Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 9 de 9
Filtrar
1.
J Vasc Surg ; 77(2): 386-395.e3, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36152982

RESUMO

OBJECTIVE: The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively. METHODS: A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment. RESULTS: Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results. CONCLUSIONS: EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.


Assuntos
Aneurisma da Aorta Abdominal , Tratamento Conservador , Correção Endovascular de Aneurisma , Humanos , Aneurisma da Aorta Abdominal/cirurgia , Análise Custo-Benefício , Resultado do Tratamento
3.
Cardiovasc Intervent Radiol ; 42(1): 28-33, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30288590

RESUMO

BACKGROUND: Percutaneous endovascular aneurysm repair (PEVAR) has been shown to have high success rates, shorter operating times and length of stay compared to open access. However, there exists a lack of long-term follow-up data on these patients, and questions remain regarding longer-term outcomes. This study aims to assess the long-term complications and evolution of accessed vessels post-PEVAR. METHODS: Sixty-one cases of bilateral PEVAR (122 groins) with > 36 months follow-up were analysed. Vessel diameter, calcification, dissection, lymphocele, pseudoaneurysm and thrombus formation were reviewed at 30th day and at the most recent follow-up CT. Notes were reviewed for groin infections, haematomas and nerve injury. Complications were considered 'major' if they required intervention or treatment. RESULTS: Mean follow-up time from procedure to most recent scan was 49.9 months. There were no major short- or long-term complications. The early complication rate was 9.8%, with six pseudoaneurysms, four dissections, one thrombus, one nerve injury and no lymphoceles, haematomas or groin infections. The long-term complication rate was 0.8%, with only one pseudoaneurysm. The remainder of early complications resolved naturally without intervention. Accessed vessel showed significantly (P ≤ 0.05) increased diameter and calcification between 30th day and last follow-up scan. CONCLUSION: This study provides the largest clinical cohort and the longest mean follow-up time reported in the literature and demonstrates the long-term safety of PEVAR. PEVAR has a very low long-term complication rate, without any major complications in our cohort. The accessed common femoral arteries do not show stenosis or thrombosis. Minor short-term complications appear to gradually resolve without intervention. Larger multi-centre studies are recommended.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Artéria Femoral/cirurgia , Virilha/irrigação sanguínea , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/terapia , Fatores de Tempo , Resultado do Tratamento
5.
J Infect ; 76(2): 132-139, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29126814

RESUMO

OBJECTIVE: To assess impact of a topical decontamination regimen on rates of catheter-related bloodstream infections (CRBSI) in intensively-treated haematology patients. METHODS: A historically-controlled cohort study was used to evaluate the effect of applying chlorhexidine or Octenisan® body washes and nasal Prontoderm® ointment for 5 days around the time of Hickman line insertion on the incidence of CRBSI and infection-free catheter time. Lines inserted during a 24 month period prior to implementation of the decolonisation regimen were compared with those inserted during a 12 month period after the intervention was applied. RESULTS: During the post-intervention period, 163 lines were inserted in 147 patients, compared to 303 lines in 242 patients in the pre-intervention period. CRBSI rates in treated and untreated patients respectively were 6.8 and 35.0 cases per 10,000 line-days by 21 days (p = 0.009), and 14.4 and 26.0 cases respectively per 10,000 line-days by 180 days (p = 0.025). The incidence rate of Staphylococcus aureus CRBSI in treated and untreated patients were 0.0 and 4.6 cases per 10,000 line-days respectively (p = 0.012). Multivariable Cox regression estimated an 81% probability (95% confidence interval 74%-85%) that a treated line develops a CRBSI later than an untreated line by 21 days post-insertion. CONCLUSION: Implementation of this safe and effective topical decontamination regimen enhances routine CRBSI-prevention measures for haematology patients requiring central venous line insertion.


