RESUMO
Crohn's disease (CD) and Takayasu's arteritis (TA) are inflammatory granulomatous autoimmune disorders. Simultaneous occurrence of CD and TA in the same individual is rare. We report two cases treated with biologic agents. Case 1: A 16-year-old male presented with abdominal pain, nausea, vomiting. CT angiogram showed thickening of the terminal ileum, wall thickening and narrowing of multiple large and medium arteries including aorta and left common carotid. Colonoscopy with biopsy of the stenotic ileocecal valve confirmed CD. Resected carotid artery pathology was consistent with TA. Treatment was initially begun with prednisone, then methotrexate was started followed by infliximab. Due to side effects, methotrexate was switched to azathioprine. He remained asymptomatic. Case 2: A 38-year-old male with well-characterized Crohn's ileocolitis for 15 years, who had been treated with prednisone, mesalamine, sulfasalazine, and azathioprine presented with chest, upper back and abdominal pain. CT angiogram showed vasculitis of large and medium arteries, with stenosis of the right renal artery, and wall thickening of the sigmoid colon. He was diagnosed with TA. He underwent treatment with infliximab and adalumimab on different occasions, which were later discontinued due to fever, bacteremia and complications from sepsis. He remained on prednisone and azathioprine. In these two patients with both CD and TA the diagnoses were confirmed by imaging and pathologic findings. Both patients developed vascular complications. Tumor necrosis factor inhibitor therapy was effective in one patient but discontinued in the other due to infection. Further research into the association of CD and TA may provide clues to their etiologies and guide effective interventions.
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Upper extremity trauma can be penetrating or blunt in etiology. The close proximity of vein, artery and nerve makes for a complicated presentation and potentially complicated reconstruction. Orthopedic and neurologic injuries can cause the more long term disability of these patients, but vascular injuries are initially more life threatening. Control of vascular injuries can be particularly difficult due to anatomic issues in the upper extremities. The intervention carried significant morbidity until evolution to endovascular approaches occurred. By reconstructing the injury from a more ''remote'' access site, less concomitant injury to the extremity can be encountered. However, although control of vascular injuries may result in greater survival rates with less morbidity from the procedure, long term outcome remains dependent upon concomitant injuries. This review will encompass both vascular and neurologic injuries secondary to trauma to the upper extremity and outline some of the trends in management.
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Falso Aneurisma/terapia , Implante de Prótese Vascular , Embolização Terapêutica , Traumatismos do Sistema Nervoso/cirurgia , Extremidade Superior/irrigação sanguínea , Ferimentos e Lesões/complicações , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Falso Aneurisma/cirurgia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Embolização Terapêutica/instrumentação , Humanos , Desenho de Prótese , Radiografia , Stents , Artéria Subclávia/lesões , Artéria Subclávia/cirurgia , Resultado do Tratamento , Ferimentos e Lesões/diagnóstico por imagem , Ferimentos e Lesões/cirurgia , Ferimentos e Lesões/terapiaRESUMO
Endovascular abdominal aortic aneurysm repair (EVAR) poses certain challenges to the vascular surgeon. Based upon our 6-year experience, we have highlighted important aspects of patient selection. EVAR can be performed in patients with significant co-morbidities, but technical success may be limited by anatomic criteria. Short to mid-term outcomes report low mortality and morbidity from EVAR. Acute and delayed conversion, rupture, endoleak, limb occlusion, and migration are complications occurring in EVAR; their frequency, presentation and management are described. EVAR has up to 90% success rate at several years follow-up including the use of secondary procedures. Secondary procedures are not infrequent after EVAR; thus close follow-up is of the utmost importance. We predict that EVAR will continue to be a valuable tool in the future.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/tendências , Previsões , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/tendências , Seleção de Pacientes , Complicações Pós-Operatórias , StentsRESUMO
Ureteral injury during aortic surgery may lead to life-threatening consequences. Unlike gynecologic or abdominal surgical procedures in which ureteral injuries more commonly occur, this type of iatrogenic injury may be particularly hazardous because of the presence of prosthetic graft material. Ureteral obstruction by extrinsic compression, from an anteriorly placed graft limb or retroperitoneal fibrosis, is the most commonly reported type of ureteral complication. In most vascular surgical series, direct ureteral injury occurs in less than 1% of cases, and ureteral obstruction occurs from 2% to 14% of aortoiliac reconstructions. Prevention of ureteral injury begins with an intimate knowledge of the anatomy of the ureter along its entire course from the abdomen to the pelvis, and a realization of possible anomalies. Recognition of an injury is the next key to a successful outcome. Intraoperative recognition of an injury may allow immediate repair with a high rate of success. There are many options for the management of ureteral injuries depending on the nature of the injury, the time of diagnosis, and the level of the ureter at which the injury has occurred. The authors review the anatomy and most common causes of ureteral injury during aortic surgery and provide a guide to appropriate surgical management of these injuries.
