RESUMEN
BACKGROUND AND PURPOSE: International recommendations advocate that carotid endarterectomy (CEA) should be performed within 2 weeks from the index event in symptomatic carotid artery stenosis (sCAS) patients. However, there are controversial data regarding the safety of CEA performed during the first 2 days of ictus. The aim of this international, multicenter study was to prospectively evaluate the safety of urgent (0-2 days) in comparison to early (3-14 days) CEA in patients with sCAS. METHODS: Consecutive patients with non-disabling (modified Rankin Scale scores ≤2) acute ischaemic stroke or transient ischaemic attack due to sCAS (≥70%) underwent urgent or early CEA at five tertiary-care stroke centers during a 6-year period. The primary outcome events included stroke, myocardial infarction or death during the 30-day follow-up period. RESULTS: A total of 311 patients with sCAS underwent urgent (n = 63) or early (n = 248) CEA. The two groups did not differ in baseline characteristics with the exception of crescendo transient ischaemic attacks (21% in urgent vs. 7% in early CEA; P = 0.001). The 30-day rates of stroke did not differ (P = 0.333) between patients with urgent (7.9%; 95% confidence interval 3.1%-17.7%) and early (4.4%; 95% confidence interval 2.4%-7.9%) CEA. The mortality and myocardial infarction rates were similar between the two groups. The median length of hospitalization was shorter in urgent CEA [6 days (interquartile range 4-6) vs. 10 days (interquartile range 7-14); P < 0.001]. CONCLUSIONS: Our findings highlight that urgent CEA performed within 2 days from the index event is related to a non-significant increase in the risk of peri-procedural stroke. The safety of urgent CEA requires further evaluation in larger datasets.
Asunto(s)
Isquemia Encefálica/cirugía , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Accidente Cerebrovascular/cirugía , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/etiología , Estenosis Carotídea/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/etiología , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE/BACKGROUND: To review the incidence of post-carotid endarterectomy (CEA) cranial nerve injury (CNI), and to evaluate the risk factors associated with increased CNI risk. METHODS: The study was a meta-analysis. Pooled rates with 95% confidence intervals (CIs) were calculated for CNIs after primary CEA. Odds ratios (ORs) were calculated for potential risk factors. A fixed-effects model or a random effects model (Mantel-Haenszel method) was used for non-heterogeneous and heterogeneous data, respectively. Meta-regression analysis was performed to examine the influence of publication year upon CNI rate. RESULTS: Twenty-six articles, published between 1970 and 2015, were included in the meta-analysis, corresponding to 20,860 CEAs. Meta-analysis revealed that the vagus nerve was the most frequently injured cranial nerve (pooled injury rate 3.99%, 95% CI 2.56-5.70), followed by the hypoglossal nerve (3.79%, 95% CI 2.73-4.99). Fewer than one seventh of these injuries are permanent (vagus nerve: 0.57% [95% CI 0.19-1.10]; hypoglossal nerve: 0.15% [95% CI 0.01-0.39]). A statistically significant influence of publication year on the vagus and hypoglossal nerve injury rate was found, with the injury rate having decreased from about 8% to 2% and 1%, respectively, over the last 35 years. Urgent procedures (OR 1.59, 95% CI 1.21-2.10; p = .001), as well as return to the operating room for a neurological event or bleeding (OR 2.21, 95% CI 1.35-3.61; p = .002) were associated with an increased risk of CNI, whereas no statistically significant association was found between CNIs and the type of anaesthesia, the use of a patch, redo operation, and the use of a shunt. CONCLUSION: The vagus nerve appears to be the most frequently injured cranial nerve after CEA, followed by the hypoglossal nerve, with only a small proportion of these injuries being permanent. The CNI rate has significantly decreased over the past 35 years to a point indicating that CNIs should not be considered a major influencing factor in the decision making process between CEA and stenting.
