RESUMO
AIM: Because embolic complications can occur during carotid angioplasty and stenting (CAS), a new device, the Parodi Anti-Emboli System (PAES) was developed to protect the brain from embolization. We describe our initial experience with this device. METHODS: Between September 1999 and December 2003, CAS was performed in 200 consecutive patients (146 men; mean age, 70.4 years) with symptomatic (52%) or asymptomatic (48%) severe carotid artery stenosis (>70%). De novo lesions were present in 169 patients, restenosis in 18, and radiation-induced stenosis in 13. Wallstents were inserted in all cases, with selective predilatation, and the PAES was employed during all CAS procedures. Patients were evaluated by a neurologist before and after CAS. Minor strokes, major or fatal strokes, and myocardial infarctions that occurred within 30 days of the procedure were recorded. RESULTS: The overall technical success rate for CAS using the PAES (with the PAES placed in position percutaneously) was 99%. The overall perioperative stroke and death rate was 1.5%. There were four transient neurologic events after CAS, three of which were related to hemodynamic instability and one to postoperative embolization. CONCLUSIONS: Our experience indicates that CAS using the PAES is safe and effective. The protection device may prevent the debris released by angioplasty from entering the cerebral circulation. Additional studies of this device are warranted.
Assuntos
Angioplastia com Balão/instrumentação , Implante de Prótese Vascular/instrumentação , Estenose das Carótidas/terapia , Stents , Idoso , Idoso de 80 Anos ou mais , Argentina , Encéfalo/irrigação sanguínea , Estenose das Carótidas/patologia , Estenose das Carótidas/cirurgia , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Acidente Vascular Cerebral/prevenção & controle , Resultado do TratamentoAssuntos
Derivação Arteriovenosa Cirúrgica/métodos , Artéria Braquial/patologia , Artéria Braquial/cirurgia , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Primitiva/patologia , Artéria Carótida Interna/patologia , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/métodos , Idoso , Idoso de 80 Anos ou mais , Doenças das Artérias Carótidas/patologia , Estenose das Carótidas/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: An endoleak results from the incomplete endovascular exclusion of an aneurysm. We developed an experimental model to analyze hemodynamic changes within the aneurysm sac in the presence of an endoleak, with and without a simulated open collateral branch. METHODS: With a latex aneurysm model connected to a pulsatile pump, pressures were measured simultaneously within the system (systemic pressure) and the aneurysm sac (intrasac pressure). The experiments were performed without endoleak (control group) and after creating a 3.5-mm (group 1), 4.5-mm (group 2), and 6-mm (group 3) diameter orifice in the endograft, simulating an endoleak. Pressures were also registered with and without a patent aneurysm side branch. RESULTS: In each endoleak group, the intrasac diastolic pressure (DP) and mean pressure (MP) were significantly higher than the systemic DP and MP (P =.01, P =.006, and P =.001, respectively), although the pressure curve was damped. The presence of an open side branch significantly reduced the intrasac DP and MP. CONCLUSION: In this model, intrasac pressures were significantly higher than systemic pressures in the presence of all endoleaks, even the smallest ones. Intrasac pressures higher than systemic pressure may pose a high risk for aneurysm rupture. Although patent side branches significantly reduce these pressures, the aggressive management of an endoleak should be pursued.
Assuntos
Aneurisma/fisiopatologia , Aneurisma/cirurgia , Aneurisma Roto/etiologia , Implante de Prótese Vascular , Humanos , Modelos Cardiovasculares , Complicações Pós-Operatórias/etiologia , PressãoRESUMO
PURPOSE: To examine the inflammatory impact of endovascular and conventional surgery of abdominal aortic aneurysm (AAA) as assessed by the activation of neutrophils and serum levels of pro- and anti-inflammatory cytokines. METHODS: Twenty-four patients undergoing AAA exclusion were treated with either endovascular (n = 14) or conventional (n=10) techniques. Clinical and hematological data, respiratory burst of neutrophils, and the expression of adhesion and activation molecules (CD18, CD11b, CD69, and HLA-DR) were analyzed by flow cytometry. The enzyme-linked immunosorbent assay technique was used to measure proinflammatory cytokine interleukin (IL)-8 and anti-inflammatory cytokines IL-1 receptor antagonist (IL-1RA) and transforming growth factor beta1 (TGF-beta1). RESULTS: All patients, most of whom had normal cytokine values before surgery, were successfully treated. No significant changes were found in surface antigens. Basal respiratory burst was quite heterogeneous; in all cases respiratory burst activity decreased after surgery and remained low throughout the observation period. Despite marked interpatient differences, IL-1RA and IL-8 increased after surgery, whereas TGF-beta1 decreased, although the variation achieved statistical significance only in the conventional group. Elevated IL-1RA returned to normal within 48 hours in the endoluminal group, whereas the level remained high in the conventional group in the last sample. CONCLUSIONS: Despite heterogeneity before surgery, the respiratory burst decreased for most of the patients regardless of the approach, and both techniques increased IL-1RA. Although both procedures seemed to decrease TGF-beta1, the difference was significant only with the conventional approach. IL-1RA levels fell toward basal values quicker in the endograft patients, suggesting that the endoluminal approach was less aggressive.
