Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 25
Filtrar
1.
Ann Surg ; 274(6): e1030-e1037, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31851006

RESUMO

BACKGROUND: SSMD are used to enhance transparency, improve quality and facilitate patient choice. The use of SSMD is controversial, but patients' views on such data are largely unknown. OBJECTIVES: The aim of this study was therefore to explore the views of patients and to identify their priorities for outcome reporting in vascular surgery. METHODS: A prospective questionnaire study of 165 patients receiving care in a single academic vascular unit was performed. Data on patients' current understanding and use of SSMD, together with future priorities were collected. RESULTS: Of the 165 patients 80% were unaware of SSMD. 72% thought they should be made aware of the data, although 63% thought they were likely to misinterpret the results. The majority recognized the utility of SSMD to inform treatment (60%) and surgeon (53%) choice. The majority prioritize the patient-surgeon relationship (90%) and past experiences of care (71%) when making treatment decisions. A significant majority (66% vs 49%; P < 0.005) would favour hospital-level to surgeon-level data. The main patient priorities for future outcome reporting were waiting list length (56%), the quality of hospital facilities (55%), and patient satisfaction (54%). CONCLUSIONS: The aims of SSMD reporting are not currently being met, and both patients and healthcare professionals have shared concerns over the nature and usefulness of the data. Patients express a preference for hospital-level outcomes and prioritize the experience of receiving care over outcomes when making treatment decisions. Future outcome reporting should include patient-directed hospital-level metrics that are readily accessible and understood by all.


Assuntos
Medidas de Resultados Relatados pelo Paciente , Inquéritos e Questionários , Procedimentos Cirúrgicos Vasculares , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Psicometria , Reino Unido
2.
J Vasc Surg ; 69(5): 1482-1489, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30527939

RESUMO

OBJECTIVE: Video motion analysis (VMA) uses fluoroscopic sequences to derive information on catheter and guidewire movement and is able to calculate two-dimensional catheter tip path length (PL) on the basis of frame-by-frame pixel coordinates. The objective of this study was to evaluate the effect of anatomic complexity on the efficiency of completion of defined stages of simulated carotid artery stenting as measured by VMA. METHODS: Twenty interventionists each performed a standardized easy, medium, and difficult carotid artery stenting case in random order on an ANGIO Mentor (Simbionix, Airport City, Israel) simulator. Videos of all procedures were analyzed using VMA software, and performance was expressed in terms of two-dimensional guidewire tip trajectory distance (PL). Comparisons of PL were used to identify differences in cannulation performance of the participants between the three cases of varying difficulty. The procedure was subdivided into four procedural phases: arch navigation, common carotid artery (CCA) cannulation, external carotid manipulation, and carotid lesion crossing. Comparisons of PL were used to identify differences in performance between the three cases of varying difficulty for each of the procedural phases. RESULTS: There were significant differences in PL in relation to anatomic complexity, with a stepwise increase in PL from easy to difficult cases: easy, median of 5000 pixels (interquartile range, 4075-5403 pixels); intermediate, 9059 (5974-14,553) pixels; difficult, 17,373 (11,495-26,594) pixels (P < .001). Similarly, during CCA cannulation, there was a stepwise increase in PL from easy to difficult cases: easy, 749 (603-1403) pixels; intermediate, 3274 (1544-8142) pixels; difficult, 8845 (5954-15,768) pixels (P < .001). There were no observed differences across the groups of anatomic difficulty for the phases of arch navigation, external carotid manipulation, and carotid lesion crossing. CONCLUSIONS: Increasing anatomic complexity leads to significant increases in PL of endovascular tools, in particular during CCA cannulation. This increase in tool movement may have a bearing on clinical outcome.


Assuntos
Angioplastia/educação , Estenose das Carótidas/terapia , Cateterismo Periférico , Competência Clínica , Educação de Pós-Graduação em Medicina/métodos , Destreza Motora , Treinamento por Simulação , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia/instrumentação , Estenose das Carótidas/diagnóstico por imagem , Cateterismo Periférico/instrumentação , Feminino , Humanos , Masculino , Estudos Prospectivos , Distribuição Aleatória , Índice de Gravidade de Doença , Stents , Análise e Desempenho de Tarefas , Dispositivos de Acesso Vascular , Gravação em Vídeo
4.
J Cardiovasc Surg (Torino) ; 59(3): 317-321, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29557586

