RESUMEN
BACKGROUND: Popliteal vein aneurysm (PVA) may be an incidental finding on imaging, but often presents in the context of acute venous thromboembolism (VTE). The role of anticoagulation with or without surgical excision versus expectant management is ill defined. METHODS: In this single-center, retrospective, cohort study, patient records from January 2002 to December 2013 were queried for terminology consistent with PVA. Demographic data and clinical outcomes were extracted via chart review. RESULTS: A total of 21 patients with PVA were identified (57% male). Mean follow-up was 38 ± 31 months. Mean PVA diameter was 2.5 ± 1.1 cm; 67% were saccular (with the remainder being fusiform), 19% contained thrombus, 67% were left sided, and bilateral PVA was present in 24% of cases. At the time of PVA diagnosis, 14% had pulmonary embolism. Treatment consisted of observation only (62%), anticoagulation (19%), surgery (5%), or both anticoagulation and surgery (14%). There were no recurrences of VTE once treated, although there was 1 acute deep venous thrombosis in a patient who was managed conservatively. Two patients had recurrent PVA after surgery, and there were 2 surgical complications (transient foot drop and hematoma). CONCLUSIONS: PVA is associated with VTE. Based on our series, it is unclear if incidentally discovered PVA (without VTE) warrants treatment with anticoagulation and/or surgical repair. Further multicenter studies are needed to establish the indications for safety and durability of surgery.
Asunto(s)
Aneurisma/diagnóstico , Aneurisma/terapia , Vena Poplítea , Adulto , Algoritmos , Aneurisma/complicaciones , Anticoagulantes/uso terapéutico , Diagnóstico por Imagen , Manejo de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Embolia Pulmonar/etiología , Recurrencia , Resultado del Tratamiento , Procedimientos Quirúrgicos VascularesAsunto(s)
Enfermedades Cardiovasculares/cirugía , Aceptación de la Atención de Salud , Relaciones Médico-Paciente , Procedimientos Quirúrgicos Vasculares , Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/terapia , Dibujos Animados como Asunto , Femenino , Humanos , Masculino , Medicina en las Artes , Grupo de Atención al Paciente , Cooperación del Paciente , Satisfacción del Paciente , Prevalencia , Factores de RiesgoRESUMEN
OBJECTIVES: We sought to determine the long-term results of revision procedures performed for repair of stenotic lesions in infrainguinal vein bypass grafts. METHODS: A retrospective review of 188 vein grafts, from a total series of 1260 bypasses, undergoing revision of stenotic lesions between January 1, 1987, and December 31, 2002, at Brigham & Women's Hospital was undertaken. Lesions were identified by recurrence of symptoms, change in examination findings, or with routine duplex ultrasound graft surveillance. Demographic and medical risk factors, and surgical variables were analyzed with respect to patency outcomes after the initial graft revision, with descriptive statistics, logistic regression, and life table analysis. Primary and secondary patency rates were determined from the time of graft revision. RESULTS: Patients included 108 men (57%) and 80 women (42%) who underwent revision at a mean age of 67.8 years. One hundred thirty grafts required only a single revision, whereas 58 required subsequent additional revisions. Revision procedures included 99 vein patches (52.7%), 23 jump grafts (12.2%), 23 interposition grafts (12.2%), 8 transpositions to new outflow vessels (4.3%), and 35 balloon angioplasty procedures (18.6%). During a mean follow-up of 1535 days, 5-year primary patency rate was 49.3% +/- 4.5% (SE) and 5-year secondary patency rate was 80.3% +/- 3.6%. There was no difference in patency rate for different revision procedures, type of vein graft, indication for the original procedure, or for patients with diabetes mellitus or renal disease. The overall limb salvage rate was 83.2% +/- 3.5% 5 years after graft revision. With COX proportional hazard analysis of time to failure of the revision procedure, the outflow level of the original bypass and the time of revision proved to be an important predictor of durability of the graft revision. Revision of popliteal bypass grafts resulted in a 60% 5-year primary patency rate, whereas revision of tibial grafts resulted in a 42% 5-year primary patency rate (P = .004; hazard ratio [HR], 2.06). Five-year secondary patency rates were 90% and 76%, respectively (P = .009; HR = 3.43). The timing of the graft revision proved an additional predictor. Grafts revised within 6 months of the index operation had lower primary patency than those with later revisions (42.9% vs 80.7%, respectively; HR = 1.754; P = .0152). CONCLUSIONS: Vein graft revisions offer durable patency and limb salvage rates after repair of stenotic infrainguinal bypass grafts. Vigilant ongoing surveillance is essential, because 30.9% of revised grafts will develop additional lesions that will require repair. Tibial level bypass grafts that require early repeat intervention to treat graft stenosis are at particular risk for development of subsequent lesions.