Assuntos
Anti-Infecciosos Locais/farmacologia , Infecções Relacionadas a Cateter/sangue , Infecções Relacionadas a Cateter/prevenção & controle , Cateteres Venosos Centrais/microbiologia , Clorexidina/farmacologia , Descontaminação/métodos , Administração Tópica , Idoso , Bacteriemia/prevenção & controle , Infecções Relacionadas a Cateter/epidemiologia , Cateteres Venosos Centrais/efeitos adversos , Estudos de Coortes , Feminino , Hematologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Infecções Estafilocócicas/sangue , Infecções Estafilocócicas/prevenção & controle , Staphylococcus aureus/efeitos dos fármacos , Atenção Terciária à Saúde , Reino Unido/epidemiologia
6.
Cardiovasc Intervent Radiol ; 38(5): 1244-51, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25762487

RESUMO

PURPOSE: PTC and stenting procedures are associated with significant risks including life-threatening haemorrhage, sepsis, renal failure and high mortality rates. PTC tract closure methods are utilised to reduce haemorrhagic complications despite little evidence to support their use. The current study assesses the incidence of haemorrhagic complications following PTC and stenting procedures, both prior to and following the introduction of a dedicated expanding gelatin foam-targeted embolisation liver tract closure technique. MATERIALS AND METHODS: Haemorrhagic complications were retrospectively identified in patients undergoing PTC procedures both prior to (subgroup 1) and following (subgroup 2) the introduction of a dedicated targeted liver tract closure method between 9/11/2010 and 10/08/2012 in a single tertiary referral centre. Mean blood Hb decrease following PTC was established in subgroups 1 and 2. Kaplan-Meier life-table analysis was performed to compare survival outcomes between subgroups using the log-rank test. RESULTS: Haemorrhagic complications were significantly reduced following the introduction of the targeted PTC tract closure method [(12 vs. 3 % of subgroups 1 (n = 101) and 2 (n = 92), respectively (p = 0.027)]. Mean blood Hb decrease following PTC was 1.40 versus 0.68 g/dL in subgroups 1 and 2, respectively (p = 0.069). 30-day mortality was 14 and 12 % in subgroups 1 and 2, respectively. 50 % of the entire cohort had died by 174 days post-PTC. CONCLUSION: Introduction of liver tract embolisation significantly reduced haemorrhagic complications in our patient cohort. Utilisation of this method has the potential to reduce the morbidity and mortality burden associated with post-PTC haemorrhage by preventing bleeding from the liver access tract.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/métodos , Embolização Terapêutica/métodos , Hemorragia/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Stents , Idoso , Sistema Biliar/diagnóstico por imagem , Colangiografia , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Resultado do Tratamento
7.
J Vasc Interv Radiol ; 24(4): 528-33, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23462063

RESUMO

PURPOSE: To assess the effectiveness of flow reversal as an alternative means of cerebral protection by using transcranial Doppler recordings and diffusion-weighted imaging (DWI) as surrogate markers of brain injury. MATERIALS AND METHODS: Eighteen patients with symptomatic carotid artery disease were recruited. Magnetic resonance imaging was performed before the intervention and at 3 and 24 hours and 30 days after the intervention to detect new ischemic lesions with DWI. Transcranial Doppler recordings were made during the procedure to assess for microembolic signals (MESs). Data were compared against data from a historical control cohort of patients who underwent CAS placement with or without filter protection (n = 15 each) under the same protocol in a different study. RESULTS: There were fewer periprocedural new lesions on DWI in the reverse-flow cohort compared with the historical control cohort with filter protection (P = .084). Reverse flow revealed significantly fewer MESs during the whole procedure compared with the filter-protected group (P = .01) but not the unprotected group (P = .55). There was a marked decrease in MES counts for reverse flow protection during the embologenic stages of the procedure (P = .004). CONCLUSIONS: Use of the reverse flow device was associated with fewer overall lesions on DWI and proportionately fewer positive scans compared with the use of filter-type devices (P = .08, not significant). Transcranial Doppler recordings demonstrated a significant reduction in embolization to the brain during carotid artery stent placement with the use of reverse-flow cerebral protection.


Assuntos
Angioplastia/instrumentação , Isquemia Encefálica/prevenção & controle , Doenças das Artérias Carótidas/terapia , Circulação Cerebrovascular , Imagem de Difusão por Ressonância Magnética , Embolia Intracraniana/prevenção & controle , Perfusão/métodos , Stents , Ultrassonografia Doppler Transcraniana , Idoso , Angioplastia/efeitos adversos , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico , Doenças das Artérias Carótidas/fisiopatologia , Dispositivos de Proteção Embólica , Feminino , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/etiologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Valor Preditivo dos Testes , Fatores de Tempo , Resultado do Tratamento
8.
Radiology ; 258(2): 538-45, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21163919

