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Biodegradable hydrogel-based matrices are becoming more widely utilized for a variety of medical applications, including SpaceOAR which is a hydrogel injected into the recto-prostatic space under ultrasound guidance to protect the rectum during prostate radiation therapy. Although a greater number of these procedures are being performed, there are no case reports on the potential complications which may result. In this report, we present the first case of retrograde embolization of SpaceOAR hydrogel into the right common iliac artery during routine office administration, as well as subsequent interventional angiography, inpatient and outpatient management, and clinical and imaging results at 1.5-month patient follow-up.
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RATIONALE AND OBJECTIVES: To assess the efficacy and safety of percutaneous stenting for the palliative treatment of malignant superior vena cava syndrome (SVCS). METHODS AND MATERIALS: Literature review of retrospective studies was performed regarding direct procedural complications (fatal and non-fatal), clinical effectiveness, and patency rates (primary and secondary) of percutaneous transluminal stenting for the palliative treatment of malignant SVCS. Pooled rates and 95% confidence intervals were calculated for fatal complications, non-fatal complications, clinical effectiveness, primary patency, and secondary patency. Pooled rates were presented overall and by stent types (Wallstent, Nitinol stents, Steel stents and Stent Graft). Odds ratios and 95% confidence intervals were calculated to compare rates by stent type. RESULTS: Overall fatal complications rate was 1.46%, 95% CI [0.91 -2.23], non-fatal complications rate was 8.28%, 95% CI [6.91 -9.83], clinical effectiveness was 90.50%, 95% CI [88.86 -91.97], primary patency rate was 86.18%, 95% CI [84.06-88.12], secondary patency rate was 94.05 %, 95% CI [91.82 -95.82]. Primary patency rate of the Wallstent group was 83.38%, 95% CI [79.34 -86.90], and significantly higher for the Nitinol group 94.87%, 95% CI [87.40 -98.60], OR = 3.67, p = 0.01, and for the Stent Graft group 96.10%, 95% CI [89.00 -99.20], OR = 4.92, p = 0.01. Secondary patency rate for the Wallstent group was 93.33%, 95% CI [88.87 -96.40] and significantly lower for the Steel group 77.42%, 95% CI [58.90 -90.41], OR = 0.25, p = 0.01. CONCLUSION: Percutaneous stenting is a safe option for palliative treatment of patients with malignant SVCS with greater than 90% of patients experiencing immediate relief of symptoms, low rates of fatal complications (1.46%) and high patency rates (86.18% primary patency and 94.05% secondary patency).
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Síndrome de la Vena Cava Superior , Humanos , Cuidados Paliativos , Estudios Retrospectivos , Acero , Stents/efectos adversos , Síndrome de la Vena Cava Superior/diagnóstico por imagen , Síndrome de la Vena Cava Superior/cirugía , Resultado del TratamientoRESUMEN
Persistent fetal communications between the carotid and vertebrobasilar systems are rare and most often discovered incidentally. We present the case of a patient with oropharyngeal cancer status post chemotherapy, radiation therapy, and surgical resection who developed acute oropharyngeal hemorrhage on postoperative day 36, originating from branches of the ligated external carotid artery stump by retrograde flow through a proatlantal intersegmental artery type 2. This hemorrhage was successfully controlled with coil embolization through percutaneous access of the external carotid artery without recurrence at 1-year follow-up.
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BACKGROUND: Patient-derived xenograft (PDX) models increasingly are used in translational research. However, the engraftment rates of patient tumor samples in immunodeficient mice to PDX models vary greatly. METHODS: Tumor tissue samples from 308 patients with non-small cell lung cancer were implanted in immunodeficient mice. The patients were followed for 1.5 to approximately 6 years. The authors performed histological analysis of PDXs and some residual tumor tissues in mice with failed PDX growth at 1 year after implantation. Quantitative polymerase chain reaction and enzyme-linked immunoadsorbent assay were performed to measure the levels of Epstein-Barr virus genes and human immunoglobulin G in PDX samples. Patient characteristics were compared for PDX growth and overall survival as outcomes using Cox regression analyses. Disease staging was based on the 7th TNM staging system. RESULTS: The overall engraftment rate for PDXs from patients with non-small cell lung cancer was 34%. Squamous cell carcinomas had a higher engraftment rate (53%) compared with adenocarcinomas. Tumor samples from patients with stage II and stage III disease and from larger tumors were found to have relatively high engraftment rates. Patients whose tumors successfully engrafted had worse overall survival, particularly those individuals with adenocarcinoma, stage III or stage IV disease, and moderately differentiated tumors. Lymphoma formation was one of the factors associated with engraftment failure. Human CD8-positive and CD20-positive cells were detected in residual samples of tumor tissue that failed to generate a PDX at 1 year after implantation. Human immunoglobulin G was detected in the plasma of mice that did not have PDX growth at 14 months after implantation. CONCLUSIONS: The results of the current study indicate that the characteristics of cancer cells and the tumor immune microenvironment in primary tumors both can affect engraftment of a primary tumor sample.