Asunto(s)
Oclusión de Injerto Vascular/cirugía , Vena Ilíaca/trasplante , Pierna/irrigación sanguínea , Recuperación del Miembro/métodos , Enfermedades Vasculares Periféricas/cirugía , Procedimientos Quirúrgicos Vasculares/efectos adversos , Anciano , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/diagnóstico por imagen , Rechazo de Injerto , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Vasculares Periféricas/diagnóstico por imagen , Probabilidad , Radiografía , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Grado de Desobstrucción Vascular/fisiología , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
OBJECTIVE: Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome. METHODS: We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping. RESULTS: Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis. CONCLUSION: Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/etiología , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Reoperación , Vísceras/irrigación sanguínea , Vísceras/cirugía , Anciano , Anciano de 80 o más Años , Aorta Torácica/patología , Aorta Torácica/trasplante , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/etiología , Rotura de la Aorta/mortalidad , Rotura de la Aorta/cirugía , Boston , Femenino , Arteria Femoral/patología , Arteria Femoral/trasplante , Estudios de Seguimiento , Humanos , Arteria Ilíaca/patología , Arteria Ilíaca/trasplante , Masculino , Arteria Mesentérica Superior/patología , Arteria Mesentérica Superior/trasplante , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/mortalidad , Recurrencia , Arteria Renal/patología , Arteria Renal/trasplante , Análisis de Supervivencia , Resultado del Tratamiento , Vísceras/patologíaRESUMEN
OBJECTIVE: HMG-CoA reductase inhibitors (statins) broadly reduce cardiovascular events, effects that are only partly related to cholesterol lowering. Recent studies suggest important anti-inflammatory and antiproliferative properties of these drugs. The purpose of this study was to determine the influence of statin therapy on graft patency after autogenous infrainguinal arterial reconstructions. METHODS: A retrospective analysis of consecutive patients (1999-2001) who underwent primary autogenous infrainguinal reconstructions with a single segment of greater saphenous vein was performed. Patients were categorized according to concurrent use of a statin. Graft lesions (identified by duplex surveillance) and interventions were tabulated. Comparisons between groups were made by using the Fisher exact test for categorical variables and the Student t test for continuous variables. Patency, limb salvage, and survival were compared by log rank test. A stepwise Cox proportional hazards analysis was then employed to ascertain the relative importance of factors influencing graft patency. RESULTS: A total of 172 patients underwent 189 primary autogenous infrainguinal arterial reconstructions (94 statin, 95 control) during the study period. The groups were well matched for age, indication, and atherosclerotic risk factors. Procedures were performed primarily for limb salvage (92%), with 65% to an infrapopliteal target. Perioperative mortality (2.6%) and major morbidity (3.2%) were not different between groups. There was no difference in primary patency (74% +/- 5% vs 69% +/- 6%; P =.25), limb salvage (92% +/- 3% vs 90% +/- 4%; P =.37), or survival (69% +/- 5% vs 63% +/- 5%; P =.20) at 2 years. However, patients on statins had higher primary-revised (94% +/- 2% vs 83% +/- 5%; P <.02) and secondary (97% +/- 2% vs 87% +/- 4%; P <.02) graft patency rates at 2 years. Of all factors studied by univariate analysis, only statin use was associated with improved secondary patency (P =.03) at 2 years. This was confirmed by multivariate analysis. The risk of graft failure was 3.2-fold higher (95% confidence interval, 1.04-10.04) for the control group. Perioperative cholesterol levels (available in 47% of patients) were not statistically different between groups. CONCLUSIONS: Statin therapy is associated with improved graft patency after infrainguinal bypass grafting with saphenous vein.
