RESUMEN
STUDY DESIGN: A prospective study. OBJECTIVE: To investigate the incidence of vertebral artery (VA) occlusion and whether anterior spinal artery (ASA) is occluded in cervical facet dislocation. SETTING: University hospital, China. METHODS: During a 2-year period, 21 conventional patients with cervical facet dislocation were prospectively enrolled. All patients received computed tomography angiography (CTA) to assess the patency of the VA, anterior radiculomedullary arteries (ARAs), and ASA at the time of injury. Clinical data were documented, including demographics, symptomatic vertebrobasilar ischemia, American Spinal Injury Association Impairment Scale (ASIA) grades, and ASA and VA radiological characteristics. RESULTS: VA unilateral occlusion occurred in 5 of 21 patients (24%), including 2 with unilateral facet dislocation and 3 with bilateral facet dislocation. No ASA occlusion was found in all 21 patients, including 5 with VA unilateral occlusion. No patients had symptomatic vertebrobasilar ischemia. CONCLUSIONS: VA occlusion occurs in approximately one-fourth of cervical facet dislocations, with infrequent symptomatic vertebrobasilar ischemia. ASA is not occluded following cervical facet dislocation, even with unilateral VA occlusion.
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Vértebras Cervicales , Angiografía por Tomografía Computarizada , Luxaciones Articulares , Arteria Vertebral , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Prospectivos , Angiografía por Tomografía Computarizada/métodos , Arteria Vertebral/diagnóstico por imagen , Arteria Vertebral/lesiones , Anciano , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/irrigación sanguínea , Adulto , Luxaciones Articulares/diagnóstico por imagen , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Arteriopatías Oclusivas/diagnóstico por imagenRESUMEN
BACKGROUND Cerebrovascular occlusion is a critical health concern associated with strokes, a leading cause of mortality worldwide. Large vessel occlusion, constituting a significant portion of acute ischemic strokes, presents serious patient outcomes. Occlusions involving multiple extracranial vessels are rare but pose challenges in early detection due to potential absence of overt symptoms. CASE REPORT A 65-year-old man with a significant smoking history and no prior history of hypertension or cardiovascular disease presented with recurrent generalized tonic seizures occurring 4 to 5 times daily. Despite normal neurological examinations, neck sonography indicated potential obstruction in the carotid and vertebral arteries. Conventional angiography revealed mild coronary artery plaques but complete occlusion of all cranial branches originating from the aorta, alongside porcelain aorta. Neck CT angiography confirmed complete occlusion of the supra-aortic branches of the aorta and absence of the right internal carotid artery, with evidence of proximal occlusion of the left internal carotid artery. Medical management without surgical intervention was pursued due to the patient's stable condition. He was discharged with a medication regimen including antiplatelet therapy and statins. Four-month follow-up showed significant symptom improvement, with minimal changes in brain blood flow circulation noted on CT. CONCLUSIONS This case underscores the brain's remarkable adaptive capacity in withstanding severe vascular challenges. The rarity of multiple extracranial vessel occlusions and presence of porcelain aorta further complicated the case. Utilizing advanced imaging techniques and personalized treatment approaches are crucial in managing complex vascular conditions. Ongoing research and careful monitoring are essential to advance understanding and management in such cases.
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Angiografía por Tomografía Computarizada , Humanos , Masculino , Anciano , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/diagnóstico por imagen , Arteriopatías Oclusivas/diagnóstico por imagenAsunto(s)
Cilostazol , Procedimientos Endovasculares , Arteria Femoral , Arteria Poplítea , Tetrazoles , Humanos , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Arteria Poplítea/cirugía , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/cirugía , Cilostazol/uso terapéutico , Cilostazol/efectos adversos , Resultado del Tratamiento , Tetrazoles/uso terapéutico , Tetrazoles/efectos adversos , Factores de Tiempo , Procedimientos Endovasculares/efectos adversos , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/cirugía , Grado de Desobstrucción Vascular/efectos de los fármacos , MasculinoAsunto(s)
Arteria Femoral , Arteria Poplítea , Humanos , Arteria Poplítea/cirugía , Arteria Poplítea/diagnóstico por imagen , Arteria Femoral/cirugía , Arteria Femoral/diagnóstico por imagen , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Masculino , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Anciano , Arteriopatías Oclusivas/cirugía , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/fisiopatologíaRESUMEN
