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BACKGROUND: We assessed trends in aortic dissection (AD) death rates in 23 countries from 2000 to 2017. METHODS: We extracted AD mortality data for countries with high usability data from the World Health Organization (WHO) Mortality Database and from the Center for Disease Control (CDC) WONDER Database for the United States of America (USA). Age Standardized Death Rates (ASDRs) per 100,000 population were computed. Trends were assessed by locally weighted scatter plot smoother (LOWESS) regression. RESULTS: Between 2000 and 2017, ASDRs from AD decreased in Australia, Belgium, Croatia, Denmark, France, Italy, New Zealand, Norway, Sweden, the United Kingdom, and the USA for both sexes. Increasing AD mortality was observed in Austria, Czech Republic, Germany, Hungary, Israel, and Japan for both sexes. The largest absolute increases in ASDR were in Japan for men (+1.59) and women (+1.11). The largest percentage decreases were in Norway for men (-0.91) and in New Zealand (-0.6) for women. In 2017, the highest mortality rates were in Japan for both sexes (3.22 and 2.09, respectively). The lowest ASDR was in Kyrgyzstan for both sexes (0.16 and 0.10, respectively). ASDRs for AD in 2017 were higher for men than women in all countries included. Spain had the greatest difference between the gender's mortality rates with a 2.71-fold higher mortality average rate in men. CONCLUSION: We identified an overall decrease in AD mortality in most included countries, while an increase was noted in other countries including Israel and Japan.
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Disección Aórtica , Disección Aórtica/diagnóstico , República Checa , Europa (Continente)/epidemiología , Femenino , Humanos , Masculino , Mortalidad , Noruega , Reino Unido/epidemiología , Estados Unidos , Organización Mundial de la SaludAsunto(s)
Infecciones por Coronavirus/epidemiología , Hospitales de Enseñanza/estadística & datos numéricos , Neumonía Viral/epidemiología , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Anciano , COVID-19 , Infecciones por Coronavirus/prevención & control , Femenino , Humanos , Londres/epidemiología , Masculino , Pandemias/prevención & control , Neumonía Viral/prevención & control , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
BACKGROUND: Silent cerebral infarction is brain injury detected incidentally on imaging; it can be associated with cognitive decline and future stroke. This study investigated cerebral embolization, silent cerebral infarction and neurocognitive decline following thoracic endovascular aortic repair (TEVAR). METHODS: Patients undergoing elective or emergency TEVAR at Imperial College Healthcare NHS Trust and Guy's and St Thomas' NHS Foundation Trust between January 2012 and April 2015 were recruited. Aortic atheroma graded from 1 (normal) to 5 (mobile atheroma) was evaluated by preoperative CT. Patients underwent intraoperative transcranial Doppler imaging (TCD), preoperative and postoperative cerebral MRI, and neurocognitive assessment. RESULTS: Fifty-two patients underwent TEVAR. Higher rates of TCD-detected embolization were observed with greater aortic atheroma (median 207 for grade 4-5 versus 100 for grade 1-3; P = 0·042), more proximal landing zones (median 450 for zone 0-1 versus 72 for zone 3-4; P = 0·001), and during stent-graft deployment and contrast injection (P = 0·001). In univariable analysis, left subclavian artery bypass (ß coefficient 0·423, s.e. 132·62, P = 0·005), proximal landing zone 0-1 (ß coefficient 0·504, s.e. 170·57, P = 0·001) and arch hybrid procedure (ß coefficient 0·514, s.e. 182·96, P < 0·001) were predictors of cerebral emboli. Cerebral infarction was detected in 25 of 31 patients (81 per cent) who underwent MRI: 21 (68 per cent) silent and four (13 per cent) clinical strokes. Neurocognitive decline was seen in six of seven domains assessed in 15 patients with silent cerebral infarction, with age a significant predictor of decline. CONCLUSION: This study demonstrates a high rate of cerebral embolization and neurocognitive decline affecting patients following TEVAR. Brain injury after TEVAR is more common than previously recognized, with cerebral infarction in more than 80 per cent of patients.
