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1.
J Vasc Surg ; 80(1): 32-44.e4, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38479540

RESUMO

OBJECTIVE: The purpose of this study was to create a risk score for the event of mortality within 3 years of complex fenestrated visceral segment endovascular aortic repair utilizing variables existing at the time of preoperative presentation. METHODS: After exclusions, 1916 patients were identified in the Vascular Quality Initiative who were included in the analysis. The first step in development of the risk score was univariable analysis for the primary outcome of mortality within 3 years of surgery. χ2 analysis was performed for categorical variables, and comparison of means with independent Student t-test was performed for ordinal variables. Variables that achieved a univariable P value less than 0.1 were then placed into Cox regression multivariable time dependent analysis for the development of mortality within 3 years. Variables that achieved a multivariable significance of less than 0.1 were utilized for the risk score, with point weighting based on the beta-coefficient. Variables with a beta coefficient of 0.25 to 0.49 were assigned 1 point, 0.5 to 0.74 2 points, 0.75 to 0.99 3 points, and 1.0 to 1.25 4 points. A cumulative score for each patient was then summed, the percentage of patients at each score experiencing mortality within 3 weeks was then calculated, and a comparison of score outcomes was conducted with binary logistic regression. Area under the curve analysis was performed. RESULTS: The primary outcome of mortality within 3 years of surgery occurred in 12.8% of patients (245/1916). The mean age for the study population was 73.35 years (standard deviation [SD], 8.26 years). The mean maximal abdominal aortic aneurysm (AAA) diameter was 60.43 mm (SD, 10.52 mm). The mean number of visceral vessels stented was 3.3 (SD, 0.76). Variables present at the time of surgery that were included in the risk score were: hemodialysis (3 points); age >87, chronic obstructive pulmonary disease, hypertension, AAA diameter >77 mm (all 2 points); and body mass index <20 kg/m2, female sex, congestive heart failure, active smoking, chronic renal insufficiency, age 80 to 87 years, and AAA diameter 67 to 77 mm (all 1 point). BMI >30 kg/m2 (mean, 34.46 kg/m2) and age <67 years were protective (-1 point). Testing the model resulted in an area under the curve of 0.706. Hosmer and Lemeshow goodness of fit test for logistic regression utilizing the 15 different risk score total groups revealed a model predictive accuracy of 87.3%. Significant escalations in 3-year mortality were noted to occur at scores of 6 and greater. Mean AAA diameter was significantly larger for patients who had higher risk scores (P < .001). CONCLUSIONS: A novel risk score for mortality within 3 years of fenestrated visceral segment aortic endograft has been developed that has excellent accuracy in predicting which patients will survive and derive the strongest benefit from intervention. This facilitates risk-benefit analysis and counseling of patients and families with realistic long-term expectations. This potentially enhances patient-centered decision-making.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Fatores de Risco , Medição de Risco , Feminino , Masculino , Fatores de Tempo , Idoso , Implante de Prótese Vascular/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Resultado do Tratamento , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Técnicas de Apoio para a Decisão , Valor Preditivo dos Testes , Modelos Logísticos , Análise Multivariada , Distribuição de Qui-Quadrado , Modelos de Riscos Proporcionais , Bases de Dados Factuais , Área Sob a Curva , Pessoa de Meia-Idade , Sistema de Registros , Curva ROC , Correção Endovascular de Aneurisma
2.
J Vasc Surg Cases Innov Tech ; 10(2): 101427, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38375348

RESUMO

Arterial-enteric fistulas occur from a multitude of causes, especially following surgical manipulation of vasculature. The development of an iliac artery-enteric fistula (IEF) occurs rarely in patients with failed pancreatic transplants. IEFs warrant urgent intervention due to the high mortality from hemorrhagic and septic shock. The diagnosis can be delayed by a lack of suspicion, the low sensitivity of diagnostic tests, and the nonspecific signs of fistulas on computed tomography. The management of IEFs is adapted from guidelines for arterial-enteric fistulas of other causes, with little consensus on ideal vascular reconstruction and postoperative antimicrobial management. The outcomes are limited to the short-term results from case reports and case series. We report two cases of IEFs in patients with a history of simultaneous pancreatic kidney transplant. Our patients underwent successful resolution of gastrointestinal bleeding and sepsis, with definitive management of fistula resection and interposition iliac artery bypass. The index of suspicion for IEFs should be high, and they should be considered as a source of anemia or gastrointestinal bleeding of an unknown source in patients with failed pancreatic transplant. Definitive management should be pursued in patients who can tolerate fistula resection, allograft explant, and arterial reconstruction.

