RESUMEN
BACKGROUND: Worldwide, peripheral arterial disease (PAD) is a disease with high morbidity, affecting more than 200 million people. Our objective was to analyze the surgical treatment for PAD performed in the Unified Health System of the city of São Paulo during the last 11 years based on publicly available data. METHODS: The study was conducted with data analysis available on the TabNet platform, belonging to the DATASUS. Public data (government health system) from procedures performed in São Paulo between 2008 and 2018 were extracted. Sex, age, municipality of residence, operative technique, number of surgeries (total and per hospital), mortality during hospitalization, mean length of stay in the intensive care unit and amount paid by the government system were analyzed. RESULTS: A total of 10,951 procedures were analyzed (either for claudicants or critical ischemia-proportion unknown); 55.4% of the procedures were performed on males, and in 50.60%, the patient was older than 65 years. Approximately two-thirds of the patients undergoing these procedures had residential addresses in São Paulo. There were 363 in-hospital deaths (mortality of 3.31%). The hospital with the highest number of surgeries (n = 2,777) had lower in-hospital mortality (1.51%) than the other hospitals. A total of $20,655,272.70 was paid for all revascularizations. CONCLUSIONS: Revascularization for PAD treatment has cost the government system more than $20 million over 11 years. Endovascular surgeries were performed more often than open surgeries and resulted in shorter hospital stays and lower perioperative mortality rates.
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Procedimientos Endovasculares , Claudicación Intermitente/terapia , Isquemia/terapia , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/terapia , Investigación en Sistemas de Salud Pública , Servicios Urbanos de Salud , Procedimientos Quirúrgicos Vasculares , Anciano , Brasil/epidemiología , Enfermedad Crítica , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/mortalidad , Femenino , Financiación Gubernamental , Costos de la Atención en Salud , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos , Claudicación Intermitente/economía , Claudicación Intermitente/mortalidad , Isquemia/economía , Isquemia/mortalidad , Tiempo de Internación , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/economía , Enfermedad Arterial Periférica/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Servicios Urbanos de Salud/economía , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/economía , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
INTRODUCCIÓN: Los ratones SR-B1 KO/ApoER6 1h/h que son alimentados con una dieta rica en grasas saturadas, desarrollan enfermedad coronaria aterosclerótica severa, complicaciones isquémicas e insuficiencia cardíaca, con alta mortalidad. Los estudios con este modelo se han enfocado fundamentalmente en la enfermedad coronaria y menos en el remodelado cardíaco. El OBJETIVO del trabajo ha sido caracterizar el remodelado miocárdico, evaluar la evolución temporal de la función ventricular izquierda y la sobrevida asociada a enfermedad cardíaca por ateromatosis. MÉTODO: Ratones homocigotos SR-B1 KO/ApoER6 1h/h fueron alimentados por 8 semanas con dieta aterogénica o dieta normal y se comparó la sobrevida en ambos grupos. A las 4 semanas se realizó un ecocardiograma bidimensional. En los ratones eutanasiados se evaluó en la pared cardíaca fibrosis miocárdica y tamaño de los cardiomiocitos por morfometría, apoptosis con técnica de TUNEL e infiltración por células inflamatorias mononucleares (ED1) por inmunohistoquímica. RESULTADOS: En el grupo que recibió dieta aterogénica la sobrevida se redujo en 46,7% (p < 0.001), debido a muerte súbita y a falla cardíaca progresiva. En este grupo, a las 4 semanas se observó dilatación de cavidades izquierdas y disminución de la fracción de eyección del ventrículo izquierdo en comparación con el grupo control (79,3 ± 1,3% vs 66 ± 3,7%, p<0,01). También se observó aumento de la masa cardíaca relativa de 2.1 veces (p<0,001) y del peso pulmonar relativo en 80% (p<0,001), sin cambios en las dimensiones de los cardiomiocitos. En el miocardio de los ratones que recibieron dieta aterogénica hubo un aumento de la fibrosis cardíaca de 7.9 veces (p < 0.01) y del número de cardiomiocitos apoptóticos en 55.9 veces (p < 0.01), junto a un aumento del número de células inflamatorias mononucleares ED1. CONCLUSIONES: En el modelo de falla cardíaca severa de etiología isquémica con alta mortalidad en el ratón homocigoto SR-B1 KO/ApoER6 1h/h sometido a una dieta aterogénica, con falla cardíaca izquierda por disfunción sistólica, el remodelado patológico del miocardio está dado fundamentalmente por apoptosis y fibrosis. También se observa un aumento discreto de macrófagos en la pared cardíaca. Es posible que el edema parietal también pueda ser un mecanismo de remodelado relevante en este modelo.
Abstract: SR-B1 KO/ApoER6 1h/h mice fed a high saturated fat diet develop severe coronary atheromatosis, and cardiac failure with a high mortality rate. Cardiac remodeling under these conditions has not been well studied. AIM: To evaluate the time course of left ventricular function, cardiac remodeling and survival associated to the administration of an atherogenic diet. METHOD: Homozygote SR-B1 KO/ApoER6 1h/h mice received an atherogenic diet for 8 weeks. Mice receiving a normal diet served as controls. Survival rate, myocardial fibrosis, cardiomyocyte size, apoptosis and infiltration by inflammatory or mononuclear cells were compared between groups. A TUNEL technique was used to evaluate apoptosis. RESULTS: A 46.7% survival reduction compared to controls was observed in the experimental group (p<0.01), due to left ventricular and atrial dilatation associated to a decrease in ejection fraction (79,3 ± 1,3% vs 66 ± 3,7%, p<0,01, respectively). Also, an increased cardiac weight, 2.6 times greater was observed in the experimental group, compared to controls. Mice receiving the atherogenic diet showed an 80% increased lung weight. There was no evident change in cardiomyocytes, but there was more (7.9 times) cardiac fibrosis (p<0.01) and 55.9 times more apoptotic cells. (p<0.01), along with a greater number of inflammatory cells and ED1 mononuclear cells. CONCLUSION: Mice receiving an atherogenic diet develop heart failure and reduced survival rate. This is associated with cardiac remodeling with underlying apoptosis an ventricular wall fibrosis. It is posible that wall edema might contribute to the observed cardiac remodeling.