Assuntos
Angioplastia , Aneurisma da Aorta Abdominal/cirurgia , Citocinas/sangue , Neutrófilos/metabolismo , Explosão Respiratória/fisiologia , Idoso , Idoso de 80 Anos ou mais , Sedimentação Sanguínea , Proteína C-Reativa/metabolismo , Feminino , Humanos , Proteína Antagonista do Receptor de Interleucina 1 , Masculino , Pessoa de Meia-Idade , Sialoglicoproteínas/sangue , Fator de Crescimento Transformador beta/sangue , Fator de Crescimento Transformador beta1 , Resultado do TratamentoRESUMO
OBJECTIVE: The purpose of the study was to assess the effectiveness of cerebral protection devices during carotid artery angioplasty and stent placement. METHODS: Between September 1998 and September 1999, carotid angioplasty and stenting were performed in 46 patients with symptomatic (39.1%) or asymptomatic (60.9%) severe carotid artery stenosis. Wallstents were used in all patients with selective predilatation. Cerebral protection devices were used in 25 of these patients. Primary end points were perioperative neurologic complications and mortality. Data were collected prospectively. RESULTS: The overall combined end point of all neurologic deficits and death rate was 4.34%. Two neurologic events (one transient ischemic attack and one minor stroke) occurred in the unprotected group (9.53%) versus none in the group with cerebral protection. This difference is not statistically significant. The mortality rate was 0% for both groups. On an intention to treat basis, the overall technical success rate for carotid angioplasty was 97.8%, and for placement of cerebral protection devices it was 100%. An important number of particles of different sizes were captured in all cases in which cerebral protection devices were used. CONCLUSION: Experience has shown that cerebral protection during carotid angioplasty and stenting is technically feasible and appears to be effective in preventing procedure-related neurologic complications. Further investigation is warranted.
Assuntos
Angioplastia com Balão/instrumentação , Estenose das Carótidas/terapia , Ataque Isquêmico Transitório/prevenção & controle , Stents , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Pesquisa , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler TranscranianaRESUMO
The radiocontrast substance gadoterate meglumine (Gd-DOTA) is used in magnetic resonance imaging. Because of its low rate of adverse drug reactions, we evaluated Gd-DOTA as an alternative contrast medium in diagnostic and therapeutic procedures. Twenty-three consecutive procedures were performed using undiluted contrast agent Gd-DOTA (376.9 mg/mL, Dotarem) in digital subtraction techniques. A dosage of 30-90 mL was used. Serum creatinine levels were registered before and at 24 and 48 hr after the procedure. Based on this limited experience, Gd-DOTA may be used as an alternative contrast agent in selected endovascular procedures, when iodine is contraindicated.
Assuntos
Angiografia , Gadolínio , Meglumina , Compostos Organometálicos , Meios de Contraste , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Procedimentos Cirúrgicos VascularesRESUMO
PURPOSE: To report the use of an aortic endograft to treat a ruptured false aneurysm at the anastomosis of an aortofemoral bypass graft. METHODS AND RESULTS: A 68-year-old man with a 30-year-old aorto-right femoral bypass and multiple comorbidities was admitted to the hospital complaining of acute abdominal pain. Imaging identified a 60-mm ruptured aortic false aneurysm with associated retroperitoneal hematoma, a 9-cm right femoral false aneurysm, and a calcified 23-mm left common iliac aneurysm. Two slightly overlapping Vanguard straight stent-grafts were implanted in the aorta and left common iliac artery in an emergency procedure owing to the patient's high surgical risk. The anastomotic false aneurysm and the bypass were excluded. A left-to-right femorofemoral bypass was performed to re-establish flow to the right femoral artery with ligation of the external iliac artery. The patient recovered uneventfully. He remained well with a successful repair until his death of a myocardial infarction 6 months after the procedure. CONCLUSIONS: Endovascular grafting can be used successfully for the urgent treatment of aortic false aneurysm rupture.