3.
Surg Clin North Am ; 103(4S): e1-e11, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-37839825

RESUMO

Endovascular aortic aneurysm repair and thoracic endovascular aortic repair have been shown to reduce blood loss, operative time, length of hospital stay, mortality, and morbidity compared with open surgical repair for abdominal aortic aneurysms and thoracic aortic aneurysms. However, there are anatomical constraints that limit the application of the endovascular approach in 30% to 40% of patients, including those with short necks, excessive angulation, or aneurysms with the involvement of aortic side branches such as supra-aortic trunks, arch aneurysms, visceral arteries, or internal iliac arteries.


Assuntos
Aneurisma da Aorta Abdominal , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Prótese Vascular , Stents , Resultado do Tratamento , Fatores de Risco , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Desenho de Prótese
4.
Ann Vasc Surg ; 97: 147-156, 2023 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-37495096

RESUMO

BACKGROUND: Since their inception, Integrated Vascular Surgery Residency (IVSR) programs have expanded widely and attracted highly competitive medical students by offering a more focused approach to learning both open surgical and endovascular techniques. However, despite substantial modifications to the training paradigm, a shortage of vascular surgeons is still projected through 2050. We aimed to gather and analyze fourth-year medical students' knowledge and perceptions of vascular surgery (VS) to further inform strategies for recruiting future vascular surgeons. METHODS: We sent anonymous electronic questionnaires to fourth-year medical students at 7 allopathic and 3 osteopathic medical schools, with questions detailing demographics, specialty preferences, and exposure to and perceptions of VS. Descriptive statistics were obtained, and responses were compared between students applying to surgical specialties (SS) and nonsurgical specialties (NSS). RESULTS: Two hundred eleven of 1,764 (12%) participants responded (56% female). 56% reported VS exposure, most commonly during the third year. 64 (30%) planned to apply to SS. 57% of respondents reported knowledge of the management of vascular disease, and 56% understood procedures performed by vascular surgeons. Ranking the importance of factors in choosing specialties, SS selected "experiences gained during medical school rotations" (P < 0.05), "types and/or variety of treatment modalities used in this field" (P < 0.001), and "interest in the pathology or disease processes treated" (P < 0.05) as highest priorities. NSS preferred "lifestyle (work-life balance) as an attending" (P < 0.001). Only 7% of all respondents believed vascular surgeons have a good work-life balance, with a larger percentage of SS (P < 0.001) agreeing. Stratified by gender, female students rated "limited ability of childbirth during residency and/or postponement of family plans" (P < 0.05), "gender-related concerns, such as discrimination at work or unfair career possibilities" (P < 0.001), and "fear of unfair competition" (P < 0.05) as potential negative aspects of VS careers. 55% of respondents believed the IVSR makes VS more appealing. CONCLUSIONS: Medical students perceive poor quality of life and work-life balance as deterring factors to a career in VS. Opportunities exist to educate students on the pathologies treated, procedures performed, and attainable quality of life available in our field. We should also continue to develop recruitment strategies to stimulate student interest and increase early exposure in VS.


Assuntos
Procedimentos Endovasculares , Internato e Residência , Especialidades Cirúrgicas , Estudantes de Medicina , Humanos , Feminino , Masculino , Qualidade de Vida , Escolha da Profissão , Resultado do Tratamento , Especialidades Cirúrgicas/educação , Inquéritos e Questionários
5.
Ann Vasc Surg ; 95: 23-31, 2023 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-37236537

RESUMO

BACKGROUND: Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch. METHODS: Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions. RESULTS: 288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change. CONCLUSIONS: In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality.