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Animales , Ratones , Remodelación Ventricular , Dieta Aterogénica , Insuficiencia Cardíaca/etiología , Hiperlipidemias/patología , Isquemia/etiología , Fibrosis , Análisis de Supervivencia , Función Ventricular Izquierda , Apoptosis , Ratones Noqueados , Disfunción Ventricular , Modelos Animales de Enfermedad , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/patología , Isquemia/fisiopatología , Isquemia/mortalidad , Isquemia/patologíaRESUMEN
BACKGROUND: To evaluate the rates of limb salvage, survival, and perioperative mortality in patients with acute limb ischemia (ALI) submitted to endovascular revascularization with pharmacomechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT). METHODS: This was a retrospective consecutive cohort study of patients with ALI who were submitted to endovascular treatment with PMT or fibrinolysis at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2015 and December 2018. The limb salvage rate and survival rate at 720 days were analyzed in both the PMT (group 1) and CDT treatment (group 2), as well as the perioperative mortality rate (PMR) at 30 days after surgery. RESULTS: One hundred twelve patients were admitted to the emergency department with ALI between July 2015 and December 2018. Seventeen patients diagnosed with Rutherford III irreversible ALI and 46 patients submitted to open surgery were excluded. Thus, 49 patients were submitted to endovascular surgery; 18 (36.7%) were classified into group 1, and 31 (63.3%) were classified into group 2. The clinical data were equal between the 2 groups, but there was a higher prevalence of thrombophilia in group 1 (3 cases; P < 0.001). The limb salvage rate and the overall survival rate at 720 days were similar between groups 1 and 2 (87.8% vs. 89.7%, P = 0.78 and 84.7% vs. 69.2%, P = 0.82, respectively). There was no statistical difference regarding secondary patency rates at 720 days between groups 1 and 2 (group 1, 81.9% and group 2, 78.8%; P = 0.66). The PMR was 16.7% (8 patients) within the first 30 days. Group 2 had a higher overall mortality rate (OMR) (6 patients, 19.3%, P = 0.03). Regarding the PMT group, there was a higher rate of complications such as myoglobinuria, hematuria, acute renal failure, and death in the subgroup of patients in whom there were performed more than 150 cycles/sec during the surgery (P < 0.001). CONCLUSIONS: In the present study, the PMT and CDT endovascular procedures had similar limb salvage, overall survival, and secondary patency rates. However, the OMR was higher in the CDT group. Another important finding was related to the number of cycles/sec performed in the PMT group, in whom patients with more than 150 cycles/sec have presented with higher rates of hematuria, myoglobinuria, acute renal failure, and death.
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Procedimientos Endovasculares , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Trombectomía , Terapia Trombolítica , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Brasil , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Factores de Riesgo , Trombectomía/efectos adversos , Trombectomía/mortalidad , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: The objective of this study was to evaluate the long-term estimates of limb salvage and survival in patients with acute limb ischemia (ALI) receiving open surgery or endovascular revascularization. METHODS: This was a retrospective consecutive cohort study of patients with ALI who underwent open surgery or endovascular treatment at the Vascular and Endovascular Surgery Unit, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2010 and July 2016. The overall mortality, limb salvage, and survival rates at 720 days were analyzed in both the open surgery (group 1) and endovascular treatment (group 2) groups. RESULTS: A total of 69 patients were admitted for a limb salvage procedure. The mean follow-up period was 822 ± 480.5 days. All of the analyses were performed at 720 days. Of the 69 patients, 46 (66.6%) were in group 1 and 23 (33.4%) in group 2. The clinical characteristics were similar between the groups, except for higher rates of chronic kidney disease (P = .04) and arrhythmia (P = .01) in group 1. Group 1 had a higher postoperative ankle-brachial index (P = .03). Concerning the Rutherford classification, group 1 had a higher prevalence of Rutherford IIB ALI (P = .003). The preoperative creatine kinase level was higher in group 1 than in group 2 (780 [range, 198-6546] mg/dL and 245 [65-78] mg/dL, respectively). A creatine kinase level >200 mg/dL was seen in 65.2% and 47.8% of patients in group 1 and group 2, respectively (P = .028). The limb salvage and overall survival estimates at 720 days were similar between group 1 and group 2 (79.2% vs 90.6% [P = .27] and 53% vs 60.8% [P = .45], respectively). The overall mortality rate was 10.1% (seven patients) within the first 30 days, and it was higher in group 1 (six patients [13.0%]; P = .03). CONCLUSIONS: Both open surgery and endovascular procedures are safe treatments of patients with ALI, with acceptable limb salvage and survival rates. No previous study has suggested the preferred treatment of ALI. However, based on this study and the overall literature, endovascular treatment may be the preferred treatment of patients with Rutherford I and IIA ALI; open surgery may be the best option for ALI due to arterial embolism and for Rutherford IIB acute arterial thrombosis because of a greater urgency to restore blood flow.
