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Case reports provide a salient contribution to the field of plastic surgery through the timely dissemination of knowledge on previously underreported topics. Once a time-honored hallmark of the surgical literature, the perceived value of case reports has decreased with the ongoing prioritization of higher levels of evidence. In this study, we aimed to assess long-term trends in case report publication rates and discuss the continued merits of case reports in the modern-day landscape. Methods: A PubMed search was used to identify articles published in six prominent plastic surgery journals since 1980. Articles were separated as case reports versus all other publication types. The total number of articles published by group was tracked, and citation rates were compared across groups. Additionally, the most cited articles from each journal were identified for both groups. Results: A total of 68,444 articles were included for analysis. In 1980, there were 181 case reports published compared with 413 other articles across all six journals. In 2022, there were 188 case reports published compared with 3343 other articles. When comparing citations per year of case reports versus other article types across all journals since 1980, case reports were found to be cited significantly less frequently (P < 0.001). Conclusions: Case reports have been published and cited less frequently than other types of literature over the last 42 years. However, despite these trends, they have demonstrated significant historical contributions and provide continued value as an impactful forum for highlighting novel clinical entities.
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Enfermedades Musculoesqueléticas , Canadá , Humanos , Noruega , Cirujanos , Estados UnidosRESUMEN
BACKGROUND: Musculoskeletal injuries are more common among surgeons than among the general population. However, little is known about these types of injuries among plastic surgeons specifically. The authors' goals were to evaluate the prevalence, nature, causes, and potential solutions of these musculoskeletal injuries among plastic surgeons in three different countries: the United States, Canada, and Norway. METHODS: A survey was e-mailed to plastic surgeons in the United States, Canada, and Norway, soliciting their demographics, practice description, history of musculoskeletal issues, potential causes of these symptoms, and proposed suggestions to address these injuries. The prevalence of various musculoskeletal symptoms was calculated, and predictors of these symptoms were evaluated using multivariate logistic regression. RESULTS: The survey was sent to 3314 plastic surgeons, with 865 responses (response rate, 26.1 percent); 78.3 percent of plastic surgeons had musculoskeletal symptoms, most commonly in the neck, shoulders, and lower back. U.S. surgeons were significantly more likely to have musculoskeletal symptoms than Norwegian surgeons (79.5 percent versus 69.3 percent; p < 0.05); 6.7 percent of all respondents required surgical intervention for their symptoms. The most common causative factors were long surgery duration, tissue retraction, and prolonged neck flexion. The most common solutions cited were core-strengthening exercises, stretching exercises, and frequent adjustment of table height during surgery. CONCLUSIONS: Plastic surgeons are at high risk for work-related musculoskeletal injuries. Ergonomic principles can be applied in the operating room to decrease the incidence and severity of those injuries, and to avoid downstream sequelae, including the need for surgery.
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Salud Laboral , Traumatismos Ocupacionales/epidemiología , Encuestas y Cuestionarios , Heridas y Lesiones/etiología , Adulto , Canadá/epidemiología , Estudios Transversales , Femenino , Humanos , Incidencia , Internacionalidad , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Enfermedades Musculoesqueléticas/epidemiología , Enfermedades Musculoesqueléticas/etiología , Enfermedades Musculoesqueléticas/fisiopatología , Noruega/epidemiología , Traumatismos Ocupacionales/etiología , Traumatismos Ocupacionales/fisiopatología , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/métodos , Cirujanos/estadística & datos numéricos , Cirugía Plástica/efectos adversos , Cirugía Plástica/métodos , Estados Unidos/epidemiología , Heridas y Lesiones/epidemiología , Heridas y Lesiones/fisiopatologíaRESUMEN
Since 2009, the face transplant team at Brigham and Women's Hospital in Boston has performed 6 successful partial and full facial transplantations on carefully selected patients. The development of these techniques has led to a new era in facial reconstruction which now more correctly can be described as facial restoration. Besides the obvious facts of giving someone with a missing or severely disfigured face a new appearance, facial restoration has led to many other interesting observations in terms of immunologic models, airway functionality, sensory recovery and cerebral cortical functioning. In this article, we present an overview of our experience, and where we are today-also presenting some of the interesting avenues that have opened and will lead us further in the daunting experience of facial allotransplantation.