BACKGROUND: Aortoiliac occlusive disease (AIOD) has traditionally been treated with aortobifemoral bypass (ABF). Unibody endograft (UBE) for AIOD, however, has been increasingly utilized in selected patients. We report outcomes of patients undergoing ABF or UBE for AIOD. METHODS: Patients (2016-2021) undergoing elective ABF or UBE with a unibody device for AIOD were identified at an academic institution. Chi-square and Kaplan-Meier analysis were used to evaluate outcomes by group. RESULTS: One hundred thirty-one patients undergoing UBE or ABF were screened, with 82 included. Twenty-one patients underwent UBE (25.6%) and 61 (74.4%) underwent ABF. UBE patients were older (63.8 vs. 58.2 years; P = 0.01), with a higher prevalence of diabetes (52.4 vs. 19.7%; P = 0.004). Significant differences were seen between UBE and ABF including a shorter surgery length (214 vs. 360 min; P = 0.0001), less blood loss (300 vs. 620 mls; P = 0.001), larger minimum aortic diameter (14.6 vs. 12.6; P = 0.0006), larger common iliac artery (9.5 vs. 7.9; P = 0.005) and lower postoperative ankle-brachial index (0.8 vs. 0.9; P = 0.04). There were no differences in TASC C/D iliac lesions in the UBE than ABF group (66.6% vs. 63.9%; P < 0.82) or Trans-Atlantic Inter-Society Consensus classification femoropopliteal lesions. Unadjusted analysis revealed no significant differences between UBE and ABF for 30-day mortality (0 vs. 1.6%; P = 1), stroke (0 vs. 3.3%; P = 1), or major adverse cardiac events (4.8 vs. 4.9%; P = 1). There were no significant differences in mid-term surgical outcomes over a mean follow-up period of 23.7 months between UBE and ABF groups; specifically endovascular (0 vs. 8.2%; P = 0.3) or open/hybrid reintervention (9.5 vs. 14.8%; P = 0.7) with similar limb occlusion (4.8 vs. 27.8; P = 0.12). Kaplan-Meier estimated primary, primary-assisted, and secondary patency at 36 months were similar with 94%, 100%, and 94% for UBE and 86%, 95%, and 86% for ABF, respectively. Estimated survival at 36 months was 95% for UBE and 97% for ABF (P = 0.8). CONCLUSIONS: Equivalent outcomes were seen between AIOD treated with UBE or ABF in similar patient populations. Mid-term outcomes such as reintervention and patency are similar for UBE and ABF. We still recommend ABF over UBE as a primary modality of treatment in surgically fit patients with greater complexity aortoiliac lesions and with smaller arterial diameters, especially women.
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Enfermedades de la Aorta , Arteriopatías Oclusivas , Implantación de Prótesis Vascular , Prótesis Vascular , Procedimientos Endovasculares , Arteria Femoral , Arteria Ilíaca , Grado de Desobstrucción Vascular , Humanos , Femenino , Masculino , Persona de Mediana Edad , Arteria Ilíaca/cirugía , Arteria Ilíaca/fisiopatología , Arteria Ilíaca/diagnóstico por imagen , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/fisiopatología , Arteriopatías Oclusivas/cirugía , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/mortalidad , Arteriopatías Oclusivas/diagnóstico por imagen , Estudios Retrospectivos , Resultado del Tratamiento , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Anciano , Factores de Tiempo , Arteria Femoral/cirugía , Arteria Femoral/fisiopatología , Arteria Femoral/diagnóstico por imagen , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Procedimientos Endovasculares/instrumentación , Factores de Riesgo , Diseño de Prótesis , Complicaciones Posoperatorias/etiología , Medición de RiesgoAsunto(s)
Isquemia , Arteria Poplítea , Humanos , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/cirugía , Isquemia/diagnóstico por imagen , Isquemia/etiología , Masculino , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/cirugía , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Valor Predictivo de las Pruebas , Adulto , Constricción Patológica , Ultrasonografía Doppler , Flujo Sanguíneo RegionalAsunto(s)
Embolia Pulmonar , Arteria Subclavia , Humanos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/etiología , Embolia Pulmonar/complicaciones , Arteria Subclavia/diagnóstico por imagen , Masculino , Femenino , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/cirugía , Embolia Paradójica/diagnóstico por imagen , Embolia Paradójica/complicaciones , Embolia Paradójica/etiología , Persona de Mediana Edad , AncianoRESUMEN
BACKGROUD: The learning curve and midterm results of aortoiliac occlusive disease (AIOD) revascularization by robot-assisted laparoscopic (RAL) surgery may be known. METHODS: A prospective single-center study was conducted in the vascular surgery department of Georges Pompidou European Hospital (Paris, France). Patients with AIOD treated by RAL from February 2014 to February 2019 were included. Demographic characteristics, past medical history, Trans-Atlantic Inter-Society Consensus (TASC) lesions classifications, mortality, primary and secondary patency, as well as complication rates were collected. Safety was analyzed by the cumulative sum control chart method with a conversion rate of 10%, operative time by cumulative average-time model, and primary and secondary patency by the Kaplan-Meier method. RESULTS: Seventy patients were included, 18 (25.7%) with TASC C lesions and 52 (74.3%) with TASC D lesions. Before discharge, 14 (24.3%) patients had surgical complications. Among them, 10 (14.3%) required at least one reintervention. One (1.4%) patient died during the hospitalization. The learning curve in terms of safety (conversion rate) was 13 cases with an operating time of 220 minutes after 35 patients. During follow-up (median 37 months [21; 49]), 63 patients (91.3%) improved their symptoms, 53 (76.8%) became asymptomatic, and 3 graft limb occlusions occurred. The primary patency at 12, 24, 36, and 48 months was 94%, 92%, 92%, and 92%, respectively, while the secondary patency for the same intervals was 100%, 98.1%, 98.1%, and 98.1%, respectively. CONCLUSIONS: Robotic surgery in AIOD revascularization seems safe and effective; allowing to treat patients with few comorbidities and severe lesions, in a dedicated center experienced in RAL, with excellent patency. Prospective clinical trials should be performed to confirm safety.