Assuntos
Transtornos de Deglutição , Divertículo , Cardiopatias Congênitas , Doenças Vasculares , Adolescente , Humanos , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aorta Torácica/anormalidades , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Divertículo/diagnóstico por imagem , Divertículo/cirurgia , Divertículo/complicações , Cardiopatias Congênitas/complicações , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgia , Artéria Subclávia/anormalidades , Resultado do Tratamento , Doenças Vasculares/complicações , Adulto , Pessoa de Meia-Idade
6.
J Vasc Surg ; 77(5): 1339-1348.e6, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-36657501

RESUMO

OBJECTIVE: Aberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset. METHODS: Patients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak. RESULTS: Overall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms. CONCLUSIONS: Treatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate.


Assuntos
Aneurisma , Implante de Prótese Vascular , Divertículo , Procedimentos Endovasculares , Acidente Vascular Cerebral , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Endoleak/etiologia , Aneurisma/diagnóstico por imagem , Aneurisma/cirurgia , Aneurisma/complicações , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgia , Artéria Subclávia/anormalidades , Procedimentos Endovasculares/efeitos adversos , Acidente Vascular Cerebral/etiologia , Divertículo/diagnóstico por imagem , Divertículo/cirurgia , Aorta Torácica/cirurgia , Resultado do Tratamento , Implante de Prótese Vascular/efeitos adversos
7.
J Vasc Surg Cases Innov Tech ; 8(4): 756-759, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36438669

RESUMO

A 52-year-old man presented with a chronic type A10 aortic dissection with subsequent aneurysmal degeneration of the left common iliac artery measuring up to 4.6 cm. He had previously undergone hemiarch replacement, which was complicated by renal failure. Owing to the presence of the growing aneurysm, he was unable to be listed for renal transplantation. He declined open operative repair. A novel dual true and false lumen stent graft technique using thoracic endografts was performed to successfully exclude the aneurysm. Follow-up imaging demonstrated aneurysm sac regression, with the patient subsequently undergoing renal transplantation.

8.
Crit Care Explor ; 2(6): e0140, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32696003

RESUMO

OBJECTIVES: To describe a case of acute limb ischemia caused by arterial thrombosis due to coronavirus disease 2019. DESIGN: Clinical observation of a patient. SETTING: Academic medical center. PATIENT: A 59-year-old female with history of hypertension, hyperlipidemia, and prior smoking. INTERVENTION: Clinical observation and data extraction from electronic medical records. MEASUREMENTS AND MAIN RESULTS: We report a case of peripheral arterial thrombosis associated with coronavirus disease 2019, resulting in acute limb ischemia of the right lower extremity. This event was heralded by a sudden and significant elevation in d-dimer levels. At the time of surgery, a long, gelatinous clot was retrieved from the right popliteal artery. Perioperatively, she continued to have absent pedal Doppler signals and after multiple embolectomy attempts, required distal arterial cut down with removal of additional thrombi and resultant improvement of distal arterial flow. CONCLUSIONS: This case demonstrates the importance of regularly checking d-dimer levels and vigilant monitoring for arterial thrombotic events, as they can rapidly become catastrophic.

9.
J Vasc Surg ; 70(5): 1576-1584, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-30852041

RESUMO

BACKGROUND: Endovascular aneurysm repair (EVAR) is currently the most common treatment of abdominal aortic aneurysms. Potential predictors of long-term survival after EVAR include physiologic, functional, and cognitive status, but assessments of these conditions have been difficult to standardize. Objective radiographic findings, such as skeletal muscle atrophy, or sarcopenia, may provide an additional means for selection of patients. This study investigates sarcopenia as a method to predict 1-year survival in patients undergoing EVAR. METHODS: A single-institution retrospective review was conducted of all patients who underwent elective EVAR from September 2002 to June 2014. Patients with an available periprocedural computed tomography (CT) scan and clinical data were included in the analysis. Normalized total psoas cross-sectional area (nTPA) was measured on axial CT images using the area of the bilateral psoas muscle at the third lumbar vertebral level normalized to the square of patient height. A threshold for optimal estimate of sarcopenia based on nTPA was determined using a receiver operating characteristic curve. Sarcopenia was evaluated as an independent risk predictor using univariate, multivariate, and survival analysis. RESULTS: A total of 272 EVAR-treated patients were evaluated, including 237 men and 35 women with a median age of 72 years and mean body mass index of 28.6 kg/m2. There was a significant increase in overall mortality in patients in the lowest quartile of nTPA (Q1, 23.53%; Q2, 13.24%; Q3, 7.35%; Q4, 5.88%; P = .01). The estimated nTPA threshold for increased mortality after EVAR was 500 mm2/m2. Using this threshold, sarcopenia accounted for 57% of the risk effect in our 1-year survival model. CONCLUSIONS: Sarcopenia can assist in identifying EVAR candidates who are less likely to benefit from surgery. It can be readily evaluated from preoperative CT scans and may be a useful tool in evaluation of abdominal aortic aneurysm patients with applications in risk evaluation and telemedicine.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Sarcopenia/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Seleção de Pacientes , Valor Preditivo dos Testes , Músculos Psoas/diagnóstico por imagem , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sarcopenia/diagnóstico , Sarcopenia/etiologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
10.
Ann Vasc Surg ; 54: 27-32, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30253190