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Enfermedades de las Arterias Carótidas/cirugía , Traumatismos del Nervio Craneal/epidemiología , Endarterectomía Carotidea/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Traumatismos del Nervio Craneal/diagnóstico , Traumatismos del Nervio Craneal/fisiopatología , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Recuperación de la Función , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The widespread use of central venous catheters, ports, pacemakers, and defibrillators has increased the incidence of benign superior vena cava syndrome (SVCS). This study aimed at reviewing the results of open and endovascular treatment of SVCS. METHOD: Medical literature databases were searched for relevant studies. Studies with more than five adult patients, reporting separate results for the SVC were included. Nine studies reported the results of endovascular treatment of SVCS including 136 patients followed up for a mean of 11-48 months. Causes of SVCS were central venous catheters and pacemakers (80.6%), mediastinal fibrosis (13.7%), and other (5.6%). Percutaneous transluminal angioplasty (PTA) and stenting was performed in 73.6%, PTA only in 17.3%, and thrombolysis, PTA, and stenting in 9%. Four studies reported the results of open repair of SVCS including 87 patients followed up between 30 months and 10.9 years. The causes were mediastinal fibrosis (58.4%), catheters and pacemakers (28.5%), and other (13%). Operations performed included a spiral saphenous interposition graft, other vein graft, PTFE graft, and human allograft. Thirteen patients required re-operations (15%) before discharge mainly for graft thrombosis. RESULTS: In the endovascular group technical success was 95.6%. Thirty day mortality was 0%. Regression of symptoms was reported in 97.3%. Thirty-two patients (26.9%) underwent 58 secondary procedures. In the open group the 30 day mortality was 0%. Symptom regression was reported in 93.5%. Twenty-four patients (28.4%) underwent a total of 33 secondary procedures. CONCLUSIONS: Endovascular is the first line treatment for SVCS caused by intravenous devices, whereas surgery is most often performed for mediastinal fibrosis. Both treatments show good results regarding regression of the symptoms and mid-term primary patency, with a significant incidence of secondary interventions.
Asunto(s)
Angioplastia de Balón , Implantación de Prótesis Vascular , Síndrome de la Vena Cava Superior/terapia , Terapia Trombolítica , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Femenino , Oclusión de Injerto Vascular/etiología , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Stents , Síndrome de la Vena Cava Superior/diagnóstico por imagen , Síndrome de la Vena Cava Superior/epidemiología , Síndrome de la Vena Cava Superior/fisiopatología , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVES: The aim was to evaluate the safety and efficacy of heparin reversal with protamine after completion of carotid endarterectomy (CEA), summarising the available data from both randomised and non-randomised studies. METHODS: The study was a meta-analysis. Pooled odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated for the outcomes of stroke and wound haematoma among patients receiving or not receiving protamine after CEA. Meta-regression analysis was performed to examine whether the documented differences were modified by potentially meaningful patient related or procedure related predictors, namely publication year, general anesthesia used, number of patients treated, mean age (years), males, neurological symptoms, use of patch, and use of shunt. RESULTS: Seven studies were included in the meta-analysis reporting on 3,817 patients receiving protamine after CEA and 6,070 patients not receiving protamine for heparin reversal. Only one study was randomised. A statistically significant reduction in wound haematoma requiring re-operation was recorded after heparin reversal with protamine in patients undergoing CEA (OR, 0.42, 95% CI, 0.22-0.80, p = .008). In contrast, no significant difference was observed in stroke rates between groups of patients that received and did not receive protamine (OR, 0.71, 95% CI, 0.49-1.03, p = .07). Meta-regression analysis did not reveal any significant effect mediated by the modifiers examined. CONCLUSION: On the basis of the available data, heparin reversal with protamine seems to reduce the risk of wound haematoma, without increasing the risk of procedural stroke. However, taking into account the limitations of the analysis, further studies are needed to increase the level of evidence provided by the current meta-analysis.
