diagnóstico , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Prótesis Vascular , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/cirugía , Contraindicaciones , Urgencias Médicas , Endarterectomía Carotidea , Femenino , Humanos , Complicaciones Intraoperatorias , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Análisis Multivariante , Oportunidad Relativa , Selección de Paciente , Estudios Prospectivos , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Factores de Riesgo , Stents , Accidente Cerebrovascular/prevención & control , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
OBJECTIVES: To evaluate the efficacy of surgical thrombectomy combined with endovascular reconstruction for acute ilio-femoral/caval venous thrombosis. METHODS: Twenty consecutive patients with acute, symptomatic ilio-femoral/-caval thrombosis underwent valve-preserving thrombectomy with immediate endovascular repair between October 1996 and October 2003. Thrombectomy was classified by intraoperative venography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because endovascular repair was not performed. RESULTS: Left-sided venous thrombosis predominated (90%). Lesions were located in the common iliac vein (85%), the external iliac vein (10%), and the inferior vena cava (5%). Three TYPE II lesions and 17 TYPE III lesions (11 spurs, one hypoplasia, one fibrosis, one haematoma, and three others) were diagnosed. Catheter-directed recanalisation (thrombectomy/thrombolysis) resolved TYPE II lesions in three patients. Balloon angioplasty (one patient), iliac stenting (15 patients [two with thrombolysis]), and caval stenting (one patient) were employed in TYPE III stenoses. No serious complication or death occurred. Mean follow-up was 21 months. Of 20 patients clinical results were excellent in 18 patients who maintained patency of their reconstructed iliac veins. Primary and secondary patency rates were 80 and 90%, respectively. CONCLUSIONS: Ilio-caval venous obstructions detected intraoperatively can be reconstructed in a one-stage combined procedure. The specific endovascular approach depends on the type of residual venous obstruction. Excellent mid-term results indicate that the proposed thrombectomy classification (TYPE I-IV) and treatment algorithm optimises the results in selected patients with symptomatic venous thrombosis.
Asunto(s)
Angioplastia/métodos , Implantación de Prótesis Vascular/métodos , Trombectomía/métodos , Terapia Trombolítica/métodos , Trombosis de la Vena/cirugía , Adolescente , Adulto , Algoritmos , Femenino , Vena Femoral , Humanos , Vena Ilíaca , Masculino , Persona de Mediana Edad , Stents , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Vena Cava InferiorRESUMEN
Representative data on peripheral arterial disease (PAD) in community-based office practice are scarce while at the same time of high interest. Thus, we aimed to determine the prevalence of peripheral arterial disease (PAD), comorbidity of atherothrombotic manifestations, and treatment intensity among elderly diabetic patients in primary care. In this monitored cross-sectional study, 344 general practitioners throughout Germany determined the ankle-brachial index (ABI) of 6880 consecutive, unselected patients aged 65 years or older with bilateral Doppler ultrasound measurements. PAD was defined according to the recent American Heart Association guidelines (using the higher of the 2 systolic ankle pressures: ABI < 0.9) or peripheral revascularisation, or amputation because of PAD. Coronary events (CAD) and cerebrovascular events (CVD) were taken from the patient's history without additional diagnostic measures. Diabetes was defined according to the clinical diagnosis of the physician and/or HbA1c > or = 6.5 % and/or intake of oral antidiabetic medication and/or application of insulin. 1.743 patients were classified as diabetics: the median disease duration was 6 years (1st; 3rd quartile: 2; 11), median HbA1c 6.6 % (5.9; 7.3), mean age 72.5 +/- 5.4 years, and 51.4 % were females. Diabetics had in comparison with non-diabetics a higher prevalence of PAD defined as ABI < 0.9 (26.3 % vs. 15.3 %, univariate odds ratio 2.0 [95 % confidence interval: 1.7; 2.3]), intermittent claudication (5.1 % vs. 2.1 %, OR: 2.5 [1.9; 3.4]), known CAD (16.1 % vs. 10.6 %, OR: 1.6 [1.4; 1.9]), and known CVD (6.8 % vs. 4.8 %; OR: 1.4 [1.2; 1.8]). 57.4 % of the diabetics with previously known PAD (as only atherothrombotic manifestation) received antiplatelet therapy (vs. 75.1 % with CAD and/or CVD only). The ABI was suitable as screening measure in the primary care setting. In elderly diabetics in comparison to non-diabetics, the prevalence of PAD was very high. Despite the known benefits of antiplatelet therapy, PAD patients were less intensively treated than patients with CAD or CVD.
Asunto(s)
Arteriopatías Oclusivas/epidemiología , Arteriopatías Oclusivas/terapia , Angiopatías Diabéticas/epidemiología , Enfermedades Vasculares Periféricas/epidemiología , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/tratamiento farmacológico , Estudios Transversales , Angiopatías Diabéticas/tratamiento farmacológico , Angiopatías Diabéticas/terapia , Femenino , Alemania/epidemiología , Humanos , Masculino , Oportunidad Relativa , Enfermedades Vasculares Periféricas/tratamiento farmacológico , Enfermedades Vasculares Periféricas/terapia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Prevalencia , Garantía de la Calidad de Atención de Salud , Valores de Referencia , Factores de Riesgo , SístoleRESUMEN
Surgical management of distinct thoracic aneurysmal lesions stands at the crossroads. Until recently, the only treatment options for thoracic aortic lesions were surgical repair or medical management. There is increasing evidence that endovascular therapy will be useful in treating thoracic aortic disease, possibly becoming the preferred approach. Endovascular surgery will affect the incidence of open thoracic aortic surgery not only by producing a lower mortality risk but also a significantly lower incidence of paraplegia. In designing adequate treatment options of complex and difficult-to-treat thoracic aortic lesions, novel three-dimensional imaging reconstructions are mandatory.