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1.
Methodist Debakey Cardiovasc J ; 20(3): 13-18, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38765214

RESUMO

With a multitude of options for pulmonary embolism management, we review the most common diagnostic tools available for assessing risk as well as how each broad risk category is typically treated. Right heart dysfunction is the cornerstone for triage of these patients and should be the focus for decision-making, especially in challenging patients. We aim to provide a modern, clinical perspective for PE management in light of the multitude of intervention options.


Assuntos
Tomada de Decisão Clínica , Embolia Pulmonar , Embolia Pulmonar/terapia , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/fisiopatologia , Embolia Pulmonar/diagnóstico por imagem , Humanos , Fatores de Risco , Resultado do Tratamento , Medição de Risco , Valor Preditivo dos Testes , Terapia Trombolítica/efeitos adversos , Embolectomia , Procedimentos Endovasculares/efeitos adversos , Anticoagulantes/uso terapêutico , Anticoagulantes/efeitos adversos , Seleção de Pacientes , Trombectomia
2.
Artigo em Inglês | MEDLINE | ID: mdl-38765216

RESUMO

Introductory overview for Methodist DeBakey Cardiovascular Journal Issue 20.3 on Pulmonary Embolism, written by the issues' guest editors.


Assuntos
Embolia Pulmonar , Embolia Pulmonar/terapia , Embolia Pulmonar/diagnóstico , Humanos , Fatores de Risco , Resultado do Tratamento
3.
Int J Med Robot ; 17(3): e2249, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33634563

RESUMO

BACKGROUND: Robotic-assisted endovascular surgery enables us to perform interventions from long distances. This study evaluates the workflow and telecommunication requirements of telerobotic peripheral vascular interventions. METHODS: Ten superficial femoral artery cases were performed by the operator being 44 miles away from the interventional suite, with an endovascular robotic system, on a high-fidelity endovascular simulator. Procedural success, technical success, fluoroscopy time, residual stenosis, contrast dose and network delay were registered. Communication success was assessed after each procedure on a scale from 1 (unacceptable) to 5 (ideal). RESULTS: Procedural success and technical success were 100% and 80%, respectively. The mean residual stenosis, fluoroscopy time and contrast dose were 1.7 ± 5.25%, 6.5 ± 1.8 min and 58.8 ± 14.8 ml. The mean network latency was 38.9 ± 3.5 ms. Median communication success scores were 4.5 (min: 4, max: 5) reported by both the operator and the bedside technician on a scale of 1 (unacceptable) to 5 (ideal). CONCLUSION: With a stable network connection and good communication protocol, a high success rate was achieved for remote robotic-assisted peripheral vascular intervention in an ex vivo model.


Assuntos
Procedimentos Endovasculares , Procedimentos Cirúrgicos Robóticos , Estudos de Viabilidade , Humanos , Stents , Resultado do Tratamento
4.
J Vasc Surg Venous Lymphat Disord ; 7(3): 420-427, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30792152

RESUMO

OBJECTIVE: Outflow tract stenosis is the leading cause of hemodialysis access loss. Many lesions are highly resistant to endovascular treatment, necessitating open surgical intervention. We present our experience using medial claviculectomy for treatment of recalcitrant lesions at the thoracic outlet. METHODS: We retrospectively reviewed patients who underwent medial claviculectomy for dialysis-associated venous thoracic outlet syndrome at our institution between February 2013 and February 2018. Data collection included demographics, past medical history, access history, subsequent procedures, preoperative and postoperative brachial volume flows, and access use. RESULTS: We performed 25 medial claviculectomies in 25 patients with central venous stenosis. Four patients underwent concomitant central venous bypass and were excluded from this study. Twelve accesses were created at our institution; of these, the average access age was 41.6 months (±26.7 months). All patients previously underwent multiple angioplasty attempts to treat outflow stenosis and continued to have residual symptoms and poor fistula function. Medial claviculectomy with venolysis and angioplasty were performed to treat residual outflow stenosis at the level of the subclavian vein. Twenty-one patients had residual stenosis requiring angioplasty. Six patients had subclavian rupture requiring stent graft placement. All patients reported symptom improvement and immediate use of the fistula after medial claviculectomy. Nineteen (76%) patients reported complete resolution of symptoms after the procedure. Ultimately, eight (32%) ipsilateral arteriovenous accesses were lost, and six (24%) patients died in follow-up with patent, functional fistulas. Median length of follow-up was 17 months (interquartile range, 5-28 months). The 18-month primary patency and secondary patency with regard to subclavian vein interventions were 28% (95% confidence interval, 13.8%-56.1%) and 84% (95% confidence interval, 69.7%-100%), respectively. One patient required ligation for high-output cardiac failure. One patient had contralateral brachiocephalic jailing, which was corrected with kissing brachiocephalic stents. CONCLUSIONS: Medial claviculectomy is an effective treatment of recalcitrant central venous stenosis of the thoracic outlet. Balloon angioplasty or stent or stent graft placement is often necessary after extrinsic compression is alleviated and demonstrates acceptable secondary patency rates.


Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Clavícula/cirurgia , Descompressão Cirúrgica/métodos , Osteotomia , Diálise Renal , Veia Subclávia/cirurgia , Síndrome do Desfiladeiro Torácico/cirurgia , Doenças Vasculares/cirurgia , Adulto , Idoso , Angioplastia com Balão/instrumentação , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Clavícula/diagnóstico por imagem , Descompressão Cirúrgica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Stents , Veia Subclávia/diagnóstico por imagem , Veia Subclávia/fisiopatologia , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/etiologia , Síndrome do Desfiladeiro Torácico/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/etiologia , Doenças Vasculares/fisiopatologia , Grau de Desobstrução Vascular
5.
Vascular ; 25(5): 525-532, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28372484

RESUMO

Objective Systemic anticoagulation remains the standard for acute lower extremity (LE) deep venous thrombosis (DVT), but growing interest in catheter-directed thrombolysis (CDT) and its potential to reduce the incidence of post-thrombotic syndrome (PTS) has led to advent of ultrasound-accelerated CDT (US-CDT). Few studies to date have examined the outcomes of US-CDT against traditional CDT (T-CDT). Methods This is a retrospective, single-center review of all patients treated for acute LE DVT over a five-year period with either US- and T-CDT. Patients were stratified based on demographics, presentation, co-morbidities, risk factors, and peri-procedural data. Results Seventy-six limbs in 67 patients were treated; 51 limbs in 42 patients were treated with US-CDT, and 25 limbs in 25 patients were treated with T-CDT. Adjuncts include: pharmacomechanical thrombolysis ( n = 28 vs. 20, p = 0.04), angioplasty ( n = 22 vs. 18, p = 0.11), stenting ( n = 30 vs. 6, p ≤ 0.001), and IVC filter insertion ( n = 5 vs. 0, p = 0.07). Mean lysis times were 21 ± 1.7 and 24 ± 1.8 h for US- and T-CDT, respectively ( p = 0.26). Thirty (25 ultrasound, 5 traditional) limbs had complete lysis. Thirty-one (22 ultrasound, 9 traditional) limbs had incomplete lysis. Fifteen (4 ultrasound, 11 traditional) limbs had ineffective lysis ( p = 0.002 in favor of ultrasound). Four patients (3 US-CDT, 1 T-CDT) had recurrent ipsilateral thrombosis within 30 days ( p = 0.60). By Kaplan-Meier analysis, there were no significant difference between primary patency, primary-assisted patency, secondary patency, re-thrombosis, and recurrent symptoms at 6, 12, and 24 months. Conclusion US-CDT does not significantly improve mid-term patencies but results in greater acute clot burden reduction in patients with acute LE DVTs compared to T-CDT, which may be beneficial in reducing the long-term incidence of PTS.