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Adenocarcinoma/patología , Carcinoma de Pulmón de Células no Pequeñas/patología , Modelos Animales de Enfermedad , Neoplasias Pulmonares/patología , Adenocarcinoma/genética , Adenocarcinoma/inmunología , Animales , Antígenos CD20/inmunología , Antígenos CD20/metabolismo , Linfocitos B/inmunología , Linfocitos B/metabolismo , Linfocitos T CD8-positivos/inmunología , Linfocitos T CD8-positivos/metabolismo , Carcinoma de Pulmón de Células no Pequeñas/genética , Carcinoma de Pulmón de Células no Pequeñas/inmunología , Xenoinjertos , Humanos , Estimación de Kaplan-Meier , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/inmunología , Ratones Endogámicos NOD , Ratones Noqueados , Ratones SCID , Estadificación de Neoplasias , Ensayos Antitumor por Modelo de Xenoinjerto/métodosRESUMEN
INTRODUCTION: We sought to assess the incidence and risk factors of bleeding after ultrasound-guided internal jugular (USGIJ) catheter insertion in severely thrombocytopenic cancer patients, as safe platelet (PLT) count threshold remains controversial. METHODS: Retrospective study of 52 patients with hematologic malignancies and severe thrombocytopenia who underwent USGIJ catheter insertion between 2014 and 2016. Group A included patients with prophylactic PLT transfusion and Group B without. Statistical analysis was performed. RESULTS: Group A included 28 patients and Group B 24. Baseline characteristics were equally distributed. Median catheter size was 12 Fr and tunneled in 20/52 patients. Median PLT count was not statistically different between the groups, before transfusion and after the procedure. Postoperative minor bleeding occurred in 10/52 patients, similar between groups. Lower PLT count, larger catheter caliber and trend for AML diagnosis were identified as risk factors for bleeding. Age, gender, BMI, renal dysfunction and tunneled insertion were not significant. CONCLUSION: Incidence of minor bleeding is low in severely thrombocytopenic patients after USGIJ catheter insertion. Prophylactic platelet transfusion may be reserved for patients with identified risk factors.
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Cateterismo Venoso Central/efectos adversos , Neoplasias Hematológicas/complicaciones , Hemorragia Posoperatoria/epidemiología , Trombocitopenia/complicaciones , Ultrasonografía Intervencional/efectos adversos , Adulto , Anciano , Femenino , Humanos , Incidencia , Venas Yugulares , Masculino , Persona de Mediana Edad , Transfusión de Plaquetas , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Imaging is a critical component of the pre-procedure evaluation and planning of endovascular aneurysm repair (EVAR). Imaging is the mainstay for proper assessment of procedural candidacy, relevant vascular anatomy, device selection, and surgical approach. Computed tomography angiography (CTA) has long been considered the preferred modality for pre-operative imaging and evaluation prior to EVAR. Recently, advances in image quality and software technology have further enhanced the proceduralist's ability to plan and perform EVAR. In this review, we highlight the current state of the art to provide interventionalists a contemporary assessment of the available tools for pre-operative imaging and evaluation prior to EVAR.
