RESUMO
BACKGROUND: Epidemiology of peripheral arterial disease is currently unknown in French West Indies (Antilles). AIMS AND METHODS: The aim of this study is to present peripheral arterial disease (PAD) occurring in the French West Indian subjects through the analysis of our database of vascular surgery. The study population included 754 patients (mean age 73 +/- 10 years), mostly from African descents. The main clinical presentation was critical limb ischemia (66%, including tissue loss in 48% of cases), followed by claudication (20%). The lesions affected the infragenicular arteries in 86% of cases, including 24% isolated to this level as well as 51% combined to femoro-popliteal lesions and only 7% of cases affecting the aorto-iliac level. RESULTS: Ankle-brachial index was at 0.57 +/- 0.13 and 0.34 +/- 0.22 (p<0.001) in patients with claudication and critical limb ischemia (CLI), respectively. The severity scores were significantly higher in claudicants with aorto-iliac disease and CLI patients with infragenicular lesions. Except for hypertension (85%) and obesity (19%), the other risk factors were differently distributed between the 2 groups. While in the CLI group, patients were older, with higher rates of female sex, diabetes (62% vs. 48%, p<0.001) and severe renal failure, claudicants were significantly younger, with higher rates of smokers among men (75% vs. 51%, p<0.001) and moderate dyslipidemia (52% vs. 36%, p<0.001). The association with carotid stenosis (12%) and ischemic heart disease (18%) were quite uncommon. Renal disease (glomerular filtration rate<60 ml/mn/1.73 m2) was present in 61% of cases. CONCLUSION: This study highlights clear differences regarding the presentation, localization and associations of PAD in the West Indies subjects managed in vascular surgery, especially with a severe infragenicular disease, even in claudicants. This study suggests the effect of a different distribution of risk factors as well as other ethnic and socio-economic factors.
Assuntos
Doenças da Aorta/cirurgia , Extremidades/irrigação sanguínea , Claudicação Intermitente/etiologia , Isquemia/etiologia , Doenças Vasculares Periféricas/cirurgia , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Tornozelo/irrigação sanguínea , Doenças da Aorta/complicações , Doenças da Aorta/epidemiologia , Doenças da Aorta/etiologia , Doenças da Aorta/fisiopatologia , Pressão Sanguínea , Artéria Braquial/fisiopatologia , Estado Terminal , Feminino , Artéria Femoral/cirurgia , Guadalupe/epidemiologia , Humanos , Artéria Ilíaca/cirurgia , Claudicação Intermitente/epidemiologia , Claudicação Intermitente/fisiopatologia , Claudicação Intermitente/cirurgia , Isquemia/epidemiologia , Isquemia/fisiopatologia , Isquemia/cirurgia , Masculino , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/complicações , Doenças Vasculares Periféricas/epidemiologia , Doenças Vasculares Periféricas/etiologia , Doenças Vasculares Periféricas/fisiopatologia , Artéria Poplítea/cirurgia , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricosRESUMO
OBJECTIVES: This prospective study was designed to evaluate the complications of percutaneous tube thoracostomy (PTT) performed for chest trauma in our institution and to determine predictive factors. METHODS: One hundred and thirty-four primary PTTs were performed in 128 patients for blunt (83) and penetrating (45) chest traumas. Failure was defined as undrained hemothorax or pneumothorax, post-tube removal complications and empyema. Univariate and multivariate hazard analyses were used to assess the association between potential risk factors and complications. RESULTS: The overall complication rate was 25% including 30 (23%) failures and nine (7%) improper placement with iatrogenic injuries to the lung (n = 4) or subclavian vein (n = 1). Complications were managed with 18 repeat PTTs and ten early thoracotomies for clotted hemothorax (two), persistent air leak (two), fluid collection (three) or a combination (three) at a mean delay of 6.5 +/- 2.4 days. Failure of additional PTT required late decortication for empyema (three) or decortication (three) at a mean delay of 23 +/- 7 days. One patient died postoperatively, the only death directly related to PTT failure among the four (3.1%) deaths that occurred in this study. Hospital length of stay was significantly increased in patients with PTT failure (24 +/- 19 vs. 15 +/- 8 days in uncomplicated PTT, P = 0.004). By univariate analysis, polytraumatism (relative risk (RR) 2.7, P < 0.05), the need for assisted ventilation (RR 2.7, P = 0.003) and tube insertion by emergency physicians (RR 8.7, P < 0.0001) were significantly associated with increased incidence of complications in blunt trauma. Multivariate analysis identified the performance of the procedure by operators other than thoracic surgeons and residents trained in thoracic surgery as the only independent risk factor in both blunt and penetrating trauma (RR 58 and 71, respectively, P < 0.00001). CONCLUSIONS: PTT is associated with significant morbidity and extended hospitalizations, partly related to inappropriate training of all individuals dealing with trauma care. Additional training should be recommended and some conventional indications for PTT should be revised. A prospective study is currently in progress to evaluate the benefit of early videothoracoscopy in trauma and failure of primary PTT.