Assuntos
Fibrinolíticos/administração & dosagem , Extremidade Inferior/irrigação sanguínea , Terapia Trombolítica/métodos , Terapia por Ultrassom , Trombose Venosa/terapia , Intervalo Livre de Doença , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Síndrome Pós-Trombótica/etiologia , Recidiva , Retratamento , Estudos Retrospectivos , Fatores de Risco , Texas , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Terapia por Ultrassom/efeitos adversos , Grau de Desobstrução Vascular , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/fisiopatologia
6.
Methodist Debakey Cardiovasc J ; 13(1): 34-36, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28413581

RESUMO

Although anticoagulation remains the mainstay of therapy for patients with venous thromboembolism, guidelines recommend the use of inferior vena cava (IVC) filters in those who fail anticoagulation or have contraindications to its use. Short-term use of filters has proven effective in reducing the rate of pulmonary embolism. However, their extended use is associated with a variety of complications such as thrombosis, filter migration, or caval perforation, thus making a case for timely filter retrieval. This is the case of a 68-year-old female with a history of chronic oral anticoagulation use for multiple deep venous thrombi (DVT) and pulmonary emboli (PE) who required cervical and thoracic spinal intervention for spondylosis and foramina stenosis. Given her increased risk of recurrent DVT and PE perioperatively, we elected to place a Cook Celect™ IVC filter (Cook Medical, Bloomington, IN) after oral anticoagulation was stopped for the procedure. Her treatment course was prolonged due to wound-healing complications. We elected to use the Magellan Robotic Catheter System (Hansen Medical, Mountain View, CA) for filter retrieval when she presented 6 months later with caval perforation from the filter struts. With its ease of use, superior mechanical stability, and maneuverability, robot-assisted IVC filter retrieval may be a safer and more reliable substitute for traditional navigation techniques when presented with challenging filter retrievals.


Assuntos
Remoção de Dispositivo/métodos , Procedimentos Endovasculares , Implantação de Prótese/instrumentação , Robótica , Filtros de Veia Cava , Veia Cava Inferior , Tromboembolia Venosa/terapia , Idoso , Feminino , Humanos , Desenho de Prótese , Radiografia Intervencionista , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Tromboembolia Venosa/diagnóstico por imagem
7.
J Vasc Surg Cases Innov Tech ; 3(1): 7-10, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29349363

RESUMO

Type II endoleak (T2E) leading to aneurysm sac enlargement is one of the challenging complications associated with endovascular aneurysm repair. Recent guidelines recommend embolization of T2E associated with aneurysmal sac enlargement. Various percutaneous and endovascular techniques have been reported for embolization of T2E. We report a novel technique for T2E embolization combining laparoscopic and endovascular approaches using preoperative image fusion. We believe our technique provides a more direct access to the lumbar feeding vessels that is typically challenging with transarterial or translumbar embolization techniques.

8.
Ann Thorac Surg ; 102(5): e451-e453, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27772606

RESUMO

A 62-year-old man with coronary artery disease and ischemic cardiomyopathy after coronary artery bypass grafting and insertion of a HeartMate II (Thoratec, Pleasanton, CA) left ventricular assist device (LVAD) presented with spontaneous incisional bleeding and an ascending aortic pseudoaneurysm. Aortic angiography revealed an anomalous connection between the pseudoaneurysm and the LVAD conduit. We were able to partially embolize the tract with standard techniques, but the patient returned with repeated bleeding. Using the additional stability and control afforded by the Magellan Robotic System (Hansen Medical, Mountain View, CA), a remotely steerable catheter, we were able to cannulate and completely embolize the pseudoaneurysm and occlude the anomalous tract.


Assuntos
Falso Aneurisma/cirurgia , Aorta/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Embolização Terapêutica/métodos , Falso Aneurisma/diagnóstico , Aorta/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico , Aortografia , Humanos , Masculino , Pessoa de Meia-Idade , Robótica , Tomografia Computadorizada por Raios X
9.
J Vasc Surg ; 63(2): 441-4, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26492999