RESUMO

PURPOSE: To assess whether carotid plaque hemorrhage depicted with magnetic resonance (MR) imaging was associated with thromboembolic activity as assessed with transcranial Doppler imaging. MATERIALS AND METHODS: The local research ethics committee approved the study, and all patients gave informed written consent. Between April 2005 and December 2006, patients with high-grade symptomatic carotid stenosis were prospectively recruited. All underwent MR imaging of the carotid arteries for plaque hemorrhage and diffusion-weighted imaging of the brain. Transcranial Doppler imaging of the symptomatic carotid artery was performed over 1 hour to assess the presence of microembolic signal. To determine the relationship between the presence of plaque hemorrhage and diffusion-weighted imaging-positive signal and presence of microembolic signal, a logistic regression analysis was performed. RESULTS: Fifty-one patients (23 women and 28 men; mean age ± standard deviation, 72 years ± 11) underwent complete MR imaging; 46 (86%) of these patients underwent complete transcranial Doppler imaging. In 32 (63%) patients, there was plaque hemorrhage in the index carotid artery. The presence of plaque hemorrhage increased the risk for ipsilateral abnormalities at diffusion-weighted imaging (odds ratio, 6.2 [95% confidence interval: 1.7, 21.8]; P < .05). Multiple diffusion-weighted imaging-depicted abnormalities of multiple ages were present exclusively in patients with plaque hemorrhage shown at MR imaging (12 of 32 [38%] patients with plaque hemorrhage versus none of 19 patients without plaque hemorrhage; P < .05). The presence of plaque hemorrhage also increased the presence of microembolic signal (odds ratio, 6.0 [95% confidence interval: 1.8, 19.9]; P = .003). CONCLUSION: In patients with carotid plaque hemorrhage demonstrated at MR imaging, there was increased spontaneous microembolic activity at transcranial Doppler imaging and cerebral ischemic lesion patterns suggestive of recurrent embolic events; these findings suggest that plaque hemorrhage shown at MR imaging might be a marker of thromboembolic activity and further validate the usefulness of carotid imaging in identifying patients with active carotid arterial disease.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Hemorragia/diagnóstico por imagem , Tromboembolia/diagnóstico por imagem , Ultrassonografia Doppler Transcraniana , Idoso , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Modelos Logísticos , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Recidiva
9.
J Vasc Surg ; 46(1): 31-6, 2007 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-17543492

RESUMO

BACKGROUND: Microembolization detected during the dissection phase of carotid endarterectomy (CEA) is associated with plaque instability and might be associated with perioperative morbidity. Intraplaque hemorrhage is found in unstable plaques and is detectable using magnetic resonance imaging (MRI). We aimed to ascertain whether intraplaque hemorrhage as seen on carotid MRI predicts particulate embolization in the dissection phase of CEA. METHODS: Patients with high-grade symptomatic carotid stenosis undergoing CEA were prospectively enrolled. All underwent preoperative MRI assessment of the carotid arteries for intraplaque hemorrhage and transcranial Doppler scanning during the dissection phase of the CEA to assess the presence of microembolic signals. Associations between intraplaque hemorrhage and intraoperative microembolic signals were studied. RESULTS: Analysis was undertaken on 60 participants; of these, 36 (60%) showed ipsilateral carotid MRI intraplaque hemorrhage, and 24 (40%) did not. Microembolic signals were detected during the dissection phase in 23 (38.3%) participants, and 19 had MRI-detected intraplaque hemorrhage. The association between carotid intraplaque hemorrhage and the presence of dissection phase microembolic signals was significant (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.6 to 19.7, P = .007), even after controlling for age, sex, individual surgeon, degree of stenosis, and delay from symptom to CEA (adjusted OR, 5.8; 95% CI, 1.1 to 30.4, P = .037). CONCLUSION: Intraplaque hemorrhage as detected by carotid MRI predicts particulate embolization during the dissection phase of CEA. This imaging technique can be used to identify patients with increased intraoperative thromboembolic risk, and this could influence preventive strategies.


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Hemorragia/diagnóstico , Embolia Intracraniana/etiologia , Angiografia por Ressonância Magnética , Idoso , Estenose das Carótidas/complicações , Estenose das Carótidas/patologia , Feminino , Hemorragia/etiologia , Humanos , Embolia Intracraniana/complicações , Embolia Intracraniana/diagnóstico , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento , Ultrassonografia Doppler Transcraniana
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...