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Traumatismos Faciales/cirugía , Trasplante Facial/métodos , Procedimientos de Cirugía Plástica/métodos , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Perforating vessels are a consistent anatomical finding and well described in the current literature. Any skin flap can be raised on a subcutaneous pedicle as long as it contains at least one supplying perforator. Perforator flaps have been interlinked with microsurgery and generally not widely performed by the general plastic surgeons. The aim of this paper is to present the simplicity of pedicled perforator flap reconstruction of moderate-sized defects of the extremities and torso. METHODS: We retrospectively reviewed the charts of 34 patients reconstructed using 34 freestyle pedicled perforator flaps for moderate-sized defects of the truncus and extremities. We registered indications, flap size and localization, success rate, and complications. Most importantly, we describe a simple approach to the design of freestyle pedicled perforator flaps and elaborate on technical aspects in the context of current literature. RESULTS: The reconstructive goals were achieved in all cases without any total flap loss or major complications. Minor complications occurred in 7/34 (21 %) cases consisting of venous congestion leading to distal tip necrosis or epidermolysis; partial flap loss was significant in 4 cases, however never more than 10 % of the total flap size. Reconstruction was performed on the lower limb in 13 cases, upper limb in 12, and 9 cases were on the truncus. The angle of rotation was 90° in 21 cases and 180° in 13 cases. The most common indication was reconstruction of oncological skin defects; melanoma 19, BCC 6, SCC 2, other 7. The flap size varied from 1.5×3 cm to 12×22 cm. The perforator identification was done by intraoperative exploration in 17 cases and by color Doppler ultrasonography in 17 cases. CONCLUSIONS: Moderate-sized defects of the torso and extremities can be successfully reconstructed by pedicled perforator flaps. The flap dissection is simple, and the complication rates comparable to other reconstructive options. Level of evidence IV, therapeutic study.
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INTRODUCTION: We present Scandinavia's first series of immediate alloplastic breast reconstructions with an acellular dermal matrix. MATERIAL AND METHODS: Data were collected retrospectively in 76 cases of immediate breast reconstruction using an acellular dermal matrix (ADM) and an implant. RESULTS: A total of 59 women were reconstructed between June 2011 and January 2013. Cases included 42 unilateral and 17 bilateral reconstructions. A large number of patients had adjuvant therapy, hormone therapy (34), radiation therapy (27) or chemotherapy (38). The median age was 51 years (30-70 years) and the median follow-up period was 326 days (68-624 days). The co-morbidity factors included hypertension (n = 11), diabetes (n = 2) and 19 patients were smokers. Unsuccessful reconstructions counted ten cases (13%), eight of these due to necrosis and/or wound dehiscence (10%) and two due to infection (3%). The failure rate in non-smokers was 2/52 (4%) compared with 8/24 (33%) in smokers, p = 0.001. In hypertensive patients, the failure rate was 6/12 (50%) compared with 4/64 (6%)in normotensive patients, p = 0.001. 70% of the failed reconstructions occurred in patients older than 65 years of age. CONCLUSION: Immediate alloplastic breast reconstruction using an ADM can be recommended to healthy non-smoking patients. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.
