RESUMO
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.