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Aorta Torácica/cirugía , Infarto Cerebral/etiología , Procedimientos Endovasculares , Embolia Intracraneal/etiología , Trastornos Neurocognitivos/etiología , Placa Aterosclerótica/cirugía , Complicaciones Posoperatorias/etiología , Anciano , Anciano de 80 o más Años , Infarto Cerebral/diagnóstico , Infarto Cerebral/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Embolia Intracraneal/diagnóstico , Embolia Intracraneal/epidemiología , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Trastornos Neurocognitivos/diagnóstico , Trastornos Neurocognitivos/epidemiología , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Factores de RiesgoRESUMEN
OBJECTIVE: Stroke caused by cerebral embolization constitutes a principal risk during arch manipulation and thoracic endovascular aortic repair (TEVAR). This study investigates the incidence of cerebral embolization during catheter placement in the aortic arch, and compares robotic and manual techniques. METHODS: Intra-operative transcranial Doppler (TCD) was performed in 11 patients undergoing TEVAR. Wire and catheter placement in the arch was performed by two experienced operators. Manual and robotic catheter placement and removal were compared for each patient; 44 manoeuvres were studied in total. A conventional 5Fr pigtail catheter was used for manual cannulation via a 5Fr access sheath. The 6Fr/9Fr co-axial Magellan endovascular robotic system was used for robotic navigation operated from a remote workstation. The number of high intensity transient signals (HITS) detected by TCD during different stages of TEVAR was recorded. RESULTS: The median procedural embolization rate was 173 (interquartile range 97-240). There were significantly fewer HITS detected during robotic catheter placement with six in total (median 0, IQR 0-1), compared with 38 HITS (median 2, IQR 1-5) during manual catheter placement (p = .018). There were no HITS detected during robotic catheter removal by auto-retraction as per manufacturer instructions. On two occasions, however, when the robotic catheter system was removed manually without correcting for articulation, it resulted in one HIT in one case and 11 HITS in the second case. CONCLUSIONS: Robotic catheter placement is feasible during TEVAR, and results in significantly less cerebral embolization compared with manual techniques. The active manoeuvrability, control, and stability of the robotic system is likely to reduce contact with an atheromatous aortic arch wall, and thereby reduce dislodgement of particulate matter and result in less embolization. The importance of adhering to manufacturer instructions during use and removal of the robotic catheter is also highlighted.
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Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Procedimientos Endovasculares/instrumentación , Embolia Intracraneal/prevención & control , Procedimientos Quirúrgicos Robotizados/instrumentación , Dispositivos de Acceso Vascular , Anciano , Aorta Torácica/diagnóstico por imagen , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Estudios de Factibilidad , Femenino , Humanos , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/etiología , Masculino , Persona de Mediana Edad , Tomografía Computarizada Multidetector , Factores de Riesgo , Procedimientos Quirúrgicos Robotizados/efectos adversos , Stents , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler TranscranealRESUMEN
Purpose The aim of this paper is to report our experience of type II endoleak treatment after endovascular aneurysm repair with intra-arterial injection of the embolizing liquid material, Onyx liquid embolic system. Methods From 2005 to 2012, we performed a retrospective review of 600 patients, who underwent endovascular repair of an abdominal aortic aneurysm. During this period, 18 patients were treated with Onyx for type II endoleaks. Principal findings The source of the endoleak was the internal iliac artery in seven cases, inferior mesenteric artery in seven cases and lumbar arteries in four cases. Immediate technical success was achieved in all patients and no endoleak from the treated vessel recurred. During a mean follow-up of 19 months, no major morbidity or mortality occurred, and one-year survival was 100%. Conclusions Treatment of type II endoleaks with Onyx is safe and effective over a significant time period.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Dimetilsulfóxido/administración & dosificación , Embolización Terapéutica/métodos , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Arteria Ilíaca , Vértebras Lumbares/irrigación sanguínea , Arteria Mesentérica Inferior , Polivinilos/administración & dosificación , Tantalio/administración & dosificación , Anciano , Anciano de 80 o más Años , Angiografía de Substracción Digital , Angiografía por Tomografía Computarizada , Dimetilsulfóxido/efectos adversos , Combinación de Medicamentos , Embolización Terapéutica/efectos adversos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Inyecciones Intraarteriales , Masculino , Arteria Mesentérica Inferior/diagnóstico por imagen , Polivinilos/efectos adversos , Estudios Retrospectivos , Tantalio/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Aortic dissection is a life-threatening process in which the weakened wall develops a tear, causing separation of wall layers. The dissected layers separate the original true aortic lumen and a newly created false lumen. If untreated, the condition can be fatal. Flow rate in the false lumen is a key feature for false lumen patency, which has been regarded as one of the most important predictors of adverse early and later outcomes. Detailed flow analysis in the dissected aorta may assist vascular surgeons in making treatment decisions, but computational models to simulate flow in aortic dissections often involve several assumptions. The purpose of this study is to assess the computational models adopted in previous studies by comparison with in vivo velocity data obtained by means of phase-contrast magnetic resonance imaging (PC-MRI). Aortic dissection geometry was reconstructed from computed tomography (CT) images, while PC-MRI velocity data were used to define inflow conditions and to provide distal velocity components for comparison with the simulation results. The computational fluid dynamics (CFD) simulation incorporated a laminar-turbulent transition model, which is necessary for adequate flow simulation in aortic conditions. Velocity contours from PC-MRI and CFD in the two lumens at the distal plane were compared at four representative time points in the pulse cycle. The computational model successfully captured the complex regions of flow reversal and recirculation qualitatively, although quantitative differences exist. With a rigid wall assumption and exclusion of arch branches, the CFD model over-predicted the false lumen flow rate by 25% at peak systole. Nevertheless, an overall good agreement was achieved, confirming the physiological relevance and validity of the computational model for type B aortic dissection with a relatively stiff dissection flap.
