RESUMEN
OBJECTIVES: Conversion of a previous endovascular aneurysm repair (EVAR) with suprarenal fixation is a challenging situation even in the elective setting. The outcomes of a technique based on preservation of the first proximal covered stent of the endograft, used as a "neo-neck" for proximal anastomosis, are presented. METHODS: From 2001 to 2014, nine patients underwent elective conversion of a previous suprarenally fixed EVAR. After supraceliac clamping, the aneurysm sac was opened and the endograft identified; the fabric was cut beyond the first covered stent together with its native aortic wall in order to create a "neo-neck." An aortic balloon was inflated into the visceral aorta to avoid back bleeding. A Dacron bifurcated tube graft (Intergard, Maquet) was then sutured to the neo-neck mimicking endobanding, passing the stitches into the aortic wall and the first covered stent. RESULTS: The mean age was 68 years (range, 52-84 years). The stent grafts removed were four Zenith (Cook Medical), three Endurant (Medtronic), and two E-vita (Jotec). The indication for conversion was type 1A (n = 2), type 2 (n = 2), and type 3 (n = 1) endoleak, complete endograft thrombosis (n = 2), and abdominal pain with sac enlargement with no radiological sign of endoleak (n = 2). Blood loss was 1,428 mL (range 500-3,000 mL); the visceral ischemic time to perform the proximal anastomosis was 23.5 min ± 2.3 min). The post-operative complication rate was 11% (n = 1/9) related to a case of sac wall bleeding requiring re-intervention; mortality at 30 days was 0%. At 22 months (range, 8-41) the computed tomography angiogram demonstrated no signs of leaks or anastomotic pseudoaneurysm. CONCLUSION: Preservation of the proximal covered stent of an endograft with suprarenal fixation used as an infrarenal "neo-neck" with incorporation of the aorta to the suture line during elective surgical explantation simplifies the procedure, and can be achieved with very low early morbidity and mortality; furthermore, it seems to be durable over mid-term follow up.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Remoción de Dispositivos , Procedimientos Endovasculares , Complicaciones Posoperatorias/cirugía , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico , Aortografía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Remoción de Dispositivos/efectos adversos , Procedimientos Quirúrgicos Electivos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Diseño de Prótesis , Reoperación , Estudios Retrospectivos , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim was to evaluate long-term outcomes and sac volume shrinkage after endovascular popliteal artery aneurysm repair (EVPAR). METHODS: This study was a retrospective review of all EVPAR cases between 1999 and 2012. Sac volume shrinkage, long-term patency, limb salvage, and survival were evaluated using Kaplan-Meier estimates. The association of anatomical and clinical characteristics with patency was evaluated using multivariate analysis. RESULTS: Forty-six EVPAR were carried out in 42 patients (mean age 78 years, 86% male; mean sac volume 45.5 ± 3.5 mL). In 93% of cases (n = 43) the procedure was elective, while in 7% of cases it was for rupture (n = 2) or acute thrombosis (n = 1). Of the 43 patients who underwent elective repair, 58% were asymptomatic and 42% symptomatic (14 claudication, 3 rest pain, and 1 compression symptoms). Technical success was 98%. Mean duration of follow-up was 56 ± 21 months. Primary patency at 1, 3, and 5 years was 82% (SE 2), 79% (SE 4), and 76% (SE 4), while secondary patency was 90% (SE 5), 85% (SE 4), and 82% (SE 1) respectively; at 5 years there was 98% limb salvage and an 84% survival rate. During follow-up 11 limbs had stent graft failure: six required conversion, one underwent amputation, and four continued with mild claudication. Of those with graft failure, 63% (7/11) occurred within the first year of follow-up. The mean aneurysm sac volume shrinkage between preoperative and 5-year post-procedure measurement was significant (45.5 ± 3.5 mL vs. 23.0 ± 5.0 mL; p < .001). Segment coverage >20 cm was a negative predictor for patency (HR 2.76; 95% CI 0.23; p = .032). CONCLUSIONS: EVPAR provides successful aneurysm exclusion with good long-term patency, excellent limb salvage, and survival rates. Close surveillance is nevertheless required, particularly during the first postoperative year. Patients requiring long segment coverage (>20 cm) may be at increased risk for failure.
Asunto(s)
Aneurisma/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Arteria Poplítea/cirugía , Anciano , Anciano de 80 o más Años , Aneurisma/diagnóstico , Aneurisma/mortalidad , Aneurisma/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Procedimientos Quirúrgicos Electivos , Urgencias Médicas , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Análisis Multivariante , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Modelos de Riesgos Proporcionales , Falla de Prótesis , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
AIM: Aim of the study was to evaluate a single center experience on hybrid treatment for thoracic aortic diseases, including aortic arch and ascending aorta endografting needing a total debranching from descending thoracic aorta and an antegrade endograft deployment from left ventricle. METHODS: Between January 2004 and December 2010 48 patients underwent thoracic aorta endografting, with coverage of at least one supra-aortic artery, because of atherosclerotic, dissecting and post-traumatic aneurysms or complications of previous aortic surgery. Supra-aortic trunks revascularization was obtained from ascending aorta, common carotid arteries and, in three cases, from descending thoracic aorta since the unavailability of common inflow sites. In three cases the antegrade endograft introduction through left ventricle (transapical approach, 2 cases) or ascending aorta (one case) was the only possibility for a safe deployment. RESULTS: Three groups have been identified on the basis of the proximal landing zone. Group A (27 patients): zone 2; Group B (9 patients): zone 1; Group C (12 patients): zone 0. The 30 days mortality was respectively 7.4%, 0% and 16%. Post operative paraplegia occurred in the 7.4% of group A, respiratory insufficiency and infections were the main post-operative complications with an incidence reaching 30% in each group. CONCLUSION: Hybrid procedures on aortic arch represent a possible treatment for cases unfit for open surgery despite the complication rates and mortality are not negligible. In selected cases, the endografting can be extended up to beyond the landing zone 0 where an antegrade transventricular endograft deployment and a supra-aortic perfusion from descending thoracic aorta represent a feasible option.
Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Ventrículos Cardíacos/cirugía , Anciano , Anastomosis Quirúrgica/instrumentación , Angiografía , Aorta Torácica/fisiopatología , Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/fisiopatología , Velocidad del Flujo Sanguíneo , Ecocardiografía , Diseño de Equipo , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Estudios Retrospectivos , Tomografía Computarizada de Emisión de Fotón Único , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
AIM: The risk for developing stroke increases with the advancing age, peaking over age 80. In elderly patients, carotid endarterectomy may provide prophylaxis against stroke. Aim of our study was to compare patients 80 years or older with patients younger than 80 undergoing carotid endarterectomy. Endpoints were perioperative mortality and morbidity. METHODS: From January 1996 to December 2002, 1 659 patients underwent a 1 733 carotid endarterectomy for a symptomatic or asymptomatic significant carotid lesion. Among them, 125 patients were 80 years or older. We analyzed death and stroke rate from cerebrovascular accidents, TIA as well as non cerebrovascular complications and death rate postoperatively and in the long term follow-up. The Pearson's chi-squared(2) test was used for the statistical analysis on risk factors, morbidity and mortality. The Log rank test was used for cumulative stroke-free and survival rates between the 2 groups (level of confidence p<0.05). RESULTS: Risk factors were similar in both groups. No statistical difference was observed in the stroke, TIA, mortality and stroke free rates between the 2 groups. CONCLUSIONS: The results of our study show that perioperative and postoperative mortality and morbidity as well as the long-term stroke-free rate does not differ significantly in patients 80 years or older compared to patients younger than 80 undergoing carotid endarterectomy.
Asunto(s)
Estenosis Carotídea/cirugía , Endarterectomía Carotidea/mortalidad , Ataque Isquémico Transitorio/epidemiología , Tablas de Vida , Accidente Cerebrovascular/epidemiología , Factores de Edad , Anciano de 80 o más Años , Estenosis Carotídea/diagnóstico , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Tasa de SupervivenciaRESUMEN
OBJECTIVES: To retrospectively evaluate the safety and the long-term results of retrograde brachiocephalic and common carotid angioplasty and stenting (AS) performed for >70% stenosis synchronously with the carotid endarterectomy (CEA). PATIENTS: Sixteen patients operated between April 1999 and March 2002. RESULTS: 14/16 procedures were successful. There was no neurological morbidity or mortality. Per-operative angiography showed the optimal stent positioning and patency of both proximal and distal arteries in all patients. In the follow-up, all patients showed patency of the treated vessels without restenosis and the absence of any cerebrovascular symptoms. CONCLUSION: Intra-operative retrograde AS combined with CEA is an effective, safe and durable alternative to conventional surgery when a tandem significant proximal lesion is identified in a patient with an high grade carotid stenosis.
Asunto(s)
Angioplastia de Balón , Arteriopatías Oclusivas/cirugía , Tronco Braquiocefálico , Arteria Carótida Común , Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Stents , Anciano , Anciano de 80 o más Años , Angiografía de Substracción Digital , Arteriopatías Oclusivas/diagnóstico por imagen , Tronco Braquiocefálico/diagnóstico por imagen , Arteria Carótida Común/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Radiografía Intervencional , Estudios RetrospectivosRESUMEN
BACKGROUND: On the basis of personal experience and studies, the importance to diagnose quickly the seriousness of an acute pancreatitis with the help of simple and credible criteria of evaluation is underlined. It's also underlined the help of endoscopic papillosphincterotomy in the initial phase of a biliary pancreatitis; in fact this exam permits to perform a laparoscopic cholecystectomy in a second time and reduce surgical trauma. METHODS: Personal experience with 288 cases of acute pancreatitis (AP), during a twenty-year period (1975-1996) is described. In 61% of cases the AP was associated with biliary illness, and in 13% with alcohol abuse. Real important for therapeutic implication and prognostic significance is the classification of severity of acute attack, by using clinical evaluation (pain, fever, jaundice, abdominal tenderness), multiparametric score (i.e. Imrie's score, Ranson's criteria, SAPS or APACHE II score system) and morphological evaluation of the pancreas (echo and CT scan). 151 patients have been admitted at different times to surgery, the cholecystectomy being the more common surgical procedure, with a surgical rate of 52%. RESULTS: The overall mortality has been 7.2%, ranging from 45.4% in 17 severe necrotic haemorrhagic AP to 2.1% for the mild one. CONCLUSIONS: The widespread use of endoscopic retrograde colangiopancreatography (associated to endoscopic sphincterotomy if necessary) and the recent but universally accepted diffusion of laparoscopic cholecystectomy have changed the modern approach to surgical treatment of biliary associated AP, ensuring mininvasive less traumatic surgical procedures.