RESUMO
OBJECTIVES: Peripheral artery disease is a worldwide epidemic that affects millions of patients, especially the elderly. It has a prevalence of 20% in individuals >80 years old. Although peripheral artery disease affects >20% of octogenarians, information about limb salvage rates in this patient population is limited. Therefore, this study aims to understand the impact of bypass surgery on limb salvage in patients aged >80 years with critical limb ischemia. METHODS: We conducted a retrospective analysis by querying the electronic medical records at a single institution from 2016 through 2022 to identify the population of interest and analyzed their outcomes after lower extremity bypass. The primary outcomes were limb salvage and primary patency, with hospital length of stay and 1-year mortality as secondary outcomes. RESULTS: We identified 137 patients who met the inclusion criteria. The lower extremity bypass population was divided into two cohorts: <80 years old (n = 111) with a mean age of 66 or ≥80 years old (n = 26) with a mean age of 84 years. The gender distribution was similar (P = .163). No significant difference was found in the two cohorts when it came to coronary artery disease, chronic kidney disease, or diabetes mellitus. However, when current and former smokers were grouped together, they were significantly more common in the younger cohort when compared with nonsmokers (P = .028). The primary end point of limb salvage was not significantly different between the two cohorts. Hospital length of stay was not significantly different between the two cohorts with 4.13 days vs 4.17 days in the younger vs octogenarian cohorts, respectively (P = .95). The 30-day all-cause readmissions were also not found to be significantly different between the two groups. The primary patency at 1 year was 75% and 77% (P = .16) for the <80-year-old and ≥80-year-old cohorts, respectively. Mortality was low in both cohorts, with two and three for the younger and octogenarian populations, respectively; thus, no analysis was performed. CONCLUSIONS: Our study shows that octogenarians who undergo the same preoperative risk assessment as younger populations have similar outcomes when it comes to primary patency, hospital length of stay, and limb salvage when comorbidities were considered. Further studies need to be done to determine the statistical impact on mortality in this population with a larger cohort.
Assuntos
Isquemia Crônica Crítica de Membro , Doença Arterial Periférica , Idoso de 80 Anos ou mais , Idoso , Humanos , Octogenários , Estudos Retrospectivos , Resultado do Tratamento , Isquemia/diagnóstico por imagem , Isquemia/cirurgia , Fatores de Risco , Grau de Desobstrução Vascular , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgiaRESUMO
Popliteal artery entrapment syndrome is a rare source of claudication in young people. We present the case of a 15-year-old male athlete who presented with intermittent numbness of his right foot with exertion. Imaging revealed classic compression from a right type III popliteal artery entrapment. The left popliteal artery was chronically occluded with a large collateral vessel. He underwent release of the accessory bands of the gastrocnemius muscle with significant arteriolysis on the right side via a posterior approach. Chronic popliteal artery entrapment can be treated from a posterior approach, resulting in arterial occlusion and will be asymptomatic if well collateralized.
RESUMO
OBJECTIVE: The objective of this study was to determine the demographics and subjective rationale for failure to present for retrieval of patients who had an inferior vena cava (IVC) filter placed. METHODS: Between January 1, 2010, and September 12, 2017, there were 242 patients who had retrievable IVC filters placed. Demographics and indications for filter placement were retrospectively analyzed. All patients who failed to have the filter retrieved were contacted by Institutional Review Board-approved telephone survey to delineate the reason that the filter was not removed. RESULTS: Of 242 patients with IVC filters placed, 53 (22%) patients presented for filter retrieval at Abington-Jefferson Health. Patients who presented for filter retrieval were statistically younger (46 years vs 65 years; P < .001). The most common indication for filter placement in both groups was preoperative placement for bariatric surgery, but this percentage was higher in the group that presented for filter retrieval (70% [37/53] in the retrieved group vs 47% [88/189] in the nonretrieved group; P = .018). After telephone survey that reached 146 patients, it was determined that 46 (32%) patients who did not return for filter retrieval were told to keep the filter in place secondary to comorbidities, 28 (19%) did not remember being instructed to follow up for retrieval, and 18 (12%) did not want another procedure. Twenty-four patients were deceased at the time of telephone survey (16%). The remainder of the patients had the filter removed at an outside institution or gave another reason. CONCLUSIONS: Our study documented a disappointingly low rate of filter retrieval. Patients with IVC filters who failed to present for retrieval were more likely to be older and frequently did not understand the complications of leaving a filter in place and the need to have the filter retrieved. Patient education should be increased to better capture patients with IVC filters and to improve retrieval rates, but our study showed that a significant percentage of patients do not have filters retrieved because of comorbidities or they do not want another procedure.