Asunto(s)
Implantación de Prótesis Vascular , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Grado de Desobstrucción Vascular/efectos de los fármacos , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/mortalidad , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/terapia , Boston , Terapia Combinada , Femenino , Arteria Femoral/efectos de los fármacos , Arteria Femoral/fisiopatología , Arteria Femoral/cirugía , Estudios de Seguimiento , Humanos , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/fisiopatología , Masculino , Persona de Mediana Edad , Arteria Poplítea/efectos de los fármacos , Arteria Poplítea/fisiopatología , Arteria Poplítea/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Reoperación , Estudios Retrospectivos , Vena Safena/efectos de los fármacos , Vena Safena/fisiopatología , Vena Safena/cirugía , Estadística como Asunto , Análisis de Supervivencia , Arterias Tibiales/efectos de los fármacos , Arterias Tibiales/fisiopatología , Arterias Tibiales/cirugía , Tiempo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To quantitatively describe the temporal changes in elastic properties and wall dimensions in lower-extremity vein grafts after implantation. DESIGN OF STUDY: This is a prospective study of patients (N = 38) undergoing lower extremity bypass grafts (N = 41) with autologous veins. Pulse wave velocity (PWV), luminal diameter, and wall thickness measurements were obtained by duplex ultrasound scan intraoperatively and at 1, 3, and 6 months postoperatively for assessment of graft dimensions and wall stiffness. RESULTS: Lower extremity vein grafts showed an increase in PWV (from 16 +/- 1 to 21 +/- 3 cm/s; mean +/- SEM; P =.08), reflecting an increase in wall stiffness (from 1.2 +/- 0.2 to 2.5 +/- 0.7 x 10(6) dynes/cm; P =.02) and wall thickness (from 0.47 +/- 0.03 to 0.61 +/- 0.004 mm; P =.04) over the first 6 months after implantation. Changes in lumen diameter were positively correlated with changes in external graft diameter (P <.01) and negatively correlated with initial lumen diameter (P <.01) but not with changes in the wall thickness. CONCLUSIONS: These results suggest complex remodeling of vein grafts during the first several months after implantation, with increased wall thickness occurring independent of variable changes in lumen diameter. Simultaneously, a marked increase in wall stiffness over this interval suggests a likely role for collagen deposition.
Asunto(s)
Arteriopatías Oclusivas/fisiopatología , Extremidad Inferior/irrigación sanguínea , Músculo Liso Vascular/patología , Venas/fisiopatología , Venas/trasplante , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Implantación de Prótesis Vascular , Fenómenos Fisiológicos Cardiovasculares , Elasticidad , Femenino , Humanos , Extremidad Inferior/diagnóstico por imagen , Extremidad Inferior/cirugía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Trasplante Autólogo , Ultrasonografía Doppler Dúplex/métodos , Venas/diagnóstico por imagen , Venas/cirugíaRESUMEN
Groin infections adjacent to vascular bypass grafts continue to be a source of morbidity. The authors reviewed retrospectively 9 consecutive patients with early localized groin infections treated at their institution with sartorius or rectus femoris muscle flaps between 1998 and 2002. All wounds were initially opened and drained. Wounds with necrotic tissue were treated with serial surgical debridements, with a vacuum-assisted closure device, or with wet-to-dry dressing changes. Two bypass grafts were excised and replaced in the presence of marked exposure or pseudoaneurysm. Small wounds were closed with a turnover sartorius flap and larger wounds were closed with either a muscle or musculocutaneous rectus femoris flap. Groin wounds healed in all patients without subsequent graft exposure, rupture, or pseudoaneurysm. Local wound therapy with staged debridement and muscle flaps is effective for most early localized graft infections.
Asunto(s)
Ingle/cirugía , Músculo Esquelético/trasplante , Colgajos Quirúrgicos , Infección de la Herida Quirúrgica/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Arteria Femoral/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Enfermedades Vasculares/cirugía , Cicatrización de HeridasRESUMEN
PURPOSE: To determine the costs, sensitivity for detection of significant stenoses, and proportion of equivocal multi-detector row computed tomographic (CT) angiography results in the work-up of patients with intermittent claudication that would make this imaging examination cost-effective compared with gadolinium-enhanced magnetic resonance (MR) angiography. MATERIALS AND METHODS: A decision model was used to compare the societal cost-effectiveness of a new imaging modality with that of gadolinium-enhanced MR angiography. Main outcome measures were quality-adjusted life years (QALYs) and lifetime costs. By using threshold analysis of a given willingness to pay per QALY, target values for costs, sensitivity for detection of significant stenoses, and proportion of cases requiring additional work-up with intraarterial digital subtraction angiography owing to equivocal results of the new modality were determined. The base case evaluated was that of 60-year-old men with severe intermittent claudication and assumed an incremental cost-effectiveness threshold of 100,000 US dollars per QALY. RESULTS: If treatment were limited to angioplasty, a new imaging modality would be cost-effective if the costs were 300 US dollars and the sensitivity was 85%, even if up to 35% of patients needed additional work-up. When both angioplasty and bypass surgery were considered as treatment options, a new imaging modality was cost-effective if the costs were 300 US dollars, the sensitivity was higher than 94%, and 20% of patients required additional work-up. CONCLUSION: Multi-detector row CT angiography, as compared with currently used imaging modalities such as MR angiography, has the potential to be cost-effective in the evaluation of patients with intermittent claudication.