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Procedimientos Endovasculares , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Procedimientos Quirúrgicos Vasculares , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Brasil , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/diagnóstico , Isquemia/mortalidad , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Supervivencia sin Progresión , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
OBJECTIVE: This study aimed to report the long-term limb salvage, survival and patency rates of endovascular treatment for aortoiliac occlusive disease (AIOD) when outflow was achieved through the profunda femoris artery (PFA) only vs both the PFA and superficial femoral artery (SFA). METHODS: From January 2008 to July 2016, patients with AIOD who underwent aortoiliac angioplasty at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, were classified into two groups according to whether they had femoral outflow via the PFA only (group 1) or both the PFA and SFA (group 2) in the affected leg. The primary outcome was amputation-free survival. The secondary outcomes were the patency and overall survival rates. RESULTS: In total, 69 aortoiliac angioplasties were performed in 69 patients: 22 patients (31.8%) in group 1 and 47 (67.2%) in group 2. A total of 12 reinterventions (17.4%) were performed, seven (31.8%) in group 1 and five (10.2%) in group 2, without statistical significance between the groups (P = .063). The mean clinical follow-up period was 2500 ± 880.5 days. Both the primary and secondary patency rates analyzed at 1800 days were similar between groups 1 and 2 (80.2% vs 82.3%; P = .80 and 84.7% vs 97.6%; P = .10, respectively). Furthermore, the limb salvage rates at 1800 days were similar between groups 1 and 2 (91.3% vs 86.1%; P = .60), as were the survival rates (74.7% vs 78%; P = .80). The Bollinger score was worse in group 1 (P = .001), as expected, because of occlusion of the SFA. However, the PFA and popliteal artery scores were similar between the two groups. Occlusion of the SFA did not influence the limb salvage rate according to univariate analysis (P = .509) and multivariate Cox regression analysis (P = .671). CONCLUSIONS: The patency of the SFA does not interfere with the outcomes of endovascular treatment for chronic AIOD. The PFA in conjunction with the popliteal artery as the sole outflow route for iliac endovascular treatment is associated with similar patency, survival, and limb salvage rates as those for outflow through both the PFA and SFA.
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Enfermedades de la Aorta/cirugía , Procedimientos Endovasculares , Arteria Femoral/fisiopatología , Arteria Ilíaca/cirugía , Isquemia/cirugía , Recuperación del Miembro , Enfermedad Arterial Periférica/cirugía , Grado de Desobstrucción Vascular , Anciano , Amputación Quirúrgica , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/fisiopatología , Brasil , Enfermedad Crónica , Circulación Colateral , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Recuperación del Miembro/efectos adversos , Recuperación del Miembro/mortalidad , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Flujo Sanguíneo Regional , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular disease in the general population. Although numerous treatments have been adopted for patients at different disease stages, no option other than amputation is available for patients presenting with critical limb ischaemia (CLI) unsuitable for rescue or reconstructive intervention. In this regard, prostanoids have been proposed as a therapeutic alternative, with the aim of increasing blood supply to the limb with occluded arteries through their vasodilatory, antithrombotic, and anti-inflammatory effects. This is an update of a review first published in 2010. OBJECTIVES: To determine the effectiveness and safety of prostanoids in patients with CLI unsuitable for rescue or reconstructive intervention. SEARCH METHODS: For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (January 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). In addition, we searched trials registries (January 2017) and contacted pharmaceutical manufacturers, in our efforts to identify unpublished data and ongoing trials. SELECTION CRITERIA: Randomised controlled trials describing the efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments for patients presenting with CLI without chance of rescue or reconstructive intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. We resolved disagreements by consensus or by consultation with a third review author. MAIN RESULTS: For this update, 15 additional studies fulfilled selection criteria. We included in this review 33 randomised controlled trials with 4477 participants; 21 compared different prostanoids versus placebo, seven compared prostanoids versus other agents, and five conducted head-to-head comparisons using two different prostanoids.We found low-quality evidence that suggests no clear difference in the incidence of cardiovascular mortality between patients receiving prostanoids and those given placebo (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.41 to 1.58). We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared with placebo (RR 0.97, 95% CI 0.86 to 1.09). Adverse events were more frequent with prostanoids than with placebo (RR 2.11, 95% CI 1.79 to 2.50; moderate-quality evidence). The most commonly reported adverse events were headache, nausea, vomiting, diarrhoea, flushing, and hypotension. We found moderate-quality evidence showing that prostanoids reduced rest-pain (RR 1.30, 95% CI 1.06 to 1.59) and promoted ulcer healing (RR 1.24, 95% CI 1.04 to 1.48) when compared with placebo, although these small beneficial effects were diluted when we performed a sensitivity analysis that excluded studies at high risk of bias. Additionally, we found evidence of low to very low quality suggesting the effects of prostanoids versus other active agents or versus other prostanoids because studies conducting these comparisons were few and we judged them to be at high risk of bias. None of the included studies assessed quality of life. AUTHORS' CONCLUSIONS: We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared against placebo. Moderate-quality evidence showed small beneficial effects of prostanoids for rest-pain relief and ulcer healing when compared with placebo. Additionally, moderate-quality evidence showed a greater incidence of adverse effects with the use of prostanoids, and low-quality evidence suggests that prostanoids have no effect on cardiovascular mortality when compared with placebo. None of the included studies reported quality of life measurements. The balance between benefits and harms associated with use of prostanoids in patients with critical limb ischaemia with no chance of reconstructive intervention is uncertain; therefore careful assessment of therapeutic alternatives should be considered. Main reasons for downgrading the quality of evidence were high risk of attrition bias and imprecision of effect estimates.