Assuntos
Remoção de Dispositivo , Perda de Seguimento , Implantação de Prótese/instrumentação , Filtros de Veia Cava , Adulto , Fatores Etários , Idoso , Comorbidade , Feminino , Pesquisas sobre Atenção à Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Recusa do Paciente ao TratamentoRESUMO
OBJECTIVE: Type II endoleaks (T2ELs) are commonly observed after endovascular aneurysm repair (EVAR). We sought to determine whether time at onset of T2ELs correlated with the need to intervene based on sac expansion or rupture. METHODS: Between 1998 and 2015, 462 EVARs performed at our institution had duplex ultrasound surveillance in our accredited noninvasive vascular laboratory. Computed tomography and arteriography were reserved for abnormal duplex ultrasound findings. The need for intervention for T2ELs was classified according to time at onset after EVAR. Interventions for T2ELs were performed only for sac expansion >5 mm or rupture. We defined early-onset T2ELs as <1 year after EVAR and delayed or late onset as >1 year of follow-up. RESULTS: Of the 462 EVARs, 96 patients (21%) developed T2ELs after implantation. Of these, 65 (68%) had early and 31 (32%) had late onset (mean, 12 months; range, 1-112 months). Early T2ELs resolved without treatment in 75% (49/65) of cases compared with only 29% (9/31) of late T2ELs (P < .0001). Intervention was required for only 8% (5/65) of patients with early T2ELs (5 sac expansions, 0 ruptures) compared with 55% (17/31) for late T2ELs (16 sac expansions, 1 rupture; P < .0001). The remaining patients were observed for persistent T2ELs with no sac growth (17% [11/65] early vs 16% [5/31] late; P = .922). CONCLUSIONS: Less than one-third (29%) of T2ELs that develop after 1 year will resolve spontaneously and about half (55%) will require intervention for sac growth or rupture. T2ELs that develop >1 year after EVAR should be followed up with a more frequent surveillance protocol and perhaps with a lower threshold to intervene.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Embolização Terapêutica , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/epidemiologia , Ruptura Aórtica/terapia , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Embolização Terapêutica/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/epidemiologia , Humanos , Ligadura , Philadelphia/epidemiologia , Prevalência , Sistema de Registros , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler DuplaRESUMO
BACKGROUND: Carotid artery occlusive disease can cause stroke by embolization, thrombosis, and hypoperfusion. The majority of strokes secondary to cervical carotid atherosclerosis are believed to be of embolic etiology. However, cerebral hypoperfusion could be an important factor in perioperative stroke. We retrospectively reviewed the stump pressure (SP) of carotid endarterectomy (CEA) of patients at Pennsylvania Hospital to identify whether physiologic perfusion differences account for differences in perioperative stroke rates, particularly in octogenarians. METHODS: We conducted a retrospective review of our prospectively maintained database for CEA performed between 1992 and 2015. SP was measured and recorded for 1190 patients. A low SP was defined as systolic pressure <50 mm Hg. Shunts were used only for patients under general anesthesia with SP <50 mm Hg, for awake patients with neurologic changes with carotid clamping, and in some patients with recent stroke. RESULTS: Symptomatic patients were more likely to have SP <50 mm Hg compared with asymptomatic patients (35.6% vs 26.2%; P = .0015). Patients having SP <50 mm Hg had a higher postoperative stroke rate compared with patients with SP >50 mm Hg (2.9% vs 0.9%; P = .0174). Octogenarians were more likely to have a lower SP compared with patients younger than 80 years (35.7% vs 27.7%; P = .0328). Symptomatic patients with low SP were at highest risk for perioperative stroke (6.4% vs 1.2%; P = .001) compared with patients without these factors. CONCLUSIONS: SP is a marker for decreased cerebrovascular reserve and along with symptomatic status identifies those at highest risk for periprocedural stroke with CEA. Whereas patients older than 80 years may benefit from carotid intervention, they are likely to be at somewhat elevated stroke risk because of higher prevalence of low SP, and shunting does not eliminate this risk.