Asunto(s)
Endarterectomía Carotidea/métodos , Antagonistas de Heparina/uso terapéutico , Hemorragia Posoperatoria/prevención & control , Protaminas/uso terapéutico , Accidente Cerebrovascular/inducido químicamente , Endarterectomía Carotidea/efectos adversos , Humanos , Accidente Cerebrovascular/etiologíaRESUMEN
OBJECTIVES: The aim of this study was to investigate risk factors for endograft limb occlusion after endovascular abdominal aneurysm repair (EVAR), using a case control design. METHODS: All patients presenting with endograft limb occlusion after elective EVAR between January 2010 and June 2013, along with age, sex, and type of endograft matched controls were included in the study. The impact of atherosclerotic risk factors, anatomic characteristics of the aneurysm, procedural details, and antiplatelet therapy was investigated. Multivariate logistic regression analysis and conditional logistic regression analysis for 1:3 matched pairs deriving adjusted odds ratios (ORs) with 95% confidence intervals (CIs) in order to detect significant risk factors for endograft limb occlusion among cases and controls were modeled. RESULTS: Of the 439 patients treated by EVAR, 18 patients (4.1%) presented with endograft limb occlusion. These patients were compared to 54 matched controls. Limb occlusion was associated with iliac artery angulation ≥ 60° (OR = 5.76, 95% CI =1.24-26.74; p = .03) or perimeter calcification ≥ 50% (OR =5.87, 95% CI = 1.10-31.32; p = .04). Limb occlusion was also associated with ≥ 15% endograft oversizing in the common iliac artery (OR = 5.54, 95% CI = 1.11-27.60; p = .04). No other risk factors for limb occlusion were recognized. CONCLUSIONS: The presence of significant angulation and calcification of the iliac arteries as well as excessive limb oversizing appear to be independent predictors of endograft limb occlusion after EVAR.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares/estadística & datos numéricos , Oclusión de Injerto Vascular/epidemiología , Anciano , Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Estudios de Casos y Controles , Causalidad , Procedimientos Endovasculares/efectos adversos , Femenino , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/terapia , Humanos , Incidencia , Pierna/irrigación sanguínea , Modelos Logísticos , Masculino , Pronóstico , Diseño de Prótesis , Reoperación , Factores de Riesgo , Stents/efectos adversos , Trombectomía , Trombosis/epidemiología , Trombosis/etiología , Trombosis/cirugía , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , UltrasonografíaRESUMEN
BACKGROUND AND PURPOSE: Many medical societies now recommend carotid stenting as an alternative to endarterectomy which raises the question of whether the ESVS guidelines are still valid. This review addresses the validity of the ESVS guidelines that refer to carotid stenting based on the evidence available today. METHODS: We conducted a review and meta-analysis based on the original ESVS guidelines paper and articles published over the past 2 years. RESULTS: For symptomatic patients, surgery remains the best option, since stenting is associated with a 61% relative risk increase of periprocedural stroke or death compared to endarterectomy. However, centres of excellence in carotid stenting may achieve comparable results. In asymptomatic patients, there is still no good evidence for any intervention because the stroke risk from an asymptomatic stenosis is very low, especially with the best modern medical treatment. CREST and CAVATAS have verified that mid-term stroke prevention after successful stenting is similar to endarterectomy. EVA-3S, SPACE, ICSS and CREST have provided additional evidence regarding the role of age in choosing therapeutic modality. The role of the cerebral protection devices is challenged by the imaging findings of small randomised trials but supported by large systematic reviews. CONCLUSIONS: The ESVS guidelines that refer to carotid stenting not only remain valid but also have been further strengthened by the latest available clinical data. An update of these guidelines including all of the recent evidence is needed to provide an objective and up-to-date interpretation of the data.
Asunto(s)
Angioplastia/normas , Estenosis Carotídea/terapia , Endarterectomía Carotidea , Guías de Práctica Clínica como Asunto/normas , Sociedades Médicas/normas , Angioplastia/instrumentación , Angioplastia/mortalidad , Enfermedades Asintomáticas , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/mortalidad , Endarterectomía Carotidea/normas , Europa (Continente) , Medicina Basada en la Evidencia/normas , Humanos , Selección de Paciente , Medición de Riesgo , Factores de Riesgo , Stents/normas , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Resultado del TratamientoRESUMEN
OBJECTIVES/DESIGN: The aim of the study was to investigate debris captured in filter embolic protection devices (EPDs) during carotid artery stenting (CAS) and its possible correlation with plaque echogenicity and other risk factors. MATERIALS/METHODS: Between June 2010 and March 2011, 51 consecutive CAS patients (11 females, mean age 71.2 ± 7, 10 symptomatic) who underwent 53 procedures were included in this prospective study. Ultrasonographic Gray-Weale plaque type (I-V, echolucent to echogenic) characterisation was obtained in all cases. The same type of stent and filter EPD was used. Filters were collected and, after macroscopic evaluation, they were examined using the Thin-Prep(®) liquid-based cytology (LBC) technique. RESULTS: Technical success was 100%. Thirty-day stroke and death rates were 1.8% (1/53) and 0%, respectively. Visible debris was detected in eight (15%) filters, whereas LBC revealed the presence of embolic material particles in 30 filters (56.6%). The presence of embolic material into the filter EPD was 2.38-fold increased for every category change from type IV to type I carotid plaques (OR = 2.38, 95%CI = 1.15-4.93). This association remained robust even after adjustment for age, gender and known atherosclerotic disease risk factors (OR = 2.26, 95%CI = 1.02-5.02). In multivariate analysis for risk factors, hypertension was associated with increased presence of embolic material detection in filter EPD (OR = 20.4, 95%CI = 1.28-326.1). The time distance from symptom to CAS was inversely correlated with debris quantity in EPD (Spearman rho -0.716; p = 0.02). CONCLUSIONS: Echolucent plaques, smaller time frame from last symptom and hypertension were associated with increased presence of embolic material.