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Isquemia/tratamiento farmacológico , Pierna/irrigación sanguínea , Enfermedades Vasculares Periféricas/tratamiento farmacológico , Prostaglandinas/uso terapéutico , Alprostadil/uso terapéutico , Amputación Quirúrgica/estadística & datos numéricos , Epoprostenol/uso terapéutico , Humanos , Iloprost/uso terapéutico , Isquemia/mortalidad , Pierna/cirugía , Úlcera de la Pierna/tratamiento farmacológico , Nafronil/uso terapéutico , Ácidos Nicotínicos/uso terapéutico , Pentoxifilina/uso terapéutico , Prostaglandinas/efectos adversos , Ensayos Clínicos Controlados Aleatorios como Asunto , Vasodilatadores/uso terapéuticoRESUMEN
OBJECTIVE: Acute limb ischemia (ALI) is the cause of significant morbidity and mortality. Although ALI after cardiac surgery is associated with high rates of morbidity and mortality, there are no robust, controlled analyses of the risk factors and outcomes of ALI in this setting. We aimed to identify risk factors for and to delineate outcomes after ALI in patients undergoing cardiac surgery. METHODS: We performed a retrospective review of prospectively collected data on patients undergoing cardiac surgery at our institution between 2002 and 2012. RESULTS: Between 2002 and 2012, there were 11,343 patients who underwent major open cardiac surgery, with 156 cases of ALI for an incidence of 1.4%. In a multivariable model, significant risk factors for ALI included body surface area (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.18-0.92), current smoking status (OR, 2.2; 95% CI, 1.3-3.7), peripheral arterial disease (OR, 2.5; 95% CI, 1.6-3.7), nonelective operative status (OR, 1.9-5.0; 95% CI, 1.2-19.7), use of extracorporeal membrane oxygenation (OR, 5.6; 95% CI, 2.5-11.6) or intra-aortic balloon pump (OR, 4.7; 95% CI, 2.9-7.5), and valve operation (OR, 2.1; 95% CI, 1.1-4.0). There were 105 (67%) patients who developed ALI who required an operation, and 27 (17%) required an amputation on the index admission. ALI was associated with a significant reduction in long-term survival (hazard ratio, 3.72; 95% CI, 2.97-4.65; P < .0001). CONCLUSIONS: ALI is associated with significant morbidity and mortality, and it is also associated with reduced long-term survival. Those patients with the risk factors described require extra vigilance to limit the risk of ALI and should be managed in accordance with the patient's overall clinical condition and goals of care.
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Aorta Torácica/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Extremidades/irrigación sanguínea , Isquemia/etiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Enfermedad Aguda , Anciano , Aorta Torácica/fisiopatología , Procedimientos Quirúrgicos Cardíacos/mortalidad , Distribución de Chi-Cuadrado , Femenino , Humanos , Isquemia/diagnóstico , Isquemia/mortalidad , Isquemia/fisiopatología , Masculino , Análisis Multivariante , Oportunidad Relativa , Philadelphia , Modelos de Riesgos Proporcionales , Flujo Sanguíneo Regional , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND: Amputations of lower limbs can be conducted as one-stage amputation (OSA) or staged amputation (SA) procedures. The objective of this study was to analyze technical success and mortality rates of both techniques, as well as factors that might influence outcomes in patients with critical limb ischemia (CLI). METHODS: A retrospective study of 185 consecutive patients with CLI who underwent amputations in the period 2004-2011. Primary end points were rates of technical success (healing without dehiscence or reintervention) and mortality. The influence on outcomes of demographic data, clinical status, and comorbidities was also analyzed by logistic regression. RESULTS: A total of 101 SA (91 patients) and 106 OSA (94 patients) were analyzed. SA had proportionally higher success rate (SA 77.2% vs. OSA 66.0%, P = 0.0253), lower perioperative mortality rate (SA, 10.9% vs. OSA, 20.7%, P = 0.0247), and lower 30-day mortality rate (SA, 12.2% vs. OSA, 23.8%, P = 0.0220) in spite of more cases with Rutherford classes 5 and 6 (SA, 87.1% vs. OSA, 72.6%, P = 0.0047), diabetes (71.2% vs. 55.6%, P = 0.0076), and infection (44.5% vs. 28.3%, P = 0.0061). Logistic regression demonstrated that in SA, success was more frequent in patients with diabetes who did not use insulin (P = 0.0072), in those with transfemoral amputations (P = 0.0392), with no coronary artery disease (P = 0.0053), and in foot infection (P = 0.0446), while for OSA success was more frequent in nondiabetic patients (P = 0.0077), limbs without infection (P = 0.0298), amputations at foot level (P = 0.0155), or transfemoral amputations (P = 0.0030). CONCLUSIONS: SA had a higher rate of technical success and lower mortality rates than OSA, even with greater number of patients with diabetes and more severe cases of ischemia and infection. However, prospective studies comparing both techniques are needed for further evidence.
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Amputación Quirúrgica/métodos , Pie Diabético/cirugía , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Infección de Heridas/cirugía , Anciano , Amputación Quirúrgica/efectos adversos , Amputación Quirúrgica/mortalidad , Comorbilidad , Enfermedad Crítica , Pie Diabético/diagnóstico , Pie Diabético/mortalidad , Pie Diabético/fisiopatología , Femenino , Humanos , Isquemia/diagnóstico , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de Heridas , Infección de Heridas/diagnóstico , Infección de Heridas/mortalidad , Infección de Heridas/fisiopatologíaRESUMEN
OBJECTIVE: The association of antiphospholipid antibody syndrome (APS) and hypercoagulability is well known. Arterial compromise leading to ischemia of organs and/or limbs in patients with APS is uncommon, frequently unrecognized, and rarely described. We evaluated our institutional experience. METHODS: Retrospective review was conducted. From August 2007 to September 2016, 807 patients with diagnosis of APS were managed in our Institution. Patients with primary and secondary APS who required interventions were examined. Demographics, comorbidities, manifestations, procedures, complications, and other factors affecting outcomes were recorded. RESULTS: Fourteen patients (mean age 35 years old, standard deviation ±14) were evaluated and treated by our service. Six (43%) of them had primary APS and 8 (57%) had secondary APS; 11 (79%) were female. Two (14%) experienced distal aorta and iliac arteries involvement, 3 (21%) visceral vessels disease, 2 (14%) in upper and 7 (50%) in the lower extremity vasculatures. Thirteen (93%) patients underwent direct open revascularization and 1 with hand ischemia (Raynaud disease) underwent sympathectomy. During the mean follow-up period of 48 months, reinterventions included a revision of the proximal anastomosis of an aortobifemoral bypass graft, 1 (7%) abdominal exploration for bleeding, 1 (7%) graft thrombectomy, and 4 (29%) amputations (2 below the knee, 1 above the knee, and 1 transmetatarsal). One (7%) death occurred secondary to sepsis in a patient who had acute mesenteric ischemia. Significant differences in clinical manifestations and outcomes were not observed among patients with primary and secondary APS. All patients remained on systemic anticoagulation. CONCLUSION: APS is a prothrombotic disorder that may lead to arterial involvement with less frequency than the venous circulation but has significant morbidity and limb loss rate. Arterial reconstruction seems feasible in an attempt to salvage organs and limbs; however, research is necessary to establish the optimal anticoagulation regime and long-term management following surgical interventions.