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Aneurisma de la Aorta/fisiopatología , Disección Aórtica/fisiopatología , Simulación por Computador , Imagen por Resonancia Magnética/métodos , Modelos Cardiovasculares , Disección Aórtica/patología , Aneurisma de la Aorta/patología , Velocidad del Flujo Sanguíneo , Diástole/fisiología , Humanos , Hidrodinámica , Masculino , Persona de Mediana Edad , Sístole/fisiología , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVES: Identification of those patients with high-risk asymptomatic carotid plaques remains an elusive but essential step in stroke prevention. Inflammation is a key process in plaque destabilization and the propensity of atherosclerotic lesions to cause clinical sequelae. There is currently no clinical imaging technique available to assess the degree of inflammation associated with plaques. This study aims at visualizing and characterizing atherosclerosis using antibody-conjugated superparamagnetic iron oxide (SPIO) particles as an MRI probe to assess inflammation in human atherosclerotic plaques. METHODS: Atherosclerotic plaques were collected from 20 consecutive patients (n=10 from symptomatic patients, n=10 from asymptomatic patients) undergoing carotid endarterectomy (CEA) for extracranial high-grade internal carotid artery (ICA) stenosis (>70% luminal narrowing). Inflammatory markers on human atherosclerotic plaques were detected and characterized by ex vivo magnetic resonance imaging (MRI) using anti-VCAM-1 antibody and anti-E-selectin antibody-conjugated SPIO with confirmatory immunohistochemistry. RESULTS: Inflammation associated with human ex vivo atherosclerotic plaques could be imaged using dual antibody-conjugated SPIO by MRI. Symptomatic plaques could be distinguished from asymptomatic ones by the degree of inflammation, and the MR contrast effect was significantly correlated with the degree of plaque inflammation (r=.64, p<.001). The asymptomatic plaque population exhibited heterogeneity in terms of inflammation. The dual-targeted SPIO-induced MR signal not only tracked closely with endothelial activation (i.e. endothelial expression of VCAM-1 and E-selectin), but also reflected the macrophage burden within plaque lesions, offering a potential imaging tool for quantitative MRI of inflammatory activity in atherosclerosis. CONCLUSIONS: These functional molecular MRI probes constitute a novel imaging tool for ex vivo characterization of atherosclerosis at a molecular level. Further development and translation into the clinical arena will facilitate more accurate risk stratification in carotid artery disease in the future.