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Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/cirurgia , Ureter/lesões , Procedimentos Cirúrgicos Vasculares , Humanos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Fatores de Risco , Procedimentos Cirúrgicos Vasculares/efeitos adversosRESUMO
PURPOSE: Proponents of carotid angioplasty and stenting suggest that "high risk" patients, defined as patients excluded from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS), may have a significantly higher risk of stroke with carotid endarterectomy (CEA). However, this selected patient cohort has been poorly studied. METHODS: A retrospective review of patients who underwent CEA during a 2-year period at a tertiary referral institution was performed. Each patient was evaluated and categorized, according to the exclusion criteria, by NASCET and ACAS standards. Statistical analysis using chi(2) and Fisher exact tests was performed. RESULTS: There were 366 CEAs performed on 348 patients, including 32 (8.7%) for recurrent stenosis. A subgroup of 169 (46.2%) patients were trial ineligible. Focal ipsilateral symptoms were present in 148 (40.4%) of the patients. There were 9 (2.5%) strokes and 1 (0.3%) death, secondary to a major stroke, for an overall stroke and death rate of 2.5%. Trial-eligible patients had a stroke/death rate of 1.5% (3/197) while trial-ineligible patients had a 3.6% (6/169) stroke/death rate (P = .17). CONCLUSION: Patients who were considered high risk for CEA as defined by trial ineligibility were common, comprising approximately half of our patients. Although trial-ineligible patients had a nonsignificant trend toward higher neurologic morbidity when compared with the eligible group, the risks were still comparable with NASCET/ACAS results. CEA was a safe procedure even in this "high risk" group. As such, ineligibility for a randomized carotid intervention trial should not be employed as a "de novo" indication for carotid stenting.
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Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/etiologia , Idoso , Idoso de 80 Anos ou mais , Angioplastia/efeitos adversos , Estenose das Carótidas/classificação , Estenose das Carótidas/diagnóstico por imagem , Comorbidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Louisiana/epidemiologia , Masculino , Morbidade , Recidiva , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Stents/efeitos adversos , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento , UltrassonografiaRESUMO
OBJECTIVES: The purpose of this study was to compare in a randomized, prospective, and controlled study, the performance of a multilayered, self-sealing polyurethane vascular access graft (PVAG) and expanded polytetrafluoroethylene (ePTFE) vascular access grafts in hemodialysis applications. Performance measures included graft survival, complications, time to early cannulation, and hemostasis times after cannulation. STUDY DESIGN: A total of 142 patients were randomized equally to receive one of the two grafts after meeting all eligibility requirements. All patients were followed up prospectively to 12 months or to the end of secondary patency. Specifically, this study documented the performance of the PVAG and ePTFE grafts by determining the patencies and complications for both grafts. RESULTS: Patient characteristics between the two groups were similar with respect to risk factors and demographic characteristics (P >.05). Life-table patencies from the date of first dialysis were primary patency: PVAG 55% versus ePTFE 47% (6 months) and PVAG 44% versus ePTFE 36% (12 months) and secondary patency: PVAG 87% versus ePTFE 90% (6 months) and PVAG 78% versus ePTFE 80% (12 months). None of these differences were significant (P >.05). Both primary and secondary patencies were also not significantly different when the date of implantation was the starting point. Adverse events and complications were similar for the two groups, except the PVAG group had a higher incidence of technical complications