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BACKGROUND: The appropriateness of percutaneous intervention for moderate to severe carotid in-stent restenosis (C-ISR) is unclear. We therefore sought to compare stroke/death/myocardial infarction (MI) rates between percutaneous interventions and nonoperative management for ≥50% C-ISR. METHODS: We performed a single-center retrospective review of consecutive patients presenting with ≥50% C-ISR to the vascular surgery service. Demographics, comorbidities, and intraoperative and postoperative variables were obtained. The degree of stenosis was verified by review of digital subtraction or computed tomography angiograms. The primary outcome was stroke/death/MI after the diagnosis of ≥50% C-ISR. χ2, Kruskal-Wallis, and Kaplan-Meier analysis was used to quantify outcomes of the patients treated percutaneously vs nonoperatively. RESULTS: During a 13-year period, 59 patients (75 C-ISRs) presented with ≥50% C-ISRs (n = 58 male [98%]; n = 57 C-ISRs asymptomatic [76%]) with a median age of 67.5 years (62.8-74.6). The initial pathologic process underlying the original stent was atherosclerosis in 33 (70%), radiation induced in 10 (21%), prior carotid endarterectomy in 4 (9%), and unknown in 28 (37%). Forty C-ISRs underwent a percutaneous intervention (19 percutaneous angioplasty only [48%]; 21 repeated stent and percutaneous angioplasty [52%]). Median follow-up for the entire cohort was 948 days (283-2322) and similar between the intervention and nonintervention arms. There were no significant differences between the arms with respect to age (P = .16), medical comorbidities (P > .05), original stent type (P = .46), or clopidogrel use (P = .74). At 30 days, there was one stroke and subsequent death in the intervention arm and none in the nonintervention arm. During the follow-up period, a median of 1.0 procedure was required to maintain patency. By Kaplan-Meier analysis, there were no statistically significant differences between the intervention and nonintervention arms with respect to stroke/death/MI as a composite or any of the individual components at last follow-up (P = .82). Kaplan-Meier estimated patency was not significantly superior in the intervention vs the nonintervention arm (8.0 years ± 1.1 vs 5.3 years ± 0.7; P = .14). CONCLUSIONS: Over 13 years, percutaneous interventions for ≥50% C-ISR were safe and durable. However, interventions fail to improve long-term stroke/death/MI or patency rates relative to nonintervention. Intervention for C-ISR may not be necessary, although future appropriately powered, prospective trials will be necessary to confirm these findings and to determine the appropriateness of interventions for C-ISR.
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Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Estenosis Carotídea/terapia , Stents , Anciano , Angiografía de Substracción Digital , Angioplastia de Balón/mortalidad , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/mortalidad , Estenosis Carotídea/fisiopatología , Distribución de Chi-Cuadrado , Angiografía por Tomografía Computarizada , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Recurrencia , Retratamiento , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/etiología , Texas , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: Risk of progression to various stages of chronic kidney disease (CKD) after endovascular aortic aneurysm repair (EVAR) is unknown. This study estimates progression rates to stage 3 and 4 CKD after EVAR and identifies potential predictors for progression. METHODS: EVAR cases (2006-2012) were retrospectively reviewed. Freedom of progression to CKD was estimated using Kaplan-Meier analysis, and predictors for progression were identified using Cox proportional hazards model. RESULTS: Two hundred and twelve consecutive patients at a single academic institution underwent EVAR for infrarenal aneurysms. Estimated freedom from progression to stage 3 CKD was 80%, 76%, and 63% at 6, 12, and 18 months, respectively, and for stage 4, 97%, 96%, and 93% at 6, 12, and 18 months, respectively. Stage 3 CKD predictors of progression included age (odds ratio (OR): 1.106, p = 0.001), diabetes (OR: 3.052, p = 0.04), perioperative use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers (OR: 3.249, p = 0.02), and operative blood loss (OR: 1.002, p < 0.01). Stage 4 predictors included preoperative hemoglobin (OR: 0.473, p = 0.04) and baseline renal function (OR: 0.928, p = 0.001). Intraoperative contrast administration did not impact CKD development. CONCLUSIONS: Progression to stage 3 CKD after EVAR occurs more frequently and at a higher rate compared with progression to stage 4. Different risk factors are associated with progression to each of those stages of CKD.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Insuficiencia Renal Crónica/complicaciones , Anciano , Aneurisma de la Aorta Abdominal/complicaciones , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Implantación de Prótesis Vascular/efectos adversos , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Procedimientos Endovasculares/efectos adversos , Humanos , Estimación de Kaplan-Meier , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Texas , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To understand the relationship between self-perceived severity of intermittent claudication and various associated nonclinical factors, we examined how correlates in domains of physical activity (ie, clinical, psychological, behavioral, social, and environmental factors) relate to exertional limb symptoms. METHODS: A survey was administered to individuals with intermittent claudication during their initial outpatient assessment. The subjects' self-reported exertional limb symptom severity and classic-versus-atypical claudication classification was based on the Walking Impairment Questionnaire (WIQ) and San Diego Claudication Questionnaire (SDCQ), respectively. We evaluated psychosocial and environmental factors, osteoarthritis symptoms, health, behaviors, and beliefs. Logistic and