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OBJECTIVE: Thoracic central vein (TCV) obstruction (TCVO) in the presence of upper extremity (UE) hemodialysis access can present as superior vena cava syndrome (SVCS) and cause vascular access dysfunction and failure. We report the techniques and results of endorevascularization of TCVO in hemodialysis patients, which allowed for long-term functioning vascular access in the UE. METHODS: From June 2009 to February 2020, 45 hemodialysis patients underwent TCV endorevascularization. The indications for surgery were TCVO or SVCS that threatened the function of a preexisting upper arm access or contraindicated placement of a new upper arm access. Conventional endovascular techniques were used when feasible. Patients with unfavorable anatomy were treated using a transseptal needle to cross difficult intrathoracic stenosis and occlusions or to facilitate an inside-out central venous access technique. The reestablishment of venous outflow was accomplished with angioplasty, stenting, and/or placement of HeRO conduits. Successful revascularization was followed by hemodialysis access revision or a new UE access placement. We recorded the risk factors and procedural outcomes, patency rates, complications, and mortality. RESULTS: The mean age was 53 ± 16.3 years, and 51% were women. The most common risk factors were diabetes mellitus (64.2%) and hypertension (56%). Twenty-five patients (55.5%) had symptoms of SVCS. These symptoms resolved after the TCV procedure in all cases. Crossing of the TCV lesion was successful using a conventional catheter and wire in 26 cases (57.8%) and transseptal needle in 17 cases (37.8%), including 12 using an inside-out central venous access technique. Treatment of the TCV lesion included a HeRO conduit in 20 cases (44.4%), stenting in 17 (37.7%), and transluminal balloon angioplasty alone in 7 (15.5%). Other veins were treated in 33 cases (73.3%). The overall technical success rate was 95.5%. Two intraoperative complications occurred, including one case of severe hypotension and one of fatal cardiac tamponade. Of the 16 patients with preexisting UE access, its function was preserved in all 16 (100%). In 24 of 27 patients (85.7%), new arm access was successfully created after the TCV procedure. The overall clinical success rate was 88.9%. The average follow-up was 663.4 days (median, 507 days; range, 0-2679 days). During follow-up, 26 patients had undergone 90 procedures to maintain access function, 21 had undergone repeat endovascular interventions, and 17 had undergone open procedures. Eight patients (17.8%) had developed infection, five involving HeRO conduits that required excision with loss of access. During the follow-up period, 14 patients (31%) had died of unrelated causes, and 34 patients (75.5%) maintained functional access. CONCLUSIONS: The results of the present study have shown that endorevascularization of TCVO reconstruction is effective in maintaining function or allowing the creation of UE hemodialysis access, with acceptable complication rates.
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Angioplastia de Balón , Derivación Arteriovenosa Quirúrgica , Implantación de Prótesis Vascular , Diálisis Renal , Síndrome de la Vena Cava Superior/terapia , Extremidad Superior/irrigación sanguínea , Adulto , Anciano , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Derivación Arteriovenosa Quirúrgica/efectos adversos , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Perú , Estudios Retrospectivos , Stents , Síndrome de la Vena Cava Superior/diagnóstico por imagen , Síndrome de la Vena Cava Superior/etiología , Síndrome de la Vena Cava Superior/fisiopatología , Texas , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: There is inequality in access to recent advancements in endovascular treatment of acute ischemic stroke (AIS), and Mexico is unusually sensitive to such inequality. AIMS: To report the initial experience of the Mexican Endovascular Reperfusion Registry (MERR). METHODS: The MERR is an academic, independent, prospective, multicenter, observational registry of patients treated with endovascular reperfusion techniques in Mexican hospitals. The registry includes information on demographic and clinical characteristics, diagnostic procedures, treatments, selected time metrics, and outcomes. RESULTS: In all, 49 (57.1% female) patients from 8 centers were included and had the following characteristics: median National Institute of Health Stroke Scale score, 16; median Alberta Stroke Program Early CT Score score, 9; received intravenous tissue-type plasminogen activator, 49%; and treated with mechanical devices, 39 (79.6%), including 20 treated with stent retriever alone, 2 with retriever and intra-arterial thrombolysis (IAt), 10 with catheter aspiration (4 in combination with IAt), 6 with a combination of catheter aspiration and stent retriever, and 1 with IAt followed by balloon angioplasty. Recanalization (TICI 2b or better) was achieved in 69.4% of the patients. The median clot to recanalization time was 30 minutes. A modified Rankin scale ≤2 was achieved in 44.9% of the patients, and 68.2% of these were treated with stent retriever (P = .011). Procedure-related morbidity was 12.2%, 7 patients presented intracerebral hemorrhage (71.4% asymptomatic), and all-cause mortality was 6.1%. CONCLUSIONS: Endovascular treatment of AIS in Mexico is feasible and has an efficacy comparable to that of other countries. Still, many challenges remain, especially pertaining to high costs and difficulties in equality in access to treatment.