Asunto(s)
Angioplastia/instrumentación , Estenosis Carotídea/terapia , Dispositivos de Protección Embólica , Embolia/prevención & control , Placa Aterosclerótica/terapia , Stents , Anciano , Angioplastia/efectos adversos , Enfermedades Asintomáticas , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/mortalidad , Distribución de Chi-Cuadrado , Embolia/etiología , Embolia/mortalidad , Embolia/patología , Femenino , Grecia , Humanos , Hipertensión/complicaciones , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Placa Aterosclerótica/complicaciones , Placa Aterosclerótica/diagnóstico por imagen , Placa Aterosclerótica/mortalidad , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Factores de Tiempo , Resultado del Tratamiento , UltrasonografíaRESUMEN
BACKGROUND: To compare eversion (ECEA) and conventional (CCEA) carotid endarterectomy from randomised and non-randomised studies. METHODS: Pooled odds ratios (ORs) with 95% confidence intervals (95%CIs) and numbers needed to treat (NNTs) were appropriately calculated. A sub-analysis was performed on studies directly comparing ECEA vs. patch CEA (PCEA). Meta-regression analysis was performed to examine the effect of potentially meaningful patient-related, procedure-related and definition-related modifiers. Power calculations were also conducted. RESULTS: A total of 21 studies were deemed eligible (8530 ECEA and 7721 CCEA procedures), seven of which were randomised and 14 non-randomised. ECEA was associated with significant reduction in perioperative stroke (OR = 0.46, 95%CI: 0.35-0.62, NNT = 68, 95%CI: 56-96), death (OR = 0.49, 95%CI: 0.34-0.69, NNT = 100, 95%CI: 85-185) and stroke-related death (OR = 0.40, 95%CI: 0.23-0.67, NNT = 147, 95%CI: 115-270); the results were replicated at the sub-analysis on PCEA. Concerning long-term outcomes, ECEA presented with a significant reduction in late carotid artery occlusion (OR = 0.48, 95%CI: 0.25-0.90, NNT = 143, 95%CI: 100-769) and late mortality (OR = 0.76, 95%CI: 0.61-0.94, NNT = 40, 95%CI: 25-167); the sub-analysis on PCEA replicated only the finding on late mortality. Meta-regression analysis did not point to significant effects mediated by the examined modifiers. Power calculations suggested adequate statistical power. CONCLUSIONS: ECEA compared to CCEA may be associated with a lower incidence in both short-term and long-term outcomes, which does not seem to be hampered by potentially meaningful modifiers.
Asunto(s)
Estenosis Carotídea/cirugía , Endarterectomía Carotidea/métodos , Anciano , Estenosis Carotídea/mortalidad , Intervalos de Confianza , Humanos , Números Necesarios a Tratar , Oportunidad Relativa , Complicaciones Posoperatorias/prevención & control , Ensayos Clínicos Controlados Aleatorios como Asunto , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/prevención & control , Análisis de SupervivenciaRESUMEN
OBJECTIVES/DESIGN: In symptomatic patients treated with ipsilateral carotid artery stenting (CAS) plus intensive lipid lowering, we assessed the changes of osteopontin (OPN), osteoprotegerin (OPG) and the Gray-Scale Median (GSM) score contralateral to symptomatic carotid stenosis. MATERIALS/METHODS: Forty-six symptomatic patients (group A) with significant carotid stenosis (North American Symptomatic Carotid Endarterectomy Trial (NASCET): >70%) underwent ipsilateral CAS. Those patients had simultaneously contralateral low-grade carotid stenosis (NASCET: 30-69%). Group B included 67 symptomatic patients with low-grade bilateral carotid stenosis (NASCET: 30-69%), but without indications for revascularisation. All patients were treated with atorvastatin (10-80mg) to target low-density lipoprotein (LDL)<100mgdl(-1). Blood samples and plaques' GSM score contralateral to brain infarct were assayed at baseline and after 6 months. RESULTS: At baseline, there were no significant differences between groups (p>0.05). Six-month atorvastatin treatment equivalently improved lipid profile in both groups (p<0.05). The parameters hsCRP, OPN and OPG were significantly down-regulated within both groups, but to a greater extent in group A (p<0.05). Besides this, contralateral GSM score was significantly improved from baseline in both groups (p<0.01), but that increment was more pronounced in group A (vs. group B; p=0.041). These changes were inversely correlated with changes in OPN (p=0.014), OPG (p=0.011) and LDL (p=0.041). CONCLUSION: Ipsilateral CAS plus intensive lipid-lowering therapy was associated with enhanced contralateral carotid plaque stability and attenuated inflammatory burden and calcification inhibitors to a greater extent than atorvastatin therapy alone in patients with bilateral carotid stenosis.