linear regressions identified factors with a strong independent association with total WIQ scores and the SDCQs. RESULTS: A cohort of 102 subjects (99.0% male) was enrolled in the study. The median age was 65 years with a median ankle-brachial index of 0.69. Forty-three subjects (43%) had "typical" claudication per SDCQs. Individuals with atypical claudication were more likely to report higher Aberdeen Clinical Back Pain Questionnaire scores (odds ratio, 1.04; P = .04) and no depressive symptoms (odds ratio, 8.30; P = .03). Exertional limb symptom severity among the entire cohort was significantly associated with increasing osteoarthritis symptoms (P <.001), age (P = .02), a reserved personality (P = .008), and the belief that an exercise regimen would not improve symptoms (P = .005), self-perceived levels of boredom (P = .002), and the belief that exercise (P = .002) was the best way to improve symptoms were associated with decreased symptom severity. When restricted to those with atypical pain, significant factors associated with increasing exertional symptom severity included age greater than 60 years (P = .005), osteoarthritis (P = .02), alcohol use (P = .01), belief that exercise would not improve walking (P = .03), and difficulty walking around the neighborhood (P = .02). When restricted to those with classic claudication, significant factors associated with increasing exertional limb symptom severity included frequent pain or aching in the calves while walking or sitting (P = .03 [walking]; P = .01 [sitting]) and occasional morning joint stiffness (P = .007). Exertional limb symptom severity was also associated with high limitations at home (P = .003) and a belief that exercise would not improve walking (P = .005) among those with classic claudication. CONCLUSIONS: Symptom severity and type of pain are associated with a number of nonclinical factors. A multidomain approach, as indicated by the models above, would benefit the continuum of care for intermittent claudication, where management is integrated and coordinated among multiple lines of care.
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Ambiente , Tolerancia al Ejercicio , Conocimientos, Actitudes y Práctica en Salud , Claudicación Intermitente/psicología , Autoimagen , Conducta Social , Anciano , Anciano de 80 o más Años , Índice Tobillo Braquial , Distribución de Chi-Cuadrado , Depresión/epidemiología , Depresión/psicología , Conductas Relacionadas con la Salud , Estado de Salud , Humanos , Claudicación Intermitente/diagnóstico , Claudicación Intermitente/epidemiología , Claudicación Intermitente/fisiopatología , Dolor de la Región Lumbar/epidemiología , Dolor de la Región Lumbar/fisiopatología , Dolor de la Región Lumbar/psicología , Masculino , Salud Mental , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Osteoartritis/epidemiología , Osteoartritis/fisiopatología , Osteoartritis/psicología , Prevalencia , Factores de Riesgo , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , Texas/epidemiología , CaminataRESUMEN
Compartment syndrome of the leg is a well-recognized complication known to follow urgent revascularization done for acute limb ischemia, but compartment syndrome of the foot has not been reported after the ischemia-reperfusion sequence. Herein we report a case of foot fasciotomy done for compartment syndrome that occurred after urgent revascularization. We suggest that foot fasciotomies should be considered in particular circumstances of acute lower leg ischemia, such as infrapopliteal thromboembolic events, prolonged ischemia, and persistent or worsening foot symptoms that follow revascularization and calf fasciotomies.
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Síndromes Compartimentales/etiología , Pie/irrigación sanguínea , Isquemia/cirugía , Procedimientos Quirúrgicos Vasculares/efectos adversos , Enfermedad Aguda , Anciano de 80 o más Años , Síndromes Compartimentales/diagnóstico , Síndromes Compartimentales/fisiopatología , Síndromes Compartimentales/cirugía , Descompresión Quirúrgica/métodos , Fasciotomía , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatología , Masculino , Recuperación de la Función , Flujo Sanguíneo Regional , Reoperación , Resultado del TratamientoRESUMEN
BACKGROUND: Observational data indicate that carotid artery stenting (CAS) is associated with higher incidence of subclinical cerebral microemboli than carotid endarterectomy (CEA). We hypothesized that CEA would be associated with superior performance on detailed domain-specific cognitive testing compared with CAS. METHODS: Patients with >80% asymptomatic carotid artery stenosis were randomized to CEA or CAS with side of stenosis balanced across condition. A robust battery of tests was used to assess the cognitive domains of attention, memory, mood, visual-spatial skills, motor ability, processing speed, and executive functioning ≤10 days preoperatively and postoperatively at 6 weeks and 6 months. Tests were administered using standardized conditions and were scored by individuals blinded to treatment allocation. RESULTS: Baseline cognitive performance was similar between CAS (n = 29) and CEA (n = 31) groups (P > .05). Relative to baseline, verbal and visual memory and attention functions substantially improved in the CAS and CEA groups at 6 months (multiple cognitive tests achieved statistical significance). Compared with CEA, cognitive processing speed (Stroop Color test: 9.0 vs 7.3, P = .04; and Stroop Word test: 9.0 vs 7.4, P = .05) was superior in the CAS group at 6 weeks. Executive functioning (phonemic verbal fluency: 10.6 vs 8.4, P = .043) and motor function (Grooved Pegboard of nondominant extremity: 45.7 vs 38.9, P = .022) were also superior in the CAS group at 6 months. Tests of attention, memory, and visual-spatial skills were similar between CAS and CEA patients at 6 weeks and 6 months. CONCLUSIONS: Carotid revascularization improves memory and attention within the first 6 postoperative months. Compared with CEA, CAS produces improvements in cognitive processing speed, executive functioning, and motor function.