Assuntos
Traumatismos Torácicos/cirurgia , Toracostomia/efeitos adversos , Adulto , Análise de Variância , Competência Clínica , Feminino , Hemotórax/cirurgia , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumotórax/cirurgia , Estudos Prospectivos , Fatores de Risco , Falha de Tratamento , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/cirurgiaRESUMO
OBJECTIVE: This study was performed to investigate the endothelium-dependent relaxation and contractile responses to endothelin-1 in subcutaneous resistive arteries from Caribbean patients with advanced atherosclerotic femoro-crural arterial disease. DESIGN AND METHODS: Small subcutaneous arteries (inner diameter 200 um) from control subjects (n=8) and atherosclerotic patients (n=8) were dissected from fat biopsies obtained at routine vascular surgery and mounted in vitro on a wire-myograph measuring parietal tension under isometric conditions. RESULTS: Acetylcholine-induced relaxation (10-6 M) was significantly reduced in pre-contracted arteries from atherosclerotic patients (24 + or - 16 percent vs 17 percent in control, p<0.001). Smooth muscle relaxation to sodium nitroprusside was comparable in both groups. Contractions elicited by endothelin-1 (10-9 M) were significantly lower and almost suppressed in both the atherosclerotic group (1.2 + or - 0.8 Kpa) and in the hypertensive subgroup of control subjects (n=4, 1.2= 0r - 1.2 Kpa) comparatively to normotensive control subjects (12.3 + or - 6.9 Kpa, p<0.001). Contractile responses induced by endothelin-1 at higher concentrations (10-8 - 10-7 M), noradrenaline and hyperosmolar potassium were comparable in both groups. CONCLUSIONS: These data suggest a specific impairment of both endothelium-dependent relaxation and contractility in lower limb subcutaneous resistive arteries from Caribbean patients with atherosclerotic femoro-crural arterial disease. These changes in vessels which largely determine proximal vascular resistance may contribute to ischaemic complications in this vascular bed including skin ulcerations and gangrene.(Au)
Assuntos
Humanos , Óxido Nítrico/uso terapêutico , Arteriosclerose/tratamento farmacológico , Acetilcolina/administração & dosagem , Endotelina-1/efeitos dos fármacos , Região do Caribe , Isquemia Miocárdica/complicaçõesRESUMO
This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age +/- SEM: 73 +/- 15 yrs) admitted for critical limb ischaemia. 145 (84%) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisations were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14% in the "Amputation" group and 9% in the "Revascularisation" group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 of 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82%. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17%, p < 0.05; and 37 vs 13%, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the "Revascularisation" group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the "Amputation" group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56%), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.
Assuntos
Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Artéria Poplítea/cirurgia , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica/efeitos adversos , Amputação Cirúrgica/métodos , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/mortalidade , Distribuição de Qui-Quadrado , Feminino , Gangrena/etiologia , Humanos , Isquemia/etiologia , Perna (Membro)/cirurgia , Úlcera da Perna/etiologia , Masculino , Pessoa de Meia-Idade , Reoperação/métodos , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/mortalidadeRESUMO
This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age ñ SEM:73 ñ 15 yrs) admitted for critical limb ischaemia. 145 (84 percent) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisation were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14 percent in the "Amputation" group and 9 percent in the "Revascularisation" group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 to 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17 percent, p < 0.05; and 37 vs 13 percent, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the "Revascularisation" group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the "Amputation" group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56 percent), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.(AU)
Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia/cirurgia , Perna (Organismo)/irrigação sanguínea , Amputação Cirúrgica , Resultado do Tratamento , Complicações Pós-Operatórias , Gangrena/cirurgia , Estudos RetrospectivosRESUMO
This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age +/- SEM: 73 +/- 15 yrs) admitted for critical limb ischaemia. 145 (84) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisations were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14in the [quot ]Amputation[quot ] group and 9in the [quot ]Revascularisation[quot ] group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 of 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17, p < 0.05; and 37 vs 13, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the [quot ]Revascularisation[quot ] group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the [quot ]Amputation[quot ] group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Artéria Poplítea/cirurgia , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Amputação Cirúrgica/efeitos adversos , Amputação Cirúrgica/métodos , Distribuição de Qui-Quadrado , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/mortalidade , Estudos Retrospectivos , Gangrena/etiologia , Isquemia/etiologia , Perna (Membro)/cirurgia , Procedimentos Cirúrgicos Vasculares/mortalidade , Reoperação/métodos , Resultado do Tratamento , Taxa de Sobrevida , Úlcera da Perna/etiologiaRESUMO