RESUMO

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) is the preferred first-line treatment for abdominal aortic aneurysms. Current postprocedure surveillance recommendations by manufacturers are a 1-month computed tomography angiography (CTA) followed by a 12-month CTA in most circumstances. The objective of this study is to determine the utility of the 1-month CTA following elective EVAR and determine if initial surveillance at 6-month CTA is appropriate. METHODS: A single-center retrospective chart review of all elective EVARs at a tertiary medical center over a 12-year period was conducted. Patients were excluded if postoperative surveillance imaging was not available. Data analysis encompassed demographics, chart review, and imaging including angiogram and cross-sectional imaging to asses for endoleaks and other findings. RESULTS: There were 363 patients who underwent elective EVAR and had available postoperative imaging during the study period. Within the 1-month follow-up, a CTA group of 316 patients was detected with 98 (31%) endoleaks. Of these, 5 (1.5%) required intervention: 1 for infolding of an iliac limb and 4 for type I endoleak which was present on completion angiogram-3 in patients treated outside of instructions for use and 1 with a type Ib endoleak on intraoperative completion imaging. In the 158 patients with 1 and 3-month CTAs, there were 47 persistent endoleaks, 9 previously undetected endoleaks not seen in 1-month CTA, and 13 resolved endoleaks. Three patients (1.2%) underwent intervention for type II endoleak and aneurysm expansion. In 47 patients with only a 6-month CTA, there were 16 endoleaks not seen on completion angiography and 2 of which were treated with reintervention-1 for a type I endoleak and 1 for a type II endoleak. CONCLUSIONS: There is limited utility to 1-month surveillance CTA in patients undergoing elective EVAR within the device instructions for use that has no evidence of type I endoleak on completion angiography. It is safe to start routine EVAR surveillance at 6 months in this patient population. This has implications when considering bundled and value-based payments in the longitudinal care of abdominal aortic aneurysm patients.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aortografia/métodos , Implante de Prótese Vascular , Angiografia por Tomografia Computadorizada , Endoleak/diagnóstico por imagem , Procedimentos Endovasculares , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Implante de Prótese Vascular/efeitos adversos , Diagnóstico Precoce , Endoleak/etiologia , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Illinois , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
11.
J Vasc Surg Venous Lymphat Disord ; 6(6): 724-729, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30336900

RESUMO

BACKGROUND: Deep venous thrombosis isolated to the iliac veins is uncommon. Venous duplex ultrasound (DU) is widely accepted as the screening modality of choice for lower extremity deep venous thromboses. This investigation evaluated the accuracy and efficacy of DU in diagnosis of iliac vein thrombosis. METHODS: We conducted a single-center retrospective review of patients who were diagnosed with iliac vein thrombosis between January 1, 2006, and December 31, 2015. Patients included in our analysis needed to have both DU and cross-sectional imaging performed within a month of each other. The efficacy of DU in diagnosis of iliac vein thrombosis was determined using cross-sectional imaging as a standard for diagnosis. RESULTS: In total, our query yielded 80 patients with a diagnosis of iliac vein thrombosis in the medical chart; 48 patients had both cross-sectional imaging and DU performed within 1 month of each other. There were 36 patients who had cross-sectional imaging positive for iliac vein thrombosis; only 10 (27.8%) of these patients were found to have iliac vein thrombosis by DU. Thus, 26 patients (72.2%) were not diagnosed accurately by DU. On the basis of our data, the sensitivity and positive predictive value of DU compared with cross-sectional imaging in diagnosis of iliac vein thrombosis were 27.8% and 76.9%, respectively. We did not identify any patient-specific factors that influenced the discrepancy between DU and cross-sectional imaging. CONCLUSIONS: Our current protocol of lower extremity venous DU is not an effective tool in diagnosis of iliac vein thrombosis. All patients with clinically suspected iliac vein thrombosis should be evaluated with specific pelvic ultrasound protocols or cross-sectional imaging.