Asunto(s)
Angiografía de Substracción Digital/economía , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/economía , Tomografía Computarizada por Rayos X/economía , Angiografía de Substracción Digital/métodos , Medios de Contraste , Análisis Costo-Beneficio , Costos y Análisis de Costo , Árboles de Decisión , Gadolinio , Humanos , Claudicación Intermitente/terapia , Angiografía por Resonancia Magnética/economía , Años de Vida Ajustados por Calidad de Vida , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X/métodosRESUMEN
PURPOSE: The efficacy of carotid endarterectomy (CEA) for prevention of stroke has been demonstrated in randomized trials; however, the optimal approach in patients excluded from these trials or who have other significant comorbid conditions remains controversial, particularly with the advent of percutaneous interventions. We examined the influence of putative risk factors on outcome of CEA in a single-center experience. METHODS: A retrospective analysis of 1370 consecutive CEA performed from 1990 to 1999 was undertaken. Preoperative risk factors examined included age older than 80 years, congestive heart failure, chronic obstructive pulmonary disease, renal failure (serum creatinine concentration > 2.0 mg/dL), contralateral carotid artery occlusion, recurrent ipsilateral carotid artery stenosis, ipsilateral hemispheric symptoms within 6 weeks, and recent coronary bypass grafting (CABG). The Fisher exact test was used to identify baseline variables associated with perioperative (30 days) risk for stroke or death. Multivariate analysis with Poisson regression was used to study the effect of all univariate criteria in combination. RESULTS: In the overall cohort, there were 32 adverse events (2.3%), including 11 deaths (0.8%), 6 disabling strokes (0.4%), and 10 nondisabling strokes (0.7%). There was no significant difference in incidence of perioperative stroke or death between patients with one or more risk factors (n = 689) and those with no risk factors (low risk, n = 681). Thirty-day mortality was significantly greater in patients with two or more risk factors compared with patients with no risk factors (2.8% vs 0.3%; P =.04), but no significant difference was noted in perioperative stroke rate (2.3% vs 1.0%). Univariate analysis demonstrated that contralateral carotid occlusion (n = 75) was the only significant predictor of adverse outcome (5 events, 6.7%) among the variables tested; this was confirmed with multivariate analysis (relative risk, 4.3; 95% confidence interval, 1.2-12.3; P =.01). Five-year survival for patients with two or more risk factors was notably diminished compared with that for patients with no risk factors (38.7% +/- 5.9% vs 75.0% +/- 2.6%; P <.001). Contralateral occlusion was also associated with reduced 5-year survival (38 +/- 11% vs 67 +/- 2%; P <.004). CONCLUSION: CEA can be safely performed in patients deemed at high risk, including those aged 80 years or older and others with significant comorbid conditions, with combined stroke and mortality rates comparable to those found in randomized trials, ie, the Asymptomatic Carotid Atherosclerosis Study and the North American Symptomatic Carotid Endarterectomy Trial. Contralateral occlusion may be a predictor for moderately increased perioperative risk and for reduced long-term survival. Caution may be warranted in asymptomatic patients with multiple risk factors, in whom presumed long-term benefit of CEA may be compromised by markedly reduced 5-year survival.