RESUMO

Flexible robotic catheters are an emerging technology which provide an elegant solution to the challenges of conventional endovascular intervention. Originally developed for interventional cardiology and electrophysiology procedures, remotely steerable robotic catheters such as the Magellan system enable greater precision and enhanced stability during target vessel navigation. These technical advantages facilitate improved treatment of disease in the arterial tree, as well as allowing execution of otherwise unfeasible procedures. Occupational radiation exposure is an emerging concern with the use of increasingly complex endovascular interventions. The robotic systems offer an added benefit of radiation reduction, as the operator is seated away from the radiation source during manipulation of the catheter. Pre-clinical studies have demonstrated reduction in force and frequency of vessel wall contact, resulting in reduced tissue trauma, as well as improved procedural times. Both safety and feasibility have been demonstrated in early clinical reports, with the first robot-assisted fenestrated endovascular aortic repair in 2013. Following from this, the Magellan system has been used to successfully undertake a variety of complex aortic procedures, including fenestrated/branched endovascular aortic repair, embolization, and angioplasty.


Assuntos
Aorta , Doenças da Aorta/terapia , Cateterismo Periférico/instrumentação , Procedimentos Endovasculares/instrumentação , Robótica/instrumentação , Dispositivos de Acesso Vascular , Animais , Aorta/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/fisiopatologia , Cateterismo Periférico/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Desenho de Equipamento , Humanos , Maleabilidade , Radiografia Intervencionista , Resultado do Tratamento
6.
EuroIntervention ; 13(12): e1460-e1467, 2017 12 08.
Artigo em Inglês | MEDLINE | ID: mdl-28649951

RESUMO

AIMS: Video motion analysis (VMA) uses fluoroscopic sequences to derive catheter and guidewire movement, and is able to calculate 2D catheter-tip path length (PL) on the basis of frame-by-frame pixel coordinates. The objective of this study was to validate VMA in coronary angiography as a method of skill assessment. METHODS AND RESULTS: Forty-seven coronary interventions performed by 10 low- (<1,000 cases; group A), five medium- (1,000-4,000; group B) and six high- (>4,000; group C) experience-volume cardiologists were prospectively recorded and analysed using VMA software. Total PL was calculated and procedure, fluoroscopy times, and radiation dose were recorded. Comparisons of PL were made between groups of experience. Groups A, B and C performed 24, 14 and 6 paired (right and left coronary) cannulations, respectively. Calculation of PL was possible in all recorded cases and significantly correlated with procedure (p=<0.001, rho=0.827) and fluoroscopy times (p=<0.001, rho=0.888). Median total path length (combined right and left coronaries) was significantly shorter in group C which used 3,836 pixels of movement (IQR: 3,003-4,484) vs. 10,556 (7,242-31,408) in group A (p=<0.001) and 8,725 (5,187-15,150) in group B (p=0.013). CONCLUSIONS: VMA in coronary angiography is feasible and PL is able to differentiate levels of experience.


Assuntos
Angiografia Coronária/normas , Intervenção Coronária Percutânea/normas , Gravação em Vídeo , Competência Clínica , Humanos , Avaliação de Processos em Cuidados de Saúde
7.
Int J Comput Assist Radiol Surg ; 11(6): 1121-31, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27072837

RESUMO

PURPOSE: Transcatheter aortic valve implantation (TAVI) demands precise and efficient handling of surgical instruments within the confines of the aortic anatomy. Operational performance and dexterous skills are critical for patient safety, and objective methods are assessed with a number of manipulation features, derived from the kinematic analysis of the catheter/guidewire in fluoroscopy video sequences. METHODS: A silicon phantom model of a type I aortic arch was used for this study. Twelve endovascular surgeons, divided into two experience groups, experts ([Formula: see text]) and novices ([Formula: see text]), performed cannulation of the aorta, representative of valve placement in TAVI. Each participant completed two TAVI experiments, one with conventional catheters and one with the Magellan robotic platform. Video sequences of the fluoroscopic monitor were recorded for procedural processing. A semi-automated tracking software provided the 2D coordinates of the catheter/guidewire tip. In addition, the aorta phantom was segmented in the videos and the shape of the entire catheter was manually annotated in a subset of the available video frames using crowdsourcing. The TAVI procedure was divided into two stages, and various metrics, representative of the catheter's overall navigation as well as its relative movement to the vessel wall, were developed. RESULTS: Experts consistently exhibited lower values of procedure time and dimensionless jerk, and higher average speed and acceleration than novices. Robotic navigation resulted in increased average distance to the vessel wall in both groups, a surrogate measure of safety and reduced risk of embolisation. Discrimination of experience level and types of equipment was achieved with the generated motion features and established clustering algorithms. CONCLUSIONS: Evaluation of surgical skills is possible through the analysis of the catheter/guidewire motion pattern. The use of robotic endovascular platforms seems to enable more precise and controlled catheter navigation.