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Angioplastia/instrumentación , Calcinosis/terapia , Estenosis Carotídea/terapia , Ácidos Heptanoicos/uso terapéutico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Osteopontina/sangre , Osteoprotegerina/sangre , Pirroles/uso terapéutico , Stents , Ultrasonografía Doppler , Anciano , Atorvastatina , Biomarcadores/sangre , Proteína C-Reactiva/metabolismo , Calcinosis/sangre , Calcinosis/diagnóstico por imagen , Calcinosis/tratamiento farmacológico , Estenosis Carotídea/sangre , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/tratamiento farmacológico , Terapia Combinada , Regulación hacia Abajo , Femenino , Grecia , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
The European Society for Vascular Surgery has recently published updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence (A: randomized controlled trials, B: well-conducted clinical studies, C: expert opinion). The following document summarizes the evidence on which these recommendations were based, in order to keep physicians from various disciplines updated on the advances in the field of the invasive management of carotid disease.
Asunto(s)
Estenosis Carotídea/terapia , Endarterectomía Carotidea/normas , Stents , Anestesia General , Anestesia Local , Estenosis Carotídea/cirugía , Medicina Basada en la Evidencia , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Guías de Práctica Clínica como AsuntoRESUMEN
BACKGROUND: Our aim was to investigate the association of inflammation and Chlamydia pneumoniae infection with the presence and severity of peripheral arterial disease. METHODS: Twenty-eight patients whose initial claudication distance (ICD) in the traditional constant-load treadmill test was <200 m, underwent femoral endarterectomy as part of their interventional treatment (group A). Group B consisted of 23 patients whose ICD was >200 m and were put on medication and a daily exercise program. The control group consisted of 30 non-vascular patients of the Ophthalmology Department (group C). We measured the levels of C-reactive protein, fibrinogen, vascular cell adhesion molecule-1 and tumor necrosis factor-alpha, and the titers of IgA and IgG antibodies against C. pneumoniae in the serum of all the patients. Finally, the atheromas and vein segments of group A patients, were immunohistochemically (IHC) examined for the presence of C. pneumoniae. RESULTS: Peripheral arterial disease (PAD) patients, had significantly higher CRP (p=0.026) and anti-Cp IgA levels (p=0.001) when compared to control subjects, after a multiple linear regression analysis. The odds ratio for the prevalence of femoral atherosclerosis was 3.16 for IgA seropositive patients (CI 1.15-8.67). When comparing group A and group B patients, CRP (p=0.003) and IgA (p=0.011), were significantly correlated with severe PAD. Group A patients with positive immunohistochemical examination of the plaque, had higher anti-Cp IgA levels (p=0.023) and TNF-alpha values (p=0.031), compared to the IHC negative patients. C. pneumoniae was detected in 50% of the femoral atheromas, but in only 3.6% of the veins. CONCLUSION: This study supports the hypothesis that inflammation (CRP) and chronic C. pneumoniae infection (IgA seropositivity), have an important role in lower limb atherosclerosis and correlate with the severity of the disease.