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Angioplastia de Balón , Isquemia Encefálica/terapia , Países en Desarrollo , Accidente Cerebrovascular/terapia , Trombectomía , Terapia Trombolítica , Anciano , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Angioplastia de Balón/mortalidad , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidad , Femenino , Accesibilidad a los Servicios de Salud , Disparidades en Atención de Salud , Humanos , Masculino , México , Persona de Mediana Edad , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Stents , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Trombectomía/efectos adversos , Trombectomía/instrumentación , Trombectomía/mortalidad , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Resultado del Tratamiento , Dispositivos de Acceso VascularRESUMEN
BACKGROUND: The use of stents for treating central venous occlusion is well described. Limited evidence exists related to Palmaz balloon-expandable stent use in inferior vena cava (IVC) reconstruction. We analyzed patency and complication rates after IVC reconstruction using Palmaz stents. METHODS: From 2002 to 2019, 37 patients (mean age: 51 year) underwent IVC reconstruction with 68 Palmaz stents. Indications were symptomatic chronic venous obstruction in the infrarenal (n = 25) and intrahepatic (n = 12) IVC. Demographic, operative, and imaging data were evaluated. Clinical data, abdominal CT, and/or duplex ultrasound were used to determine patency at follow-up. RESULTS: Restoration of caval patency was achieved in all patients, with complications in 2/37 (5.4%) patients (thrombus formation within the stent; stent embolization eight days after placement). Follow-up data were available for 27 patients. Primary patency was maintained through last follow-up in 19/27 (70%) patients (mean: 1.1 year), with successful stent redilation performed in 6 patients. Mean duration of primary-assisted patency (n = 5) was 1.2 year. Late lumen loss was (n = 13) was 40% during a mean time to follow-up of 2.0 years. Primary patency in patients with occlusion secondary to malignancy was 109 day (range: 1 day-1.0 year), whereas primary patency in patients with occlusion from other etiologies was 1.1 year (range: 2 day-5.9 year). The Kaplan-Meier analysis demonstrated primary and primary-assisted patency of 66% and 84%, respectively, at 24 and 48 months. CONCLUSIONS: Palmaz balloon-expandable stents for IVC reconstruction is feasible and effective for symptomatic IVC occlusion. Risk of stent migration was low.
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Angioplastia de Balón/instrumentación , Stents , Vena Cava Inferior , Trombosis de la Vena/terapia , Adulto , Anciano , Angioplastia de Balón/efectos adversos , Constricción Patológica , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/fisiopatología , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/fisiopatologíaRESUMEN
BACKGROUND: Incomplete venous thrombolysis and residual nonstented iliac vein disease are known predictors of recurrent deep venous thrombosis (DVT). Controversy exists as to whether the number of thrombolysis sessions affects total stent treatment length or stent patency. The goal of this study was to evaluate the outcomes of patients who underwent single vs multiple catheter-directed lysis sessions with regard to stent extent and patency. METHODS: Consecutive patients who underwent thrombolysis and stenting for acute iliofemoral DVT between 2007 and 2018 were identified and divided into two groups on the basis of the number of treatments performed (one vs multiple sessions). Operative notes and venograms were reviewed to determine the number of lytic sessions performed and stent information, including size, location, total number, and length treated. End points included total stent length, 30-day and long-term patency, and post-thrombotic syndrome (Villalta score ≥5). The χ2 comparisons, logistic regression, and survival analysis were used to determine outcomes. RESULTS: There were 79 patients who underwent lysis and stenting (6 bilateral interventions; mean age, 45.9 ± 17 years; 48 female). Ten patients (12 limbs) underwent single-stage treatment with pharmacomechanical thrombolysis, and the remaining 69 (73 limbs) had two to four operating room sessions combining pharmacomechanical and catheter-directed thrombolysis. Patients who underwent a single-stage procedure were older and more likely to have a malignant disease. These patients received less tissue plasminogen activator compared with the multiple-stage group (17.2 ± 2.2 mg vs 27.6 ± 11.6 mg; P = .008). Average stent length was 8.8 ± 5.2 cm for the single-stage group vs 9.2 ± 4.6 cm for the multiple-stage group (P = .764). Patients who underwent a single-stage procedure had no difference in average length of stay from that of patients who underwent multiple sessions (8.5 days vs 5.9 days; P = .269). The overall 30-day rethrombosis rate was 7.3%. Two-year patency was 72.2% and 74.7% for the single and multiple stages, respectively (P = .909). The major predictors for loss of primary patency were previous DVT (hazard ratio [HR], 5.99; P = .020) and incomplete lysis (HR, 5.39; P = .014) but not number of procedures (HR, 0.957; P = .966). The overall post-thrombotic syndrome rate was 28.4% at 5 years and was also not associated with the number of treatment sessions. CONCLUSIONS: Single- vs multiple-stage thrombolysis for DVT is not associated with a difference in extent of stent coverage. Patency rates remain high for iliac stenting irrespective of the number of lytic sessions, provided lysis is complete and the diseased segments are appropriately stented.