RESUMO

OBJECTIVE: Ischemic steal syndrome (ISS) and pathologic high flow (HF) are a complications after hemodialysis access creation. Their management is complex and varied with most requiring surgical revision for correction of symptoms. Revision using distal inflow (RUDI) has been described in small series for the treatment of ISS. We present our experience with RUDI for the treatment of ISS and pathologic HF. METHODS: We retrospectively reviewed consecutive patients who underwent RUDI for ISS from April, 2010 to March, 2014. Data collection included demographic characteristics, medical histories, subsequent procedures, volume flows, access usage, limb salvage, and patient survival. RESULTS: We performed 29 RUDI procedures in 28 patients (16 women, 12 men). Indications for surgery were pathologic HF in 13 and ISS in 19. Ten percent had previous banding for ISS or HF. Sixty-nine percent of patients had a history of diabetes. Fifty-two percent had a history of atherosclerotic disease. Mean time to intervention from creation was 40 months (range, 6-88 months). Accesses included 1 upper arm graft and 27 brachial artery-based fistulas. Outflow included 25 cephalic veins and 3 basilic veins. Distalization targets were 19 radial arteries and 10 ulnar arteries. Mean flow reduction was 1191 mL/min. Primary assisted patency at 1 year was 74%. Secondary patency at 1 year was 87%. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 69% and partial in 31%. CONCLUSIONS: RUDI is an effective and durable treatment of ISS and HF comparable with reported experiences with distal revascularization-interval ligation, proximalization of the arterial inflow, and banding. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.


Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Artéria Braquial/cirurgia , Isquemia/cirurgia , Diálise Renal , Extremidade Superior/irrigação sanguínea , Velocidade do Fluxo Sanguíneo , Artéria Braquial/fisiopatologia , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Artéria Radial/fisiopatologia , Artéria Radial/cirurgia , Fluxo Sanguíneo Regional , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Artéria Ulnar/fisiopatologia , Artéria Ulnar/cirurgia , Grau de Desobstrução Vascular , Veias/fisiopatologia , Veias/cirurgia
10.
Ann Vasc Surg ; 31: 91-8, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26627317

RESUMO

BACKGROUND: Endovascular revascularization is an established approach for limb salvage in the setting of critical limb ischemia. However, failure rate of antegrade recanalization in complex femoropopliteal to infrapopliteal occlusions is as high as 20%. We report a series of 21 patients who underwent retrograde pedal access and recanalization of below-the-knee chronic total occlusions after failed antegrade attempts. METHODS: This is a retrospective review of prospectively maintained data for all patients who underwent ultrasound-guided percutaneous pedal access for retrograde endovascular treatment of advanced tibial vessel disease between 2011 and 2014. All patients had undergone prior unsuccessful attempts at antegrade revascularization. Pedal vessel access was followed by angioplasty with selective stenting and completion angiogram. Patients were followed up with duplex ultrasound to evaluate for patency. Time-dependent outcomes were determined by Kaplan-Meier survival analyses. Median follow-up was 9 months. RESULTS: A total of 21 patients (17 men, 4 women, mean age 68) underwent retrograde tibial recanalization. Eighty-one percent of the patients presented with Rutherford category 4, 5, or 6 critical limb ischemia. The average Prevent III amputation risk score was 7.0 ± 2.9. Eighteen patients (86%) were medium or high risk (Prevent III amputation risk score ≥ 4). Retrograde pedal access was successful in 95% of the patients (dorsalis pedis = 11, posterior tibial = 5, anterior tibial = 4). Retrograde revascularization was achieved in 14 patients (67%) using balloon angioplasty (n = 14) and additional stent placement (n = 2). Revascularization failed in 7 patients (33%). There were no pedal access site complications. Forty-eight percent of the patients experienced improvement or resolution of their symptoms. The 30-day major adverse cardiac events (MACE), major adverse limb events (MALE), and amputations were all 5%. At 1 year, limb salvage was 88 ± 8% with amputation-free survival of 61 ± 12% and freedom from MALE of 81 ± 10%. Primary assisted and secondary patencies were both 84 ± 10% at 1 year. CONCLUSIONS: Early outcomes for ultrasound-guided retrograde pedal access show that it is safe, with low 30-day mortality, and a low rate of MACE. Freedom from MALE and limb salvage are both high at 1-year follow-up. This technique expands revascularization options after failed conventional endovascular antegrade approaches.


Assuntos
Procedimentos Endovasculares , Doença Arterial Periférica/terapia , Tíbia , Idoso , Amputação Cirúrgica , Doença Crônica , Intervalo Livre de Doença , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Stents , Tíbia/diagnóstico por imagem , Tíbia/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Ultrassonografia de Intervenção , Grau de Desobstrução Vascular
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