Assuntos
Falso Aneurisma/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Stents , Doença Aguda , Idoso , Anastomose Cirúrgica/efeitos adversos , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Angiografia , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/etiologia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/etiologia , Evolução Fatal , Artéria Femoral/cirurgia , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Tomografia Computadorizada por Raios XRESUMO
Twenty-nine cases of post-traumatic false aneurysms and arteriovenous fistulas (AVF), with a mean follow-up of 24 months (1-65 months), are presented here. Diagnosis was established by color duplex and arteriogram. The time between injury and treatment varied between 3 days and 61 months. Endovascular treatment was accomplished using a covered Palmaz stent [vein, polytetrafluoroethylene (PTFE), or polyester], Corvita endoluminal graft, or a Wallgraft. Complimentary treatment of a branch injury was performed using a detachable balloon in one patient. The initial result was favorable for all patients. One case of asymptomatic stenosis of an iliac stent graft and three occlusions of the stent (one subclavian, one axillary, and one internal carotid) were registered during the follow-up period, and no clinical manifestations of the occlusions were reported. Endovascular treatment of post-traumatic false aneurysms and AVF appears to be a promising alternative for treatment of these lesions. Less pain and disability as well as rapid recovery time and lower cost after endovascular treatment compare favorably to the standard surgical technique.
Assuntos
Falso Aneurisma/cirurgia , Fístula Arteriovenosa/cirurgia , Implante de Prótese Vascular , Stents , Adulto , Falso Aneurisma/etiologia , Artérias/lesões , Fístula Arteriovenosa/etiologia , Materiais Biocompatíveis , Feminino , Humanos , Masculino , Politetrafluoretileno , Desenho de Prótese , Resultado do TratamentoRESUMO
PURPOSE: To report a surgical technique to preserve the internal iliac arteries (IIAs) and facilitate endovascular repair of abdominal aortic aneurysms (AAAs) with extensive iliac artery involvement. TECHNIQUE: A new iliac artery bifurcation is created surgically through an 8-cm lower left abdominal incision by implanting the IIA onto the distal external iliac artery either directly or by using a tube graft interposition. Careful technique is required to avoid embolic complications, but after relocating the bifurcation, aortic endografting can be performed, either simultaneously or staged, depending upon patient characteristics. CONCLUSIONS: Relocation of the iliac artery bifurcation appears to be a good alternative to preserve pelvic arterial flow in selected candidates for endoluminal AAA repair.
Assuntos
Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Artéria Ilíaca/cirurgia , Anastomose Cirúrgica , Angiografia , Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Prótese Vascular , Materiais Revestidos Biocompatíveis , Colágeno , Humanos , Artéria Ilíaca/diagnóstico por imagem , Poliésteres , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: A complete immunohistochemical characterization in complicated carotid plaques is still lacking. The cellular components of 165 carotid endarterectomy specimens were analyzed to assess their role in the pathogenesis of plaque rupture and intraplaque hemorrhage without rupture. METHODS AND RESULTS: The fibrous caps at the sites of plaque rupture showed CD68+ macrophages, T-lymphocytes, and scarce B-lymphocytes. Ruptured plaques showed mononuclear infiltrates in the caps, shoulders, and bases of the plaques in 85% of the cases. Only 46% of nonruptured plaques showed such infiltrates (P <.0001). Two types of lipid cores were recognized: avascular or mildly vascularized and highly vascularized. The vessels of the latter type reacted with CD31 and CD34. In 57.5% of the cases, the base and the shoulders of the plaques showed neoformed, CD34+ vessels, often surrounded by mononuclear infiltrates. Intraplaque hemorrhage without rupture had highly vascularized lipid cores in all cases. T-lymphocytes and macrophages were in close contact with neoformed vessels. CONCLUSIONS: Plaque rupture is characterized by mononuclear cell infiltration of the caps, whereas intraplaque hemorrhage without rupture is characterized by extensive vascularization of the plaque.