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Enfermedades de la Aorta , Arteriopatías Oclusivas , Arteria Ilíaca , Curva de Aprendizaje , Procedimientos Quirúrgicos Robotizados , Grado de Desobstrucción Vascular , Humanos , Masculino , Femenino , Procedimientos Quirúrgicos Robotizados/efectos adversos , Arteria Ilíaca/cirugía , Arteria Ilíaca/fisiopatología , Arteria Ilíaca/diagnóstico por imagen , Anciano , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Persona de Mediana Edad , Arteriopatías Oclusivas/cirugía , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/mortalidad , Estudios Prospectivos , Factores de Riesgo , Complicaciones Posoperatorias/etiología , Laparoscopía/efectos adversos , Paris , Competencia Clínica , Tempo OperativoRESUMEN
BACKGROUND: Endovascular therapy (EVT) dramatically improves clinical outcomes for patients with anterior circulation emergent large vessel occlusion (ELVO) strokes. With recent publication of two randomized controlled trials in favor of EVT for basilar artery occlusions, the Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee provides this focused update for the existing SNIS guideline, 'Current endovascular strategies for posterior circulation large vessel occlusion stroke.' METHODS: A structured literature review and analysis of studies related to posterior circulation large vessel occlusion (basilar or vertebral artery) strokes treated by EVT was performed. Based on the strength and quality of the evidence, recommendations were made by consensus of the writing committee, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS: Based on the results of the most recent randomized, controlled trials on EVT for basilar or vertebral artery occlusion, the expert panel agreed on the following recommendations. For patients presenting with an acute ischemic stroke due to an acute basilar or vertebral artery occlusion confirmed on CT angiography, National Institutes of Health Stroke Scale (NIHSS) score of ≥6, posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) ≥6, and age 18-89 years: (1) thrombectomy is indicated within 12 hours since last known well (class I, level B-R); (2) thrombectomy is reasonable within 12-24 hours from the last known well (class IIa, level B-R); (3) thrombectomy may be considered on a case by case basis for patients presenting beyond 24 hours since last known well (class IIb, level C-EO). In addition, thrombectomy may be considered on a case by case basis for patients aged <18 years or >89 years on a case by case basis (class IIb, level C-EO). CONCLUSIONS: The indications for EVT of ELVO strokes continue to expand and now include patients with basilar artery occlusion. Further prospective, randomized controlled trials are warranted to elucidate the efficacy and safety of EVT in populations not included in this set of recommendations, and to confirm long term outcomes.