Assuntos
Estenose da Valva Aórtica/cirurgia , Cateterismo Cardíaco/métodos , Catéteres , Competência Clínica , Procedimentos Cirúrgicos Robóticos/métodos , Análise e Desempenho de Tarefas , Substituição da Valva Aórtica Transcateter/métodos , Valva Aórtica , Fenômenos Biomecânicos , Cateterismo , Fluoroscopia , Humanos , Modelos Anatômicos , Imagens de Fantasmas
8.
J Vasc Surg ; 64(5): 1422-1432, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26386511

RESUMO

OBJECTIVE: Conventional catheter manipulation in the arch and supra-aortic trunks carries a risk of cerebral embolization. This study proposes a platform for detailed quantitative analysis of contact forces (CF) exerted on the vasculature, in order to investigate the potential advantages of robotic navigation. METHODS: An anthropomorphic phantom representing a type I bovine arch was mounted and coupled onto a force/torque sensor. Three-axis force readings provided an average root-mean-square modulus, indicating the total forces exerted on the phantom. Each of the left subclavian, left common carotid, and right common carotid arteries was cannulated within a simulated endovascular suite with conventional (n = 42) vs robotic techniques (n = 30) by two operator groups: experts and novices. The procedure path was divided into three phases, and performance metrics corresponding to mean and maximum forces, force impact over time, standard deviation of forces, and number of significant catheter contacts with the arterial wall were extracted. RESULTS: Overall, median CF were reduced from 1.20 N (interquartile range [IQR], 0.98-1.56 N) to 0.31 N (IQR, 0.26-0.40 N; P < .001) for the right common carotid artery; 1.59 N (IQR, 1.11-1.85 N) to 0.33 N (IQR, 0.29-0.43 N; P < .001) for the left common carotid artery; and 0.84 N (IQR, 0.47-1.08 N) to 0.10 N (IQR, 0.07-0.17 N; P < .001) for the left subclavian artery. Robotic navigation resulted in significant reductions for the mean and maximum forces for each procedural phase. Significant improvements were also seen in other metrics, particularly at the target vessel ostium and for the more anatomically challenging procedural phases. Force reductions using robotic technology were evident for both novice and expert groups. CONCLUSIONS: Robotic navigation can potentially reduce CF and catheter-tissue contact points in an in vitro model, by enhancing catheter stability and control during endovascular manipulation.


Assuntos
Aorta Torácica/cirurgia , Cateterismo Periférico/instrumentação , Embolia/prevenção & controle , Procedimentos Endovasculares/instrumentação , Procedimentos Cirúrgicos Robóticos/instrumentação , Acidente Vascular Cerebral/prevenção & controle , Dispositivos de Acesso Vascular , Aorta Torácica/anormalidades , Aorta Torácica/fisiopatologia , Cateterismo Periférico/efeitos adversos , Competência Clínica , Embolia/etiologia , Embolia/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Desenho de Equipamento , Humanos , Modelos Anatômicos , Destreza Motora , Fatores de Risco , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Estresse Mecânico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/fisiopatologia , Análise e Desempenho de Tarefas , Fatores de Tempo , Torque
9.
J Vasc Interv Radiol ; 25(12): 1841-8, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25000827