Asunto(s)
Aterosclerosis/sangre , Aterosclerosis/microbiología , Chlamydophila pneumoniae/aislamiento & purificación , Mediadores de Inflamación/sangre , Enfermedades Vasculares Periféricas/sangre , Enfermedades Vasculares Periféricas/microbiología , Anciano , Anticuerpos Antibacterianos/sangre , Proteína C-Reactiva/metabolismo , Estudios de Casos y Controles , Chlamydophila pneumoniae/inmunología , Estudios Transversales , Femenino , Fibrinógeno/metabolismo , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Factor de Necrosis Tumoral alfa/metabolismo , Molécula 1 de Adhesión Celular Vascular/sangreRESUMEN
PURPOSE: The aim of this article is to discuss the role of inflammation in atherosclerosis. SUMMARY: An initial chemical, mechanical or immunological insult induces endothelial dysfunction. This triggers a cascade of inflammatory reactions, in which monocytes, macrophages, T lymphocytes and vascular smooth muscle cells participate. Leukocyte adhesion molecules, cytokines, growth factors and metalloproteinases participate in all stages of atherogenesis. Almost all of the traditional risk factors for atherosclerosis are associated with and participate in the inflammatory process. Many infectious agents, mainly Chlamydia pneumoniae, have been proposed as potential triggers of the cascade. The immune system has been implicated in plaque formation, through the activation of cellular and humoral immunity against innate or microbial heat shock protein 60. Methods of detection of systemic or local plaque inflammation have been developed and research is being conducted on the potential use of anti-inflammatory and antibiotic drugs in atherosclerosis.
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Aterosclerosis/fisiopatología , Inflamación/fisiopatología , Aterosclerosis/inmunología , Aterosclerosis/microbiología , Infecciones Bacterianas/fisiopatología , Endotelio Vascular/fisiopatología , Humanos , Inflamación/inmunología , Inflamación/microbiología , Factores de RiesgoRESUMEN
Pseudoaneurysms of the arterial anastomosis are rare complications of renal transplantation. We report three cases of patients with extrarenal pseudoaneurysms and describe their treatment by endovascular placement of covered stents. Two of these aneurysms were due to vascular infections by fungi. An 8-week antifungal therapy proved to be successful in preventing the risk of fungal infection of the graft material in both patients. All three of our grafts remained open 2 months to 3 years after their placement with no evidence of stenosis or infection.
Asunto(s)
Aneurisma Falso/cirugía , Arteria Ilíaca , Trasplante de Riñón/efectos adversos , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/cirugía , Obstrucción de la Arteria Renal/diagnóstico por imagen , Anciano , Resultado Fatal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Obstrucción de la Arteria Renal/cirugía , Stents , Resultado del TratamientoRESUMEN
AIM: Focal adhesion kinase (FAK) is an enzyme of the tyrosine kinase group linked to signaling pathways between cells and their extracellular matrix. FAK expression in tumor cells in vitro may correlate with their ability for invasion and metastasis. METHODS: FAK protein expression was examined immunohistochemically in 80 cases of colon adenocarcinoma, and correlated with clinicopathological parameters; tumor proliferative capacity, reflected by Ki-67 antigen expression; and survival. RESULTS: All tumor samples were FAK positive compared to normal colonic mucosa. FAK protein overexpression was seen in 32 out of 80 cases. FAK protein overexpression did not correlated with tumor histological grade, stage, Ki-67 positivity or survival. CONCLUSIONS: Raised FAK protein expression was noted by immunohistochemistry in human colon carcinoma cases. The implication are discussed.
Asunto(s)
Adenocarcinoma/enzimología , Biomarcadores de Tumor/análisis , Neoplasias del Colon/enzimología , Proteínas Tirosina Quinasas/análisis , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias del Colon/patología , Neoplasias del Colon/cirugía , Femenino , Quinasa 1 de Adhesión Focal , Proteína-Tirosina Quinasas de Adhesión Focal , Regulación Enzimológica de la Expresión Génica , Regulación Neoplásica de la Expresión Génica , Humanos , Inmunohistoquímica , Antígeno Ki-67/análisis , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Análisis de SupervivenciaRESUMEN
OBJECTIVES: to summarize existing evidence regarding the benefits and the risks of all available interventional and medical means aimed at cardiac risk reduction in patients undergoing vascular surgery. DESIGN: review of the literature. MATERIALS AND METHODS: a critical review of all studies examining the impact of various prophylactic cardiac maneuvers on perioperative outcome following vascular surgery was performed. Overall mortality, cardiac mortality and myocardial infarction rate were used as the outcome measures. RESULTS: coronary artery bypass grafting is associated with a 60% decrease in perioperative mortality in patients undergoing vascular surgery, but in most of the cases this decrease does not outweigh the combined risk of the cardiac and the subsequent noncardiac vascular procedure. Data supporting the cardioprotective effect of percutaneous transluminal angioplasty in the perioperative setting are insufficient. beta-blockade has been shown to decrease perioperative mortality and cardiac morbidity in both high-risk (strong evidence) and low-risk (weak evidence) patients. CONCLUSIONS: coronary revascularization is rarely indicated to simply get the patient through vascular surgery and should be reserved for patients who would need it irrespective of the scheduled vascular procedure. Among all available pharmacological agents, including beta-blockers, alpha-agonists, calcium channel blockers and nitrates, only beta-blockers have been proven to reduce the cardiac risk of vascular surgery.