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Síndrome Antifosfolípido/complicaciones , Isquemia/cirugía , Enfermedad Arterial Periférica/cirugía , Trombofilia/etiología , Procedimientos Quirúrgicos Vasculares , Adulto , Anticoagulantes/uso terapéutico , Síndrome Antifosfolípido/diagnóstico , Síndrome Antifosfolípido/tratamiento farmacológico , Síndrome Antifosfolípido/mortalidad , Aortografía/métodos , Angiografía por Tomografía Computarizada , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/etiología , Isquemia/mortalidad , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/etiología , Enfermedad Arterial Periférica/mortalidad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Trombofilia/diagnóstico , Trombofilia/tratamiento farmacológico , Trombofilia/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Adulto JovenRESUMEN
BACKGROUND: The relative benefit of higher statin dosing in patients with peripheral artery disease has not been reported previously. We compared the effectiveness of low- or moderate-intensity (LMI) versus high-intensity (HI) statin dose on clinical outcomes in patients with peripheral artery disease. METHODS AND RESULTS: We reviewed patients with symptomatic peripheral artery disease who underwent peripheral angiography and/or endovascular intervention from 2006 to 2013 who were not taking other lipid-lowering medications. HI statin use was defined as atorvastatin 40-80 mg or rosuvastatin 20-40 mg. Baseline demographics, procedural data, and outcomes were retrospectively analyzed. Among 909 patients, 629 (69%) were prescribed statins, and 124 (13.6%) were treated with HI statin therapy. Mean low-density lipoprotein level was similar in patients on LMI versus HI (80±30 versus 87±44 mg/dL, P=0.14). Demographics including age (68±12 versus 67±10 years, P=0.25), smoking history (76% versus 80%, P=0.42), diabetes mellitus (54% versus 48%, P=0.17), and hypertension (88% versus 89%, P=0.78) were similar between groups (LMI versus HI). There was a higher prevalence of coronary artery disease (56% versus 75%, P=0.0001) among patients on HI statin (versus LMI). After propensity weighting, HI statin therapy was associated with improved survival (hazard ratio for mortality: 0.52; 95% confidence interval, 0.33-0.81; P=0.004) and decreased major adverse cardiovascular events (hazard ratio: 0.58; 95% confidence interval 0.37-0.92, P=0.02). CONCLUSIONS: In patients with peripheral artery disease who were referred for peripheral angiography or endovascular intervention, HI statin therapy was associated with improved survival and fewer major adverse cardiovascular events compared with LMI statin therapy.
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Atorvastatina/administración & dosificación , Dislipidemias/tratamiento farmacológico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Claudicación Intermitente/tratamiento farmacológico , Isquemia/tratamiento farmacológico , Enfermedad Arterial Periférica/tratamiento farmacológico , Rosuvastatina Cálcica/administración & dosificación , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Angiografía , Atorvastatina/efectos adversos , Biomarcadores/sangre , Enfermedad Crítica , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Prescripciones de Medicamentos , Dislipidemias/sangre , Dislipidemias/diagnóstico por imagen , Dislipidemias/mortalidad , Procedimientos Endovasculares , Femenino , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Claudicación Intermitente/sangre , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/mortalidad , Isquemia/sangre , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Estimación de Kaplan-Meier , Lípidos/sangre , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Pautas de la Práctica en Medicina/tendencias , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Rosuvastatina Cálcica/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. METHODS: We conducted a retrospective institutional review board-approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010-January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near-infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. RESULTS: A total of 91 patients were placed on ECMO via femoral arterial cannula (16-F to 24-F) for a mean duration of 9 days (range, 1-40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20-Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. CONCLUSIONS: Limb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.
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Cateterismo Periférico/instrumentación , Oxigenación por Membrana Extracorpórea/efectos adversos , Isquemia/prevención & control , Pierna/irrigación sanguínea , Perfusión/instrumentación , Dispositivos de Acceso Vascular , Adulto , Anciano , Amputación Quirúrgica , Angioplastia , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/mortalidad , Protocolos Clínicos , Diseño de Equipo , Oxigenación por Membrana Extracorpórea/mortalidad , Fasciotomía , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Perfusión/efectos adversos , Perfusión/mortalidad , Imagen de Perfusión/métodos , Flujo Sanguíneo Regional , Estudios Retrospectivos , Factores de Riesgo , Espectroscopía Infrarroja Corta , Trombectomía , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: The objective of this study was to determine whether the number of infrapopliteal arteries undergoing endovascular treatment is associated with the limb salvage rate in patients with critical limb ischemia (CLI). METHODS: This was a retrospective, consecutive cohort study of CLI patients who underwent infrapopliteal angioplasty at the Vascular and Endovascular Surgery Service of the Hospital do Servidor Público Estadual, São Paulo, between January 2009 and January 2013. The primary outcome variable was the limb salvage rate. The secondary outcome variables were patency, survival, plantar arch quality, and operative mortality rate. RESULTS: Overall, 109 infrapopliteal angioplasties were performed in 92 patients, and the initial technical success rate was 95.6%. Based on the analyses of the arteriography of the endovascular procedures, the patients were classified into two groups according to whether they had undergone endovascular treatment of one artery (group 1) or two arteries (group 2). The mean outpatient follow-up time was 430 ± 377.5 days. The analyses were performed at 180 and 360 days. There were 72 angioplasties (66%) in group 1 and 37 (34%) in group 2. Hypertension was more frequent in group 1 (93.1%) than in group 2 (78.4%; P = .03). Other clinical characteristics were similar in both groups. Regarding postoperative complications, the incidence of acute kidney failure was lower in group 1 (0% vs 8.1%, respectively; P = .037). The limb salvage rate at 360 days was similar in groups 1 and 2 (89.4% vs 89.3%, respectively; P = .595). The secondary patency rate at 360 days was also similar in groups 1 and 2 (59.9% vs 60.9%, respectively; P = .571). The perioperative mortality rate was lower in group 1 (4.2% vs 16.2%, respectively; P = .039), but the survival rate at 360 days was similar in both groups (82.1% vs 75.1%, respectively; P = .931). The frequencies of complete, incomplete, and absent plantar arch were similar in both groups. The estimated limb salvage rates for patients with complete plantar arch or incomplete/absent plantar arch were 96.2% and 84.6%, respectively (P = .467), at 360 days. CONCLUSIONS: Our results suggest that it is not necessary to treat the largest number of arteries possible in CLI patients. Instead, the most amenable artery for endovascular procedures should be treated to improve limb salvage and secondary patency rates.