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Procedimientos Endovasculares , Insuficiencia Vertebrobasilar , Anciano , Anciano de 80 o más Años , Humanos , Arteriopatías Oclusivas/cirugía , Arteriopatías Oclusivas/terapia , Arteriopatías Oclusivas/diagnóstico por imagen , Arteria Basilar/diagnóstico por imagen , Arteria Basilar/cirugía , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/normas , Guías de Práctica Clínica como Asunto/normas , Trombectomía/métodos , Insuficiencia Vertebrobasilar/cirugía , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Insuficiencia Vertebrobasilar/terapia , Adolescente , Adulto Joven , Adulto , Persona de Mediana EdadRESUMEN
BACKGROUND: Covered endovascular reconstruction of aortic bifurcation (CERAB) is increasingly used as a first line-treatment in patients with aortoiliac occlusive disease (AIOD). We sought to compare the outcomes of patients who underwent CERAB compared with the gold standard of aortobifemoral bypass (ABF). METHODS: The Vascular Quality Initiative was queried for patients who underwent ABF or CERAB from 2009 to 2021. Propensity scores were generated using demographics, comorbidities, Rutherford class, and urgency. The two groups were matched using 5-to-1 nearest-neighbor match. Our primary outcomes were 1-year estimates of primary patency, major adverse limb events (MALEs), MALE-free survival, reintervention-free survival, and amputation-free survival. Standard statistical methods were used. RESULTS: A total of 3944 ABF and 281 CERAB cases were identified. Of all patients with AIOD, the proportion of CERAB increased from 0% to 17.9% between 2009 and 2021. Compared with ABF, patients who underwent CERAB were more likely to be older (64.7 vs 60.2; P < .001) and more often had diabetes (40.9% vs 24.1%; P < .001) and end-stage renal disease (1.1% vs 0.3%; P = .03). In the matched analysis (229 CERAB vs 929 ABF), ABF patients had improved MALE-free survival (93.2% [±0.9%] vs 83.2% [±3%]; P < .001) and lower rates of MALE (5.2% [±0.9%] vs 14.1% [±3%]; P < .001), with comparable primary patency rates (98.3% [±0.3%] vs 96.6% [±1%]; P = .6) and amputation-free survival (99.3% [±0.3%] vs 99.4% [±0.6%]; P = .9). Patients in the CERAB group had significantly lower reintervention-free survival (62.5% [±6%] vs 92.9% [±0.9%]; P < .001). Matched analysis also revealed shorter length of stay (1 vs 7 days; P < .001), as well as lower pulmonary (1.2% vs 6.6%; P = .01), renal (1.8% vs 10%; P < .001), and cardiac (1.8% vs 12.8%; P < .001) complications among CERAB patients. CONCLUSIONS: CERAB had lower perioperative morbidity compared with ABF with a similar primary patency 1-year estimates. However, patients who underwent CERAB experienced more major adverse limb events and reinterventions. Although CERAB is an effective treatment for patients with AIOD, further studies are needed to determine the long-term outcomes of CERAB compared with the established durability of ABF and further define the role of CEARB in the treatment of AIOD.
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Enfermedades de la Aorta , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Arteria Femoral , Recuperación del Miembro , Grado de Desobstrucción Vascular , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/fisiopatología , Arteria Femoral/cirugía , Arteria Femoral/fisiopatología , Arteria Femoral/diagnóstico por imagen , Factores de Tiempo , Factores de Riesgo , Amputación Quirúrgica , Arteria Ilíaca/cirugía , Arteria Ilíaca/fisiopatología , Arteria Ilíaca/diagnóstico por imagen , Medición de Riesgo , Arteriopatías Oclusivas/cirugía , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/mortalidad , Prótesis Vascular , Resultado del Tratamiento , Bases de Datos Factuales , Complicaciones Posoperatorias/etiologíaAsunto(s)
Arteriopatías Oclusivas , Cateterismo Periférico , Arteria Radial , Humanos , Arteria Radial/diagnóstico por imagen , Factores de Riesgo , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/etiología , Cateterismo Periférico/efectos adversos , Resultado del Tratamiento , Punciones , Medición de Riesgo , Masculino , Femenino , Anciano , Persona de Mediana Edad , Grado de Desobstrucción Vascular , Constricción Patológica , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/efectos adversosRESUMEN
BACKGROUND: Transverse aortic arch obstruction is a challenging lesion for which stent implantation provides a potentially important alternate therapy. The objectives were to evaluate the technical, procedural, and medium-to-long-term clinical outcomes of percutaneous stent implantation of transverse aortic arch obstruction. METHODS: This is a retrospective, multicenter study of transverse aortic arch stent implantation. Univariable and multivariable analyses were performed. RESULTS: Index catheterization included 187 stent implants in 146 patients. The median age is 14.3 years (interquartile range, 9.3-19), weight is 53 kg (30-69), and follow-up is 53 months (12-120). The most common stent design was open cell (n=90, 48%). Stents overlapped 142 arch vessels (37 carotid arteries) in 118 (81%) cases. Technical and procedural success rates were 100% and 88%, respectively. Lower weight (P=0.018), body surface area (P=0.013), and minimum-to-descending aortic diameter ratio (P<0.001) were associated with higher baseline aortic gradient. The residual gradient was inversely associated with implant and final dilation diameters (P<0.001). The combined incidence of aortic injury and stent-related complications was 14%. There were no reports of abnormal brain scans or stroke. Blood pressure cuff gradient, echocardiographic arch velocity, and hypertension rates improved within 1-year follow-up with increased antihypertensive medication use. Reintervention was reported in 60 (41%) patients at a median of 84 (22-148) months to first reintervention. On multivariable logistic regression, residual aortic gradient >10 mmâ Hg was associated with increased odds of reintervention at all time points when controlling for each final dilation diameter, weight, and minimum-to-descending aortic diameter ratio. CONCLUSIONS: Transverse aortic arch stent implantation has high rates of technical, procedural, and medium-to-long-term clinical success. Aortic gradient >10 mmâ Hg is associated with increased odds of reintervention at 1-year and most recent follow-ups. Open cell stent design was frequently used for its advantages in conformability, perfusion of arch vessels, low fracture rate, and the ability to perform effective angioplasty of side cells.