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Estenosis Carotídea/diagnóstico , Selectina E/metabolismo , Compuestos Férricos , Inflamación/metabolismo , Imagen por Resonancia Magnética/métodos , Placa Aterosclerótica/diagnóstico , Molécula 1 de Adhesión Celular Vascular/metabolismo , Anciano , Biomarcadores/metabolismo , Estenosis Carotídea/etiología , Estenosis Carotídea/cirugía , Medios de Contraste , Endarterectomía Carotidea , Femenino , Humanos , Inmunohistoquímica , Inflamación/diagnóstico , Masculino , Placa Aterosclerótica/complicaciones , Placa Aterosclerótica/metabolismo , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: Takayasu arteritis (TA) predisposes to the development of arterial stenoses and aneurysms, and is associated with considerable morbidity and mortality amongst young patients. The aims of this study were to analyse indications and outcomes of surgical intervention, and to assess the potential benefits of immunosuppression and the use of perioperative imaging. METHODS: This was a retrospective review of patients with TA referred between 2001 and 2012. RESULTS: A series of 97 patients with TA, seen at a single tertiary centre, is reported. Immunosuppression was required in 87 patients (90 per cent). Thirty-seven (38 per cent) underwent 64 procedures: 27 patients underwent 33 open surgical procedures and 20 patients had 31 endovascular procedures. After a median follow-up of 6 years, the overall success rate was 79 per cent for open surgery (mean graft patency 9.4 years) and 52 per cent for endovascular procedures (P = 0.035). Procedural failure was significantly reduced in patients receiving preoperative immunosuppression, and particularly endovascular procedures (P = 0.001). In addition to clinical examination and measurement of acute-phase reactants, combination non-invasive imaging including Doppler ultrasonography, [18F]fluorodeoxyglucose combined positron emission and computed tomography (CT), magnetic resonance angiography and CT angiography was used to identify arterial lesions, establish the diagnosis and monitor treatment outcomes. CONCLUSION: Outcomes of vascular intervention in TA may be improved by detailed preoperative assessment including measurement of disease activity, and by ensuring optimal immunomodulatory therapy before and after the procedure.
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Procedimientos Endovasculares/métodos , Arteritis de Takayasu/cirugía , Adulto , Angioplastia/métodos , Aneurisma de la Aorta Torácica/patología , Aneurisma de la Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/cirugía , Enfermedades de las Arterias Carótidas/patología , Enfermedades de las Arterias Carótidas/fisiopatología , Enfermedades de las Arterias Carótidas/cirugía , Terapia Combinada , Constricción Patológica/patología , Constricción Patológica/fisiopatología , Constricción Patológica/cirugía , Enfermedad Coronaria/patología , Enfermedad Coronaria/fisiopatología , Enfermedad Coronaria/cirugía , Dilatación Patológica/patología , Dilatación Patológica/fisiopatología , Dilatación Patológica/cirugía , Femenino , Fluorodesoxiglucosa F18 , Humanos , Terapia de Inmunosupresión/métodos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios , Radiofármacos , Recurrencia , Obstrucción de la Arteria Renal/patología , Obstrucción de la Arteria Renal/fisiopatología , Obstrucción de la Arteria Renal/cirugía , Reoperación , Estudios Retrospectivos , Stents , Arteritis de Takayasu/patología , Arteritis de Takayasu/fisiopatología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Ultrasonografía Doppler , Grado de Desobstrucción Vascular/fisiologíaRESUMEN
INTRODUCTION: Splanchnic and renal artery aneurysms (SRAAs) are uncommon but potentially life-threatening in case of rupture. Whether these aneurysms are best treated by open repair or endovascular intervention is unknown. The aim of this retrospective study is to report the results of open and endovascular repairs in two European institutions over a fifteen-year period. We have reviewed the available literature published over the 10 last years. METHODS: All patients with SRAAs diagnosed from 1995 to 2010 in St Marys Hospital (London, UK) and Henri Mondor Hospital (Créteil, France) were reviewed. Preoperative clinical and anatomical data, operative management and outcomes were recorded from the charts and analyzed. RESULTS: 40 patients with 51 SRAAs were identified. There were 21 males and 19 females with a mean age of 57 ± 14.9 years. The aneurysms locations were: 14 (27%) renal, 11 (22%) splenic, 7 (14%) celiac trunk, 7 (14%) superior mesenteric artery, 4 (8%) hepatic, 4 (8%) pancreaticoduodenal arcades, 3 (6%) left gastric and 1 (2%) gastroduodenal. 4 patients presented with a ruptured SRAA. 17 SRAAs in 16 patients were treated by open repair, 15 in 15 patients were treated endoluminally and 17 (mean diameter: 18 mm, range: 8-75 mm) were managed conservatively. One patient with metastatic pulmonary cancer with two mycotic aneurysms of the superior mesenteric artery (75 mm) and celiac trunk (15 mm) was palliated. After endovascular treatment, the immediate technical success rate was 100%. There was no significant difference between open repair and endovascular patients in terms of 30-day post-operative mortality rate and peri-operative complications. No in-hospital death occurred in patients treated electively. Postoperatively, four patients (1 ruptured and 3 elective) suffered non-lethal mild to severe complication in the open repair group, as compared with one in the endovascular group (p = .34). The mean length of stay was significantly higher after open repair as compared with endovascular repair (17 days, range: 8-56 days vs. 4 days, range: 2-6; p < .001). The mean follow-up time was 17.8 months (range: 0-143 months) after open repair, 15.8 months (range: 0-121 months) after endovascular treatment, and 24.8 (range: 3-64 months) for patient being managed conservatively. No late death related to the VAA occurred. In each group, 2 successful reoperations were deemed necessary. In the endovascular group, two patients presented a reperfusion of the aneurysmal sac at 6 and 24 months respectively. CONCLUSION: No significant difference in term of 30-day mortality and post-operative complication rates could be identified between open repair and endovascular treatment in the present series. Endovascular treatment is a safe alternative to open repair but patients are exposed to the risk of aneurysmal reperfusion. This mandates careful long-term imaging follow up in patients treated endoluminally.