RESUMO

PURPOSE: To provide a technical description of robot-assisted uterine artery embolization and to investigate the safety and feasibility of the Magellan (Hansen Medical, Mountain View, California, USA) robotic catheter in this complex arterial bed. MATERIALS AND METHODS: Five women (mean age, 48.8 y) underwent robot-assisted bilateral uterine artery embolization over a 10-month period using the Magellan robotic catheter. Demographic, clinicopathologic, and endovascular performance metric data (fluoroscopy and cannulation times) were recorded as well as short-term outcomes. RESULTS: Robotic cannulation of bilateral internal iliac and uterine arteries was successful in all cases. Median right and left internal iliac artery cannulation and total fluoroscopy times were 3 minutes (interquartile range [IQR], 1.5-4 min), 2 minutes (IQR, 1.5-4 min), and 11 minutes (IQR, 9.5-14 min). Median right and left uterine artery cannulation times were both 11 minutes (IQR, 6.5-15 min and 8-12 min, respectively). Technical success was 100%. All patients were discharged on postoperative day 1, and there were no major or access site complications. At 6 months after the procedure, all patients reported significant improvement of symptoms, with a median increase in health-related quality-of-life score of 58% (48.5%-61.75%). CONCLUSIONS: The use of the new-generation Magellan system in uterine artery embolization is feasible and appears to be safe. The additional navigational capability and added maneuverability of the NorthStar catheter (Hansen Medical, Mountain View, California) may facilitate selective catheterization of small iliac artery divisions and may be useful in any procedure where complex arterial selection is needed.


Assuntos
Menorragia/cirurgia , Robótica/instrumentação , Embolização da Artéria Uterina/instrumentação , Saúde da Mulher , Adulto , Catéteres , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Fluoroscopia/métodos , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Robótica/métodos , Resultado do Tratamento , Embolização da Artéria Uterina/efeitos adversos , Embolização da Artéria Uterina/métodos
10.
Cardiovasc Intervent Radiol ; 37(4): 920-7, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24196270

RESUMO

PURPOSE: This study evaluates a fully immersive simulated angiosuite for training and assessment of technical endovascular and human factor skills during a crisis scenario. MATERIALS AND METHODS: Virtual reality (VIST-C, Mentice) simulators were integrated into a simulated angiosuite (ORCAMP, Orzone). Teams, lead by experienced (N = 5) or trainee (N = 5) endovascular specialists, performed simulated endovascular ruptured aortic aneurysm repair (rEVAR). Timed performance metrics were recorded as surrogate measures of performance. Participants (N = 22) completed postprocedure questionnaires evaluating face validity, as well as technical and human factor aspects, of the simulation on a Likert scale from 1 (not at all) to 5 (very much). RESULTS: Experienced team leaders were significantly faster than trainees in obtaining proximal control with an intra-aortic occlusion balloon (352 vs. 501 s, p = 0.047) and all completed the procedure within the allotted time, whilst no trainee was able to do so. Total fluoroscopy times were significantly lower in the experienced group (782 vs. 1,086 s, p = 0.016). Realism of the simulated angiosuite was scored highly by experienced team leaders (median 4/5, IQR 4-5). Participants found the simulation useful for acquiring technical (4/5, IQR 4-5) and communication skills (4/5, IQR 4-5) and particularly valuable for enhancing teamwork (5/5, IQR 4-5) and patient safety (5/5, IQR 4-5). CONCLUSION: This study shows feasibility of creation of a crisis scenario in a fully immersive angiosuite simulation and team performance of a simulated rEVAR. Performance metrics differentiated between experienced specialists and trainees, and the realism of the simulation exercise and environment were rated highly by experienced endovascular specialists. This simulation has potential as a powerful training and assessment tool with opportunities to improve team performance in rEVAR through both technical and human factor skills training.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Competência Clínica , Procedimentos Endovasculares , Capacitação em Serviço , Equipe de Assistência ao Paciente/organização & administração , Interface Usuário-Computador , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Inquéritos e Questionários , Análise e Desempenho de Tarefas
11.
J Vasc Surg ; 59(3): 615-22, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24342068