Assuntos
Artérias Carótidas/patologia , Estenose das Carótidas/patologia , Imunofenotipagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais , Especificidade de Anticorpos , Artérias Carótidas/imunologia , Artéria Carótida Externa/imunologia , Artéria Carótida Externa/patologia , Artéria Carótida Interna/imunologia , Artéria Carótida Interna/patologia , Estenose das Carótidas/imunologia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Vascular surgeons are increasingly encountering older patients with large aneurysms associated with severe comorbid conditions. This situation can increase operative morbidity and elevate the mortality rate of aortic surgery over 60%. With some frequency many patients will represent a prohibitive risk for conventional graft replacement. The endoluminal treatment of 110 patients has proved to be feasible and may represent an alternative solution. One hundred six of the patients had an abdominal aortic aneurysm and in four patients, the thoracic aorta was involved. All of them underwent endoluminal repair for the aortic pathology using the combination of stents and grafts in aorto-aortic or aorto-iliac position, with straight, tapered, or bifurcated stent-graft devices. The results are as follows: Initial success was 84% in aorto-aortic abdominal devices and 100% in aorto-aortic thoracic devices. In aorto-iliac devices, initial success was 75%. Late success rates were 62% of the initial group and 80% of the initially successful group.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular/métodos , Stents , Idoso , Aorta Abdominal/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/mortalidade , Prótese Vascular/efeitos adversos , Cateterismo , Feminino , Humanos , Artéria Ilíaca , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Stents/efeitos adversosRESUMO
The authors offer an overview of their 20-year involvement in the development of an endovascular graft for abdominal aortic aneurysm exclusion. Clinical experience gained throughout 6 years of clinical evaluation are reviewed, along with observations and insights on preoperative assessment, implantation techniques, and complications.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Prótese Vascular , Animais , Aneurisma da Aorta Abdominal/diagnóstico , Humanos , Complicações Pós-Operatórias , Desenho de Prótese , StentsRESUMO
Between September 1990 and June 1995, 103 patients were treated with transluminal placed endovascular grafts: 87 had abdominal aortic aneurysms (AAA), two had iliac artery aneurysms (one in association with an AAA), 3 had thoracic aneurysms, and 12 had vascular injuries in various localization of the arterial tree. The AAAs were excluded from the blood flow with a device composed of a balloon-expandable stent (modification of the Palmaz stent) attached to a Dacron graft designed to expand at both ends of the accompanying stent extension. An 18F sheath containing the stent-graft device was introduced through a small cut-down in the common femoral arteries and advanced under fluoroscopic guidance. Color duplex, contrast-enhanced computed tomography (CT) scanning and angiography were performed before the procedure and then every 6 months. (Arteriography was performed once during the follow-up period and whenever other studies disclosed an abnormal finding.) A total of 87 patients (75 men, 12 women) harboring an AAA were treated: Forty-five patients underwent an aortoaortic procedure (8 patients had only a proximal stent implanted, and 37 had proximal and distal stents). Forty-two patients were treated by implanting an aortoiliac graft, completing the procedure with a femorofemoral bypass. The contralateral common iliac artery was occluded by means of an occluding stent. One type A dissecting aneurysm and two descending thoracic aneurysms were successfully treated by the endovascular technique. The longest follow-up period was 60 months and the shortest 1 month. Initial success was obtained in 84% of the aortoaortic cases and in 75% of the aortoiliac procedures. Long-term follow-up (> 12 months) disclosed 78% success for the aortoaortic cases and 90% for the aortoiliac procedures. Late failures included distal aortic dilatation, distal leak into the aneurysmal cavity, and proximal leak into the aneurysm. All trauma cases were successful over the short and long terms. Trauma cases included false aneurysms (common carotid, subclavian, common femoral arteries) and arteriovenous fistulas (subclavian, aortocava, common iliac-cava and superficial femoral artery and vein). We concluded that stent-graft combination devices appear to be an alternative for treating vascular trauma and aneurysms. Initial success for treating AAAs is almost 100%, and late success in aortoiliac cases is also high (90%) for aortoaortic reconstruction. However, late failures are frequent and require further evaluation in relation to a persistent increase in the diameter of the proximal neck and distal cuff.