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Angioplastia , Isquemia/terapia , Recuperación del Miembro , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Anciano , Anciano de 80 o más Años , Angiografía , Angioplastia/efectos adversos , Angioplastia/mortalidad , Índice Tobillo Braquial , Brasil , Enfermedad Crítica , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Modelos de Riesgos Proporcionales , Retratamiento , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: The purpose of this study was to evaluate the importance of the "angiosome" concept in patients with critical limb ischemia treated with infrapopliteal angioplasty, analyzing limb salvage, secondary function, and survival rates between those treated with and without reference to the concept of the angiosome (groups 1 and 2, respectively). METHODS: This was a retrospective, consecutive cohort study that evaluated 95 patients with critical limb ischemia who underwent infrapopliteal angioplasty at the Division of Vascular and Endovascular Surgery, São Paulo State Public Servants' Hospital, Brazil, between January 2009 and January 2013. Of the total 92 patients (109 limbs) who underwent angioplasty, 48 (52.2%) patients were in group 1 and 44 (47.8%) patients were in group 2. RESULTS: There was no difference between groups 1 and 2 in terms of the location, lesion severity, or active infection of the infrapopliteal angioplasty. However, groups 1 and 2 differed in their postoperative ankle-brachial indices, which were 0.95 ± 0.18 and 0.85 ± 0.18, respectively (P = 0.001). The estimates of limb salvage were similar in groups 1 and 2 (87% and 92.3%, respectively, at 360 days; P = 0.241). The analysis of secondary function did not differ between the 2 groups (65.1% and 58.3%, respectively, within 360 days; P = 0.92). Operative mortality was 8.3% in group 1 and 8% in group 2 (P = 0.60), and survival at 360 days was 78.5% in group 1 and 78.3% in group 2 (P = 0.86), which were not significantly different. CONCLUSIONS: In this study, we found no evidence to support revascularization based on the concept of the angiosome in preference to revascularization of the artery that is most amenable to endovascular treatment for limb salvage and secondary function.
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Isquemia/terapia , Recuperación del Miembro , Extremidad Inferior/irrigación sanguínea , Modelos Cardiovasculares , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Anciano , Anciano de 80 o más Años , Angioplastia/efectos adversos , Angioplastia/mortalidad , Índice Tobillo Braquial , Brasil , Enfermedad Crítica , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The purpose of this study was to evaluate the association of gender with outcomes of peripheral vascular intervention (PVI) for intermittent claudication and critical limb ischemia (CLI). METHODS: We reviewed 3338 patients (1316 [39%] women) undergoing PVI for claudication (1892; 57%) or CLI (1446; 43%) in the Vascular Study Group of New England from January 2010 to June 2012. Kaplan-Meier analysis, stratified by indication, was used to assess relationships between gender and the main outcome measures of major amputation, reintervention, and survival during the first year. RESULTS: Indications for PVI included claudication (n = 719 [38%] vs n = 1173 [62%]) and CLI (n = 597 [41%] vs n = 849 [59%]) in women and men, respectively (P = .0028). Women were older (69 vs 66 mean years; P < .00001), with less diabetes (43% vs 49%; P = .01), renal insufficiency (4.6% vs 7.3%; P = .0029), coronary artery disease (28% vs 35%; P < .00001), smoking (76% vs 86%; P = .01), and statin use (60% vs 64%; P = .0058). Technical success (95% vs 94%; P = .11), vascular injury (1.3% vs 1.0%; P = .82), and distal embolization (1.6% vs 1.3%; P = .46) were similar. Higher rates of hematoma (7.1% vs 3.4%; P ≤ .0001) and access site occlusion (0.91% vs 0.24%; P = .0085) were observed in women compared with men. There were no differences in major amputation (0.6% vs 0.6%; P = .81) or mortality (2.1% vs 1.5%; P = .20) rates at 30 days between women and men. Reinterventions (surgical and percutaneous) were similar between genders for claudicants (log-rank test, P = .75) and CLI patients (log-rank test, P = .93). Major amputation rates during the first year were not different for women and men and with claudication (log-rank test, P < .55) or CLI (log-rank test, P < .23). One-year survival was not different between women and men with claudication (95% vs 96%; P = .19) or CLI (77% vs 79%; P = .35). CONCLUSIONS: Whereas we observed higher rates of access site complications including hematoma and occlusion in women, we found no other evidence for gender disparity in reinterventions, major amputation, or survival rates after PVI for patients with claudication or CLI.