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Angioplastia de Balón/instrumentación , Cateterismo Periférico , Vena Femoral/efectos de los fármacos , Fibrinolíticos/administración & dosificación , Vena Ilíaca/efectos de los fármacos , Stents , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Grado de Desobstrucción Vascular/efectos de los fármacos , Trombosis de la Vena/tratamiento farmacológico , Adulto , Angioplastia de Balón/efectos adversos , Cateterismo Periférico/efectos adversos , Femenino , Vena Femoral/diagnóstico por imagen , Vena Femoral/fisiopatología , Fibrinolíticos/efectos adversos , Fibrinolíticos/economía , Humanos , Vena Ilíaca/diagnóstico por imagen , Vena Ilíaca/fisiopatología , Masculino , Persona de Mediana Edad , Síndrome Postrombótico/etiología , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Terapia Trombolítica/efectos adversos , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/fisiopatología , Adulto JovenRESUMEN
OBJECTIVE: To describe and standardize an original protocol for fractional flow reserve (FFR) pre and postangioplasty in an initial series of patients with clinically manifested transplant renal artery stenosis (TRAS). BACKGROUND: There is no data in the literature about the use of FFR in TRAS. METHODS: Patients with TRAS detected in a noninvasive study were referred to diagnostic angiography and stenosis considered visually severe (≥ 60%) were included. After selective cannulation, a PressureWire 0.014" (Certus™-St. Jude Medical) was advanced to the distal portion of the vessel. Resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) and translesional systolic pressure gradient were obtained and FFR and hyperemic translesional systolic and mean pressure gradients (HSG and HMG) were registered after papaverine induced maximum hyperemia-pre and poststent implantation. Creatinine levels and office blood pressure measurements were registered at the baseline, 6 and 12 months after intervention. RESULTS: Ten consecutive patients had successful stent implantation and were included. After treatment, significant increase in FFR (0.76 ± 0.09 vs. 0.96 ± 0.04, P < 0.001) and reduction in systolic hyperemic gradients (-41.40 ± 19.18, P < 0.001) and mean (-24.00 ± 11.65, P < 0.001) were observed. A strong negative correlation was observed between FFR and percent stenosis diameter-%SD (r = -0.89, P < 0.001) and HSG (r = -0.9, P < 0.001) as well as a strong positive correlation between FFR and baseline Pd/Pa ratio (r = 0.9, P < 0.001). CONCLUSION: FFR was a well-tolerated, valid and reproducible tool during percutaneous intervention for TRAS. Good correlation was observed between FFR and others hemodynamic parameters of lesion severity.
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Cateterismo Periférico/métodos , Hemodinámica , Trasplante de Riñón/efectos adversos , Obstrucción de la Arteria Renal/diagnóstico , Arteria Renal/fisiopatología , Circulación Renal , Adulto , Angioplastia de Balón/instrumentación , Angiografía por Tomografía Computarizada , Femenino , Humanos , Hiperemia/fisiopatología , Masculino , Persona de Mediana Edad , Papaverina/administración & dosificación , Valor Predictivo de las Pruebas , Arteria Renal/diagnóstico por imagen , Arteria Renal/cirugía , Obstrucción de la Arteria Renal/fisiopatología , Obstrucción de la Arteria Renal/cirugía , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Stents , Factores de Tiempo , Resultado del Tratamiento , Vasodilatadores/administración & dosificaciónRESUMEN
BACKGROUND: The objective of this study was to evaluate the relationship between inflammatory markers, such as interleukin (IL)-1ß, IL-6, IL-8, IL-10, tumor necrosis factor α (TNF-α), transforming growth factor ß (TGF-ß), and highly sensitive C-reactive protein, and the development of arterial restenosis 6 months after femoropopliteal percutaneous transluminal angioplasty (PTA) with covered stent implantation. METHODS: We recruited 27 patients of a tertiary hospital in Brazil who were treated with covered stents for atherosclerotic peripheral arterial disease. Serum samples were collected before stent implantation, then 24 hr later, and 6 months after the procedure. RESULTS: At 6-month follow-up, 4 patients (15%) presented restenosis. IL1- ß, IL-6, IL-8, and TNF-α levels showed a statistically significant reduction after both 24 hr and 6 months compared with pretreatment levels (P < 0.01). There were increased levels of IL-10 and TGF-ß both 24 hr and 6 months after PTA and stenting compared with pretreatment levels (P < 0.01). None of the cytokines studied were correlated with restenosis. CONCLUSIONS: This study demonstrated a significant increase in anti-inflammatory TGF-ß and IL-10 and a decrease in proinflammatory cytokines IL-1ß, IL-6, IL-8, and TNF-α 6 months after the procedure, but no inflammatory marker was independently identified as a risk factor for in-stent restenosis.
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Angioplastia de Balón/instrumentación , Arteria Femoral , Mediadores de Inflamación/sangre , Interleucinas/sangre , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Stents , Adulto , Anciano , Angioplastia de Balón/efectos adversos , Biomarcadores/sangre , Brasil , Constricción Patológica , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico por imagen , Arteria Poplítea/diagnóstico por imagen , Estudios Prospectivos , Diseño de Prótesis , Recurrencia , Factores de Riesgo , Centros de Atención Terciaria , Factores de Tiempo , Factor de Crecimiento Transformador beta/sangre , Resultado del Tratamiento , Factor de Necrosis Tumoral alfa/sangreRESUMEN
PURPOSE: To describe a novel technique designed to safely and precisely deploy the Supera stent accurately at the ostium of the proximal superficial femoral artery (SFA) without compromising the profunda and common femoral arteries. TECHNIQUE: After antegrade crossing of the chronic total occlusion (CTO) at the SFA ostium and accurate predilation of the entire SFA lesion, a retrograde arterial access is obtained. The Supera stent is navigated in retrograde fashion to position the first crown to be released just at the SFA ostium. Antegrade dilation is performed across the retrograde access site to obtain adequate hemostasis. The technique has been applied successfully in 21 patients (mean age 78.1±8.2 years; 13 men) with critical limb ischemia using retrograde Supera stenting from the proximal anterior tibial artery (n=6), the posterior tibial artery (n=2), retrograde stent puncture in the mid to distal SFA (n=2), the native distal SFA/proximal popliteal segment (n=6), and the distal anterior tibial artery (n=5). No complications were observed. CONCLUSION: Distal retrograde Supera stent passage and reverse deployment allow precise and safe Supera stenting at the SFA ostium.