From 1993 to 1995, a prospective study was conducted to assess immediate and long term results of carotid endarterectomy with cerebral monitoring of the awake patient under cervical block anaesthesia. 31 procedures were performed in 27 patients (68 ñ 10 years) with atherosclerotic stenosis of the internal carotid artery (>70 percent). Indications were transient ischaemic attacks (41 percent), hemispheric stroke with mild or moderate deficits at 6 weeks (33 percent) or asymptomatic high-grade stenosis (26 percent). 13 patients (44 percent) with cerebral hypodensity at preoperative brain CT-scan were at high-risk of cerebral ischaemia. Cervical block anaesthesia provided excellent analgesia and comfort in all patients. 5 patients (16 percent) were clamp-intolerant and required shunting. Cumulative mortality-morbidity rate was 3 percent (no death or irreversible stroke observed in this series). Follow-up was 27 ñ 17 months.(AU)
Assuntos
Adulto , Humanos , Endarterectomia das Carótidas/estatística & dados numéricosRESUMO
This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age, 71 ñ 15 years) admitted for critical limb ischemia. 145 (84 percent) had tissue loss at admission including toe gangrene or ischemic ulcer in 77 and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularizations were performed at iliofemoral (n=20), suprapopliteal (n=22) or infrapopliteal level. Postoperative mortality rate was not significantly different in the "Amputation" group (14 percent) and "Revascularizations" groups 9 percent. Infective complications were comparable in both groups although 5/14 deaths after amputations were were directly related to infections while all deaths after revascularizations resulted from cardiovascular complications. The early limb salvage after revascularizations was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p<0.03) and with significantly higher rates of heart diseases and non-ambulatory status (respectively 24 vs 17 percent, p<0.05 and 37 vs 13 percent, p<0.001) than patients in whom revascularizations were performed. The major findings were that ischemic rest pain and tissue loss confined to digit gangrene or ischemic ulcer were significantly more frequent in the group "Revascularizations" (p<0.0001), while extensive gangrene extending beyond the forefoot (p<0.0001) was significantly more frequent in group "Amputations". Therefore, late presentation of patients and enhanced tissue loss are very likely to play a role in our primary amputation rate, higher than those observed elsewhere. In patients amenable to revascularizations (56 percent), arterial reconstructiions for critical limb icshemia performed in the West Indies provide for a fair likelihood of limb salvage. (AU)
Assuntos
Humanos , Adulto , Idoso , Resumo em Inglês , Pessoa de Meia-Idade , Isquemia/cirurgia , Extremidades/cirurgia , Amputação Cirúrgica , Gangrena/complicações , Estudos RetrospectivosRESUMO
From December 1992 to October 1995, 42 infrapopliteal arterial bypass operations for limb salvage were performed in 39 patients (including 22 diabetics) with critical limb ischaemia (mean age, 71 years). Thirty-four patients (87%) had tissue loss at admission (8 ulcers, 13 digit gangrenes and 13 extensive foot infections). Angiographic findings were consistent with atherosclerotic involvement of femoral and crural arteries. Outflow anastomotic sites were the popliteal (n = 5); tibial (n = 14); peroneal (n = 14) and pedal artery (n = 9). Autogenous saphenous vein was suitable in 27 procedures and inadequate in 15 (< 3 mm diameter, with gross fibrosis or segmental occlusion) requiring prosthetic or composite grafts. Postoperative mortality rate was 10%, related to concomitant cardiovascular diseases. Mean follow-up was 14 months (range, 3-35). Fourteen bypasses failed, 5 in the early period (8-30 days) and 9 within a mean interval of 7.6 months, resulting in 6 limb amputations. Overall life-table primary graft patency rates were 72% (+/- 8) at 12 months and 61% (+/- 9) at 2 years and were not significantly different in diabetic patients compared to those in non-diabetics. Primary graft patency rates were significantly lower in prosthetic or composite grafts compared to saphenous vein grafts (75% vs 32% at 2 years- p < 0.01), respectively. Overall life-table limb salvage rates were 84% (+/- 7) and 76% (+/- 9) at 12 and 24 months, respectively. Seventy-eight per cent of patients with limb salvage were relieved of ischaemic symptoms, 57% regained the ability to ambulate with improved functional level and 85% of tissue loss healed within a mean interval of 55 days. Infrapopliteal bypass operations for critical limb ischaemia performed in Martinique provide a fair chance of limb salvage despite limitations of medical facilities.