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Implantación de Prótesis Vascular , Estenosis Carotídea/cirugía , Trastornos del Conocimiento/diagnóstico , Endarterectomía Carotidea , Implantación de Prótesis Vascular/efectos adversos , Cognición , Trastornos del Conocimiento/etiología , Endarterectomía Carotidea/efectos adversos , Humanos , Pruebas Neuropsicológicas , Proyectos Piloto , Stents , Resultado del TratamientoRESUMEN
OBJECTIVE: Screening for common carotid artery (CCA) stenosis with duplex ultrasound (DUS) velocity criteria alone can be limited by within-patient and between-patients hemodynamic variability. This study aimed to evaluate inter-CCA velocity ratio criteria to predict high-grade CCA stenosis. METHODS: This was a retrospective review of consecutive patients who underwent computed tomography angiography and DUS peak systolic velocity (PSV) measurements of bilateral CCAs, independently recorded, between 2008 and 2014. Patients with dampened CCA waveforms on DUS composed group B. The remainder without dampened waveforms constituted group A. Inter-CCA PSV ratios were calculated by dividing the higher CCA PSV by the lower one of the other side, so the ratios would always be ≥1. Ratios were subsequently paired with each respective unilateral CCA diameter stenosis and differential bilateral CCA diameter stenosis. A quadratic regression model was fitted to predict unilateral and differential stenosis. Receiver operating characteristic curve was used to determine optimal ratios for ≥50% and ≥80% CCA stenosis. The study excluded patients with carotid artery occlusion. RESULTS: From a total of 201 patients, 193 patients were included in group A and 8 in group B. Within group A, 31 patients had ≥50% unilateral stenosis and 17 had ≥50% differential stenosis. All stenoses ≥50% were identified on the same side with the higher PSV. Inter-CCA PSV ratio predicted ≥50% unilateral (r(2) = 0.536; P < .001) and differential stenosis (r(2) = 0.581; P < .001). In group B, all patients had ≥60% stenosis that was near or involved the vessel origin. An increasing inter-CCA PSV ratio showed a trend toward contralateral high-grade stenosis (r(2) = 0.596; P = .1). Receiver operating characteristic curves showed an optimal threshold CCA ratio ≥2.16 for ≥50% unilateral stenosis with 92% accuracy, 62% sensitivity, and 98% specificity (area under curve = 0.854; 95% confidence interval, 0.759-0.948) and a ratio ≥2.62 for ≥50% differential stenosis with 97% accuracy, 83% sensitivity, and 98% specificity (area under curve = 0.94; 95% confidence interval, 0.835-1). CONCLUSIONS: DUS-based CCA PSV ratio can accurately predict unilateral and differential high-grade CCA stenosis. Also, in patients with unilateral dampened waveforms, it implied contralateral severe proximal stenosis. This parameter should be further validated in prospective studies and may serve as an adjunct screening tool to detect high-grade CCA stenosis.