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Angioplastia de Balón/instrumentación , Arteria Femoral , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Stents , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Constricción Patológica , Costa Rica , Enfermedad Crítica , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Isquemia/diagnóstico por imagen , Italia , Masculino , Enfermedad Arterial Periférica/diagnóstico por imagen , Diseño de Prótesis , Resultado del Tratamiento , Estados UnidosRESUMEN
Abstract Background Endovascular management of atherosclerotic infrainguinal arteries recently shifted towards drug eluting devices, designed to locally prevent the restenosis process. Numerous clinical studies report an advantage of drug coated balloons over uncoated balloon angioplasty in treating lower extremity peripheral artery disease. However, as coating and balloon platforms are different, each device requires dedicated clinical evaluations. Objective The aim of the study is to further investigate the safety and effectiveness of a Paclitaxel-Coated Balloon for the treatment of atherosclerotic infrainguinal arteries in a real-world setting. Methods 203 patients out of a final sample of 882 were enrolled in this prospective multicenter, observational, all-comers registry during the first 12 months. The primary endpoints were major adverse events (defined as procedure or device related death within 30 days post index procedure, clinically-driven target lesion revascularization or major target limb amputation) at 6 months and freedom from clinically-driven target lesion revascularization at 12 months. Both endpoints were adjudicated by a Clinical Events Committee. Results Mean patient age was 70.2±10.4 years (60.1% male). 47.3% of the patients were diabetic and 67.5% had a history of smoking. Severe claudication was reported in 37.4% and 40% had critical limb ischemia. 257 lesions, including 13.2% in the infrapopliteal territory, were treated with Passeo-18 Lux (mean lesion length 75.1 mm±69.4, 20% occlusions, 76.3% calcified). At 6 months, the rate of major adverse events was 5.5% (95%CI 3.1-9.7). Freedom from clinically-driven target lesion revascularization at 12 months was 93.2% (95%CI 89.1-95.8). All causes mortality was 6.5% (95%CI 3.8-11.0) and overall amputation rate was 4.2% (95%CI 2.1-8.3) at 12 months. Conclusion In a real-world environment, the BIOLUX P-III registry preliminary results confirm the safety and efficacy of the Paclitaxel-Coated Passeo-18 Lux balloon as a stand-alone treatment option for atherosclerotic infrainguinal arteries.
Resumo Contexto O manejo endovascular de artérias infrainguinais ateroscleróticas recentemente tem mudado para dispositivos farmacológicos, desenhados para impedir localmente o processo de reestenose. Numerosos estudos clínicos descrevem uma vantagem da angioplastia com uso de balões farmacológicos sobre os balões convencionais no tratamento de doença arterial periférica dos membros inferiores. No entanto, considerando que as plataformas do revestimento farmacológico e dos balões são diferentes, cada dispositivo requer avaliações clínicas específicas. Objetivo Fazer investigação adicional sobre a segurança e eficácia de um balão revestido com paclitaxel para o tratamento de artérias infrainguinais ateroscleróticas em um cenário de mundo real. Métodos 203 pacientes de uma amostra final de 882 pacientes foram incluídos neste registro prospectivo observacional multicêntrico de inclusão sequencial, durante os primeiros 12 meses. Os desfechos primários foram eventos adversos maiores (definidos como morte relacionada ao procedimento ou ao dispositivo em até 30 dias após o procedimento-índice, necessidade de revascularização da lesão-alvo ou amputação significativa do membro-alvo) em 6 meses e ausência de de revascularização da lesão-alvo em 12 meses. Ambos os desfechos foram adjudicados por um comitê de eventos clínicos. Resultados A idade média foi 70,2±10,4 anos (60,1% sexo masculino). 47,3% dos pacientes eram diabéticos, e 67,5% tinham história de tabagismo. Claudicação severa foi relatada em 37,4%, e 40% apresentava isquemia crítica de membro. 257 lesões, incluindo 13,2% em território infrapoplíteo, foram tratadas com o balão Passeo-18 Lux (comprimento médio das lesões 75,1 mm±69,4, 20% oclusões, 76,3% calcificadas). Aos 6 meses, a taxa de eventos adversos maiores foi de 5,5% (95%CI 3,1-9,7). A ausência de revascularização da lesão-alvo aos 12 meses foi de 93,2% (95%CI 89,1-95,8). Mortalidade por todas as causas foi de 6,5% (95%CI 3,8-11,0) e a taxa geral de amputação foi de 4,2% (95%CI 2,1-8,3) aos 12 meses. Conclusão Em um cenário de mundo real, os resultados preliminares do registro BIOLUX P-III confirmam a segurança e eficácia do balão revestido com paclitaxel Passeo-18 Lux como opção de tratamento único para artérias infrainguinais ateroscleróticas.