RESUMO

OBJECTIVE: Fenestrated stent grafting has become increasingly popular as a means to manage complex aortic pathology, including juxta- and pararenal aneurysms. The design of a recently developed custom-made fenestrated stent graft, in theory, confers advantages when managing anatomically challenging aortic morphology. This study evaluated its feasibility in anatomically challenging scenarios. METHODS: Over a 12-month period, 20 patients received fenestrated stent grafts. Among those, 13 patients with juxtarenal or type IV thoracoabdominal aortic aneurysms underwent endovascular repair with the novel fenestrated stent graft at a single UK institution. Data on aneurysm morphology and immediate and short-term results were collected prospectively. RESULTS: The mean aneurysmal sac size was 7.3 cm (range, 5.5-10.0 cm). The mean infrarenal neck length was 4.4 mm (range, 0-9 mm), and in three cases was lined by a pre-existing infrarenal stent graft. Nine cases had an infrarenal neck angulation of 60(°) or more in either the anteroposterior or coronal planes. Five cases had ≥50% thrombus at the proximal landing zone. A total of 35 target vessels were cannulated, of which six right renal and four left renal arteries were angulated ≥120(°). Two-thirds of cannulated celiac trunks were angulated ≥120(°), and one cannulated superior mesenteric artery was angulated ≥ 140(°). Seven of the cannulated targets were stenosed more than 60%. One patient had two right renal arteries arising 3 mm from each other. Four right and four left common iliac arteries were angulated ≥90(°) in relation to the infrarenal aorta. Technical success was 100%. Median time from date of procedure to most recent follow-up with computed tomography scanning was 33 weeks. There was no type I or III endoleak. One type II endoleak was observed at the time of most recent computed tomography scanning and treated expectantly. There was a single incident of left renal artery occlusion. One patient required repair of a brachial artery, fasciotomies, and temporary haemofiltration. One patient died from ischemic heart disease 77 weeks after the procedure. CONCLUSIONS: The use of the novel fenestrated stent graft system in patients with hostile aortic aneurysmal morphology is feasible with acceptable short-term outcomes.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Desenho de Prótese , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Endoleak/etiologia , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Londres , Masculino , Estudos Prospectivos , Obstrução da Artéria Renal/etiologia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
12.
Eur J Cardiothorac Surg ; 45(5): 836-41, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24296984

RESUMO

OBJECTIVES: The use of transcatheter aortic valve implantation (TAVI) is rapidly increasing with advances in technology and improved clinical outcomes. Adoption of robotic catheter technologies could have a role in TAVI, in different stages of the procedure, to improve endovascular tool manipulation and potentially reduce the risk of cerebral embolization. The aim was to determine whether there are advantages in using a robotic catheter for TAVI in the initial stages of the procedure; aortic arch navigation and valve crossing. METHODS: A silicone in vitro model of the aorta and stenotic aortic valve was developed. Fifteen operators performed the fluoroscopy-guided simulation using manual and robotic techniques. Performance metrics-time and vessel wall contact (wall-hits) were compared (Wilcoxon's signed-rank test). RESULTS: Overall, the time taken for robotic arch navigation was increased (3.09 min interquartile range (1.24-6.29) vs 1.21 min (0.15-4.42); P = 0.03). Contact with the aortic arch wall, however, significantly decreased using the robotic catheter: wall-hits 1 (0-5) vs 6 (2-22), P < 0.01. For valve crossing, there was no significant increase in time and wall-hits when using the robotic technology. CONCLUSIONS: Use of robotic catheter technology is feasible in the initial stages of TAVI. Although it takes longer, robotic navigation reduces contact with the aortic arch wall, potentially reducing the embolic risk during endovascular manipulation. Using a robotic catheter is possible without increasing the number of wall-hits during valve crossing. This may provide a stable platform for wire positioning in the ventricle. With improvements in technology, perhaps allowing valve deployment, the stability and accuracy of the robotic arm may further improve performance.


Assuntos
Cateterismo Cardíaco/instrumentação , Cateteres Cardíacos , Modelos Cardiovasculares , Procedimentos Cirúrgicos Robóticos/instrumentação , Substituição da Valva Aórtica Transcateter/instrumentação , Cateterismo Cardíaco/métodos , Simulação por Computador , Fluoroscopia , Imagens de Fantasmas , Procedimentos Cirúrgicos Robóticos/métodos , Silicones , Substituição da Valva Aórtica Transcateter/métodos
13.
J Endovasc Ther ; 20(4): 536-43, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23914863

RESUMO

PURPOSE: To investigate the quality of stent-graft fenestrations created in vitro using different needle puncture and balloon dilation angles in different commercial endografts. METHODS: Fenestrations were made in a standardized fashion in 3 different endograft types: Talent monofilament twill woven polyester, Zenith multifilament tubular woven polyester, and Endofit thin-walled expanded polytetrafluoroethylene (PTFE). Punctures were made at 30°, 60°, and 90° angles using a 20-G needle and dilated using 6-mm standard and 7-mm cutting balloons; at least 6 fenestrations were made at each angle with standard balloons and at least 6 with cutting balloons. The 137 fenestrations were examined under light microscopy; quantitative and qualitative digital image analysis was performed to determine size, shape, and fenestration quality. RESULTS: PTFE grafts were easier to puncture/dilate, resulting in larger, elliptical fenestrations with overall better quality than the Dacron grafts; however, the puncture/dilation angle made an impact on the shape and quality of fenestrations. A significant number of fabric tears were observed in PTFE fabric at <90° puncture/dilation angles compared to Dacron grafts. In Dacron grafts, fenestration quality was significantly higher with 90° puncture/dilation angles (higher in Talent grafts). Cutting balloon use resulted in significantly more fabric tears and poor quality fenestrations in all graft types. CONCLUSION: Different endografts behave significantly differently when fenestrations are fashioned. Optimum puncture/dilation is important when considering in vivo fenestration techniques. Improvements in instrumentation, materials, and techniques are required to make this a reliable and reproducible endovascular option.