Asunto(s)
Cardiopatías/cirugía , Conducta de Reducción del Riesgo , Procedimientos Quirúrgicos Vasculares , Procedimientos Quirúrgicos Cardíacos , Fármacos Cardiovasculares/uso terapéutico , Medicina Basada en la Evidencia , Cardiopatías/diagnóstico , Cardiopatías/psicología , Humanos , Factores de RiesgoRESUMEN
OBJECTIVES: to evaluate the impact of the carotid plaque type on recurrent carotid stenosis, future cardiovascular events and patients' survival. DESIGN: open prospective study. PATIENTS AND METHODS: three hundred and eight patients who underwent a total of 338 carotid endarterectomies were included in the study. All of the patients were evaluated postoperatively with clinical examination and colour duplex 1 month after the operation and every 6 months thereafter. Mean duration of follow-up was 63 months (range: 12-144). Eight patients (3%) were lost to follow-up. Restenoses, cardiovascular events and deaths were recorded and analysed with regard to the traditional risk factors and the ultrasonographic characteristics of the plaques. Statistical analysis was performed using the Kaplan-Meier method, the log rank test and Cox regression analysis. RESULTS: cumulative restenosis rate at 10 years of follow-up was 21% and was associated with coronary artery disease (p=0.01) and echolucent plaques (p=0.02). Life-table analysis showed a 10-year survival rate of 64% and a 10-year rate of cardiovascular events of 41%. Hypertension (p=0.003), coronary artery disease (p=0.002) and echolucent plaques (p=0.01) were associated with a higher incidence of cardiovascular events.
Asunto(s)
Enfermedades Cardiovasculares/etiología , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Reestenosis Coronaria/etiología , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/diagnóstico por imagen , Enfermedades Cardiovasculares/mortalidad , Estenosis Carotídea/mortalidad , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Factores de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Ultrasonografía Doppler en ColorRESUMEN
BACKGROUND AND PURPOSE: The ability to predict future strokes in asymptomatic patients with carotid stenosis is currently limited. The management of symptomatic patients with <50% stenosis is also debatable. In this context, we performed the following open prospective study to identify factors affecting symptomatology in patients with carotid stenosis. METHODS: During 1988-1997, 442 arteries with various degrees of stenosis were followed with the use of color Duplex ultrasonography every 6 months. The main outcome measures were development of symptoms related to the carotid territory and progression in the degree of stenosis. Results of follow-up were analyzed in relation to the traditional risk factors for atherosclerosis as well as the ultrasonographic characteristics of the plaques. Statistical analysis was performed by multiple linear and Cox regression analysis. RESULTS: Mean duration of follow-up was 44 months (range, 12 to 120 months). Significant progression of stenosis occurred in 18.5% of the cases and was more frequent in younger patients (P=0.09), in patients with coronary artery disease (P=0.02), and in patients with echolucent plaques (P=0.02). In regard to clinical presentation, men (P=0.07), hypertensives (P=0.07), and patients with echolucent plaques (P=0.09) showed a trend toward higher frequency of stroke in their history. During the follow-up period, neurological events developed in 12.4% of the cases and were associated with the severity of carotid disease (P<0.001), history of neurological events (P=0.02), progression of stenosis (P=0.002), echolucent plaques (P=0.01), and hypertension (P=0.02). CONCLUSIONS: Factors other than degree of stenosis and history of neurological events are also important in determining high-risk carotid plaque. In our study hypertension, echolucent plaques, and progressive lesions were associated with an increased risk of neurological events. These factors should be taken into consideration in determining treatment strategies for carotid stenosis.