Asunto(s)
Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias , Cuidados Preoperatorios , Accidente Cerebrovascular/prevención & control , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Estudios de Cohortes , Femenino , Humanos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/fisiopatología , Tasa de Supervivencia , Grado de Desobstrucción Vascular/fisiologíaRESUMEN
OBJECTIVES: On the basis of the widespread belief that aortobifemoral bypass (ABF) represents the optimal mode of revascularization for patients with diffuse aortoiliac disease, vascular surgeons are often aggressive about its application in young adults. We undertook this retrospective evaluation of ABFs performed from 1980 to 1999 to determine whether the results justify this approach. Patients of less than 50 years of age (n = 45) were compared with those aged 50 to 59 years (n = 93) and those aged more than 60 years (n = 146). RESULTS: Younger patients were more likely to undergo operation for claudication than were older patients (72% versus 59% and 55%; P <.04). Younger patients were significantly more likely to be smokers (87%) but less likely to have diabetes, hypertension, or cerebrovascular disease. Bypasses were constructed in an end-to-end fashion in 71.1% of patients of less than 50 years versus 68.8% and 71.2% of older patients (P = not significant). The mean diameter of aortic grafts was significantly smaller in younger patients (14.6 mm) than in older patients (15.6 mm and 15.5 mm; P <.01). The need for a subsequent infrainguinal reconstruction was highest in the youngest patients (24% versus 17% and 7%; P <.01). Surgical mortality rates were low in all groups (0%, 1%, and 2.0% for increasing age groups; P = not significant). Five-year primary and secondary patency rates increased significantly with each increase in age interval: 5-year primary patency rate: less than 50 years, 66% +/- 8%; 50 to 59 years, 87% +/- 5%; more than 60 years, 96% +/-2% (P <.05 for all comparisons). Five-year secondary patency rates were: less than 50 years, 79% +/- 7%; 50 to 59 years, 91% +/- 4%; more than 60 years, 98% +/- 2% (P <.05 for all comparisons). Five-year survival rate was comparable in all three groups: less than 50 years, 93% +/- 5%; 50 to 59 years, 92% +/- 4%; more than 60 years, 87% +/- 4% (P = not significant). CONCLUSION: Increased virulence of aortic disease, smaller aortic size, and more progressive infrainguinal disease may all negatively impact the results of ABF in younger patients. Although 5-year results are acceptable, increased caution is warranted in the routine application of ABF in young patients without limb-threatening ischemia.
Asunto(s)
Factores de Edad , Aorta/patología , Aorta/cirugía , Enfermedades de la Aorta/patología , Enfermedades de la Aorta/cirugía , Arteriopatías Oclusivas/patología , Arteriopatías Oclusivas/cirugía , Arteria Femoral/cirugía , Claudicación Intermitente/patología , Claudicación Intermitente/cirugía , Evaluación de Resultado en la Atención de Salud , Procedimientos Quirúrgicos Vasculares , Adulto , Anciano , Enfermedades de la Aorta/fisiopatología , Arteriopatías Oclusivas/fisiopatología , Femenino , Arteria Femoral/fisiopatología , Humanos , Claudicación Intermitente/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Grado de Desobstrucción Vascular/fisiologíaRESUMEN
OBJECTIVE: Outcomes after surgical repair of abdominal aortic aneurysm (AAA) in patients at high risk remain poorly defined. We investigated the short-term and long-term results of open repair of infrarenal AAA in a high-risk and comparison low-risk patient population. METHODS: Conventional open surgical repair of nonruptured infrarenal AAA was performed in 572 consecutive patients from 1990 to 2000. Patients were considered at high risk if they had one or more of the following criteria: age 80 years or more, creatinine level 3.0 mg/dL or higher, severe pulmonary insufficiency, severe cardiac dysfunction, or hepatic failure. A retrospective review was carried out to determine relative risks, perioperative morbidity and mortality, and long-term survival. A P value of less than.05 was considered statistically significant. RESULTS: One hundred twenty-eight of the study patients (22%) were at high risk and 444 were at low risk. Patients at high risk were older (77 versus 69 years; P <.001), were more likely female (26% versus 16%; P <.009), and had larger (mean, 5.9 versus 5.6 cm; P <.024), more symptomatic (20% versus 13%; P <.001) aneurysms. The 30-day operative mortality rate for the high-risk group was 4.7%, compared with 0.0% (P <.001) in the low-risk group. Overall and major morbidity rates were 29% and 14% in the high-risk cohort versus 17% (P <.003) and 5% in the low-risk cohort, respectively. The 5-year survival rate was 46% (standard deviation, 5.2%) in the high-risk group versus 74% (standard deviation, 2.6%) in the low-risk group (P <.001). On multivariate analysis, age 80 years or more (P <.046), creatinine level 3.0 mg/dL or higher (P <.022), prior stroke (P <.012), and pulmonary dysfunction were significant predictors of poor operative outcome (30-day mortality and major morbidity), and female gender (P <.035), cardiac dysfunction (P <.004), creatinine level 3.0 mg/dL or higher (P <.0001), prior stroke (P <.005), and pulmonary dysfunction (P <.0001) negatively impacted long-term survival rates. CONCLUSION: This study shows that open repair of infrarenal AAA in patients at high risk can be performed with relative safety and with results that offer a benchmark with which endovascular repair can be compared. Poor long-term survival in this population, however, highlights the importance of patient selection and raises the question of whether repair of many patients at high risk is warranted.