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Aneurisma/cirugía , Arteria Renal , Circulación Esplácnica , Adulto , Anciano , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Femenino , Francia , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Reino UnidoRESUMEN
AIMS: To establish a method to assess amputation incidence that addresses the problems matching a numerator with an appropriate denominator in London and to demonstrate low amputation incidence associated with the activity of our multidisciplinary diabetic foot clinic. METHODS: Hospital-coded inpatient data was examined to derive the numerator: the number of non-traumatic amputations performed on subjects with diabetes each financial year where the Primary Care Trust commissioner code was our main local Primary Care Trust. Denominators were derived from the main local Primary Care Trust's Quality and Outcomes Framework data sets. Not all Primary Care Trust subjects with diabetes receive inpatient care at our hospital, so that the denominators were corrected for the hospital's percentage market share for the provision of inpatient diabetes care for the Primary Care Trust each financial year, derived from the Dr Foster database. RESULTS: Between April 2004 and April 2009, 44 Primary Care Trust subjects with diabetes underwent 34 minor and 10 major amputations at the hospital. Although the Primary Care Trust populations with and without diabetes increased, the hospital's Primary Care Trust percentage market share decreased, so that overall denominators decreased. The mean annual incidence of minor, major and total amputations over the five financial years was 14.7, 4.2 and 18.9 per 10 000 subjects with diabetes,respectively, and 3.9, 1.1 and 5.0 per 100 000 of the general population, respectively. CONCLUSIONS: We report for the first time amputation incidence in a London population. Acknowledging the limitations of accurately defining incidence in London, we demonstrate low amputation incidence associated with our multidisciplinary diabetic foot clinic.
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Amputación Quirúrgica/estadística & datos numéricos , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Pie Diabético/epidemiología , Anciano , Diabetes Mellitus Tipo 1/cirugía , Diabetes Mellitus Tipo 2/cirugía , Pie Diabético/cirugía , Femenino , Humanos , Incidencia , Londres/epidemiología , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: To determine the incidence and risk factors for spinal cord ischaemia (SCI) following thoracic and thoracoabdominal aortic intervention. METHODS: A prospective database of all thoracic and thoracoabdominal aortic interventions between 2001 and 2009 was used to investigate the incidence of SCI. All elective and emergency cases for all indications were included. Logistic regression was used to investigate which factors were associated with SCI. RESULTS: 235 patients underwent thoracic aortic stent grafting; 111(47%) thoracic aortic stent-grafts alone, with an additional 14(6%) branched or fenestrated thoracic grafts, 30(13%) arch hybrid procedures and 80(34%) visceral hybrid surgical and endovascular procedures. The global incidence of SCI for all procedures was 23/235 (9.8%) and this included emergency indications (ruptured TAAA and acute complex dissections) but the incidence varied considerably between types of procedures. Of the 23 cases, death occurred in 4 patients but recovery of function was seen in 6. Thus, permanent paraplegia occurred in 13/235 (5.5%) patients. Of the nine pre-specified factors investigated for association with SCI, only percentage of aortic coverage was significantly associated with the incidence of SCI; adjusted odds ratio per 10% increase in aorta covered=1.78[95% CI 1.18-2.71], p=0.007. The procedures in patients who developed SCI took longer (463.5 versus 307.2 minutes) and utilised more stents (4 versus 2). CONCLUSION: SCI following thoracic and thoracoabdominal aortic endovascular intervention is associated with the proportion of aorta covered. The degree of risk varies between different types of procedure and this should be carefully considered in both selection and consenting of patients.