Assuntos
Prótese Vascular , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Artéria Poplítea/cirurgia , Veias/transplante , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiopatias Diabéticas/diagnóstico por imagem , Angiopatias Diabéticas/cirurgia , Feminino , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Isquemia/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Artéria Poplítea/diagnóstico por imagem , RadiografiaRESUMO
From December 1992 to October 1995, 42 infrapopliteal arterial bypass operations for limb salvage were performed in 39 patients (including 22 diabetics) with limb ischaemia (mean age, 71 years). Thirty-four patients (87 percent) had tissue loss at admission (8 ulcers, 13 digit gangrenes and 13 extensive foot infections). Angiographic findings were consistent with artherosclerotic involvement of femroal and crural arteries. Outflow anastomic sites were the popliteal (n = 5); tibial (n = 14); peroneal (n = 14) and pedal artery (n = 9). Autogenous saphenous vein was suitable in 27 procedures and inadequate in 15 (<3 mm diameter, with gross fibrosis or segmental occlusion) requiring prosthetic or composite grafts. Postoperative mortality rate was 10 percent, related to concomitant cardiovascular diseases. Mean follow-up was 14 months (range, 3 - 35). Fourteen bypasses failed, 5 in the early period (8 - 30 days) and 9 within a mean interval of 7.6 months, resulting in 6 limb amputations. Overall life-table primary graft patency rates were 72 percent (ñ 8) at 12 months and 61 percent (ñ 9) at 2 years and were not significantly different in diabetic patients compared to those in non-diabetics. Primary graft patency rates were significantly lower in prosthetic or composite grafts compared to saphenous vein grafts (75 percent vs 32 percent at 2 years - p<0.01), respectively. Overall life-table limb salvage rates were 84 percent (ñ 7) and 76 percent (ñ 9) at 12 and 24 months respectively. Seventy-eight percent of patients with limb salvage were relieved of ischaemic symptoms, 57 percent regained the ability to ambulate with improved functional level and 85 percent of tissue loss healed within a mean interval of 55 days. Infrapopliteal bypass operations for critical limb ischaemia performed in Martinique provide a fair chance of limb salvage despite limitations of medical facilities. (AU)
Assuntos
Adulto , Humanos , Pessoa de Meia-Idade , Feminino , Idoso , Masculino , Artéria Poplítea/cirurgia , Isquemia/cirurgia , Extremidades/cirurgia , Índias Ocidentais , Diabetes Mellitus/complicações , Diabetes Mellitus/cirurgia , Pé Diabético/complicações , Pé Diabético/cirurgia , Resultado do TratamentoRESUMO
From December 1992 to October 1995, 42 infrapopliteal arterial bypass operations for limb salvage were performed in 39 patients (including 22 diabetics) with limb ischaemia (mean age, 71 years). Thirty-four patients (87 percent) had tissue loss at admission (8 ulcers, 13 digit gangrenes and 13 extensive foot infections). Angiographic findings were consistent with artherosclerotic involvement of femroal and crural arteries. Outflow anastomic sites were the popliteal (n = 5); tibial (n = 14); peroneal (n = 14) and pedal artery (n = 9). Autogenous saphenous vein was suitable in 27 procedures and inadequate in 15 (<3 mm diameter, with gross fibrosis or segmental occlusion) requiring prosthetic or composite grafts. Postoperative mortality rate was 10 percent, related to concomitant cardiovascular diseases. Mean follow-up was 14 months (range, 3 - 35). Fourteen bypasses failed, 5 in the early period (8 - 30 days) and 9 within a mean interval of 7.6 months, resulting in 6 limb amputations. Overall life-table primary graft patency rates were 72 percent (ñ 8) at 12 months and 61 percent (ñ 9) at 2 years and were not significantly different in diabetic patients compared to those in non-diabetics. Primary graft patency rates were significantly lower in prosthetic or composite grafts compared to saphenous vein grafts (75 percent vs 32 percent at 2 years - p<0.01), respectively. Overall life-table limb salvage rates were 84 percent (ñ 7) and 76 percent (ñ 9) at 12 and 24 months respectively. Seventy-eight percent of patients with limb salvage were relieved of ischaemic symptoms, 57 percent regained the ability to ambulate with improved functional level and 85 percent of tissue loss healed within a mean interval of 55 days. Infrapopliteal bypass operations for critical limb ischaemia performed in Martinique provide a fair chance of limb salvage despite limitations of medical facilities.