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Dermis Acelular , Neoplasias de la Mama/terapia , Hipertensión/complicaciones , Mamoplastia/métodos , Fumar/efectos adversos , Adulto , Factores de Edad , Anciano , Neoplasias de la Mama/complicaciones , Quimioterapia Adyuvante , Femenino , Humanos , Mamoplastia/efectos adversos , Mastectomía Segmentaria , Persona de Mediana Edad , Necrosis/etiología , Radioterapia Adyuvante , Estudios Retrospectivos , Dehiscencia de la Herida Operatoria/etiología , Infección de la Herida Quirúrgica/etiología , Factores de Tiempo , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
BACKGROUND: Full face transplantation raises a new set of ethical concerns and technical difficulties when compared with partial face transplantation. Previously, it was thought that full face allografts must include bilateral superficial temporal and facial arteries, dictating the need for inclusion of donor parotid glands. This would lead to poor aesthetic outcomes and limit facial nerve coaptation to the level of the main trunk, which often results in synkinesias. The authors present a new approach to full facial allograft recovery based on blood supply from facial arteries alone. This approach eliminates the need to include parotid glands, enabling more distal coaptation of facial nerve branches and targeted innervation of effector muscles. The recovery can be reproducibly performed within 4 hours. METHODS: Three mock cadaver dissections and three full face transplantations were performed. RESULTS: Donor facial allografts were dissected in cranio-caudal and lateral-to-medial fashion. Individual facial nerve branches were cut medial to parotid glands and coapted to corresponding recipient nerve branches. With the exception of one parotid gland used to add bulk, parotids were generally not included in the allografts. Relevant sensory nerves were coapted. External carotid arteries were dissected, leaving only bilateral facial arteries as the primary arterial supply. All full facial allografts were well perfused immediately following transplantation and are surviving. CONCLUSIONS: The authors describe a new, simple, and reproducible technique of full facial allograft recovery that allows perfusion using only bilateral facial arteries. Their technique follows critical principles of targeted sensory and motor nerve coaptation.
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Cara/irrigación sanguínea , Cara/inervación , Trasplante Facial/métodos , Colgajos Quirúrgicos/irrigación sanguínea , Colgajos Quirúrgicos/inervación , Anastomosis Quirúrgica/métodos , Cadáver , Disección , Cara/anatomía & histología , Cara/cirugía , Músculos Faciales/irrigación sanguínea , Músculos Faciales/inervación , Músculos Faciales/cirugía , Humanos , Técnicas de Sutura , Trasplante HomólogoRESUMEN
The purpose of this study was to evaluate complications and patient satisfaction after pedicled transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap reconstruction at a single institution. There were 346 patients identified from 1999 to 2006 who underwent 197 pedicled TRAM and 217 DIEP flap reconstructions. Flap complication rates were similar between groups, whereas pedicled TRAM reconstructions had higher rates of abdominal bulge (9.5% vs. 2.3%, P = 0.0071) and hernias (3.9% vs. 0%, P = 0.0052). DIEP flap patients had significantly higher general satisfaction (81.7% vs. 70.2%, P = 0.0395), whereas aesthetic satisfaction was similar between groups. Furthermore, DIEP flap patients, particularly those undergoing bilateral reconstructions, were more likely to choose the same type of reconstruction compared with pedicled TRAM patients (92.5% vs. 80.7%, P = 0.0113). Understanding the differences in complications and satisfaction will help physicians and patients make informed decisions about abdominal-based autologous breast reconstruction.