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Angioplastia de Balón , Aorta Torácica , Diseño de Prótesis , Stents , Humanos , Estudios Retrospectivos , Masculino , Femenino , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aorta Torácica/fisiopatología , Resultado del Tratamiento , Factores de Tiempo , Factores de Riesgo , Adolescente , Adulto Joven , Angioplastia de Balón/instrumentación , Angioplastia de Balón/efectos adversos , Niño , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/terapia , Enfermedades de la Aorta/fisiopatología , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/terapia , Constricción Patológica , Estados Unidos , AortografíaRESUMEN
BACKGROUND: Vascular graft infection is a very complex disease. Although complete excision of the infected grafts with extra-anatomic bypass or in situ reconstruction is a general treatment strategy, some concerns including reinfection in the new graft remain. CASE REPORT: An 88 year-old man presented to the hospital with abdominal swelling and bleeding. The patient had undergone revascularization for aorto-iliac occlusive disease twice in the past. The first procedure had been performed 15 years previously, with right ilio-femoral bypass grafting for right iliac artery occlusion and stent implantation for left iliac artery stenosis. The second procedure had been performed 10 years previously, with aorta-to-left femoral and left-to-right femoro-femoral bypass grafting because the terminal aorta, the first ilio-femoral bypass graft, and the stent of the left iliac artery had been occluded. The patient was diagnosed with vascular graft infection, and endovascular therapy was selected as the revascularization method prior to graft excision. It was successfully performed using various devices and techniques, followed by graft excision without critical limb ischemia. CONCLUSION: This case demonstrates that endovascular therapy prior to graft excision can be an alternative revascularization method for vascular graft infection after bypass surgery for aorto-iliac occlusive disease.
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Enfermedades de la Aorta , Arteriopatías Oclusivas , Implantación de Prótesis Vascular , Prótesis Vascular , Remoción de Dispositivos , Arteria Ilíaca , Infecciones Relacionadas con Prótesis , Humanos , Masculino , Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Resultado del Tratamiento , Anciano de 80 o más Años , Arteria Ilíaca/cirugía , Arteria Ilíaca/diagnóstico por imagen , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/etiología , Arteriopatías Oclusivas/cirugía , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/etiología , Stents , Reoperación , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Angiografía por Tomografía Computarizada , AortografíaRESUMEN
BACKGROUND: Juxtarenal aortic occlusion (JRAO), in which the occlusion of the aorta extends to just below the renal artery, is often treated by bypass surgery because of concerns about the risk of procedural failure and fatal embolization to abdominal organs when treated with endovascular treatment (EVT). This study assessed the outcome of EVT for JRAO compared with aorto-biiliac /aorto-bifemoral (AOB) or axillo-bifemoral (AXB) bypass. METHODS: A retrospective review of an international database created by 30 centers in Asia (CHronic Abdominal Aortic Occlusion, ASian Multicenter registry) was performed for patients who underwent revascularization for chronic total occlusion of the infrarenal aorta from 2007 to 2017. Of the 436 patients, 130 with JRAO (Forty-seven AOBs, 32 AXBs, and 51 EVTs) from 25 institutions were included in this study. RESULTS: Patients were significantly older in the AXB and EVT groups and more malnourished in the EVT group than the AOB group. EVT was attempted but failed in 1 patient. Seven patients (1 [2.1%] in the AOB group, 1 [3.1%] in the AXB group, and 5 [9.8%] in the EVT group) died during hospitalization, but most of the causes in the EVT group were not related to the revascularization procedure. No visceral embolism was observed, which had been concerned, even though protection was performed only in 2 cases of the EVT group. At the latest follow-up (median duration 3.0 years), the ankle-brachial pressure index was significantly higher in the order of AOB, EVT, and AXB. At 4 years, the estimated primary and secondary patency rates of the AOB group (87.5% and 90.3%, respectively) were significantly higher than the AXB group (66.7% and 68.6%, respectively). CONCLUSIONS: AOB remains the gold standard and should be the first choice for acceptable risk patients. For frail patients, EVT is a good option and likely preferable as a first-line treatment compared to AXB.