Asunto(s)
Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/cirugía , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias , Procedimientos Quirúrgicos Vasculares/efectos adversos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Femenino , Humanos , Masculino , Selección de Paciente , Radiografía , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Factores de TiempoRESUMEN
PURPOSE: To determine the optimal imaging strategy in pretreatment workup of patients with intermittent claudication with use of noninvasive imaging modalities and intraarterial digital subtraction angiography (DSA). MATERIALS AND METHODS: A decision-analytic model that considered test characteristics such as sensitivity, complications induced by the test, implications of missing lesions, and the consequences of overtreating patients, was developed to evaluate the societal cost-effectiveness (CE) of magnetic resonance (MR) angiography, duplex ultrasonography (US), and DSA. Our main outcome measures were quality-adjusted life years (QALYs), lifetime costs (in dollars), and incremental CE ratios. The base-case analysis considered a cohort of 60-year old male patients without a history of coronary artery disease who presented with severe claudication to undergo pretreatment imaging workup. RESULTS: The range in effectiveness and lifetime costs among different diagnostic workup strategies was small (largest difference in effectiveness: 0.025 QALYs; largest difference in lifetime costs: $1,800). If treatment was limited to angioplasty in patients with suitable lesions, MR angiography had an incremental CE ratio of $35,000 per QALY compared with no diagnostic workup, and DSA had an incremental CE ratio of $471,000 per QALY compared with MR angiography. If treatment options included both angioplasty and bypass surgery, DSA had an incremental CE ratio of $179,000 per QALY compared with no diagnostic workup, and MR angiography and duplex US were less effective and more costly. CONCLUSIONS: The differences in costs and effectiveness among diagnostic imaging strategies for patients with intermittent claudication are slight and MR angiography or duplex US can replace DSA without substantial loss in effectiveness and with a slight cost reduction.
Asunto(s)
Angiografía de Substracción Digital/economía , Claudicación Intermitente/diagnóstico , Angiografía por Resonancia Magnética/economía , Ultrasonografía Doppler en Color/economía , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Humanos , Claudicación Intermitente/economía , Claudicación Intermitente/terapia , Modelos Económicos , Años de Vida Ajustados por Calidad de Vida , Sensibilidad y EspecificidadRESUMEN
The optimal approach to revascularization for chronic mesenteric ischemia has not been firmly established during the past three decades. The present study was undertaken to evaluate the safety and results of primary mesenteric revascularization for chronic mesenteric ischemia by transaortic endarterectomy. A descriptive retrospective analysis of 14 patients who underwent trap-door transaortic endarterectomy for primary mesenteric revascularization was performed. Clinical presentations of the patients included abdominal pain (n=13) and weight loss (n=7). All patients underwent preoperative aortography and subsequent elective reconstruction. Demographic features, perioperative, and long-term outcomes were analyzed. The study population consisted of 12 females and two males with a mean age of 67 years. The mean operative duration was 3 hours with an ischemic time of 33 minutes. The initial success rate of mesenteric revascularization was 93%. One early graft failure was salvaged with urgent embolectomy without bowel resection. There was no hospital mortality, but the overall postoperative morbidity rate was 50% (n=7). Thirteen patients (93%) were discharged within 2 weeks. Late recurrent ischemia and intestinal infarction developed in one patient, requiring emergency bowel resection. Sustained relief of symptoms was achieved in 13 of 14 patients (93%). The overall survival rates were 85% +/-10.0% and 77% +/-11.7% at 1 and 3 years, respectively. Transaortic endarterectomy is a safe and effective technique for elective primary mesenteric revascularization for patients with chronic mesenteric ischemia. This approach allows simultaneous revascularization of multiple visceral arteries and achieves durable relief of symptoms.