Assuntos
Prótese Vascular , Stents , Aorta/cirurgia , Teste de Materiais , Desenho de Prótese , Punções
14.
J Vasc Interv Radiol ; 24(2): 191-6, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23369555

RESUMO

A 67-year-old man underwent robot-assisted three-vessel fenestrated endovascular aneurysm repair (FEVAR) for a 7.3-cm juxtarenal aneurysm. The 6-F robotic catheter was manipulated from a remote workstation, away from the radiation source. Robotic cannulation of the left renal artery was achieved within 3 minutes. System setup time was 5 minutes. There were no postoperative complications. Computed tomography angiography performed at discharge and at 4-month follow-up confirmed target vessel patency with no evidence of an endoleak. Selective cannulation of target vessels during FEVAR using this novel technology is feasible. Endovascular robotics may have a role in simplifying complex endovascular tasks and potentially reducing radiation exposure to the operator.


Assuntos
Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/instrumentação , Robótica/instrumentação , Cirurgia Assistida por Computador/instrumentação , Telemedicina/instrumentação , Idoso , Procedimentos Endovasculares/métodos , Desenho de Equipamento , Análise de Falha de Equipamento , Humanos , Masculino , Radiografia , Robótica/métodos , Cirurgia Assistida por Computador/métodos , Telemedicina/métodos , Resultado do Tratamento
15.
Ann Vasc Surg ; 26(8): 1127.e1-7, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23068430

RESUMO

BACKGROUND: Unintentional renal artery occlusion after endovascular aortic aneurysm repair (EVAR) is an uncommon phenomenon. The sequelae from this specific complication are severe; consequently, the topic of renal artery coverage is a pertinent issue. We present a case series of patients undergoing EVAR with unintentional renal artery coverage, review the treatment options available, and suggest a treatment algorithm for this scenario based on the evidence. METHODS AND RESULTS: We report four patients who were found to have renal artery occlusion after EVAR detected up to 5 weeks postoperatively. Renal revascularization was achieved using endovascular renal artery stenting in two patients, and open hepato-spleno-renal bypass in the remaining two cases. Treatment strategies used led to symptom resolution and recovery of renal function in all cases. CONCLUSIONS: Both open and endovascular techniques may be used as procedures to treat this condition-the choice of procedure is primarily determined by accessibility of the renal orifice.


Assuntos
Aneurisma/cirurgia , Angioplastia com Balão , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Artéria Femoral/cirurgia , Obstrução da Artéria Renal/terapia , Veia Safena/transplante , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Aneurisma/diagnóstico por imagem , Angioplastia com Balão/instrumentação , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Artéria Femoral/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/etiologia , Obstrução da Artéria Renal/cirurgia , Reoperação , Stents , Tomografia Computadorizada por Raios X , Resultado do Tratamento
16.
J Vasc Interv Radiol ; 23(10): 1369-75, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22920731

RESUMO

PURPOSE: To attempt to quantify the effect of varying degrees of iliac tortuosity on maneuverability and "torquability" of endovascular catheters in the visceral segment, comparing conventional and robotic cannulation techniques. MATERIALS AND METHODS: In a fenestrated endograft within a pulsatile phantom, 10 experienced operators cannulated the renal arteries via three different access vessels of varying iliac tortuosity with the use of conventional and robotic techniques. All procedures were performed in the angiography suite and recorded for blinded video assessment for quantitative (time, catheter-tip movements) and qualitative metrics (operator performance scores). RESULTS: In total, 120 cannulations were observed. With increasing iliac tortuosity, median time and number of catheter movements required for renal cannulation with conventional techniques increased in stepwise fashion for mild, moderate, and severe iliac tortuosity (times, 7.6 min [interquartile range (IQR), 4.6-9.3 min] vs 6.9 min [4.2-11.4 min] vs 17.7 min [13.3-22.6 min], respectively; movements, 184 [IQR, 110-351] vs 251 [207-395] vs 569 [409-616], respectively). Median renal cannulation times were significantly reduced with the use of the robotic system irrespective of mild, moderate, or severe tortuosity (times, 1.4 min [IQR, 1.1-1.9 min] vs 3 min [2.3-3.3 min] vs 2.8 min [1.5-3.9 min], respectively; movements, 19 [IQR, 14-27] vs 46 [43-58] vs 45 [40-66], respectively; P < .005). Overall operator performance scores improved significantly with the use of the robotic system irrespective of iliac tortuosity severity. CONCLUSIONS: In cases of moderate to severe iliac tortuosity, conventional catheter manipulation and control becomes an issue. The improvement in positional control and predictability seen with advanced catheter designs may be amplified in cases of severe iliac tortuosity.