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Paclitaxel/uso terapéutico , Angioplastia de Balón/instrumentación , Estudios Prospectivos , Enfermedad Arterial Periférica/cirugía , Procedimientos EndovascularesRESUMEN
BACKGROUND: The indications for conservative "best medical treatment" (BMT) versus additional renal artery stenting are a matter of ongoing debate. The RADAR study aimed to evaluate the impact of percutaneous renal artery stenting on the impaired renal function in patients with hemodynamically significant atherosclerotic renal artery stenosis (RAS). METHODS: RADAR is an international, prospective, randomized (1:1) controlled study comparing BMT alone versus BMT plus renal artery stenting in patients with duplex sonographic hemodynamically relevant RAS. Follow-up assessments were at 2, 6, and 12 months and at 3 years. The primary endpoint was change in estimated glomerular filtration rate (eGFR) at 12 months. RESULTS: Due to slow enrollment, RADAR was terminated early after inclusion of 86 of the scheduled 300 patients (28.7%). Change in eGFR between baseline and 12 months was 4.3 ± 15.4 ml/min/1.73 m2 (stent group) and 3.0 ± 14.9 ml/min/1.73 m2 (BMT group), p > 0.999. Clinical event rates were low with a 12-month composite of cardiac death, stroke, myocardial infarction, and hospitalization for congestive heart failure of 2.9% in the stent and 5.3% in the BMT group, p = 0.526, and a 3-year composite of 14.8% and 12.0%, p = 0.982. At 3 years, target vessel (re-)vascularization occurred in one patient (3.0%) in the stent group and in 8 patients (29.4%) in the BMT group. CONCLUSION: In RADAR, outcomes of renal artery stenting were similar to BMT. These results have to be interpreted with the caveat that the study did not reach its statistically based sample size. TRIAL REGISTRATION: Clinicaltrials.gov, NCT00640406. Registered on 17 March 2008.
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Angioplastia de Balón/instrumentación , Antihipertensivos/uso terapéutico , Aterosclerosis/terapia , Terminación Anticipada de los Ensayos Clínicos , Hemodinámica/efectos de los fármacos , Hipertensión Renovascular/terapia , Obstrucción de la Arteria Renal/terapia , Stents , Adulto , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/mortalidad , Antihipertensivos/efectos adversos , Aterosclerosis/diagnóstico por imagen , Aterosclerosis/mortalidad , Aterosclerosis/fisiopatología , Brasil , Europa (Continente) , Femenino , Tasa de Filtración Glomerular/efectos de los fármacos , Humanos , Hipertensión Renovascular/diagnóstico por imagen , Hipertensión Renovascular/mortalidad , Hipertensión Renovascular/fisiopatología , Masculino , Persona de Mediana Edad , Selección de Paciente , Estudios Prospectivos , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/mortalidad , Obstrucción de la Arteria Renal/fisiopatología , Tamaño de la Muestra , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler DúplexRESUMEN
BACKGROUND: This retrospective study identifies often overlooked anatomical sites for nonthrombotic venous outflow obstruction (NTVO) in patients with unexplained lower extremity edema and pain. METHODS: We reviewed the charts of 75 consecutive patients experiencing symptoms of unexplained lower extremity edema with pain that were unexplained by ultrasound, computed tomography angiography (CTA), and magnetic resonance imaging (MRI), who subsequently underwent venography in an outpatient medical office from 2010 to 2014. We categorized venograms based on the presence or absence of NTVO lesions and calculated prevalence of each at specific sites. The patients with NTVO lesions showing >50% stenosis on venography were then treated with angioplasty and/or stenting. After intervention, we documented subjective levels of pain and edema. RESULTS: Of the 75 venograms reviewed, physicians classified 52 as normal and 23 as showing evidence of compression, including 9 with May-Thurner syndrome and 14 with anatomical compressions at previously underreported sites. These 14 compression sites occurred at the following: iliofemoral vein at the inguinal ligament region (n = 7, 50%), external iliac vein at the iliac artery bifurcation (n = 1, 7.1%), both inguinal ligament region and iliac artery bifurcation (n = 4, 28.6%), and popliteal vein at the popliteal fossa (n = 2, 14.3%). Nine of the 14 patients (64.3%) reported total or near total resolution of lower extremity pain and edema at follow-up between 1 and 7 months (mean = 5.3 ± 2 months, median = 6 months) after balloon angioplasty and/or stent. Five with failed primary interventions underwent subsequent stenting and/or angioplasty and reported total or near total resolution of pain and clinical resolution of edema. CONCLUSIONS: This study provides evidence to broaden the disease profile of venous compression syndromes to other sites such as the hypogastric artery, inguinal ligament, and popliteal fossa. The results support previous research that suggests increased incidence of NTVO exists among patients with unexplained lower extremity edema and pain. In an effort to encourage further exploration, we developed a diagnostic algorithm to support a critical and systematic review of patients with lower extremity edema and pain that may go unexplained using traditional diagnostic measures, including ultrasound, CTA, and MRI alone.