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Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Isquemia de la Médula Espinal/etiología , Anciano , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Torácica/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Incidencia , Modelos Logísticos , Londres , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Selección de Paciente , Diseño de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Isquemia de la Médula Espinal/mortalidad , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the outcome of hybrid treatment of the aortic arch with supra-aortic debranching and endovascular stent-graft repair in a selected group of patients with complex disease. DESIGN: Case series study with retrospective analysis of prospectively collected non-randomised data. METHODS: Patients with hybrid repair of complex arch disease at a single centre over a 6-year period were enrolled in the study. Only patients with extensive arch pathologies requiring debranching of at least the left carotid artery were considered. Patients were divided into those who underwent complete and partial supra-aortic revascularisation. The χ2 test was used to evaluate differences in outcomes. Logistic regression analyses were applied to identify predictors of poor outcome. RESULTS: A total of 33 patients were included in the study. Complete and partial arch repair was performed in nine and 24 patients, respectively. The aortic disease extended to the thoracic and abdominal aorta in 39% and 52% of the patients, respectively. One-third of the patients (30%) were treated on an urgent/emergency basis. Elective 30-day mortality and morbidity rates were 13% and 35%, respectively. Early mortality was significantly higher in the complete arch repair group (p=0.046). Pre-existing renal impairment was identified as a poor prognostic factor. All extra-anatomic bypasses remained patent and no aortic disease-related deaths occurred during a mean follow-up period of 23 months (range, 1.5-58 months). Complete arch repair was associated with an increased incidence of late endoleak (p=0.018). CONCLUSIONS: Hybrid treatment of the aortic arch provides a feasible alternative treatment in patients who are high risk for conventional open surgical repair. Careful selection of patients is required to achieve satisfactory results.
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Aorta Abdominal/cirugía , Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Adulto , Anciano , Anciano de 80 o más Años , Aorta Abdominal/diagnóstico por imagen , Aorta Torácica/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Modelos Logísticos , Londres , Masculino , Persona de Mediana Edad , Selección de Paciente , Diseño de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Aortic dissection is the most common acute catastrophic event affecting the thoracic aorta. The majority of patients presenting with an uncomplicated type B dissection are treated medically, but 25% of these patients develop subsequent aneurysmal dilatation of the thoracic aorta. This study aimed at gaining more detailed knowledge of the flow phenomena associated with this condition. Morphological features and flow patterns in a dissected aortic segment of a presurgery type B dissection patient were analyzed based on computed tomography images acquired from the patient. Computational simulations of blood flow in the patient-specific model were performed by employing a correlation-based transitional version of Menter's hybrid k-epsilon/k-omega shear stress transport turbulence model implemented in ANSYS CFX 11. Our results show that the dissected aorta is dominated by locally highly disturbed, and possibly turbulent, flow with strong recirculation. A significant proportion (about 80%) of the aortic flow enters the false lumen, which may further increase the dilatation of the aorta. High values of wall shear stress have been found around the tear on the true lumen wall, perhaps increasing the likelihood of expanding the tear. Turbulence intensity in the tear region reaches a maximum of 70% at midsystolic deceleration phase. Incorporating the non-Newtonian behavior of blood into the same transitional flow model has yielded a slightly lower peak wall shear stress and higher maximum turbulence intensity without causing discernible changes to the distribution patterns. Comparisons between the laminar and turbulent flow simulations show a qualitatively similar distribution of wall shear stress but a significantly higher magnitude with the transitional turbulence model.