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Claudicación Intermitente/terapia , Isquemia/terapia , Pierna/irrigación sanguínea , Factores de Edad , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica/estadística & datos numéricos , Enfermedad Coronaria/complicaciones , Complicaciones de la Diabetes , Femenino , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Claudicación Intermitente/mortalidad , Isquemia/mortalidad , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Insuficiencia Renal/complicaciones , Factores Sexuales , Fumar , Resultado del TratamientoRESUMEN
OBJECTIVES: Limited information is available concerning the post-treatment neutrophil-lymphocyte ratio in critical limb ischemia patients who receive conservative therapy. Accordingly, this study was designed to evaluate the predictive value of the post-treatment neutrophil-lymphocyte ratio in critical limb ischemia patients without surgery. METHOD: From January 2009 to January 2011, critical limb ischemia patients were admitted to a vascular center. The demographic data, patient histories, comorbidities and risk factors were documented, and the differential cell count was determined at admission and seven days later after conservative therapy. The cutoff value of the post-treatment neutrophil-lymphocyte ratio was determined by an ROC curve. Patients were divided into groups A and B according to the cutoff value. Amputation-free survival was compared between groups. Univariate and multivariate analyses were used to identify independent risk factors. RESULT: A total of 172 patients were identified with a mean age 71.98±10.09 years; among them, 122 were male. A value of 3.8 was identified as the cutoff value of the post-treatment neutrophil-lymphocyte ratio. Groups A (post-treatment neutrophil-lymphocyte ratio ≥3.8) and B (post-treatment neutrophil-lymphocyte ratio <3.8) showed a significant difference in amputation-free survival (P<0.001). The 1-year, 2-year and 3-year amputation-free survival rates were 79.6%, 55.6% and 46.3%, respectively, in group A; however, in group B, these values were 89.7%, 79.3% and 75.9%, respectively. The post-treatment neutrophil-lymphocyte ratio was identified as an independent predictive factor for amputation in critical limb ischemia patients (P<0.001). CONCLUSION: The post-treatment neutrophil-lymphocyte ratio is an independent predictive factor for amputation in critical limb ischemia patients. Patients with a post-treatment neutrophil-lymphocyte ratio ≥3.8 are likely to suffer from amputation; amputation-free survival usually occurs in patients with a post-treatment neutrophil-lymphocyte ratio <3.8.
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Amputación Quirúrgica , Extremidades/irrigación sanguínea , Isquemia/sangre , Isquemia/terapia , Linfocitos , Neutrófilos , Anciano , Anciano de 80 o más Años , Enfermedad Crítica , Métodos Epidemiológicos , Femenino , Humanos , Isquemia/mortalidad , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Pronóstico , Valores de Referencia , Sensibilidad y Especificidad , Factores de TiempoRESUMEN
OBJECTIVES: The value of alternative autogenous venous conduits for treating critical limb ischaemia (CLI) with infragenicular bypass surgery is well established. In this study, the results of using arm veins as alternative conduits for treating CLI over a 15-year period have been evaluated. METHODS: This was a retrospective study. Between 1991 and 2005. 120 infragenicular bypasses using arm vein conduits (AVCs) were performed in 120 patients. CLI was the main indication (87.5%) for the procedures. The indications for using arm veins were inadequacy or absence of the ipsilateral greater saphenous vein (GSV). Survival, limb salvage, and patency rates were calculated using the Kaplan-Meier method. RESULTS: There was a predominance of male gender (65%), and the group mean age was 68.1 ± 8.3 years. The mean follow-up period was 29.6 ± 26.3 months. The operative mortality (30 days) rate was 7.5%. The main alternative conduit was non-spliced cephalic vein (37.5%). Composite grafts included GSV + AVC (45.2%), AVC + AVC (43.3%) and small saphenous vein + AVC (11.5%). The 5-year primary and secondary patency (SP) rates were 45.2 ± 5.6% and 56.5 ± 5.0%, respectively. The 5-year SP rate was greatest when using non-spliced cephalic vein (65.8 ± 7.6%), but there was no difference in cumulative patency between spliced and non-spliced veins (49.5 ± 8.0% vs. 61.2 ± 6.4%; p = 0.501). The 5-year limb salvage and survival rates were 70.6 ± 5.9% and 59.6 ± 5.8%, respectively. CONCLUSIONS: The favourable long term results of secondary patency and limb salvage rates encourage the use of arm veins as alternative conduits for infragenicular bypass surgery.
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Isquemia/cirugía , Extremidad Superior/irrigación sanguínea , Injerto Vascular/métodos , Anciano , Enfermedad Crítica , Femenino , Humanos , Isquemia/diagnóstico , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Grado de Desobstrucción Vascular , Venas/fisiopatología , Venas/trasplanteRESUMEN
OBJECTIVE: Thrombolysis as a treatment for acute limb ischemia (ALI) has become a first-line therapy based on studies published over 2 decades ago. The purpose of this study was to assess outcomes of patients treated for ALI using contemporary thrombolytic agents and endovascular techniques. METHODS: Consecutive patients with ALI of the lower extremities treated between 2005 and 2011 were identified, and their records were retrospectively reviewed. All patients were treated with tissue plasminogen activator delivered via catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombolysis (PMT), with other adjunctive endovascular or surgical interventions. Procedural success, thrombolysis duration, and 30-day and long-term outcomes were obtained for the whole series and were also compared between the CDT and PMT groups. Limb salvage and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models. RESULTS: A total of 154 limbs were treated in 147 patients presenting with ALI (Rutherford class I, 9.7%; class IIa, 70.1%; class IIb, 20.1%). The mean follow-up was 15.20 months (range, 0.56-56.84 months). Indications for intervention included embolization (14.3%), thrombosed bypass (36.4%), thrombosed stent (26.6%), native artery thrombosis (24.0%), and thrombosed popliteal aneurysm (3.2%). Technical success was achieved in 83.8% of cases, with a 30-day mortality rate of 5.2%. Procedural complications included systemic bleeding (5.2%), access site hematoma (4.5%), acute renal failure (1.9%), and distal embolization (9.7%). The mean runoff score decreased from 13.42 preintervention to 7.43 postintervention. Adjuvant revascularization procedures were required in 89.0% of patients and were endovascular (68.8%), hybrid (9.1%), or open (11.0%). Only 3.2% of patients required a fasciotomy. The overall rate of major amputation was 15.0% (18.1% for CDT only, 11.3% for PMT; P = NS). Predictors of limb loss by Cox proportional hazards models included end-stage renal disease (hazard ratio [HR], 8.563; P < .001) and poor pedal outflow, with an incremental protective effect for improved pedal outflow (HR, 0.205; P < .001 for one pedal outflow vessel; HR, 0.074; P < .001 for ≥ two pedal outflow vessels). Gender, smoking, diabetes, Rutherford score, runoff score, thrombosed popliteal aneurysm, and PMT were not significant predictors of limb loss. The use of PMT was a significant predictor of technical success (odds ratio, 2.67; P = .046). CONCLUSIONS: Endovascular therapy with thrombolysis using tissue plasminogen activator remains an effective treatment option for patients presenting with mild or moderate lower extremity ALI, with equal benefit derived with CDT or PMT. Patients with end-stage renal disease or poor pedal outflow have an increased risk of limb loss and may benefit from alternative revascularization strategies.