manifested by graft kinking when compared with the control cohort (P <.05). Additionally, there was no significant difference in complication rates between these two groups with regard to infection and bleeding. When the time to hemostasis after cannulation was compared at 5minutes or less, there were more PVAG cannulation sites that achieved hemostasis compared with ePTFE sites, and this difference was significant (P <.0001). When time to first dialysis access was compared between the two grafts, 53.9% of all PVAG grafts were cannulated before 9 days versus none with the ePTFE grafts (P <.001). However, long-term graft survival was not significantly different when PVAG patients were stratified into early (< 9 days) and the late access (9 >/= days) groups (P =.29). CONCLUSIONS: The PVAG graft allows for early access without compromising long-term performance. Both PVAG and standard ePTFE grafts have similar long-term outcomes, despite early access with the PVAG vascular access grafts.
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Materiais Biocompatíveis , Cateteres de Demora , Politetrafluoretileno , Poliuretanos , Diálise Renal/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
The development of transgenic events can be limited by many factors. These include expression levels, insert stability and inheritance, and the identification of simple insertion events. All of the factors can be related to the copy number of the transgene. Traditionally, copy number has been determined by laborious blotting techniques. We have developed an alternative approach that utilizes the fluorogenic 5' nuclease (TaqMan) assay to quantitatively determine transgene copy level in plants. Using this assay, hundreds of samples can be analyzed per day in contrast to the low throughput encountered with traditional methods. To develop the TaqMan copy number assay, we chose to utilize our highly efficient Agrobacterium-mediated transformation system of maize. This transformation procedure generates predominantly low copy number insertion events, which simplified assay development. We have also successful applied this assay to other crops and transformation systems.
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Plantas Geneticamente Modificadas/genética , Reação em Cadeia da Polimerase/métodos , Zea mays/genética , Sistemas Computacionais , Dosagem de Genes , Manose-6-Fosfato Isomerase/genética , Taq Polimerase , Transgenes/genéticaRESUMO
OBJECTIVE: To review the current research and published literature regarding the development of oral heparin therapy for the prophylaxis and treatment of deep venous thrombosis. BACKGROUND: Currently, the accepted practice of prophylaxis and/or treatment of acute deep venous thrombosis (DVT) is intravenous or subcutaneous (SQ) heparin followed by oral warfarin or SC low molecular weight heparin (LMWH) therapy followed by warfarin. Both of which are less than ideal. More recently, advances have been made towards an effective oral heparin preparation that would resolve many of the drawbacks to the current therapies. METHODS: A review of the current and relevant English literature identified via a search of the Medline database from January 1990 to present. RESULTS: Initial oral heparin therapy for DVT was unsuccessful due to presumed inadequate intestinal absorption as a result of heparin's molecular and structural characteristics. The development of oral heparin therapy, based on combining heparin with the carrier molecule Sodium N-(8[2-hydroxybenzoyl]amino) caprylate (SNAC) to enhance its intestinal absorption and bioavailability for the prophylaxis and treatment of DVT has been demonstrated to be effective in animal models. More recent efforts have been aimed at human trials. CONCLUSION: Recent advances in prophylaxis and treatment of DVT have stimulated great interest among researchers to develop an effective, convenient, and well tolerated oral therapy. An effective oral heparin therapy may represent an ideal method of prophylaxis and treatment of DVT.