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Arterias Epigástricas/trasplante , Mamoplastia/métodos , Satisfacción del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Recto del Abdomen/trasplante , Colgajos Quirúrgicos , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/prevención & control , Neoplasias de la Mama/cirugía , Femenino , Estudios de Seguimiento , Humanos , Mastectomía , Persona de Mediana Edad , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
Large, full-thickness calvarial defects cause increased brain tissue compliance, often resulting in transient, transcranial herniation in the setting of normotensive intracranial pressures. Cranioplasty serves to protect the cerebrum from external injury, provide an aesthetic contour, and alleviate neurological symptoms. Traditional options for management include head elevation, osmotic diuresis, mild hyperventilation, durotomy with closure following fluid evacuation, expansile cranioplasty, lobectomy, and procedure abortion with prolonged helmet therapy. Patients treated conservatively with helmet therapy commonly are noncompliant and sustain repeated minor trauma to unprotected cerebral contents. Furthermore, recent literature suggests that early cranioplasty may improve outcomes and reduce costs. The authors present a novel solution, bipolar duraplasty, which allows safe, transient reduction of normotensive parenchymal herniation using bipolar electrocautery. The dura of the herniated sac is cauterized using a low-set, bipolar current in a series of sagittal and coronal lines, resulting in immediate contraction and reduction allowing for definitive cranioplasty. This new method was used in a patient with a 30-cm(2) frontal bone defect following resection of a right falcine atypical meningioma. In this scenario, bipolar duraplasty was performed free of complication, and the patient has remained asymptomatic and greatly satisfied for 1 year since the procedure. This technique might facilitate earlier cranioplasty, could be applied to a wide range of patients, and may afford better neurological outcomes at a reduced cost.
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Descompresión Quirúrgica/métodos , Duramadre/cirugía , Encefalocele/cirugía , Procedimientos Neuroquirúrgicos/métodos , Craneotomía/métodos , Humanos , Masculino , Persona de Mediana Edad , Cráneo/cirugíaRESUMEN
OBJECTIVE: Older patients are thought to tolerate acute ischemia more poorly than younger patients. Since aging may depress both angiogenesis and arteriogenesis, we determined the effects of age on both angiogenesis and arteriogenesis in a model of severe acute limb ischemia. METHODS: Young adult (3-months-old) and aged (18-months-old) C57BL/6 mice underwent right common iliac artery and vein ligation and transection. Data were collected on days 0, 7, and 14. Perfusion was measured with a laser Doppler scan and compared to the contralateral limb. Functional deficits were evaluated with the Tarlov scale. Capillary density and endothelial progenitor cell (EPC) number were determined by direct counting lectin-positive/alpha-actin-negative cells and VEGFR2/CXCR4 dually-positive cells, respectively; angiography was performed to directly assess arteriogenesis. RESULTS: Young adult and aged mice had a similar degree of decreased perfusion after iliac ligation (young, n = 15: 20.4 +/- 1.9%, vs aged, n = 20: 19.6 +/- 1.3%; P = .72, analysis of variance [ANOVA]); however, young mice recovered faster and to a greater degree than aged mice (day 7, 35 +/- 6% vs 17 +/- 4%, P = .046; day 14, 60 +/- 5% vs 27 +/- 7%, P = .0014). Aged mice had worse functional recovery by day 14 compared to young mice (2.3 +/- 0.3 vs 4.3 +/- 0.4; P = .0021). Aged mice had increased capillary density (day 7, 12.9 +/- 4.4 vs 2.8 +/- 0.3 capillaries/hpf; P = .02) and increased number of EPC incorporated into the ischemic muscle (day 7, 8.1 +/- 0.9 vs 2.5 +/- 1.9 cells; P = .007) compared to young mice, but diminished numbers of collateral vessels to the ischemic limb (1 vs 9; P = .01), as seen on angiography. CONCLUSION: After severe hind limb ischemia, aged animals become ischemic to a similar degree as young animals, but aged animals have significantly impaired arteriogenesis and functional recovery compared to younger animals. These results suggest that strategies to stimulate arteriogenesis may complement those that increase angiogenesis, and may result in improved relief of ischemia.