Assuntos
Veia Ilíaca/diagnóstico por imagem , Ultrassonografia Doppler Dupla , Trombose Venosa/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Humanos , Angiografia por Ressonância Magnética , Flebografia/métodos , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos
12.
J Vasc Surg ; 65(5): 1270-1279, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28216353

RESUMO

BACKGROUND: The best management strategy for the left subclavian artery (LSA) in pathologic processes of the aorta requiring zone 2 thoracic endovascular aortic repair (TEVAR) remains controversial. We compared LSA coverage with or without revascularization as well as the different means of LSA revascularization. METHODS: A retrospective chart review was conducted of patients with any aortic diseases who underwent zone 2 TEVAR deployment from 2007 to 2014. Primary end points included 30-day stroke and 30-day spinal cord injury (SCI). Secondary end points were 30-day procedure-related reintervention, freedom from aorta-related reintervention, aorta-related mortality, and all-cause mortality. RESULTS: We identified 96 patients with zone 2 TEVAR who met our inclusion criteria. The mean age of the patients was 62 years, with 61.5% male. Diseases included acute aortic dissections (n = 25), chronic aortic dissection with aneurysmal degeneration (n = 22), primary aortic aneurysms (n = 21), penetrating aortic ulcers/intramural hematomas (n = 17), and traumatic aortic injuries (n = 11). Strategies for the LSA included coverage with revascularization (n = 54) or without revascularization (n = 42). Methods of LSA revascularization included laser fenestration with stenting (n = 33) and surgical revascularization: transposition (n = 10) or bypass (n = 11). Of the 54 patients with LSA revascularization, 44 (81.5%) underwent LSA intervention at the time of TEVAR and 10 (18.5%) at a mean time of 33 days before TEVAR (range, 4-63 days). For the entire cohort, the overall incidence of 30-day stroke was 7.3%; of 30-day SCI, 2.1%; and of procedure-related reintervention, 5.2%. At a mean follow-up of 24 months (range, 1-79 months), aorta-related reintervention was 15.6%, aorta-related mortality was 12.5%, and all-cause mortality was 29.2%. The 30-day stroke rate was highest for LSA coverage without revascularization (6/42 [14.3%]) compared with any form of LSA revascularization (1/54 [1.9%]; P = .020), with no difference between LSA interventions done synchronously with TEVAR (1/44 [2.3%]) vs metachronously with TEVAR (0/10 [0%]; P = .63). There was no significant difference in 30-day SCI in LSA coverage without revascularization (2/42 [4.8%]) vs with revascularization (0/54 [0%]; P = .11). There was no difference in aorta-related reintervention, aorta-related mortality, or all-cause mortality in coverage without revascularization (5/42 [11.9%], 6/42 [14.3%], and 14/42 [33.3%]) vs with revascularization (10/54 [18.5%; P = .376], 6/54 [11.1%; P = .641], and 14/54 [25.9%; P = .43], respectively). After univariate and multivariable analysis, we identified LSA coverage without revascularization as associated with a higher rate of 30-day stroke (hazard ratio, 17.2; 95% confidence interval, 1.3-220.4; P = .029). CONCLUSIONS: Our study suggests that coverage of the LSA without revascularization increases the risk of stroke and possibly SCI.


Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/prevenção & controle , Artéria Subclávia/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Causas de Morte , Distribuição de Qui-Quadrado , Intervalo Livre de Doença , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Fatores de Proteção , Retratamento , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/prevenção & controle , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Artéria Subclávia/diagnóstico por imagem , Fatores de Tempo , Resultado do Tratamento , Virginia , Adulto Jovem
13.
J Vasc Surg ; 64(5): 1366-1372, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27633165

RESUMO

OBJECTIVE: Duplex ultrasound (DUS) criteria are well defined for evaluating high-grade stenosis (≥70%) of the native superior mesenteric artery (SMA) and celiac artery (CA). It has been shown that native vessel criteria overestimate the degree of in-stent restenosis (ISR) and that velocity criteria for SMA and CA ISR are not well established. The objective of this study was to define DUS velocity criteria for high-grade ISR of the SMA and CA. METHODS: A retrospective review of all patients who underwent SMA or CA stenting from a single institution was performed from 2004 to 2013. Patients were excluded if they did not have a DUS examination <4 months before angiography to assess stent patency or adequate angiographic visualization of the ISR. RESULTS: There were 103 paired DUS scans and angiograms analyzed: 66 SMA studies and 37 CA studies. The average peak systolic velocity (PSV) for SMAs was 367 cm/s with <70% ISR and 536 cm/s with ≥70% ISR. The average PSV for CAs was 302 cm/s with <70% ISR and 434 cm/s with ≥70% ISR. For an ISR ≥70% in the SMA, a PSV ≥445 cm/s produced the highest sensitivity (83%) and specificity (83%), with a positive predictive value of 81% and a negative predictive value of 86%. For an ISR ≥70% in the CA, a PSV ≥289 cm/s produced the highest sensitivity (100%) and specificity (57%), with a positive predictive value of 79% and negative predictive value of 100%. CONCLUSIONS: Increasing PSV correlates with an increasing degree of ISR for both the SMA and CA. Stented vessels have increased PSV, and therefore native PSV criteria are unreliable for the determination of ISR. The PSV criteria for ≥70% stenosis are higher for ISR than for native visceral vessel stenosis. The proposed new velocity criteria define ≥70% ISR as ≥445 cm/s in stented SMAs and ≥289 cm/s in stented CAs.


Assuntos
Artéria Celíaca/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Artéria Mesentérica Superior/diagnóstico por imagem , Oclusão Vascular Mesentérica/terapia , Stents , Ultrassonografia Doppler Dupla , Idoso , Idoso de 80 Anos ou mais , Angiografia , Área Sob a Curva , Velocidade do Fluxo Sanguíneo , Artéria Celíaca/fisiopatologia , Constrição Patológica , Feminino , Humanos , Masculino , Artéria Mesentérica Superior/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Recidiva , Reprodutibilidade dos Testes , Estudos Retrospectivos , Circulação Esplâncnica , Fatores de Tempo , Grau de Desobstrução Vascular , Virginia
14.
Am Surg ; 81(8): 798-801, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26215242

RESUMO

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.


Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Acidentes por Quedas , Traumatismos Torácicos/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Ferimentos não Penetrantes/diagnóstico por imagem , Traumatismos Abdominais/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Redução de Custos , Análise Custo-Benefício , Feminino , Seguimentos , Hospitais Gerais , Humanos , Escala de Gravidade do Ferimento , Masculino , Anamnese , Pessoa de Meia-Idade , Segurança do Paciente , Exame Físico/métodos , Postura , Valor Preditivo dos Testes , Radiografia Abdominal/economia , Radiografia Abdominal/estatística & dados numéricos , Radiografia Torácica/economia , Radiografia Torácica/estatística & dados numéricos , Estudos Retrospectivos , Traumatismos Torácicos/diagnóstico , Tomografia Computadorizada por Raios X/economia , Centros de Traumatologia , Procedimentos Desnecessários/economia , Virginia , Ferimentos não Penetrantes/diagnóstico
15.
Am Surg ; 81(4): 336-40, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25831176

RESUMO

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.


Assuntos
Pneumotórax/diagnóstico , Radiografia Torácica/métodos , Tomografia Computadorizada por Raios X , Centros de Traumatologia , Ferimentos e Lesões/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Pneumotórax/etiologia , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índices de Gravidade do Trauma , Ultrassonografia , Ferimentos e Lesões/complicações , Adulto Jovem
16.
Am Surg ; 80(8): 783-6, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25105398