Assuntos
Pressão Arterial , Isquemia Encefálica/etiologia , Artérias Carótidas/cirurgia , Estenose das Carótidas/cirurgia , Circulação Cerebrovascular , Endarterectomia das Carótidas/efeitos adversos , Acidente Vascular Cerebral/etiologia , Fatores Etários , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Isquemia Encefálica/fisiopatologia , Artérias Carótidas/fisiopatologia , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Estenose das Carótidas/fisiopatologia , Bases de Dados Factuais , Feminino , Humanos , Masculino , Philadelphia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Bovine carotid artery (BCA) grafts have been described as a possibly superior alternative to expanded polytetrafluoroethylene hemoaccess grafts. However, published experience remains limited, and patency rates for nonautogenous arteriovenous grafts remain unsatisfactory. We report herein the largest published experience with the current generation of BCA grafts for dialysis access and analyze subgroups to determine whether obesity, gender, or prior access surgery influences patency. METHODS: We retrospectively reviewed 134 BCA grafts (Artegraft, North Brunswick, NJ) implanted for hemodialysis access in the upper extremities of 126 patients between January 2012 and May 2015. Patients had a mean of 1.8 prior access operations. Primary, primary assisted, and secondary patency rates were calculated using the Kaplan-Meier method, and longitudinal infection risk was tabulated. Patency differences were calculated using the log-rank method. RESULTS: For the entire group, 1-year primary patency was 32%, primary assisted patency was 49%, and secondary patency was 78%. Ten of 133 grafts (7%) developed infection requiring graft excision between 1 and 9 months after implantation. There was no statistical difference between men and women in primary or secondary patency (P = .88, P = .69). There was no difference in primary patency or secondary patency for patients with body mass index >30 or <30 (P = .85, P = .54). Patients who had a BCA graft as their first access attempt had a higher primary and primary assisted patency than that of patients who had the graft placed after prior access failure (P = .039, P = .024). CONCLUSIONS: This represents the largest published series of BCA grafts for arteriovenous grafts in the modern era. The primary patency of BCA grafts in this series was lower than that reported in a smaller randomized study. However, primary assisted and secondary patency were similar. Infection rates in this series appear to be somewhat lower than polytetrafluoroethylene infection rates reported in the literature. BCA grafts are a satisfactory alternative to expanded polytetrafluoroethylene for hemodialysis access, but larger controlled studies are needed to determine whether superior primary patency previously reported is a reproducible finding.
Assuntos
Derivação Arteriovenosa Cirúrgica/instrumentação , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Artérias Carótidas/transplante , Diálise Renal , Animais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/métodos , Bioprótese , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Índice de Massa Corporal , Artérias Carótidas/fisiopatologia , Bovinos , Feminino , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Xenoenxertos , Humanos , Estimativa de Kaplan-Meier , Masculino , Obesidade/complicações , Obesidade/diagnóstico , Philadelphia , Retratamento , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: Interventions for aortic aneurysm sac growth have been reported across multiple time points after endovascular aortic aneurysm repair (EVAR). We report the long-term outcomes of patients after EVAR monitored with duplex ultrasound (DUS) imaging with respect to the need for and type of intervention after 5 years. METHODS: We report a series of patients who were monitored with DUS imaging for a minimum of 5 years after EVAR. DUS imaging was performed in an accredited noninvasive vascular laboratory, and computed tomography angiography was only performed for abnormal DUS findings. RESULTS: There were 156 patients who underwent EVAR with follow-up >5 years (mean, 7.5 years; range, 5.1-14.5 years). Interventions for endoleak, graft limb stenosis, or thrombosis were performed in 44 patients (28%) at some time during follow-up. Of the 156 patients, 34 (22%) underwent their first intervention during the first 5 years (25 endoleaks, 9 limb stenoses, or occlusions). Four ruptures occurred, all in patients with their first intervention before 5 years. The remaining 10 patients (6%) underwent a first intervention >5 years after implantation: 3 for type I endoleak, 2 for type II endoleak with sac expansion, 2 for combined type I and II endoleaks 2 for type III endoleak, and 1 unknown type. CONCLUSIONS: Long-term follow-up of EVAR (mean, 7.5 years) revealed that approximately one in four patients will require intervention at some point during follow-up. First-time interventions were necessary in 22% of all patients in the first 5 years and in 6% of patients after 5 years, highlighting the need for continued graft surveillance beyond 5 years. All patients who had a first-time intervention after 5 years underwent an endoleak repair; none of these patients had a thrombosed limb or a rupture as a result of the endoleak.