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Anticoagulantes/administração & dosagem , Heparina/administração & dosagem , Trombose Venosa/tratamento farmacológico , Trombose Venosa/prevenção & controle , Administração Oral , Anticoagulantes/química , Anticoagulantes/farmacologia , Antitrombina III/metabolismo , Disponibilidade Biológica , Caprilatos , Química Farmacêutica , Decanoatos , Modelos Animais de Doenças , Portadores de Fármacos , Avaliação Pré-Clínica de Medicamentos , Heparina/química , Heparina/farmacologia , Humanos , Hidroxibenzoatos , Absorção Intestinal , Resultado do TratamentoRESUMO
During endovascular abdominal aortic aneurysm repair, a severely angulated aortic neck or tortuous iliac arteries can make delivery of endografts difficult. We describe a simple adjunct in which transabdominal manipulation of vessels is used, which can greatly facilitate delivery of these devices in patients with challenging anatomy.
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Aneurisma da Aorta Abdominal/terapia , Stents , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia , Humanos , Radiografia IntervencionistaRESUMO
Operative intervention causes a necessary biologic response known as the hypermetabolic stress response. Less invasive operative procedures may cause fewer metabolic and endocrine derangements. To evaluate the metabolic and endocrine differences between endovascular and transperitoneal abdominal aortic aneurysm (AAA) repair, 10 patients underwent standard open repair (open group) and 10 patients underwent endovascular repair of AAA (endovascular group) with a modular bifurcated endograft. Blood samples were obtained prior to general anesthesia (baseline) and every 6 hr for a 24-hr period. Assays for hormones related to the postoperative stress response as well as retinol-binding protein were performed. Peak hormonal values are presented in relation to the baseline. Demographic analysis of the two groups showed that there were no significant differences in age or ASA classification. The open group had a 9.6-fold increase in epinephrine release, which was significantly higher than the 1.6-fold increase in the endovascular group (p < 0.05). Elevations in cortisol were also significantly higher in the open group. Early postoperative nutritional derangements, as reflected by the levels of retinol-binding protein, were far less in the endovascular group than in the open group. Endovascular AAA repair appears to be associated with a marked reduction in the hypermetabolic stress response and nutritional deterioration, compared to traditional open repair. This reduction in physiologic stress may have salutary effects on the incidence of postoperative medical morbidity.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Estresse Fisiológico/prevenção & controle , Procedimentos Cirúrgicos Vasculares/métodos , Músculos Abdominais/cirurgia , Idoso , Implante de Prótese Vascular/métodos , Epinefrina/sangue , Feminino , Hormônios/sangue , Humanos , Hidrocortisona/sangue , Insulina/sangue , Tempo de Internação , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Proteínas de Ligação ao Retinol/análise , Stents , Estresse Fisiológico/diagnóstico , Estresse Fisiológico/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversosRESUMO
BACKGROUND: Orally administered heparin (OHEP) is unreliable because of poor absorption. Sodium N-(8[2-hydroxybenzoyl]amino) caprylate (SNAC) is an amido acid that facilitates the gastrointestinal absorption of heparin. We evaluated the effectiveness of OHEP combined with SNAC (OHEP/SNAC) in the treatment of deep-vein thrombosis (DVT). METHODS AND RESULTS: An internal jugular DVT was produced in 54 male Sprague-Dawley rats. Animals were assigned to 6 different groups for 7 days of treatment: untreated control, subcutaneous heparin (SC HEP) (300 U/kg SC TID), SNAC only (300 mg/kg PO TID), OHEP only (30 mg/kg PO TID), low-molecular-weight heparin (LMWH) (enoxaparin 5 mg/kg SC QD), and OHEP/SNAC (30 mg/kg:300 mg/kg PO TID). The activated partial thromboplastin time (aPTT) and anti-factor X (anti-Xa) levels were measured. The incidence of residual DVT after 1 week of treatment was 100% (9 of 9) in the control group versus 10% (1 of 10) in the OHEP/SNAC and 10% (1 of 10) in the LMWH groups (P<0.001). There was also a significant reduction in clot weights between these groups. Compared with controls, there were no significant differences in the residual DVT in the SNAC-only (6 of 6), OHEP-only (9 of 9), or SC HEP (8 of 10) groups. Combination OHEP/SNAC was as effective in the resolution of the clot and reducing clot weight as LMWH. The aPTT levels in the OHEP/SNAC group peaked at 30 minutes and were significantly higher than in all other groups (P<0.01). Anti-Xa levels were elevated at 15 minutes after dosing in the OHEP/SNAC group and remained significantly elevated at 4 hours (P<0.001). CONCLUSIONS: OHEP combined with a novel carrier agent (SNAC) successfully treated DVT in this rat model.