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Arteria Carótida Común/fisiología , Estenosis Carotídea/diagnóstico , Anciano , Angiografía , Velocidad del Flujo Sanguíneo , Arteria Carótida Común/diagnóstico por imagen , Estenosis Carotídea/fisiopatología , Femenino , Predicción , Humanos , Masculino , Curva ROC , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X , Ultrasonografía Doppler DúplexRESUMEN
In describing functional outcomes and independent living in a cohort of bilateral major amputees, we sought to provide current estimates of function and independence after a second major amputation in an elderly Veteran population with peripheral arterial disease and/or diabetes. After retrospectively reviewing and excluding the electronic health records of those failing to meet the inclusion criteria, we identified 40 patients with a history of unilateral major amputation who underwent a second major amputation during the defined study period. Of these, 43% (17) were bilateral transfemoral amputations (TFAs); bilateral transtibial amputations (TTAs) and TFA-TTA accounted for the rest (33% and 25%, respectively). Of the 19 (48%) patients who were ambulatory prior to bilateral amputation, only 2 (11%) remained ambulatory after the second amputation, while 17 (89%) patients lost ambulatory capabilities. Compared with those who were
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Amputación Quirúrgica/rehabilitación , Amputados/rehabilitación , Extremidad Inferior/cirugía , Limitación de la Movilidad , Recuperación de la Función , Veteranos , Caminata/fisiología , Adulto , Anciano , Anciano de 80 o más Años , Miembros Artificiales , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados UnidosAsunto(s)
Enfermedades de la Aorta/etiología , Migración de Cuerpo Extraño/etiología , Filtros de Vena Cava/efectos adversos , Trombosis de la Vena/terapia , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/terapia , Aortografía/métodos , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/terapia , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Factores de Tiempo , Tomografía Computarizada por Rayos XRESUMEN
Foot infections occurring in patients with severe peripheral arterial disease (PAD) who are not considered candidates for revascularization and limb salvage efforts are generally treated with major amputations. Herein we describe our early experiences in managing foot infections with minor amputations and palliative wound care as a strategy to avoid the functional disability often associated with major amputations. Patients with severe PAD that underwent minor amputations and subsequent palliative wound care for moderate/severe infections were paired with age-matched controls with PAD that underwent primary major amputations for foot infections. Eleven patients who underwent minor amputations and palliative wound care of 13 limbs were compared to an age-matched cohort of 12 patients undergoing 13 major amputations.The median age was 80 years in both groups. Survival at 1 and 2 years did not differ significantly between groups. All patients who were ambulatory and/or independently living remained so following palliative management; in contrast, major amputation changed ambulatory status in 75% of patients and independent living status in 50%. Palliative management did not result in ascending/systemic sepsis or progressive necrosis. The need for reoperations was uncommon in both groups. In summary, minor amputations and operative drainage with subsequent palliative wound care appears to be a safe management option in patients with severe PAD and moderate or severe foot infections that are not candidates for revascularization. Palliative management may result in less functional impairment than major amputation.
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Amputación Quirúrgica/métodos , Pie Diabético/complicaciones , Pie Diabético/cirugía , Infecciones/complicaciones , Infecciones/cirugía , Cuidados Paliativos , Enfermedad Arterial Periférica/complicaciones , Enfermedad Arterial Periférica/cirugía , Anciano , Anciano de 80 o más Años , Humanos , Persona de Mediana Edad , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Foot infections are especially common among diabetic individuals and often contribute to limb loss. We investigated the microbiology of foot infections in our hospital to further understand the microbes involved and to assist in identifying potential empiric oral antibiotic regimens for foot infections. METHODS: All moderate/severe inframalleolar foot infections that were drained surgically at a single center during a single calendar year were included. Initial isolates obtained intra-operatively were reviewed. RESULTS: A total of 39 patients underwent operative drainage, of whom 34 (87%) had diabetes mellitus. Fifty-two total specimens were obtained, consisting of 26 fluid swabs, 12 soft-tissue specimens, and 11 bone specimens. Nineteen (49%) of the specimens were obtained from toe wounds, 16 (41%) from forefoot wounds, two (5%) from midfoot wounds, and two (5%) from heel wounds. Most specimens (71%) were polymicrobial, yielding a mean of 2.2 isolates. In all, 100 individual isolates, encompassing 39 different bacterial organisms, were identified (55 gram-positive aerobes, 33 gram-negative aerobes, 11 anaerobes, and one fungus). Enterococcus species and Staphylococcus aureus were the most common bacteria, each representing 13% of isolates. Only 9% of isolates were methicillin-resistant S. aureus. Obtaining multiple specimens (e.g., both fluid and tissue) increased the yield for identification of organisms. Oral antibiotics provided adequate coverage for gram-positive organisms but not for gram-negative organisms. CONCLUSIONS: Foot infections are typically polymicrobial and may involve a wide variety of microbes. Initial gram-stain results could be used to choose better initial empiric antimicrobial therapy for such infections.