Assuntos
Aneurisma da Aorta Torácica/terapia , Cateterismo Periférico/métodos , Procedimentos Endovasculares/métodos , Artéria Ilíaca , Artéria Renal , Robótica , Terapia Assistida por Computador , Aneurisma da Aorta Torácica/diagnóstico por imagem , Cateterismo Periférico/instrumentação , Competência Clínica , Procedimentos Endovasculares/instrumentação , Desenho de Equipamento , Humanos , Artéria Ilíaca/diagnóstico por imagem , Curva de Aprendizado , Imagens de Fantasmas , Radiografia Intervencionista , Artéria Renal/diagnóstico por imagem , Robótica/instrumentação , Análise e Desempenho de Tarefas , Terapia Assistida por Computador/instrumentação , Fatores de Tempo , Tomografia Computadorizada por Raios X/instrumentação , Torque , Dispositivos de Acesso Vascular , Gravação em Vídeo
17.
J Endovasc Ther ; 19(3): 383-9, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22788891

RESUMO

PURPOSE: To assess the incidence of errors before and after implementation of a structured mental rehearsal prior to the endovascular phase of combined open/endovascular arterial procedures. METHODS: Over 6 weeks, 15 combined open/endovascular procedures (7 abdominal aorta and 8 thoracic aorta) lasting 58 hours were evaluated by a trained observer. In a blinded fashion, 2 individuals scrutinized event logs for errors, which were categorized by type, by potential to cause patient harm (danger), and by potential to disrupt the procedure (delay). After 9 procedures, a focus group-devised structured mental rehearsal was implemented prior to the endovascular phase for 6 combined procedures. Error patterns were compared before and after implementation. Data are expressed as median (range). RESULTS: The error rate during the endovascular phase of the combined procedures was higher than the non-endovascular phase [7.64/hour (1.71-9.6) vs. 3.75/hour (1.71-5.54), respectively; p = 0.05]. Error rates during the endovascular phase were lower after the intervention compared to before [2.5/hour (1.4-6.0) vs. 7.6/hour (1.7-9.6), respectively; p = 0.05]. During the endovascular phase, danger and delay scores were also lower after the intervention [1.2/error (1.0-2.0) and 1.3/error (1.0-2.3), respectively] compared to before [1.75/error (1.4-2.5) and 2.0/error (1.3-2.5), respectively] (p = 0.036 and p = 0.036 for danger and delay, respectively). CONCLUSION: A structured mental rehearsal before critical stages of procedures may reduce the rate and severity of intraoperative error.


Assuntos
Aorta Abdominal/cirurgia , Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/efeitos adversos , Competência Clínica , Procedimentos Endovasculares/efeitos adversos , Erros Médicos/prevenção & controle , Processos Mentais , Complicações Pós-Operatórias/prevenção & controle , Lista de Checagem , Comportamento Cooperativo , Grupos Focais , Humanos , Imaginação , Londres , Destreza Motora , Equipe de Assistência ao Paciente , Segurança do Paciente , Complicações Pós-Operatórias/etiologia , Fatores de Tempo , Resultado do Tratamento
18.
Radiology ; 264(2): 473-83, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22668564