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Edema/etiología , Extremidad Inferior/irrigación sanguínea , Síndrome de May-Thurner/complicaciones , Adulto , Anciano , Angioplastia de Balón/instrumentación , Angiografía por Tomografía Computarizada , Constricción Patológica , Femenino , Humanos , Angiografía por Resonancia Magnética , Masculino , Síndrome de May-Thurner/diagnóstico por imagen , Síndrome de May-Thurner/fisiopatología , Síndrome de May-Thurner/terapia , Persona de Mediana Edad , Dolor/etiología , Flebografía/métodos , Valor Predictivo de las Pruebas , Flujo Sanguíneo Regional , Estudios Retrospectivos , Stents , Resultado del Tratamiento , Ultrasonografía , Grado de Desobstrucción Vascular , Venas/diagnóstico por imagen , Venas/fisiopatologíaRESUMEN
OBJECTIVE: The purpose of this study was to investigate the roles of the kallikrein-kinin system and matrix metalloproteinases (MMPs) in the development of arterial restenosis attributable to intimal hyperplasia in the femoropopliteal arteries. METHODS: This report describes a single-center prospective study of 27 patients with peripheral artery disease who required percutaneous transluminal angioplasty and stenting of the femoropopliteal segment using covered stent grafts. The blood concentrations of total and kininogen fractions were evaluated using immunoenzymatic methods. Plasma kallikrein was evaluated by the colorimetric method. Tissue kallikrein was evaluated by the spectrophotometric method. The activity of kininase II was measured by fluorometric analysis. Quantification of MMPs was performed by zymography, and tissue inhibitors of metalloproteinases were measured by enzyme-linked immunosorbent assay. RESULTS: Four (15%) of the treated patients developed restenosis at the 6-month follow-up evaluation. These patients had significantly lower levels of high-molecular-weight kininogens (24 hours; P < .05) and low-molecular-weight kininogens (before, P < .05; 24 hours, P < .01; 6 months, P < .05) and lower levels of tissue inhibitor of metalloproteinases-2 (6 months; P < .05) than the patients without restenosis. The activity levels of plasma and tissue kallikrein, kininase II, and MMPs did not differ significantly between the patients with and without restenosis. CONCLUSIONS: This study demonstrates an involvement of the kallikrein-kinin system in in-stent restenosis, although we could not confirm the participation of metalloproteinases in the restenosis process.
Asunto(s)
Angioplastia de Balón/instrumentación , Arteria Femoral , Calicreínas/sangre , Quininógeno de Alto Peso Molecular/sangre , Quininógeno de Bajo Peso Molecular/sangre , Metaloproteinasas de la Matriz/sangre , Neointima , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Stents , Inhibidores Tisulares de Metaloproteinasas/sangre , Adulto , Anciano , Angioplastia de Balón/efectos adversos , Biomarcadores/sangre , Brasil , Constricción Patológica , Femenino , Humanos , Hiperplasia , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/enzimología , Estudios Prospectivos , Diseño de Prótesis , Recurrencia , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Paclitaxel/administración & dosificación , Angioplastia de Balón/instrumentación , Enfermedad Arterial Periférica/terapia , Arteria Poplítea/diagnóstico por imagen , Grado de Desobstrucción Vascular , Radiografía , Fumar , Ensayos Clínicos Controlados Aleatorios como Asunto , Angioplastia de Balón/efectos adversos , Complicaciones de la Diabetes/terapia , Estimación de Kaplan-Meier , Arteria Femoral/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidadRESUMEN
Portal vein (PV) thrombosis (PVT) in the absence of liver disease or thrombophilia is rare. We report a 57-year-old male with a history of stage 3 chronic kidney disease who presented at the emergency department 18 months after abdominal surgery with progressive abdominal pain and distention. Computed tomography revealed PVT with multiple collaterals and moderate ascites. He had undergone partial gastrectomy and gastrojejunal anastomosis at an outside facility for gastrointestinal stromal tumors that caused an iatrogenic stenotic lesion in the PV. The patient underwent balloon angioplasty and endovascular deployment of an 8 mm × 100 mm Viabahn covered stent (W. L. Gore and Associates, Flagstaff, Arizona) in the extrahepatic PV via a transhepatic approach; the device allowed complete restoration of prograde portal flow with clinical improvement. At 6 months from the intervention, he remains symptom-free with normal liver function tests and patent endoprosthesis on antiplatelet therapy.