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Anticoagulantes/farmacocinética , Caprilatos/farmacocinética , Portadores de Fármacos/farmacocinética , Enoxaparina/farmacocinética , Trombose Venosa/tratamento farmacológico , Administração Oral , Animais , Modelos Animais de Doenças , Injeções Subcutâneas , Veias Jugulares , Masculino , Tempo de Tromboplastina Parcial , Ratos , Ratos Sprague-DawleyRESUMO
OBJECTIVE: This experiment evaluated enterally administered low molecular weight heparin (LMWH) combined with sodium N-[10-(2-hydroxybenzoyl)amino] decanoate (SNAD) for the treatment of induced venous thrombosis. SUMMARY BACKGROUND DATA: SNAD is a delivery agent that potentiates the gastrointestinal absorption of LMWH. METHODS: Forty female pigs were equally assigned to four groups: control (saline); enteral LMWH, 2,000 IU/kg; enteral SNAD, 50 mg/kg; and enteral LMWH, 2,000 IU/kg and SNAD, 50 mg/kg. Under fluoroscopic guidance, the infrarenal vena cava was occluded with a balloon catheter. Two milliliters of ethanol was injected into the distal vena cava. The inflated balloon catheter remained in situ for 5 days, at which time animals angiographically exhibiting thrombus were randomly assigned to the four groups. Study medications were dosed at 12-hour intervals by means of a gastrostomy tube placed previously. After 7 days of treatment, thrombus was extracted. A separate group of 10 animals was used to measure plasma antifactor Xa levels for 6 hours after enteral dosing of LMWH/SNAD. RESULTS: The amount of residual thrombus after treatment with enteral LMWH/SNAD was significantly decreased. Antifactor Xa levels were significantly elevated in the LMWH/SNAD group versus baseline. CONCLUSION: The combination of enterally administered LMWH and SNAD given for 7 days appeared to decrease caval thrombosis in this model of deep vein thrombosis. Enteral LMWH/SNAD effected an increase in plasma levels of antifactor Xa.
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Anticoagulantes/administração & dosagem , Sistemas de Liberação de Medicamentos , Heparina de Baixo Peso Molecular/administração & dosagem , Veia Cava Inferior , Trombose Venosa/tratamento farmacológico , Animais , Modelos Animais de Doenças , Nutrição Enteral , Estudos de Avaliação como Assunto , Feminino , Absorção Intestinal , Distribuição Aleatória , SuínosRESUMO
PURPOSE: To report a case of paradoxical emboli to multiple visceral vessels treated with both mechanical (AngioJet device) and pharmacological (urokinase) thrombolysis. METHODS AND RESULTS: A 72-year-old man presented with a 48-hour history of symptomatic right renal ischemia, which was treated with heparinization. Five days later, an abrupt creatinine elevation prompted arteriography, which demonstrated thromboembolism of the superior mesenteric artery (SMA) and both renal arteries. The AngioJet aspiration device was employed to successfully remove the clot from the SMA; urokinase infusion restored flow to the left kidney. At the 16-month follow-up evaluation, the patient was normotensive without medication and had a stable creatinine (1.4 mg/dL). CONCLUSIONS: Because of its speed and minimal morbidity, the AngioJet device may be an attractive alternative to surgical embolectomy or pharmacological thrombolysis in highly selected cases of acute visceral artery thromboembolism.