RESUMO

PURPOSE: To determine the type and frequency of errors during vascular interventional radiology (VIR) and design and implement an intervention to reduce error and improve efficiency in this setting. MATERIALS AND METHODS: Ethical guidance was sought from the Research Services Department at Imperial College London. Informed consent was not obtained. Field notes were recorded during 55 VIR procedures by a single observer. Two blinded assessors identified failures from field notes and categorized them into one or more errors by using a 22-part classification system. The potential to cause harm, disruption to procedural flow, and preventability of each failure was determined. A preprocedural team rehearsal (PPTR) was then designed and implemented to target frequent preventable potential failures. Thirty-three procedures were observed subsequently to determine the efficacy of the PPTR. Nonparametric statistical analysis was used to determine the effect of intervention on potential failure rates, potential to cause harm and procedural flow disruption scores (Mann-Whitney U test), and number of preventable failures (Fisher exact test). RESULTS: Before intervention, 1197 potential failures were recorded, of which 54.6% were preventable. A total of 2040 errors were deemed to have occurred to produce these failures. Planning error (19.7%), staff absence (16.2%), equipment unavailability (12.2%), communication error (11.2%), and lack of safety consciousness (6.1%) were the most frequent errors, accounting for 65.4% of the total. After intervention, 352 potential failures were recorded. Classification resulted in 477 errors. Preventable failures decreased from 54.6% to 27.3% (P < .001) with implementation of PPTR. Potential failure rates per hour decreased from 18.8 to 9.2 (P < .001), with no increase in potential to cause harm or procedural flow disruption per failure. CONCLUSION: Failures during VIR procedures are largely because of ineffective planning, communication error, and equipment difficulties, rather than a result of technical or patient-related issues. Many of these potential failures are preventable. A PPTR is an effective means of targeting frequent preventable failures, reducing procedural delays and improving patient safety.


Assuntos
Erros Médicos/prevenção & controle , Equipe de Assistência ao Paciente/organização & administração , Radiografia Intervencionista/métodos , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/terapia , Eficiência , Feminino , Humanos , Masculino , Segurança do Paciente , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento
20.
J Vasc Surg ; 54(3): 799-809, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21620623

RESUMO

OBJECTIVE: Conventional catheter instability and embolization risk limits the adoption of endovascular therapy in patients with challenging arch anatomy. This study investigated whether arch vessel cannulation can be enhanced by a remotely steerable robotic catheter system. METHODS: Seventeen clinicians with varying endovascular experience cannulated all arch vessels within two computed tomography-reconstructed pulsatile flow phantoms (bovine type I and type III aortic arches), under fluoroscopic guidance, using conventional and robotic techniques. Quantitative (catheterization times, catheter tip movements, vessel wall hits, catheter deflection) and qualitative metrics (Imperial College Complex Endovascular Cannulation Scoring Tool [IC3ST]) performance scores were compared. RESULTS: Robotic catheterization techniques resulted in a significant reduction in median carotid artery cannulation times and the median number of catheter tip movements for all vessels. Vessel wall contact with the aortic arch wall was reduced to a median of zero with robotic catheters. During stiff guidewire exchanges, robotic catheters maintained stability with zero deflection, independent of the distance the catheter was introduced into the carotid vessels. Overall IC3ST performance scores (interquartile range) were significantly improved using the robotic system: Type I arch score was 26/35 (20-30.8) vs 33/35 (31-34; P = .001), and type III arch score was 20.5/35 (16.5-28.5) vs 26.5/35 (23.5-28.8; P = .001). Low- and medium-volume interventionalists demonstrated an improvement in performance with robotic cannulation techniques. The high-volume intervention group did not show statistically significant improvement, but cannulation times, movements, and vessel wall hits were significantly reduced. CONCLUSION: Robotic technology has the potential to reduce the time, risk of embolization and catheter dislodgement, radiation exposure, and the manual skill required for carotid and arch vessel cannulation, while improving overall performance scores.


Assuntos
Aorta Torácica , Artéria Carótida Primitiva , Cateterismo Periférico/instrumentação , Catéteres , Procedimentos Endovasculares/instrumentação , Robótica/instrumentação , Cirurgia Assistida por Computador/instrumentação , Aorta Torácica/diagnóstico por imagem , Aortografia/métodos , Artéria Carótida Primitiva/diagnóstico por imagem , Cateterismo Periférico/efeitos adversos , Competência Clínica , Embolia/etiologia , Embolia/prevenção & controle , Procedimentos Endovasculares/efeitos adversos , Desenho de Equipamento , Humanos , Teste de Materiais , Destreza Motora , Imagens de Fantasmas , Fluxo Pulsátil , Radiografia Intervencionista , Fluxo Sanguíneo Regional , Cirurgia Assistida por Computador/efeitos adversos , Análise e Desempenho de Tarefas , Fatores de Tempo , Tomografia Computadorizada por Raios X
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...