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Antibacterianos/farmacología , Bacterias/efectos de los fármacos , Enfermedades del Pie/microbiología , Pie/microbiología , Anciano , Anciano de 80 o más Años , Bacterias/clasificación , Bacterias/aislamiento & purificación , Pie Diabético , Femenino , Pie/cirugía , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
IMPORTANCE: No endovascular devices are commercially available in the United States to treat high-surgical risk patients with aneurysms extending to visceral arteries. Treatment options are even further limited for symptomatic patients in need of urgent treatment. OBJECTIVE: To describe a successful urgent endovascular repair of a juxtarenal abdominal aortic aneurysm with contained rupture. DESIGN, SETTING, AND PARTICIPANTS: A hybrid suite using a surgeon-modified fenestrated endovascular graft and advanced 3-dimensional imaging workstation. The patient was an 82-year-old veteran taking clopidogrel and aspirin for coronary stents with significant cardiopulmonary comorbidities including multiple prior abdominal surgeries and a single functional left kidney. INTERVENTION: Surgeon-modified fenestrated endovascular aortic aneurysm repair. MAIN OUTCOMES AND MEASURES: Clinical, laboratory, and radiographic improvement. RESULTS: The patient was discharged 5 days after an uneventful postoperative course. On short-term follow-up, the patient had an early return to his baseline functional status. The excluded aneurysm sac shrank with patent visceral branches and there was an absence of endoleak on 3-month and 6-month surveillance computed tomography angiography. CONCLUSIONS AND RELEVANCE: Surgeon-modified fenestrated stent grafts may be a viable option for selected high-surgical risk patients with symptomatic complex abdominal aortic aneurysms.
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Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/cirugía , Prótesis Vascular , Urgencias Médicas , Procedimientos Endovasculares/instrumentación , Interpretación de Imagen Asistida por Computador , Imagenología Tridimensional , Ajuste de Prótesis , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/cirugía , Tomografía Computarizada por Rayos X , Anciano de 80 o más Años , Humanos , Fallo Renal Crónico/prevención & control , Masculino , Transferencia de Pacientes , Complicaciones Posoperatorias/prevención & control , Diseño de Prótesis , ReoperaciónRESUMEN
OBJECTIVE: Patients with occlusive or aneurysmal vascular disease are repeatedly exposed to intravascular (IV) contrast for diagnostic or therapeutic purposes. We sought to determine the long-term impact of cumulative iodinated IV contrast exposure (CIVCE) on renal function; the latter was defined by means of National Kidney Foundation (NKF) criteria. METHODS: We performed a longitudinal study of consecutive patients without renal insufficiency at baseline (NFK stage I or II) who underwent interventions for arterial occlusive or aneurysmal disease. We collected detailed data on any IV iodinated contrast exposure (including diagnostic or therapeutic angiography, cardiac catheterization, IV pyelography, computed tomography with IV contrast, computed tomographic angiography); medication exposure throughout the observation period; comorbidities; and demographics. The primary end point was the development of renal failure (RF) (defined as NFK stage 4 or 5). Analysis was performed with the use of a shared frailty model with clustering at the patient level. RESULTS: Patients (n = 1274) had a mean follow-up of 5.8 (range, 2.2-14) years. In the multivariate model with RF as the dependent variable and after adjusting for the statistically significant covariates of baseline renal function (hazard ratio [HR], 0.95; P < .001), diabetes (HR, 1.8; P = .007), use of an angiotensin-converting enzyme inhibitor (HR, 0.63; P = .03), use of antiplatelets (HR, 0.5; P = .01), cumulative number of open vascular operations performed (HR, 1.2; P = .001), and congestive heart failure (HR, 3.2; P < .001), CIVCE remained an independent predictor for RF development (HR, 1.1; P < .001). In the multivariate survival analysis model and after adjusting for the statistically significant covariates of perioperative myocardial infarction (HR, 3.9; P < .001), age at entry in the cohort (HR, 1.05; P = .035), total number of open operations (HR, 1.51; P < .001), and serum albumin (HR, 0.47; P < .001), CIVCE was an independent predictor of death (HR, 1.07; P < .001). CONCLUSIONS: Cumulative IV contrast exposure is an independent predictor of RF and death in patients with occlusive and aneurysmal vascular disease.