Asunto(s)
Angioplastia de Balón , Gastrectomía/efectos adversos , Enfermedad Iatrogénica , Vena Porta , Trombosis de la Vena/terapia , Angioplastia de Balón/instrumentación , Angiografía por Tomografía Computarizada , Constricción Patológica , Humanos , Masculino , Persona de Mediana Edad , Flebografía/métodos , Vena Porta/diagnóstico por imagen , Vena Porta/fisiopatología , Portografía/métodos , Diseño de Prótesis , Stents , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiología , Trombosis de la Vena/fisiopatologíaRESUMEN
Background and rationale for the study. The purpose of this study was to assess the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) reduction for the management of TIPS-induced acute liver decompensation. Between August 2000 and November 2013, 347 patients underwent a TIPS procedure in the authors' institution; 21/347 (6%) developed post-TIPS acute liver decompensation which was managed using a percutaneous shunt reduction technique. Patient demographics, laboratory tests before and after initial TIPS and TIPS reduction, procedural data and clinical follow-up data were analysed. RESULTS: Twenty-one patients (mean age 63 years) who underwent an initial TIPS procedure for variceal bleeding (n = 7; 33%) or refractory ascites (n = 14; 67%) successfully underwent shunt reduction ten days (3-34 days) after the initial TIPS procedure. The portosystemic pressure gradient (PSPG) increased from 8 (3-17) mmHg before reduction to 12 (7-23) mmHg after shunt reduction. Survival at one and six months follow-up was 15 (71%) and 11 patients (52%), respectively. The international normalised ratio (INR) (1.7 vs. 1.5; p = 0.044) was significantly different after TIPS reduction in the non-survival group compared to the survival group. In conclusion, TIPS reduction for the management of TIPS-induced acute liver decompensation is technically feasible and is associated with a one and six-month mortality rate of 29% and 48%, respectively. Higher post-TIPS-reduction INR values may be associated with higher risk of early mortality.
Asunto(s)
Angioplastia de Balón , Implantación de Prótesis Vascular , Cirrosis Hepática/cirugía , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Complicaciones Posoperatorias/cirugía , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Angioplastia de Balón/mortalidad , Bélgica , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/fisiopatología , Masculino , Persona de Mediana Edad , Presión Portal , Derivación Portosistémica Intrahepática Transyugular/mortalidad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Diseño de Prótesis , Reoperación , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIM: To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). MATERIALS AND METHODS: We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be presente where a 'waist' was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no 'waist' is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. RESULTS: Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. CONCLUSION: When no 'waist' is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels ('vascular hitch') may be a safe and reliable surgical technique.
Asunto(s)
Angioplastia de Balón/métodos , Pelvis Renal/irrigación sanguínea , Pelvis Renal/cirugía , Laparoscopía/métodos , Obstrucción Ureteral/cirugía , Adolescente , Angioplastia de Balón/instrumentación , Calibración , Niño , Constricción Patológica/cirugía , Femenino , Humanos , Hidronefrosis/cirugía , Masculino , Presión , Reproducibilidad de los Resultados , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
ABSTRACT Aim To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). Materials and Methods We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be present where a ‘waist’ was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. Results Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. Conclusion When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels (‘vascular hitch’) may be a safe and reliable surgical technique.
Asunto(s)
Humanos , Masculino , Femenino , Niño , Adolescente , Obstrucción Ureteral/cirugía , Laparoscopía/métodos , Angioplastia de Balón/métodos , Pelvis Renal/cirugía , Pelvis Renal/irrigación sanguínea , Presión , Calibración , Reproducibilidad de los Resultados , Estudios Retrospectivos , Resultado del Tratamiento , Angioplastia de Balón/instrumentación , Constricción Patológica/cirugía , Hidronefrosis/cirugíaRESUMEN
BACKGROUND: Inflammatory activity may influence results of percutaneous transluminal angioplasty (PTA). The purpose of this study was to evaluate the relationship between (1) proinflammatory markers (interleukin [IL]-6, IL-8, tumor necrosis factor α (TNF-α), and highly sensitive C-reactive protein [CRP]); (2) type 1 T helper cell marker (IL-12); and (3) Type 2 T helper cell marker (transforming growth factor-ß [TGF-ß]) and in-stent restenosis, 6 months after femoral PTA with stent implantation. METHODS: We performed a single-center prospective study with 26 patients with peripheral artery disease requiring PTA and stenting. As control, we studied 26 patients who were submitted to diagnostic angiography. Serum samples were collected before stent implantation, 24 hr and 6 months after the procedure. To detect restenosis, a new angiography was obtained at 6 months. RESULTS: Restenosis was observed in 10 (38.5%) patients who underwent PTA and stenting. There was a trend to increased levels of IL-6, TNF-α, TGF-ß, and IL-12 24 hr after PTA and stenting compared with pretreatment. IL-8 levels showed a statistically significant reduction 24 hours after versus pretreatment (P < 0.05), 6 months vs. pretreatment, and 6 months vs. 24 hr (P < 0.01). There was no statistical difference between cytokine levels when comparing restenosis and no restenosis groups. CRP levels were already high at pretreatment. CONCLUSIONS: No inflammatory marker was independently identified as risk factor for in-stent restenosis, 6 months after femoral PTA with stent implantation. The question that remains is whether acute phase reactants will be clinically useful to predict the individual risk for in-stent restenosis.