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Aneurisma de la Aorta Torácica/patología , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/patología , Disección Aórtica/cirugía , Aorta/fisiopatología , Aorta Torácica/fisiopatología , Aneurisma de la Aorta , Técnicas de Laboratorio Clínico , Femenino , Hemodinámica , Humanos , Persona de Mediana Edad , Fenómenos Físicos , Investigación , Estrés MecánicoRESUMEN
Abdominal aortic aneurysms cause about 6000 deaths per year in England and Wales, predominantly from rupture. Significant progress has been made in recent years in developing minimally invasive, endovascular methods of treatment. This review evaluates the current management options for abdominal aortic aneurysm.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/métodos , Stents , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/prevención & control , Femenino , Humanos , Masculino , Tamizaje Masivo/economía , Tamizaje Masivo/normas , Estudios Multicéntricos como Asunto , Pronóstico , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
AIMS: To assess efficacy of conservative management of neuropathic forefoot ulcers with underlying osteomyelitis in subjects with diabetes when magnetic resonance imaging (MRI) is used to confirm or establish diagnosis and to guide antibiotic duration. METHODS: A retrospective cohort study over 6 years assessing rates of ulcer healing, relapse and amputation. Antibiotics were continued for 3-month cycles with interval MRI: if the lesion had healed and bone signal change resolved or improved, antibiotics were discontinued; if the lesion had not healed or there was no difference in bone signal change, antibiotics were continued for a further 3-month cycle; clinical or radiological deterioration resulted in endoluminal or open vascular surgical intervention where appropriate, or digital or more proximal amputation. RESULTS: There were 53 episodes in 47 subjects (mean +/- sd age 62 +/- 13 years, duration of diabetes 19 +/- 13 years, glycated haemoglobin 8.4 +/- 1.6%; six with Type 1 diabetes and seven with end-stage renal failure). Successful healing without relapse was achieved in 40 episodes (75%) [median (range) duration of antibiotics 6 (3-12) months and follow-up post-cessation of antibiotics 15 (3-58) months]. Relapse occurred in six episodes (13%) at 31 (2-38) months post-cessation of antibiotics. There were one major (2%) and eight minor (15%) amputations. Five subjects have died (11%), all without foot ulcers. CONCLUSIONS: High rates of healing and low rates of amputation were achieved. The use of MRI was associated with long courses of antibiotics, but particularly low relapse rate.
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Antibacterianos/uso terapéutico , Diabetes Mellitus Tipo 1/complicaciones , Pie Diabético/etiología , Antepié Humano , Imagen por Resonancia Magnética , Osteomielitis/complicaciones , Infección de la Herida Quirúrgica/etiología , Anciano , Algoritmos , Amputación Quirúrgica , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/terapia , Pie Diabético/diagnóstico , Pie Diabético/terapia , Femenino , Humanos , Incidencia , Imagen por Resonancia Magnética/métodos , Masculino , Osteomielitis/diagnóstico , Osteomielitis/terapia , Estudios Retrospectivos , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/terapia , Cicatrización de Heridas/fisiologíaRESUMEN
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.
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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
OBJECTIVES: To describe our experience of treating juxtarenal (JRAAA's <4mm neck) and thoracoabdominal aortic aneurysms (TAAA's) using fenestrated and branched stent graft technology. DESIGN: Prospective single centre experience. METHODS: Since 2005, 29 fenestrated/branched procedures have been performed. 15 patients are studied with JRAAAs (n=7; median neck length 0mm (IQR 0-3.8)) or TAAAs (type I (n=2), III (n=2), IV (n=4)). ASA grade III in 12/15. Maximum diameter of aneurysm 64 mm (56-74 mm). Aneurysms were excluded using covered stents or branches from the main body to patent visceral vessels (40 target vessels total). Pre-operative and follow-up CT scans (1, 3, and 12 months) were analysed by a single Vascular Interventional Radiologist. RESULTS: Technical success for cannulation and stenting of target vessels was 98%. In-hospital mortality was 0%. One patient underwent conversion to open repair. Five had major complications including one paraplegia (type III TAAA) with subsequent recovery. Median length of stay was 9 days (IQR 7-18.75). At a median follow-up of 12 months (9-14), CT confirmed 36/37 (97%) target vessels remain patent. Sac size increased >5 mm in one patient only. There were no type I endoleaks, three type II endoleaks (one embolised, two under surveillance) and three type III endoleaks (two successfully treated percutaneously, one aneurysm ruptured 18 months after endografting and died). CONCLUSION: In selected patients, fenestrated and branched stents appear to be a safe and effective alternative to surgery for juxtarenal and thoracoabdominal aneurysms. The complication and mortality rates are low. The long-term durability of this procedure, however, needs to be proven.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Stents , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/etiología , Rotura de la Aorta/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Bases de Datos como Asunto , Femenino , Humanos , Tiempo de Internación , Masculino , Paraplejía/etiología , Estudios Prospectivos , Diseño de Prótesis , Falla de Prótesis , Reoperación , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