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Embolectomia/métodos , Embolia Paradoxal/terapia , Artéria Mesentérica Superior , Obstrução da Artéria Renal/terapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem , Vísceras/irrigação sanguínea , Idoso , Embolia Paradoxal/complicações , Embolia Paradoxal/diagnóstico por imagem , Humanos , Infusões Intravenosas , Masculino , Ativadores de Plasminogênio/administração & dosagem , Radiografia , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/etiologiaRESUMO
PURPOSE: This trial was designed to identify factors affecting patency rates of primary prosthetic above-knee femoropopliteal bypass grafts at 5 years. METHODS: A multi-institutional, prospective trial randomized 240 patients to compare patency rates of Gore-tex and Hemashield above-knee femoropopliteal bypass grafts at 5 years. Univariate comparisons of patency between levels of each prognostic variable were made with the Kaplan-Meier method. Variables that had a univariate P value less than.25 or those known to be important were submitted to a Cox regression analysis. RESULTS: The patient survival rate at 5 years was 59.4%. There were no differences in primary or secondary patency rates at 5 years between the two graft materials (primary, 45% vs 43% and secondary, 68% vs 68%). The risk for graft occlusion was significantly increased for patients younger than 65 years (2.1; P =.001) and for grafts with a diameter less than 7 mm (1.65; P =.0219). Variables with no apparent independent effect on patency rates were smoking status, runoff, diabetes mellitus, sex, presenting symptoms, and postoperative treatment with aspirin or Coumadin. Noninvasive test results were not predictive of subsequent graft function. CONCLUSION: Although the type of prosthetic used for above-knee femoropopliteal bypass grafts does not affect 5-year patency rates, age and graft size do influence results. These factors should be considered before a prosthetic bypass grafting procedure. Furthermore, these data should serve as a contemporary standard, with which evolving and conventional procedures can be compared.
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Implante de Prótese Vascular , Artéria Femoral/cirurgia , Artéria Poplítea/cirurgia , Idoso , Prótese Vascular , Feminino , Oclusão de Enxerto Vascular/epidemiologia , Humanos , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Poliésteres , Politetrafluoretileno , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Grau de Desobstrução VascularRESUMO
BACKGROUND: Technology-driven innovation in medicine is frequently associated with higher costs than conventional therapy. A significantly higher cost for endovascular ($21,250, n = 190) versus open abdominal aortic aneurysm (AAA) repair ($12,342, n = 60) was suggested by a direct cost analysis of patients in a multicenter trial. Estimated inpatient costs (not charges) incurred nationwide by hospitals for endovascular and open repair of AAA were studied to validate these observed trends. METHODS: A retrospective analysis of 131 patients undergoing endovascular AAA repair was compared with 49 patients undergoing open repair as part of a Food and Drug Administration phase II prospective multicenter clinical investigation (AneuRx-Medtronic). A model to estimate costs was constructed using important clinical descriptors of these patients. These clinical characteristics where then matched with those from 22, 460 patients undergoing AAA repair obtained from a large national database (Medicare Provider Analysis and Review). Estimated hospital cost was then assigned to each study patient according to the national average of the total hospital costs for the respective matched patients in Medicare Provider Analysis and Review. RESULTS: Total inpatient hospital costs of endovascular repair were significantly higher than that of open repair ($19,985 +/- 7396 versus $12,546 +/- 5944, respectively, P =.0001). Endograft device cost ($10,400) accounted for 52% of the total cost of endovascular repair. The 1999 mean blended Medicare reimbursement for AAA repair was $18,989. CONCLUSION: In this early development stage, hospital cost for endovascular AAA repair is significantly greater than open repair when device cost greatly exceeds $5000. Although incremental reductions in cost of endovascular repair may be anticipated if use of diagnostic studies, operating time, and length of stay decrease, device cost has the single greatest impact on the expense of endovascular AAA repair. At current device pricing, mean blended Medicare reimbursement does not cover the cost of endovascular AAA repair.