Asunto(s)
Endarterectomía/métodos , Isquemia/cirugía , Arterias Mesentéricas/cirugía , Anciano , Enfermedad Crónica , Endarterectomía/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: The in situ vein (ISV) bypass is uniquely suited to technical modifications designed to reduce the wound morbidity of infrainguinal revascularization. A technique of "blind" valvulotomy and selective vein branch ligation was used, and a preliminary study was performed to assess safety and efficacy. METHODS: From November 1998 to July 2001, all patients for infrainguinal bypass procedures underwent evaluation for inclusion in the study. Thirty-five patients underwent ISV bypass procedures with an expandable, self-centering valvulotome (ESV). Intraoperative selection of veins suitable for the study was assisted with venography and duplex scanning. The ISV bypass procedures were performed with initial groin and distal incisions, with smaller incisions to ligate significant arteriovenous fistulae (AVF). Duplex graft scanning was performed at routine intervals after surgery. RESULTS: Thirty-seven ISV grafts were performed from the common femoral artery to the popliteal (n = 14), tibial (n = 20), and dorsalis pedis (n = 3) arteries. In 35 cases (95%), a full-length incision was avoided. With ESV, all valves in 34 cases (92%) were effectively lysed. Proximal extension of the distal incision was performed in four cases (10.8%). The mean number of incisions per case was 3.1 +/- 1.7. One graft failed within 30 days (2.7%), with successful revision. During the early follow-up period (9.9 +/- 7.3 months; range, 1 to 33 months), 44% of residual AVF closed spontaneously (15 of 34 AVF; 16 patients) and two anastomotic stenoses and two symptomatic AVF were corrected surgically. Four late graft occlusions occurred, with a 1-year cumulative primary patency rate of 77% and a secondary patency rate of 92%. CONCLUSION: Blind valvulotomy with ESV facilitates safe and effective minimally invasive ISV bypass. Resultant graft patency rates appear comparable with results with open techniques. This preliminary experience warrants further study to refine patient selection criteria and operative technique and to better clarify the natural history of residual AVF.
Asunto(s)
Derivación Arteriovenosa Quirúrgica/métodos , Enfermedades Vasculares Periféricas/cirugía , Vena Safena/cirugía , Anciano , Femenino , Estudios de Seguimiento , Humanos , Pierna/irrigación sanguínea , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos , Instrumentos Quirúrgicos , Factores de Tiempo , Grado de Desobstrucción VascularRESUMEN
PURPOSE: The purposes of this study were to evaluate the long-term results of different autogenous conduits used for infrainguinal bypass when ipsilateral greater saphenous vein (IGSV) is absent or inadequate and to determine the impact on the contralateral lower extremity. METHODS: The study was performed as a retrospective evaluation of a prospective vascular registry together with review of patient records and telephone follow-up. RESULTS: From January 1990 to June 2000, 226 autogenous infrainguinal reconstructions were performed in 203 patients without adequate IGSV. The patients consisted of 128 men and 98 women, with a mean age of 69 years. Prevalent risk factors included diabetes (51%) and prior coronary bypass (46%). Limb salvage was the predominant indication (93%), and 59% of the procedures were secondary reconstructions. All bypasses were completed with autogenous vein, which included contralateral greater saphenous vein (CGSV; 31%), single-segment lesser saphenous vein (5%), single-segment arm vein (19%), and autogenous composite vein (45%). Bypasses were performed to the tibial and pedal arteries in 84% of the cases. The 30-day mortality and graft occlusion rates were 1% and 9%, respectively. The overall postoperative morbidity rate was 24%, with a 7% rate of major complications. Follow-up was complete in 95% of patients over a mean period of 24 months (range, 0.1 to 106 months). The 5-year primary patency rates were significantly better for CGSV compared with autogenous composite vein grafts (61% +/- 7% versus 39% +/- 6%; P <.009). The 5-year secondary patency (60% to 73%) and limb salvage (78% to 81%) rates did not differ significantly between the three groups. Follow-up of the contralateral lower limb revealed that nine of 226 limbs (4%) were amputated at a mean of 36 months after the ipsilateral bypass. The overall 5-year contralateral limb preservation rate was 90% +/- 3%. Contralateral vein harvest and the presence of diabetes did not affect the need for bypass or amputation of the contralateral limb. CONCLUSION: For most patients with inadequate IGSV, the CGSV is the alternative conduit of choice because of its length, superior performance, ease of harvest, and minimal risk to the donor limb.