Assuntos
Falso Aneurisma/terapia , Angioplastia com Balão/instrumentação , Aneurisma Aórtico/terapia , Fístula Arteriovenosa/terapia , Prótese Vascular , Idoso , Idoso de 80 Anos ou mais , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/mortalidade , Angiografia , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/mortalidade , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/mortalidade , Causas de Morte , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Papers dealing with rupture of carotid plaque surface are few in spite of the growing importance of the subject. The aim of this study was to analyze the cellular and vascular components of surgically excised carotid endarterectomies in order to obtain information about their role in the pathogenesis of the plaque rupture and intraplaque hemorrhage. Seventy-six surgical specimens of carotid endarterectomies were used for this study. The findings of immunophenotyping of the cellular constituents of the plaques were: 1) endothelial lining: the fibrous cap at the site of the rupture showed an eroded surface with loss of the endothelial lining. Conversely, in the remaining surface a continuous, not damaged row of endothelial cells stained with anti-CD31 and anti-CD34 was observed; 2) fibrous cap: the collagenous fibrous cap at the site of erosion was attenuated and the phenotypic characterization of the cells showed inflammatory components consisting mainly of macrophages (CD68 positive), 2/3 of the total infiltration. The remaining 1/3 was composed of T-lymphocytes and scarce B-lymphocytes. A close interaction between macrophages and capillaries and macrophages and T-lymphocytes was observed; 3) lipid cores: two different types of lipid cores could be depicted. Avascular or mildly vascularized lipid cores and highly vascularized, with neoformed vessels stained with CD34 and CD31. CD34 stained endothelia of all kind of vessels; conversely, neoformed vessels showed a weak stain with CD31. T-lymphocytes were found to be in close contact with neoformed vessels, and in some cases, migrating through the endothelial cells; 4) deeper layers of the plaque: the base and the shoulder of the plaques showed in 28/76 cases neoformed vessels, thin or thick walled, CD34 positive, generally surrounded by mild to extensive mononuclear infiltrates. Atherosclerotic plaques were found to belong to six different lesions: plaque rupture plus thrombosis (18/76, 23.6%), plaque rupture plus intraplaque hemorrhage plus thrombosis (18/76, 23.6%), intraplaque hemorrhage without plaque rupture (16/76, 21.0%), plaque rupture plus intraplaque hemorrhage (5/76, 6.5%), stable calcified non complicated plaque (14/76, 18.4%) and unstable, soft, non complicated plaque (5/76, 6.5%). The first four lesions were considered as "complicated lesions". Complicated plaques presented neoformed vessels in the periphery, shoulder and base of the plaque in 22/57 (38.5%) cases. Conversely only 1/14 (7.1%) of non complicated, stable calcified plaques presented neoformed vessels, (p < 0.05). Of note, the 5 causes of unstable, soft non complicated plaque presented neoformed vessels surrounding the plaque. In 10/57 (17.5%) complicated plaques unequivocal histological signs of old hemorrhages were found surrounding those vessels. Irrespective of presenting no rupture, 11/35 plaques showed a mononuclear infiltrate in the fibrous cap. In conclusion, rupture of carotid plaques (50% of the cases), is characterized by the presence of a macrophagic infiltration of the caps and by the direct apposition of T-lymphocytes to macrophages and a close relation of these cells to endothelial cells. This highly suggests a cell-to-cell interaction, which results in an inflammatory process. Intraplaque hemorrhage without rupture represented 21% of the endarterectomies. These lesions are not related to cap erosion, but to plaque vascularization. Most lipid cores were highly vascularized with neoformed vessels with macrophages and T-cells in close contact and in some cases disrupting the endothelium. The abrupt growing of the lipid core and/or an overproduction of oxygen free radicals could lead to the breakdown of core vessels and intraplaque hemorrhage.
Assuntos
Arteriosclerose/metabolismo , Doenças das Artérias Carótidas/metabolismo , Endarterectomia das Carótidas , Adulto , Idoso , Idoso de 80 Anos ou mais , Arteriosclerose/patologia , Arteriosclerose/cirurgia , Artérias Carótidas/metabolismo , Artérias Carótidas/patologia , Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/patologia , Doenças das Artérias Carótidas/cirurgia , Endotélio Vascular/metabolismo , Endotélio Vascular/patologia , Endotélio Vascular/cirurgia , Feminino , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Ruptura EspontâneaRESUMO
Endovascular aortic graft implantation is a new procedure for the repair of arterial aneurysms. We report on the first such case successfully performed in the United States. A 76-year-old man with severe oxygen-dependent pulmonary insufficiency, coronary artery disease, and recurrent ventricular tachyrhythmia was also diagnosed as having a 7.5-cm infrarenal abdominal aortic aneurysm. Because of the high risks associated with conventional surgical repair, consent was obtained for compassionate use of an experimental device. Using local anesthesia, a 22-mm Dacron prosthesis was inserted under fluoroscopic guidance through an open, left transfemoral route. Completion arteriography demonstrated aneurysm exclusion. No blood transfusion was required and there were no perioperative complications. Further technical refinements and clinical trials will be required prior to the broad implementation of this technique.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Prótese Vascular/métodos , Polietilenotereftalatos , Stents , Idoso , Aneurisma da Aorta Abdominal/complicações , Artéria Femoral , Humanos , MasculinoRESUMO
PURPOSE: This report describes our experience with endovascular stented graft repair of abdominal aortic aneurysms and other arterial lesions. METHODS: Between September 1990 and April 1994, 57 patients were treated with endovascular stented grafts (50 with abdominal aortic aneurysms or iliac aneurysms; five with traumatic arteriovenous fistulas; one with an infected femoral false aneurysm; and one with a false aneurysm of the proximal right common carotid artery). The devices consist of either a Dacron or an autogenous vein graft sutured to a balloon-expandable stent. The stented grafts are placed through remote arteriotomies, advanced under fluoroscopic guidance to their predetermined sites, and secured into position. RESULTS: Forty of the 50 endovascular stented graft procedures used to treat abdominal aortic aneurysms or iliac aneurysms were considered successful, even though some secondary treatment was required in six patients (two open operations; four secondary endovascular procedures). The 10 failures include four early procedural deaths, one late procedural death, and five leaks. All five arteriovenous fistulas and the two false aneurysms were successfully treated with endovascular stented grafts. CONCLUSIONS: Although our experience with endovascular stented grafts has been promising, remaining problems require resolution, and further follow-up is needed. However, the potential advantages of these endovascular grafts warrant their continued evaluation.