ATP binding cassette transporter A1 (ABCA1) mediates the cellular efflux of phospholipids and cholesterol to lipid-poor apolipoprotein A1 (apoA1) and plays a significant role in high density lipoprotein (HDL) metabolism. ABCA1's role in the causation of Tangier disease, characterized by absent HDL and premature atherosclerosis, has implicated this transporter and its regulators liver-X-receptoralpha (LXRalpha) and peroxisome proliferator activated receptorgamma (PPARgamma) as new candidates potentially influencing the progression of atherosclerosis. In addition to lipid regulation, these genes are involved in apoptosis and inflammation, processes thought to be central to atherosclerotic plaque progression. A Medline-based review of the literature was carried out. Tangier disease and human heterozygotes with ABCA1 mutations provide good evidence that ABCA1 is a major candidate influencing atherosclerosis. Animal and in vitro experiments suggest that ABCA1 not only mediates cholesterol and phospholipid efflux, but is also involved in the regulation of apoptosis and inflammation. The complex and beneficial interactions between apoA1 and ABCA1 seem to be pivotal for cholesterol efflux. The expression of the ABCA1 is tightly regulated. Furthermore the plaque microenvironment could potentially promote ABCA1 protein degradation thus compromising cholesterol efflux. PPAR-LXR-ABCA1 interactions are integral to cholesterol homeostasis and these nuclear receptors have proven anti-inflammatory and anti-matrix metalloproteinase activity. Therapeutic manipulation of the ABCA1 transporter is feasible using PPAR and LXR agonists. PPAR agonists like glitazones and ABCA1 protein stabilization could potentially modify the clinical progression of atherosclerotic lesions.
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Transportadoras de Casetes de Unión a ATP/metabolismo , Arteriosclerosis/tratamiento farmacológico , Arteriosclerosis/genética , Tiazolidinedionas/uso terapéutico , Transportador 1 de Casete de Unión a ATP , Transportadoras de Casetes de Unión a ATP/genética , Animales , Arteriosclerosis/diagnóstico , HDL-Colesterol/efectos de los fármacos , HDL-Colesterol/metabolismo , Progresión de la Enfermedad , Femenino , Marcadores Genéticos/genética , Humanos , Masculino , Pronóstico , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Enfermedad de Tangier/diagnóstico , Enfermedad de Tangier/tratamiento farmacológico , Enfermedad de Tangier/genéticaRESUMEN
BACKGROUND AND PURPOSE: The ATP-binding cassette transporter A1 (ABCA1) facilitates cholesterol efflux from cells, a key process in reverse cholesterol transport. Whereas previous investigations focused on mutations causing impaired ABCA1 function, we assessed the role of ABCA1 in human carotid atherosclerotic disease. METHODS: We compared the mRNA and protein levels of ABCA1, and one of its key regulators, the liver X receptor alpha (LXRalpha), between minimally and grossly atherosclerotic arterial tissue. We established ABCA1 and LXRalpha gene expression by real-time quantitative polymerase chain reaction in 10 control and 18 atherosclerotic specimens. Presence of ABCA1 protein was assessed by immunoblotting. To determine whether differences observed at a local level were reflected in the systemic circulation, we measured ABCA1 mRNA in leukocytes of 10 patients undergoing carotid endarterectomy and 10 controls without phenotypic atherosclerosis. RESULTS: ABCA1 and LXRalpha gene expression were significantly elevated in atherosclerotic plaques (P<0.0001 and 0.03, respectively). The increased mRNA levels of ABCA1 and LXRalpha were correlated in atherosclerotic tissue (r=0.85; P<0.0001). ABCA1 protein expression was significantly reduced in plaques compared with control tissues (P<0.0001). There were no differences in leukocyte ABCA1 mRNA expression (P=0.67). CONCLUSIONS: ABCA1 gene and protein are expressed in minimally atherosclerotic human arteries. Despite significant upregulation of ABCA1 mRNA, possibly mediated via LXRalpha, ABCA1 protein is markedly reduced in advanced carotid atherosclerotic lesions. No differences in leukocyte ABCA1 expression were found, suggesting the plaque microenvironment may contribute to the differential ABCA1 expression. We propose that the decreased level of ABCA1 protein is a key factor in the development of atherosclerotic lesions.