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Isquemia/fisiopatología , Músculo Esquelético/irrigación sanguínea , Neovascularización Fisiológica , Enfermedad Aguda , Factores de Edad , Animales , Arterias/fisiopatología , Velocidad del Flujo Sanguíneo , Capilares/fisiopatología , Circulación Colateral , Modelos Animales de Enfermedad , Células Endoteliales/patología , Miembro Posterior , Arteria Ilíaca/cirugía , Vena Ilíaca/cirugía , Isquemia/patología , Flujometría por Láser-Doppler , Ligadura , Masculino , Ratones , Ratones Endogámicos C57BL , Microcirculación , Recuperación de la Función , Flujo Sanguíneo Regional , Índice de Severidad de la Enfermedad , Células Madre/patología , Factores de Tiempo , Tomografía Computarizada por Rayos XRESUMEN
Recent reports from single institutions have confirmed the efficacy of carotid endarterectomy (CEA) performed in the urgent or emergent setting, although with higher perioperative mortality and morbidity. We determined the results of urgently performed CEA in academic and community hospitals and whether patient or hospital factors affected outcome. The records of patients undergoing CEA in all nonfederal hospitals in the state of Connecticut between 1992 and 2002 were reviewed, and symptomatic patients who presented in an urgent or emergent fashion were compared to patients treated electively. Multivariable logistic regression was used to determine the effect of patient risk factors on perioperative mortality, stroke, and cardiac complications. Patients undergoing urgent CEA (n = 764, 6.3%) had higher perioperative mortality (2.0% vs. 0.3%, p < 0.0001) and stroke (2.9% vs. 1.1%, p < 0.0001) but not cardiac complications (3.0% vs. 2.2%, p = 0.14) compared to patients undergoing elective CEA (n = 11,312). Patients undergoing urgent CEA and with high rates of associated comorbidity had a higher risk of perioperative mortality (7.8% vs. 0.4, p = 0.001), stroke (10.9% vs. 0.8%, p = 0.0002), and cardiac complications (14.1% vs. 0.8%, p < 0.0001) compared to patients presenting urgently but with little comorbidity. Perioperative mortality was associated with performance of the procedure in hospitals with low bed capacity (odds ratio [OR] = 4.6, p = 0.01). Perioperative stroke was associated with renal insufficiency (OR = 5.3, p = 0.04). Perioperative cardiac complications were associated with diabetes (OR = 2.6, p = 0.03) and performance in hospitals with low bed capacity (OR = 5.0, p < 0.01). Urgent admission was associated with age >/=80 (OR = 1.2, p = 0.04), renal disease (OR = 1.8, p = 0.05), and cardiac disease (OR = 1.3, p < 0.01). Urgently performed CEA has higher perioperative mortality and stroke compared with electively performed cases. However, the subset of patients with low rates of associated comorbid medical conditions but urgently needing CEA is associated with low rates of perioperative complications. Patients with severe associated comorbid medical conditions who present urgently for CEA may form a high-risk group of patients to be considered for referral to large treatment centers or possibly alternative therapy.
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Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Urgencias Médicas , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Femenino , Capacidad de Camas en Hospitales , Mortalidad Hospitalaria , Hospitales/clasificación , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
BACKGROUND/AIMS: Age-associated changes in endothelial nitric oxide synthase (eNOS) expression have not been definitively linked to the pathophysiology of aortic aneurysms. We examined the role of eNOS in human patients and an age-appropriate mouse model. METHODS: eNOS transcripts and immunodetectable protein were assessed by quantitative PCR and immunohistochemistry in human ascending thoracic aneurysms (n = 29) and referent aortae (n = 31). Carotid aneurysms were induced with CaCl2 in young adult (3 months) and aged (18 months) C57BL/6 and eNOS-knockout (eNOS-KO) mice. RESULTS: eNOS transcripts and protein were reduced in human aneurysms compared with controls, although aortic eNOS expression also decreased with patient age. Aged wild-type mice had significantly larger aneurysm diameter than young adult mice. Aged wild-type mice had reduced eNOS transcripts and protein compared with young adult mice. Aged eNOS-KO mice had smaller aneurysms compared with aged wild-type mice but similar size aneurysms compared with young eNOS-KO and young wild-type mice. CONCLUSION: eNOS expression is reduced in both aged human and aged mouse endothelium and eNOS expression is linked to aneurysm expansion in aged but not young adult mice. These findings support the relevance of age-associated changes in eNOS expression in clinical aneurysmal disease.