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Aneurisma da Aorta Abdominal/economia , Implante de Prótese Vascular/economia , Custos Hospitalares/estatística & dados numéricos , Procedimentos Cirúrgicos Vasculares/economia , Idoso , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/estatística & dados numéricos , Distribuição de Qui-Quadrado , Feminino , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estatísticas não Paramétricas , Estados Unidos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricosRESUMO
The technique of coupled in situ electrodeposition-electrothermal atomic absorption spectrometry (ED-ETAAS) is applied to the analytes Bi, Pb, Ni and Cu. Bi, Pb, Ni and Cu are deposited quantitatively from their EDTA complexes at E(cell)=1.75, 2.0, 3.0 and 2.5 V, respectively (E(cell)=E(anode)-E(cathode)+iR). By varying the cell potential, selective reduction of free metal ions could be achieved in the presence of the EDTA complexes. For Bi(3+) and Pb(2+) this utilised the voltage windows E(cell)=0.6-1.0 and 1.8-2.0 V, respectively. For Ni, deposition at E(cell)=1.7-2.0 V achieved substantial, but not complete, differentiation between Ni(2+) (ca. 90-100% deposition) and Ni(EDTA)(2-) (ca. 12-20% deposition). An adequate voltage window was not obtained for Cu. The ability of ED-ETAAS to differentiate between electrochemically labile and inert species was demonstrated by application of both ED-ETAAS and anodic stripping voltammetry to the time-dependent speciation of Pb in freshly mixed Pb(2+)-NaCl media. Application to natural water samples is complicated by adsorption of natural organic matter to the graphite cathode.
RESUMO
The recent and continuing developments in radiotherapy, gene therapy, and the technologies of imaging, materials, and devices, as well as the techniques for their implementation, have expanded the options available for the treatment of peripheral vascular disease. Though long-term data are still lacking, percutaneous transluminal angioplasty (PTA) has developed into a treatment modality in its own right and continues to be an adjuvant treatment to traditional surgical revascularization. Numerous stents and grafts are currently available for the treatment of arterial lesions and aneurysms, while the testing of many more continues. In addition to these new devices, developments in gene therapy and brachytherapy have brought several new minimally invasive options to the treatment of peripheral vascular disease.
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BACKGROUND: In an effort to reduce time to hemostasis after angiography, several closure devices have been marketed. We report some of their complications. METHODS: A retrospective review was conducted. RESULTS: Over an 8-month study period, 2,181 diagnostic and interventional procedures were performed. Closure devices were used in 408 (19%) of these patients. The Angio-Seal closure device is composed of a collagen sponge and an absorbable polymer anchor that compresses the hole in the arteriotomy. The ProstarXL sealing device consists of a rotating barrel that deploys 4 needles through the arteriotomy, and then individual knots are extracorporeally tied. The Duett device consists of a balloon occluding catheter and injectable collagen and thrombin. Ten of the patients developed a complication from the closure device (2.5%). Four of these were subcutaneous abscesses. Two of these patients had expanding pseudaneurysms, 2 had lower extremity ischemia, and 1 patient had an acute bleed. These complications were all managed surgically. Another patient developed a retroperitoneal bleed that was managed nonoperatively. CONCLUSIONS: As the use of these devices increase, these complications will become more common.