Asunto(s)
Aorta Abdominal , Enfermedades de la Aorta , Arteriopatías Oclusivas , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Sistema de Registros , Humanos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Procedimientos Endovasculares/instrumentación , Masculino , Estudios Retrospectivos , Femenino , Anciano , Resultado del Tratamiento , Factores de Tiempo , Factores de Riesgo , Enfermedad Crónica , Persona de Mediana Edad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/instrumentación , Asia , Aorta Abdominal/cirugía , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/fisiopatología , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/fisiopatología , Enfermedades de la Aorta/mortalidad , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/cirugía , Arteriopatías Oclusivas/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Grado de Desobstrucción Vascular , Anciano de 80 o más Años , Bases de Datos Factuales , Medición de RiesgoRESUMEN
OBJECTIVE: The aim of this study was to evaluate the role of intravascular ultrasound (IVUS) for the technical assessment of kissing stents (KSs) and covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac obstructive disease involving the aortic bifurcation. METHODS: We conducted a single-center retrospective review of patients undergoing endovascular treatment of severe aorto-iliac obstructive disease (2019-2023). IVUS was performed in patients treated by KSs or CERAB according to preoperative indications, in cases of moderate/severe calcifications, mural thrombus, total occlusions, and lesion extension towards the proximity of renal or hypogastric arteries. Indications for IVUS-guided intraoperative revisions were residual stenosis or compression >30%, incomplete stent-to-wall apposition, or flow-limiting dissection at the landing site. Follow-up assessment was performed at 6 and 12 months, and then yearly. Thirty-day outcomes and 2-year patency rates were evaluated. Logistic regression was used to identify factors associated with significant technical defects detected by IVUS needing intraoperative revision. RESULTS: IVUS was used for the technical assessment of 102 patients treated by KSs (n = 57; 56%) or CERAB (n = 45; 44%) presenting with severe intermittent claudication (39%), rest pain (39%), or ischemic tissue loss (25%). Twenty-nine significant technical defects were identified by IVUS in 25 patients (25%) who then had successful intraoperative correction by additional ballooning (n = 23; 80%) or stenting (n = 6; 20%). Patients with a severely calcified chronic total occlusion (odds ratio, 1.85; 95% confidence interval, 1.01-5.27; P = .044) or severely calcified narrow aortic bifurcation with <12 mm diameter (odds ratio, 2.34; 95% confidence interval, 1.10-8.64; P = .032) were at increased risk for IVUS-guided intraoperative revision. There were no postoperative deaths and no major adverse events. Two-year primary patency was 100%. CONCLUSIONS: IVUS was used for the technical assessment of KSs/CERAB in a selected cohort of patients with severe aorto-iliac obstructive disease. This allowed the identification and intraoperative correction of a significant technical defect not detected by completion angiogram in one-quarter of patients, achieving optimal 2-year results. IVUS assessment of KSs/CERAB may be considered especially in patients with a calcified total occlusion or narrow aortic bifurcation.
Asunto(s)
Enfermedades de la Aorta , Procedimientos Endovasculares , Arteria Ilíaca , Stents , Ultrasonografía Intervencional , Grado de Desobstrucción Vascular , Humanos , Estudios Retrospectivos , Masculino , Femenino , Anciano , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Resultado del Tratamiento , Persona de Mediana Edad , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/cirugía , Enfermedades de la Aorta/fisiopatología , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Arteria Ilíaca/cirugía , Factores de Tiempo , Anciano de 80 o más Años , Valor Predictivo de las Pruebas , Factores de Riesgo , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/cirugíaRESUMEN
OBJECTIVES: Popliteal artery entrapment syndrome (PAES) is a rare condition where musculoskeletal structures compress the popliteal artery (POPA) leading to vascular compromise. This study investigates the effect of dynamic plantar- and dorsi-flexion loading on POPA hemodynamic parameters to develop a robust diagnostic ultrasound-based protocol for diagnosing functional PAES. METHODS: Healthy individuals (n = 20), recreational athletes (n = 20), and symptomatic (n = 20) PAES patients were consented. Triplex ultrasound imaging of lower limb arteries was performed (n = 120 limbs). Proximal and distal POPA's in dorsi-/plantar-flexion, in prone and erect positions, were imaged at rest and flexion. Peak systolic velocities (cm/s) and vessel diameter (antero-posterior, cm) was measured. RESULTS: Distal vessel occlusion was noted across all three groups whilst prone during plantar-flexion (62.7%). POPA occlusion was only noted in the proximal vessel within the patient group (15.8%). When prone, 50% of control (n = 40 limbs), 70% of athletes (n = 40 limbs), and 65% of patients (n = 40 limbs) had distal POPA occlusion in plantar-flexion. When prone, recreational athletes (5%), and patients (12.5%) had distal POPA compression under dorsi-flexion. POPA occlusions with the patient in erect position were only noted in the symptomatic patient group under both dorsi-flexion (15.8%) and plantar-flexion (23.7%). CONCLUSION: Compression of the POPA on ultrasound should not be the sole diagnostic criteria for PAES. POPA compression exists in asymptomatic individuals, primarily under prone plantar-flexion. To reduce false positives, ultrasound-based protocols should focus on scanning patients in the erect position only to diagnose PAES, rather than asymptomatic POPA compression. A distinction should be made between the two.