Asunto(s)
Derivación Arteriovenosa Quirúrgica , Isquemia/cirugía , Pierna/irrigación sanguínea , Vena Safena/trasplante , Anciano , Aorta Abdominal/cirugía , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Arterias Tibiales/cirugía , Factores de Tiempo , Trasplante Autólogo , Grado de Desobstrucción VascularRESUMEN
PURPOSE: Infrainguinal bypass grafting with a proximal anastomosis distal to the groin has been used increasingly to conserve available conduit and reduce wound morbidity and recovery time. The usefulness of the liberalized use of distal origin grafts (DOGs) is unknown. METHODS: Consecutive autogenous DOG procedures that were performed between 1978 and 2000 were reviewed retrospectively with a computerized registry. Procedures performed as revisions to earlier infrainguinal bypass grafting procedures and for popliteal aneurysm were excluded. RESULTS: In the 22-year study period, 249 autogenous DOG procedures were performed in 217 patients. Comparison of the 159 DOGs in patients with diabetes mellitus (+DM) with the 90 grafts in patients without diabetes mellitus (-DM) revealed more associated renal disease (33% vs 9%), preoperative foot necrosis (80% vs 52%), distal popliteal artery graft origins (49% vs 37%), and non-greater saphenous conduits used (30% vs 19%) among the +DM subgroup than the -DM subgroup (P <.05). The operative mortality rate was 2.0%, the major morbidity rate was 8.8%, the early graft failure rate was 6.4%, and the early amputation rate was 2.4%, with no differences related to diabetes mellitus. Follow-up was complete in 92% of patients in a mean interval of 27 months. At 5 years, cumulative primary graft patency rates were 62% overall, 73% for the +DM subgroup, and 45% for the -DM subgroup (P <.001). The overall limb salvage rate after DOG procedures for critical ischemia was 79%, and it was 84% for the +DM subgroup and 69% for the -DM subgroup (P <.04). The overall patient survival rate was 45%, with no difference related to diabetes mellitus. CONCLUSION: Outcome after autogenous DOG revascularization is satisfactory overall. Graft patency and limb salvage after DOG for critical ischemia are significantly better among patients with diabetes mellitus than patients without diabetes mellitus, despite significantly more bypass grafting procedures performed for foot necrosis. DOG revascularization appears to be an appropriate preference for patients with diabetes mellitus with good inflow below the groin; it should be used less liberally among patients without diabetes mellitus.
Asunto(s)
Arteriosclerosis/mortalidad , Arteriosclerosis/cirugía , Ingle/irrigación sanguínea , Ingle/cirugía , Conducto Inguinal/irrigación sanguínea , Conducto Inguinal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Arteriosclerosis/complicaciones , Complicaciones de la Diabetes , Femenino , Arteria Femoral/trasplante , Humanos , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Arteria Poplítea/trasplante , Estudios Retrospectivos , Tasa de Supervivencia , Trasplante Autólogo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To compare the costs, effectiveness, and cost-effectiveness of alternative treatment strategies for intermittent claudication. MATERIALS AND METHODS: By combining data from the literature and original patient data, a Markov decision model was developed to evaluate the societal cost-effectiveness. Patients presented with previously untreated intermittent claudication, and treatment options were exercise, percutaneous transluminal angioplasty (with stent placement, if necessary), and/or bypass surgery. Treatment strategies were defined as the initial therapy in combination with secondary treatment options should the initial therapy fail. The main outcome measures were quality-adjusted life days, expected lifetime costs (in 1995 U.S. dollars), and incremental cost-effectiveness ratios. RESULTS: Compared with an exercise program, revascularization (either angioplasty or bypass surgery) improved effectiveness by 33-61 quality-adjusted life days among patients with no history of coronary artery disease. The incremental cost-effectiveness ratio was $38,000 per quality-adjusted life year gained when angioplasty was performed whenever feasible, as compared with exercise alone, and $311,000 with additional bypass surgery. The incremental cost-effectiveness ratios were sensitive to age, history of coronary artery disease, estimated health values for no or mild claudication versus severe claudication, and revascularization costs. CONCLUSION: The results suggest that, on average, the expected gain in effectiveness achieved with bypass surgery for intermittent claudication is small compared with the costs. Angioplasty performed whenever feasible was more effective than was exercise alone, and the cost-effectiveness ratio was within the generally accepted range.