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Procedimientos Endovasculares , Fibrinolíticos/administración & dosificación , Isquemia/terapia , Extremidad Inferior/irrigación sanguínea , Trombolisis Mecánica , Enfermedad Arterial Periférica/terapia , Terapia Trombolítica , Activador de Tejido Plasminógeno/administración & dosificación , Enfermedad Aguda , Anciano , Amputación Quirúrgica , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Fibrinolíticos/efectos adversos , Humanos , Isquemia/diagnóstico , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Masculino , Trombolisis Mecánica/efectos adversos , Trombolisis Mecánica/mortalidad , Análisis Multivariante , Selección de Paciente , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Factores de Tiempo , Activador de Tejido Plasminógeno/efectos adversos , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: We report a retrospective analysis of our experience in bypass vein graft surgery to lateral tarsal, medial plantar, and lateral plantar arteries for treatment of critical limb ischemia (CLI). METHODS: Between January 1991 and February 2010, we performed 137 inframalleolar bypass graft surgeries; of these, 25 (18%) were conducted using foot branch arteries for distal implant. All patients were treated for CLI and most had extensive infrapopliteal atherosclerotic disease (TransAtlantic Inter-Society Consensus D). Mean follow-up was 46.32 months (range, 0-144 months). Main end points analyzed were cumulative patency, limb salvage, and survival. Statistic analysis of all end points was performed using Kaplan-Meier survival curves. RESULTS: There was a predominance of men (64%), and the group mean age was 66.3 years. Diabetes mellitus was the main associated disease. Eighty percent of ulcers or gangrene were restricted to the midfoot (Rutherford V CLI classification). There was a predominance of short-length grafts using the great saphenous vein as the main conduit (72%). The medial plantar artery was the main outflow artery (52%). Early graft occlusion occurred in four patients (primary failure rate, 16%). Secondary patency at 1 and 3 years was 49% and 36.8%, respectively, and limb salvage was 81.7% and 69%, respectively. Nine major amputations occurred, and 10 other minor amputations were necessary. Survival rate at 3 years was 65.4%, and 67% of patients maintained ambulation. Surgical mortality was 8%. No condition was associated with worse results with regard to secondary patency, limb salvage, or survival. CONCLUSIONS: Long-term results for developed foot branch bypass demonstrated good results for limb salvage, and it is an acceptable surgery for patients with extensive atherosclerotic disease.
Asunto(s)
Aterosclerosis/cirugía , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Injerto Vascular , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Arterias/fisiopatología , Arterias/cirugía , Aterosclerosis/diagnóstico por imagen , Aterosclerosis/mortalidad , Aterosclerosis/fisiopatología , Brasil , Distribución de Chi-Cuadrado , Enfermedad Crítica , Femenino , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Oclusión de Injerto Vascular/cirugía , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Radiografía , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Vena Safena/trasplante , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: To report our experience of long-term results of inframalleolar bypass. DESIGN: Retrospective analysis. MATERIALS AND METHODS: We analysed 122 inframalleolar bypasses performed between January 1991 and June 2005 in 116 patients. Most patients were treated for critical ischaemia (97%). The indication for the use of podalic arteries was a lack of tibial arteries with run-off to the foot. The dorsalis pedis was predominantly used for distal anastomoses (62.3%) and the greater saphenous vein (84.4%) as the conduit. The follow-up periods ranged from 1 to 60 months. The endpoints analysed were graft patency, limb salvage, preservation of deambulation and survival rate. RESULTS: The cumulative patency was 58.2% at 3 years and 53.4% at 5 years. The best results were achieved with the devalvulated greater saphenous veins. Limb salvage was 70.0% at 3 years and 50.4% at 5 years, with preserved deambulation rates of 57.3% and 47.1%, respectively. There were 36 major and 45 minor amputations. At 3 years, the survival rate was 50.2% and the surgical mortality 13%. Female sex was associated with worse results for cumulative patency and limb salvage (P<0.01). CONCLUSIONS: In the long term, inframalleolar bypass is a satisfactory option for limb salvage.
Asunto(s)
Arteriopatías Oclusivas/cirugía , Isquemia/cirugía , Recuperación del Miembro , Extremidad Inferior/irrigación sanguínea , Vena Safena/trasplante , Injerto Vascular , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/mortalidad , Arteriopatías Oclusivas/fisiopatología , Arterias/trasplante , Brasil , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/etiología , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Radiografía , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: To compare the results of percutaneous transluminal angioplasty (PTA) and bypass graft surgery (BGS) for the treatment of infrapopliteal lesions in individuals presenting with critical limb ischemia (CLI). METHOD: A total of 48 infrapopliteal PTAs and 50 infrapopliteal BGS were compared retrospectively. All grafts used nonreversed saphenous vein in a single length as a substitute. RESULTS: Secondary patency and limb salvage rates in 24 months for the surgical group were 64.7% and 73.2%, respectively. For PTA group, these values were 63.7% and 68.2%, without differences between groups (log rank; P = .45 and .39, respectively). Bypass graft surgery presented better results of secondary patency (72.9% vs 57.1%) and limb salvage (83.5% vs 53.6%) than PTA for patients with Transatlantic Inter-Society Consensus (TASC) D lesions (P = .04 and P = .01, respectively). CONCLUSIONS: Both BGS and PTA provided similar results of patency and limb salvage for individuals with infrapopliteal atherosclerotic disease presenting with CLI. Bypass graft surgery had better results than PTA when TASC D lesions were present.