Asunto(s)
Arteriopatías Oclusivas , Enfermedad Arterial Periférica , Síndrome de Atrapamiento de la Arteria Poplítea , Humanos , Arteriopatías Oclusivas/diagnóstico por imagen , Hemodinámica , UltrasonografíaRESUMEN
The purpose of this study was to propose an innovative intraoperative criterion in a liver transplantation setting that would judge arterial flow abnormality that may lead to early hepatic arterial occlusion, that is, thrombosis or stenosis, when left untreated and to carry out reanastomosis. After liver graft implantation, and after ensuring that there is no abnormality on the Doppler ultrasound (qualitative and quantitative assessment), we intraoperatively injected indocyanine green dye (0.01 mg/Kg), and we quantified the fluorescence signal at the graft pedicle using ImageJ software. From the obtained images of 89 adult patients transplanted in our center between September 2017 and April 2019, we constructed fluorescence intensity curves of the hepatic arterial signal and examined their relationship with the occurrence of early hepatic arterial occlusion (thrombosis or stenosis). Early hepatic arterial occlusion occurred in 7 patients (7.8%), including 3 thrombosis and 4 stenosis. Among various parameters of the flow intensity curve analyzed, the ratio of peak to plateau fluorescence intensity and the jagged wave pattern at the plateau phase were closely associated with this dreaded event. By combining the ratio of peak to plateau at 0.275 and a jagged wave, we best predicted the occurrence of early hepatic arterial occlusion and thrombosis, with sensitivity/specificity of 0.86/0.98 and 1.00/0.94, respectively. Through a simple composite parameter, the indocyanine green fluorescence imaging system is an additional and promising intraoperative modality for identifying recipients of transplant at high risk of developing early hepatic arterial occlusion. This tool could assist the surgeon in the decision to redo the anastomosis despite normal Doppler ultrasonography.
Asunto(s)
Arteria Hepática , Verde de Indocianina , Trasplante de Hígado , Imagen Óptica , Trombosis , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/métodos , Verde de Indocianina/administración & dosificación , Arteria Hepática/diagnóstico por imagen , Masculino , Femenino , Persona de Mediana Edad , Imagen Óptica/métodos , Trombosis/etiología , Trombosis/diagnóstico por imagen , Anciano , Adulto , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/diagnóstico , Ultrasonografía Doppler/métodos , Valor Predictivo de las Pruebas , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/diagnóstico , Arteriopatías Oclusivas/cirugía , Hígado/diagnóstico por imagen , Hígado/irrigación sanguínea , Hígado/cirugía , Colorantes/administración & dosificación , Constricción Patológica/etiología , Monitoreo Intraoperatorio/métodos , Estudios Retrospectivos , Cuidados Intraoperatorios/métodosRESUMEN
BACKGROUND: This study aimed to establish and validate a nomogram model for predicting 90-day mortality in patients with acute basilar artery occlusion receiving endovascular thrombectomy. METHODS AND RESULTS: A total of 242 patients with basilar artery occlusion undergoing endovascular thrombectomy were enrolled in our study, in which 172 patients from 3 stroke centers were assigned to the training cohort, and 70 patients from another center were assigned to the validation cohort. Univariate and multivariate logistic regression analyses were adopted to screen prognostic predictors, and those with significance were subjected to establish a nomogram model in the training cohort. The discriminative accuracy, calibration, and clinical usefulness of the nomogram model was verified in the internal and external cohorts. Six variables, including age, baseline National Institutes of Health Stroke Scale score, Posterior Circulation-Alberta Stroke Program Early CT (Computed Tomography) score, Basilar Artery on Computed Tomography Angiography score, recanalization failure, and symptomatic intracranial hemorrhage, were identified as independent predictors of 90-day mortality of patients with basilar artery occlusion and were subjected to develop a nomogram model. The nomogram model exhibited good discrimination, calibration, and clinical usefulness in both the internal and the external cohorts. Additionally, patients were divided into low-, moderate-, and high-risk groups based on the risk-stratified nomogram model. CONCLUSIONS: Our study proposed a novel nomogram model that could effectively predict 90-day mortality of patients with basilar artery occlusion after endovascular thrombectomy and stratify patients with high, moderate, or low risk, which has a potential to facilitate prognostic judgment and clinical management of stroke.