Asunto(s)
Aneurisma/diagnóstico por imagen , Angiografía/efectos adversos , Arteriopatías Oclusivas/diagnóstico por imagen , Medios de Contraste/efectos adversos , Tasa de Filtración Glomerular/efectos de los fármacos , Insuficiencia Renal/inducido químicamente , Medición de Riesgo/métodos , Adulto , Anciano , Anciano de 80 o más Años , Medios de Contraste/administración & dosificación , Femenino , Estudios de Seguimiento , Humanos , Inyecciones Intravenosas , Riñón/efectos de los fármacos , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Insuficiencia Renal/mortalidad , Insuficiencia Renal/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Texas/epidemiología , Factores de TiempoRESUMEN
BACKGROUND: Revascularization and limb salvage attempts are often offered to patients with foot wounds and chronic limb ischemia who are thought to be good-risk candidates, but some skepticism remains about the utility of these efforts for elderly patients with marginal functional status. We sought to determine whether limb preservation efforts in this population could be justified from a patient-centered, cost-effectiveness perspective. METHODS: A probabilistic Markov model was used to simulate the clinical outcomes, health utilities, and costs over a 10-year period with various management strategies. Clinical parameter estimates were obtained from previous clinical trials and large observational series. Cost estimates were obtained from cost literature and also a single-center study that reviewed total costs accumulated (including secondary amputations, wound care, outpatient nursing care, and nursing home costs). Cost (in 2011 U.S. dollars) per year of ambulation (with limb preservation or with a prosthesis after amputation) was the primary measure of cost-effectiveness. RESULTS: The total 10-year costs of revascularization--either endovascular or surgical--were lower than the costs of either local wound care alone or primary amputation. Revascularization strategies also produced more health benefits as measured in terms of years of ambulatory ability, years of limb salvage, or quality-adjusted life-years. In none of the scenarios modeled in deterministic sensitivity analyses did primary amputation prove to be cost-effective. CONCLUSIONS: Revascularization and limb preservation attempts appear less costly and provide more health benefits than wound care alone or primary amputation, even among patients with marginal functional status at baseline.
Asunto(s)
Úlcera del Pie/economía , Úlcera del Pie/terapia , Costos de la Atención en Salud , Isquemia/economía , Isquemia/terapia , Recuperación del Miembro/economía , Extremidad Inferior/irrigación sanguínea , Procedimientos Quirúrgicos Vasculares/economía , Factores de Edad , Amputación Quirúrgica/economía , Implantación de Prótesis Vascular/economía , Enfermedad Crónica , Comorbilidad , Simulación por Computador , Análisis Costo-Beneficio , Procedimientos Endovasculares/economía , Úlcera del Pie/diagnóstico , Úlcera del Pie/fisiopatología , Estado de Salud , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatología , Cadenas de Markov , Modelos Económicos , Selección de Paciente , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos , Cicatrización de HeridasRESUMEN
BACKGROUND: No consensus exists for duplex ultrasound criteria in the diagnosis of significant common carotid artery (CCA) stenosis. In general, peak systolic velocity (PSV) >150 cm/s with poststenotic turbulence indicates a stenosis >50%. The purpose of our study is to correlate CCA duplex velocities with angiographic findings of significant stenosis >60%. METHODS: We reviewed the carotid duplex records from 2008 to 2011 looking for patients with isolated CCA stenosis and no ipsilateral internal or contralateral carotid artery disease who received either a carotid angiogram or a computed tomography scan. We identified 25 patients who had significant CCA disease >60%. We also selected 74 controls without known CCA stenosis. We performed receiver operating characteristics analysis to correlate PSV and end-diastolic velocity (EDV) with angiographic stenosis >60%. The degree of stenosis was determined by measuring the luminal stenosis in comparison to the proximal normal CCA diameter. RESULTS: Most patients had a carotid angiogram (21/25), four only had a computed tomography angiography and four had both. Eighteen patients had history of neck radiation. The CCA PSV ≥250 cm/s had a sensitivity of 98.7% (81.5%-100%) and a specificity of 95.7% (92.0%-99.9%), CCA PSV ≥300 cm/s had a sensitivity of 90.9% (69.4%-98.4%) and a specificity of 98.7% (92.0%-99.9%). The CCA EDV ≥40 cm/s had a sensitivity of 95.5% (95% confidence interval of 75.1-99.8%) and specificity of 98.7% (92.0%-99.9%), EDV ≥60 cm/s had a sensitivity of 100% (75.1%-99.8%) and specificity of 87% (94.1-100%), and EDV ≥70 cm/s had a sensitivity of 86.4% (64.0%-96.4%) and specificity of 100% (94.1%-100%). The presence of both PSV <250 cm/s and EDV <60 cm/s had a 98.7% negative predictive value, and the presence of both PSV ≥250 cm/s and EDV ≥60 cm/s had 100% positive predictive value. CONCLUSIONS: Establishing CCA duplex criteria to screen patients with significant stenosis is crucial to identify those who will need further imaging modality or treatment. In our laboratory, CCA PSV ≥250 cm/s and EDV ≥60 cm/s are thresholds that can be used to identify significant (>60%) CCA stenosis with a high degree of accuracy.