Assuntos
Técnicas Hemostáticas/efeitos adversos , Técnicas Hemostáticas/instrumentação , Técnicas de Sutura/efeitos adversos , Técnicas de Sutura/instrumentação , Humanos , Estudos RetrospectivosRESUMO
PURPOSE: Sodium N-[10-(2-hydroxybenzoyl)amino]decanoate (SNAD) is a novel carrier that allows the gastrointestinal absorption of low-molecular weight heparin (LMWH). The purpose of this experiment was to evaluate oral LMWH with SNAD for the prevention of deep venous thrombosis. METHODS: Sixty Sprague-Dawley rats were equally assigned to five experimental groups: group 1 (control), oral saline solution; group 2, oral LMWH (15 mg/kg); group 3, oral SNAD (300 mg/kg); group 4, subcutaneous LMWH (5 mg/kg); and group 5, oral LMWH (15 mg/kg) and SNAD (300 mg/kg). After treatment, the jugular vein was isolated, occluded, and bathed in an ethanol and formalin solution for 2 minutes. Two hours later, the vessel was examined for patency, presence of thrombus, and thrombus weight. Serum measurement of anti-factor Xa activity was performed in a separate set of 30 rats, which were placed into the following four groups: group A, LMWH (5 mg/kg); group B, oral LMWH (15 mg/kg) and SNAD (300 mg/kg); group C, oral LMWH (15 mg/kg); and group D, SNAD (300 mg/kg). RESULTS: The animals that underwent oral LMWH/SNAD therapy had a statistically significant decrease in visible thrombi. The thrombus weight of the oral LMWH/SNAD group was significantly less than the weights of all other groups, except the subcutaneous LMWH group. Anti-factor Xa levels were significantly elevated in the LMWH/SNAD group. There was no statistically significant difference between the data for the oral LMWH/SNAD group and the subcutaneous LMWH group. CONCLUSION: The combination of oral LMWH and SNAD prevented deep venous thrombosis. The oral LMWH and SNAD therapy effected an increase in levels of anti-factor Xa.
Assuntos
Anticoagulantes/administração & dosagem , Decanoatos/administração & dosagem , Sistemas de Liberação de Medicamentos , Heparina de Baixo Peso Molecular/administração & dosagem , Hidroxibenzoatos/administração & dosagem , Veias Jugulares , Trombose Venosa/prevenção & controle , Administração Oral , Animais , Distribuição de Qui-Quadrado , Portadores de Fármacos , Fator Xa/análise , Injeções Subcutâneas , Absorção Intestinal , Placebos , Ratos , Ratos Sprague-Dawley , Grau de Desobstrução Vascular , Trombose Venosa/patologiaRESUMO
PURPOSE: Recent reports suggest that carotid endarterectomy (CEA) should not be performed in patients with end-stage renal disease (ESRD) because of an unacceptable rate of perioperative stroke and other morbidity. Because these conclusions were based on a small number of patients, we reviewed the perioperative and long-term outcome of patients with ESRD and chronic renal insufficiency (CRI) who underwent CEA at our institution. METHODS: The 1081 patients who had a CEA between 1990 and 1997 were cross-referenced with those patients in whom renal insufficiency had been diagnosed. These charts were reviewed for patient demographics and perioperative and long-term outcome. Patients undergoing CEA during a 1-year period (1993) served as controls. RESULTS: Fifty-one CEAs were performed in 44 patients with CRI (32 in 27 patients) and ESRD (19 in 17 patients). In the CRI+ESRD group, 66.7% were symptomatic, and 70.7% of the control group were symptomatic. Six operations (11.8%) in the CRI+ESRD group were redo endarterectomies. There were no perioperative strokes in the CRI+ESRD group, but one patient died 29 days postoperatively because of a myocardial infarction, for a combined stroke-mortality rate of 2.0%. The control group had a 2.6% combined stroke-mortality rate. Long-term survival analysis revealed a 4-year survival rate of 12% for patients with ESRD and 54% for patients with CRI, compared with 72% for controls (P <.05). CONCLUSION: CEA can be performed safely in patients with ESRD or CRI, with perioperative stroke and death rates equivalent to that of patients without renal dysfunction. However, the benefit of long-term stroke prevention in the asymptomatic patient with ESRD is in question because of the high 4-year mortality rate of this patient population.