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Envejecimiento/metabolismo , Enfermedades de las Arterias Carótidas/etiología , Aneurisma Intracraneal/etiología , Óxido Nítrico Sintasa de Tipo III/metabolismo , Adulto , Animales , Aorta/enzimología , Aorta/metabolismo , Aneurisma de la Aorta/enzimología , Enfermedades de las Arterias Carótidas/enzimología , Enfermedades de las Arterias Carótidas/patología , Enfermedades de las Arterias Carótidas/fisiopatología , Progresión de la Enfermedad , Humanos , Aneurisma Intracraneal/enzimología , Aneurisma Intracraneal/patología , Aneurisma Intracraneal/fisiopatología , Ratones , Ratones Endogámicos C57BL , Ratones Noqueados , Óxido Nítrico Sintasa de Tipo III/deficiencia , Óxido Nítrico Sintasa de Tipo III/genética , ARN Mensajero/metabolismoRESUMEN
Vascular smooth muscle cells exhibit varied responses after vessel injury and surgical interventions, including phenotypic switching, migration, proliferation, protein synthesis, and apoptosis. Although the source of the smooth muscle cells that accumulate in the vascular wall is controversial, possibly reflecting migration from the adventitia, from the circulating blood, or in situ differentiation, the intracellular signal transduction pathways that control these processes are being defined. Some of these pathways include the Ras-mitogen-activated protein kinase, phosphatidylinositol 3-kinase-Akt, Rho, death receptor-caspase, and nitric oxide pathways. Signal transduction pathways provide amplification, redundancy, and control points within the cell and culminate in biologic responses. We review some of the signaling pathways activated within smooth muscle cells that contribute to smooth muscle cell heterogeneity and development of pathology such as restenosis and neointimal hyperplasia.
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Músculo Liso Vascular/metabolismo , Miocitos del Músculo Liso/metabolismo , Transducción de Señal , Procedimientos Quirúrgicos Vasculares , Animales , Apoptosis , Células de la Médula Ósea/metabolismo , Diferenciación Celular , Movimiento Celular , Proliferación Celular , Constricción Patológica/metabolismo , Constricción Patológica/patología , Matriz Extracelular/metabolismo , Humanos , Hiperplasia/metabolismo , Hiperplasia/patología , Músculo Liso Vascular/lesiones , Músculo Liso Vascular/patología , Músculo Liso Vascular/fisiopatología , Músculo Liso Vascular/cirugía , Miocitos del Músculo Liso/patología , Fenotipo , Proteínas Quinasas/metabolismo , Células Madre/metabolismo , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
OBJECTIVES: Ephrin ligands and Eph receptors are signaling molecules that are differentially expressed on arteries and veins during development. We examined whether Eph-B4, a venous marker, and Ephrin-B2, an arterial marker, are regulated during vein graft adaptation in humans and aged rats. METHODS AND RESULTS: Eph-B4 transcripts and immunodetectable protein are downregulated in endothelial and smooth muscle cells of patent vein grafts in both humans and in aged rats, whereas Ephrin-B2 transcripts and protein are not strongly induced. Other markers of arterial identity, including dll4 and notch-4, are also not induced during vein graft adaptation in aged rats. Because VEGF-A is upstream of the Ephrin-Eph pathway, and expression of VEGF-A is induced only at early time points after exposure of the vein to the arterial environment, we inhibited VEGF-A in vein grafts using an siRNA-based approach. Vein grafts treated with siRNA directed against VEGF-A demonstrated a thicker intima-media containing alpha-actin, consistent with arterialization, but did not contain Eph-B4 or Ephrin-B2. CONCLUSIONS: Venous identity is preserved in the veins of aged animals, but is lost during adaptation to the arterial circulation; arterial markers are not induced. Markers of vessel identity are plastic in adults and their selective regulation may mediate vein graft adaptation to the arterial environment in aged animals and humans.