Asunto(s)
Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Arteria Femoral , Mediadores de Inflamación/sangre , Interleucinas/sangre , Enfermedad Arterial Periférica/terapia , Stents , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Brasil , Estudios de Casos y Controles , Constricción Patológica , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/inmunología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Radiografía , Recurrencia , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Concurrent severe carotid and cardiac disease is a challenging situation where staged surgery is probably the most common strategy. However, in patients with an unstable clinical presentation, the best approach is still a matter of debate. The aim of the study was to report in-hospital and midterm outcome in patients who received carotid artery stenting and synchronous cardiac surgery. METHODS: From June 1998 to July 2012, 54 consecutive patients who were treated at a high-volume university medical center with this hybrid approach were included in the study. All of the patients received carotid angioplasty while being administered aspirin and regular unfractionated heparin. Then, all of the patients were immediately transferred to the operating room for coronary and/or cardiac valve surgery. All of the patients were administered aspirin and clopidogrel once bleeding was ruled out, after surgery. RESULTS: There were 5 in-hospital surgical related deaths, and no patient suffered a stroke or required carotid urgent re-intervention. At follow-up (55 ± 28 months; range 1-144 months), there were no new neurological deficits, while one additional death occurred. CONCLUSIONS: In this series, synchronous carotid stenting and cardiac surgery were feasible with an acceptable complication rate in a high-surgical-risk population, which could not undergo staged procedures.
Asunto(s)
Angioplastia de Balón , Procedimientos Quirúrgicos Cardíacos , Enfermedades de las Arterias Carótidas/terapia , Cardiopatías/cirugía , Hemodinámica , Anciano , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Angioplastia de Balón/mortalidad , Anticoagulantes/administración & dosificación , Aspirina/administración & dosificación , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/diagnóstico , Enfermedades de las Arterias Carótidas/mortalidad , Enfermedades de las Arterias Carótidas/fisiopatología , Clopidogrel , Femenino , Cardiopatías/complicaciones , Cardiopatías/diagnóstico , Cardiopatías/mortalidad , Cardiopatías/fisiopatología , Heparina/administración & dosificación , Mortalidad Hospitalaria , Hospitales de Alto Volumen , Hospitales Universitarios , Humanos , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Factores de Riesgo , Índice de Severidad de la Enfermedad , Stents , Ticlopidina/administración & dosificación , Ticlopidina/análogos & derivados , Factores de Tiempo , Resultado del TratamientoRESUMEN
Critical upper limb ischemia caused by atherosclerosis is uncommon. Endovascular treatment, with angioplasty or stenting, has been successfully performed for subclavian and below the elbow diseases; however, there's a lack of report regarding the treatment of brachial artery disease causing critical hand ischemia. In this article, we describe the treatment of a brachial artery occlusion with endovascular stenting in a patient with chronic upper limb ischemia.
Asunto(s)
Angioplastia de Balón/instrumentación , Arteriopatías Oclusivas/terapia , Arteria Braquial , Mano/irrigación sanguínea , Isquemia/terapia , Stents , Anciano , Arteriopatías Oclusivas/diagnóstico , Arteriopatías Oclusivas/fisiopatología , Arteria Braquial/diagnóstico por imagen , Arteria Braquial/fisiopatología , Constricción Patológica , Enfermedad Crítica , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatología , Masculino , Radiografía , Flujo Sanguíneo Regional , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: The kallikrein-kinin system (KKS) has several direct and indirect effects on cells and cellular mediators involved in the inflammatory process. Studies about inflammation on percutaneous transluminal angioplasty with stent (PTA/stent) to treat peripheral arterial disease (PAD) in humans are scarce. The matrix metalloproteinases (MMPs) are calcium-dependent zinc-containing endopeptidases expressed in various cells and tissues such as fibroblasts, inflammatory cells, and, smooth muscle cells. Changes in the extracellular matrix (ECM) take place in the pathogenesis of many cardiovascular pathologies. MMPs and their inhibitors (tissue inhibitors of metalloproteinases [TIMPs]) are crucial in ECM remodeling in both physiologic and pathologic conditions. The aim of this study was to evaluate the role of the KKS and the MMP metabolism, which are important mediators that may contribute to tissue repair, in the process of arterial restenosis due to intimal hyperplasia in the femoropopliteal segment with the aim of developing new interventions. METHODS: Thirty-nine consecutive patients were selected (regardless of ethnic group, age, or sex) for revascularization, who underwent PTA/stent of the femoropopliteal segment. Twenty-five patients with the same clinical characteristics who were scheduled for diagnostic angiography but not subjected to PTA/nitinol stent were also selected. The concentrations in blood of total and kininogen fractions were evaluated using immunoenzymatic methods. Plasma kallikrein was evaluated by the colorimetric method. Tissue kallikrein was evaluated by the spectrophotometric method. The activity of kininase II was measured by fluorometric analysis. Quantification of MMPs was performed by zymography, which is an electrophoresis technique, and TIMPs were measured by enzyme-linked immunosorbent assay. RESULTS: Among the 31 patients who completed the survey, there were 10 cases of angiographically defined restenosis of >50%, and 21 cases without restenosis. There was an increase in the concentrations of the substrates (high-molecular-weight kininogens and lower molecular weight kininogens) and enzymes (plasma and tissue kallikrein) in patients with restenosis, indicating activation of this inflammatory pathway in these patients. The activity of kininase II was not significantly different between the groups of patients studied. There were no statistical differences between restenosis and no restenosis patients for both MMPs and TIMPs dosage, but there is an upward trend of MMPs in time 6 months in patients with restenosis. CONCLUSIONS: With the aim of identifying factors contributing to restenosis after endovascular intervention, this study showed evidence of high activation of the KKS in the pathologic inflammatory process of PTA/stent restenosis. In the other hand, it could not show participation of metalloproteinase metabolism in PTA/stent restenosis.