Asunto(s)
Arteriopatías Oclusivas , Procedimientos Endovasculares , Accidente Cerebrovascular , Insuficiencia Vertebrobasilar , Humanos , Arteria Basilar , Nomogramas , Resultado del Tratamiento , Estudios Retrospectivos , Trombectomía/métodos , Accidente Cerebrovascular/etiología , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Medición de Riesgo , Procedimientos Endovasculares/métodosRESUMEN
BACKGROUND: Two recent clinical trials showed mechanical thrombectomy (MT) of basilar-artery occlusions (BAO) in stroke to be safe and effective: Endovascular Treatment for Acute BAO (ATTENTION) and BAO Chinese Endovascular (BAOCHE). The trials restricted patient inclusion on both age and pre-stroke mRS, and with both trials conducted in China, population differences may affect generalisability of the trial results. METHODS: Consecutive patients with BAO undergoing MT were registered from 2017 to 2021 with retrospective data collection at a single centre with a predominantly Caucasian catchment population of 2.7 million. Age and pre-stroke modified Rankin Scale (mRS) were not absolute contraindications for MT. We present functional outcome as mRS at 90 days, patient characteristics and procedural safety compared to the trial intervention groups. RESULTS: Of the 108 included patients, 50 % achieved mRS 0-3 at 90 days and mortality was 32 %, which was no different from ATTENTION (46 %, p = 0.40, 37 %, p = 0.31, respectively) and BAOCHE (46 %, p = 0.50, 31 %, p = 0.93). Pre-stroke mRS 0 was seen in 62 %, 89 %, and 77 % of the study patients, ATTENTION, and BAOCHE, respectively. Proximal segment BAO was less common (22 % vs. 31 %, p = 0.04, and 65 %, p < 0.01) and intracranial stenting less frequently used (9 % vs. 40 % and 55 %, p < 0.01) in study patients compared to ATTENTION and BAOCHE, respectively. CONCLUSION: Outcome of MT in BAO stroke in a clinical patient cohort was similar to recent trials, despite broader patient inclusion and differences in both occluded BAO segment and use of stenting. Our study suggest that MT is safe and effective in a Caucasian population.
Asunto(s)
Arteriopatías Oclusivas , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Procedimientos Endovasculares/métodos , Arteria Basilar , Trombectomía/métodos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/cirugía , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugíaRESUMEN
BACKGROUND: Approximately half of patients who achieve successful reperfusion do not achieve functional independence. The present study sought to investigate the clinical outcomes and safety of intraarterial or intravenous tirofiban as adjunct therapy in patients with acute basilar artery occlusion who had achieved successful recanalization with endovascular treatment. METHODS AND RESULTS: In the national, prospective BASILAR (Endovascular Treatment for Acute Basilar Artery Occlusion Study) registry, 458 patients who met inclusion criteria were divided into 3 groups based on tirofiban administration (no tirofiban, n=262; intravenous tirofiban, n=101; intraarterial+intravenous tirofiban, n=95). Their clinical outcomes were compared with 90-day modified Rankin Scale scores. Adjusted odds ratios (aORs) and 95% CIs were obtained by logistic regression models and propensity score matching. Safety outcomes included any intracranial hemorrhage (ICH), symptomatic ICH, and mortality. Among 458 included patients, 184 (40.2%) achieved a favorable outcome (modified Rankin Scale score 0-3). There were no differences between the intravenous tirofiban group and the no tirofiban group in terms of safety and clinical outcomes (all P>0.05). Compared with the no tirofiban group, the intraarterial+intravenous tirofiban group had higher odds of 90-day modified Rankin Scale score 0 to 3 (aOR, 2.44 [95% CI, 1.30-4.64], P=0.006) and lower 3-month mortality (aOR, 0.38 [95% CI, 0.19-0.71], P=0.002) without an increase in any ICH (aOR, 0.34 [95% CI, 0.09-1.01], P=0.07) or symptomatic ICH (aOR, 0.23 [95% CI, 0.03-0.90], P=0.05). Similar results of intraarterial+intravenous tirofiban on improving clinical outcomes were detected in novel cohorts constructed by propensity score matching. CONCLUSIONS: Intraarterial+intravenous rather than intravenous tirofiban improved clinical outcomes without increasing the frequency of symptomatic ICH among patients with basilar artery occlusion after successful endovascular treatment. Further studies are needed to delineate the roles of intraarterial+intravenous tirofiban in patients with basilar artery occlusion receiving endovascular treatment.