Assuntos
Aneurisma/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Fístula Arteriovenosa/cirurgia , Stents , Idoso , Idoso de 80 Anos ou mais , Falso Aneurisma/cirurgia , Prótese Vascular/efeitos adversos , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Primitiva/cirurgia , Cateterismo/efeitos adversos , Feminino , Artéria Femoral/cirurgia , Seguimentos , Humanos , Aneurisma Ilíaco/cirurgia , Masculino , Pessoa de Meia-Idade , Polietilenotereftalatos , Reoperação , Veia Safena/transplante , Stents/efeitos adversos , Falha de Tratamento , Resultado do TratamentoRESUMO
We describe our experience with endoluminal repair of abdominal aortic aneurysms using the stent-graft device. Twenty-four patients underwent 25 procedures in the 27-month period ending December 31, 1992. Twenty-one of the patients were considered high-risk candidates for conventional surgical repair. The endoluminal stented grafts were aortoaortic in 16 procedures and unilateral aortoiliac in eight. One patient underwent a second procedure consisting of an ilioiliac graft to repair a separate common iliac artery aneurysm. Technical problems were primarily related to retrograde transluminal access across the iliac arteries, tortuous aneurysms, and misjudgments as to measurement of length. One patient died and another required secondary deployment of a distal stent at 4 months; subsequent aneurysm expansion mandated surgical replacement at 18 months. It is clear that this device and methodology will have to undergo further refinement before the technique is acceptable for wider clinical application. Current experience, however, is encouraging. Aneurysm exclusion with an endoluminal prosthesis is likely to become an important therapeutic alternative over the next several years.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Prótese Vascular , Stents , Idoso , Idoso de 80 Anos ou mais , Aorta Abdominal/patologia , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/patologia , Prótese Vascular/efeitos adversos , Cateterismo/efeitos adversos , Cateterismo/instrumentação , Causas de Morte , Hemorragia Cerebral/etiologia , Coagulação Intravascular Disseminada/etiologia , Embolia/etiologia , Desenho de Equipamento , Feminino , Seguimentos , Humanos , Aneurisma Ilíaco/patologia , Aneurisma Ilíaco/cirurgia , Artéria Ilíaca/patologia , Artéria Ilíaca/cirurgia , Complicações Intraoperatórias , Masculino , Polietilenotereftalatos , Desenho de Prótese , Stents/efeitos adversosRESUMO
The diagnosis of abdominal aortic aneurysm (AAA) has been established with increasing frequency during the past two decades. Although AAA may cause distal embolization, rupture remains the most common and deadly complication. For nearly 40 years, elective replacement with a synthetic graft has proved to be the most appropriate method to prevent AAA rupture, and it has been associated with a postoperative mortality rate of less than 5% at most medical centers. Nonfatal complications occur with some regularity, irrespective of the setting in which the operation is performed. Increasingly, vascular surgeons are encountering older patients with severe comorbid medical conditions that can increase operative morbidity and may significantly elevate mortality. This, in turn, can increase operative morbidity and may significantly elevate mortality for aortic surgery. An alternative form of treatment such as induction of aneurysm thrombosis generally has been abandoned despite preliminary reports ofinitial success.