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Adaptación Fisiológica/fisiología , Arterias Carótidas/trasplante , Efrina-B2/metabolismo , Receptor EphA4/metabolismo , Vena Safena/trasplante , Factores de Edad , Anastomosis Quirúrgica , Animales , Biomarcadores/análisis , Arterias Carótidas/patología , Modelos Animales de Enfermedad , Efrina-B2/análisis , Femenino , Técnica del Anticuerpo Fluorescente , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Inmunohistoquímica , Masculino , Neovascularización Fisiológica , Probabilidad , Ratas , Ratas Endogámicas F344 , Receptor EphA4/análisis , Factores de Riesgo , Vena Safena/patología , Sensibilidad y Especificidad , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
Both neointimal hyperplasia and inward remodeling contribute to restenosis and lumen loss. Nogo-B has been recently described as an inhibitor of vascular injury and neointimal hyperplasia. To determine whether Nogo-B expression may be a mediator of inward remodeling, we examine the localization of expression of Nogo-B in an in vivo model that examines both neointimal hyperplasia and inward remodeling. The rabbit carotid artery was subjected to balloon injury, outflow branch ligation to reduce flow, or both balloon injury and reduction in flow. In balloon injury-induced neointimal hyperplasia Nogo-B expression was reduced in the intima and media but stimulated in the adventitia. In low flow-induced inward remodeling medial Nogo-B expression was not reduced and adventitial Nogo-B expression was not stimulated. Low flow significantly augmented balloon injury-induced neointimal hyperplasia and was accompanied by reduced intimal and medial Nogo-B expression, and increased adventitial Nogo-B expression in both smooth muscle cells and macrophages. Low flow-induced inward remodeling is not associated with changes in medial Nogo-B expression and is distinct from injury-induced neointimal hyperplasia. Pharmacological strategies to inhibit neointimal hyperplasia and restenosis using normal flow models may only partially account for lumen loss and therefore may not accurately predict responses in patients with extensive outflow disease.
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Arterias Carótidas/patología , Estenosis Carotídea/patología , Proteínas de la Mielina/análisis , Túnica Íntima/patología , Túnica Media/patología , Animales , Apoptosis , Biomarcadores/análisis , Velocidad del Flujo Sanguíneo , Arterias Carótidas/química , Arterias Carótidas/fisiopatología , Arterias Carótidas/cirugía , Estenosis Carotídea/metabolismo , Estenosis Carotídea/fisiopatología , Cateterismo , Proliferación Celular , Tejido Conectivo/metabolismo , Tejido Conectivo/patología , Modelos Animales de Enfermedad , Hiperplasia , Ligadura , Masculino , Proteínas Nogo , Conejos , Estrés Mecánico , Resistencia a la Tracción , Túnica Íntima/química , Túnica Media/químicaRESUMEN
BACKGROUND: The deleterious effects of perioperative malnutrition on recovery after general surgery are established. Since the effects of perioperative malnutrition on recovery after vascular surgery are not known, we examined the effects of nutritional status, and risk factors predictive of malnutrition, on outcome after vascular surgery. METHODS: The records of all open index vascular cases (abdominal aortic aneurysm [AAA] repair, carotid endarterectomy [CEA], lower extremity bypass) performed at the Veterans Affairs (VA) Connecticut between July 2004 and June 2005 were reviewed. The primary outcome was mortality; secondary outcomes included infection and nutritional risk index (NRI) scores. RESULTS: Sixty-eight open vascular cases were performed during the study period. Nutritional depletion developed in 55% of patients and was more likely in patients undergoing AAA (85%) or bypass (77%) than CEA (30%; P = .0005). Patients who developed malnutrition had similar mortality as patients who did not develop postoperative malnutrition (6.1% vs. 3.7%; P = .68); however, malnourished patients had higher rates of postoperative infection (24.2% vs. 3.7%; P = .03). Chronic renal failure was the only patient-associated risk factor predictive of postoperative nutritional depletion (odds ratio 5.9, confidence interval 1.0 to 33.6; P = .04). CONCLUSIONS: Patients undergoing major open vascular surgery have high rates of postoperative malnutrition, with patients undergoing AAA repair having the highest rates of postoperative malnutrition and infection. Patients with chronic renal failure undergoing vascular surgery are associated with increased risk for postoperative malnutrition and may be a group to target for perioperative risk factor modification and nutritional supplementation.
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Fallo Renal Crónico/epidemiología , Desnutrición/etiología , Enfermedades Vasculares/epidemiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Aneurisma de la Aorta Abdominal/cirugía , Comorbilidad , Angiopatías Diabéticas/cirugía , Endarterectomía Carotidea/efectos adversos , Humanos , Desnutrición/epidemiología , Análisis Multivariante , Evaluación Nutricional , Estado Nutricional , Nutrición Parenteral , Proyectos Piloto , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Although carotid endarterectomy (CEA) is now widely accepted as the surgical therapy for carotid stenosis, the role of and indications and evidence for many pharmacologic agents that are used adjunctively in the perioperative setting have not been conclusively established. Aspirin (acetylsalicylic acid) is the pharmaceutical agent that has been studied most extensively in conjunction with CEA; other than aspirin and dextran, the use of many agents before, during, and after CEA has not been standardized. Prospective randomized trials are still needed to demonstrate efficacy, predict outcome, and determine the optimal use of these medications in their adjunctive use during CEA to improve patient care and obtain optimal surgical outcomes.
Asunto(s)
Estenosis Carotídea/terapia , Endarterectomía Carotidea/métodos , Antagonistas Adrenérgicos beta , Anestésicos Locales , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Anticoagulantes/uso terapéutico , Aspirina/uso terapéutico , Estenosis Carotídea/tratamiento farmacológico , Quimioterapia Adyuvante , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéuticoRESUMEN
OBJECTIVE: Patient, hospital, and surgeon factors affect outcome after carotid endarterectomy (CEA). The nature and importance of hospital-specific factors, especially those unrelated to procedural volume, that affect post-CEA outcome remains poorly defined. We used a statewide database to determine the impact of several hospital-associated factors on outcome after CEA. METHODS: Hospital factors were established by telephone survey and validated by repeated survey as well as by the Connecticut Hospital Association, Connecticut state, and individual hospital internet Websites. All CEA in Connecticut non-federal hospitals between 1991 and 2002 were examined, including perioperative mortality, stroke, and cardiac complications. Multivariable logistic regression was used to analyze data. RESULTS: There were 14,288 CEAs performed with 0.5% mortality, 1.3% stroke, and 2.4% cardiac complications. The only hospital factor independently predictive of perioperative mortality was few number of hospital beds (less than 132 beds; odds ratio (OR) 2.78, P = 0.032). Factors predictive of perioperative stroke included few number of beds (OR 1.96, P = 0.001) and absence of a critical pathway (OR 1.39, P = 0.038). Factors predictive of perioperative cardiac complications included few number of beds (OR 3.01, P = 0.003), absence of a critical pathway (OR 1.50, P = 0.001), and absence of dedicated vascular recovery beds (OR 1.35, P = 0.03). Combined mortality, stroke, or cardiac complications were independently predicted by few hospital beds (OR 4.58, P = 0.002), absence of a critical pathway (OR 1.81, P < or = 0.0001), or inability to perform cardiac angiography (OR 3.92, P = 0.024). CONCLUSIONS: Hospital-based factors, such as greater bed capacity, use of critical pathways, ability to perform cardiac angiography, or presence of a dedicated vascular recovery unit predict reduced perioperative mortality, stroke and cardiac complications from CEA. These results suggest that hospital-associated factors do impact surgical outcome and that surgeons need to optimize these factors, extrinsic to the patient and surgeon, to provide maximal quality of care.