RESUMO

An ultrasound (US) examination can be easily and rapidly performed at the bedside to aide in clinical decisions. Previously we demonstrated that US was safe and as effective as a chest x-ray (CXR) for removal of tube thoracostomy (TT) when performed by experienced sonographers. This study sought to examine if US was as safe and accurate for the evaluation of pneumothorax (PTX) associated with TT removal after basic US training. Patients included had TT managed by the surgical team between October 2012 and May 2013. Bedside US was performed by a variety of members of the trauma team before and after removal. All residents received, at minimum, a 1-hour formal training class in the use of ultrasound. Data were collected from the electronic medical records. We evaluated 61 TTs in 61 patients during the study period. Exclusion of 12 tubes occurred secondary to having incomplete imaging, charting, or death before having TT removed. Of the 49 remaining TT, all were managed with US imaging. Average age of the patients was 40 years and 30 (61%) were male. TT was placed for PTX in 37 (76%), hemothorax in seven (14%), hemopneumothorax in four (8%), or a pleural effusion in one (2%). Two post pull PTXs were correctly identified by residents using US. This was confirmed on CXR with appropriate changes made. US was able to successfully predict the safe TT removal and patient discharge at all residency levels after receiving a basic US training program.


Assuntos
Remoção de Dispositivo , Educação de Pós-Graduação em Medicina , Toracostomia/instrumentação , Ultrassom/educação , Ultrassonografia de Intervenção/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Internato e Residência , Masculino , Pessoa de Meia-Idade , Derrame Pleural/diagnóstico por imagem , Pneumotórax/diagnóstico por imagem , Radiografia Torácica , Estudos Retrospectivos , Toracostomia/educação , Centros de Traumatologia , Virginia
17.
J Trauma Acute Care Surg ; 77(2): 256-61, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25058251

RESUMO

BACKGROUND: Chest x-rays (CXRs) have been the mainstay for the management of thoracostomy tubes (TTs), but reports that ultrasound (US) may be more sensitive for detection of pneumothorax (PTX) continue to increase. The objective of this study was to determine if US is safe and effective for the detection of PTX following TT removal. METHODS: This was a retrospectively reviewed, prospective process improvement project involving patients who had a TT managed by the surgical team. Bedside US was performed by experienced surgeon sonographers before and after TT removal. Initially, a CXR was obtained before and after TT removal, with sonographers blinded to CXR findings. Subsequently, routine CXR was no longer obtained, and TT removal was determined by US. RESULTS: One hundred twenty-nine TTs were placed during the study. Initially, water seal and postpull US were performed on 49 TTs, with 6 tubes having only postpull imaging. US was able to detect all significant PTXs seen on CXR but identified one false-positive. Subsequently, 74 TTs had US imaging on water seal and after pull. Water seal US allowed the safe removal of 70% of the TTs. Twenty patients had no slide on water seal US and required follow-up CXR. Most importantly, US had a 100% negative predictive value for PTX during TT removal. CONCLUSION: US is safe and effective for the rapid diagnosis of PTX. This has allowed the discontinuation of routine CXR for the evaluation of PTX during TT removal for patients with adequate lung slide seen on thoracic US lung windows. LEVEL OF EVIDENCE: Diagnostic test, level II. Therapeutic study, level IV.


Assuntos
Tubos Torácicos , Remoção de Dispositivo/métodos , Pneumotórax/diagnóstico por imagem , Toracostomia/métodos , Adulto , Tubos Torácicos/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Radiografia , Estudos Retrospectivos , Toracostomia/efeitos adversos , Ultrassonografia
18.
J Surg Res ; 192(1): 134-42, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24909870

RESUMO

INTRODUCTION: Outer membrane vesicles (OMVs) were previously shown to be capable of initiating the inflammatory response seen in the transition of an infection to sepsis. However, another tenet of sepsis is the development of a hypercoagulable state and the role of OMVs in the development of this hypercoagulability has not been evaluated. The objective of this study was to evaluate the ability of OMVs to elicit endothelial mediators of coagulation and inflammation and induce platelet activation. METHODS: Human umbilical vein endothelial cells (HUVECs) were incubated with OMVs and were analyzed for the expression of tissue factor (TF), thrombomodulin, and the adhesion molecules P-selectin and E-selectin. Supernatants of OMV-treated HUVECs were mixed with whole blood and assessed for prothrombotic monocyte-platelet aggregates (MPA). RESULTS: OMVs induce significantly increased expression of TF, E-selectin, and P-selectin, whereas, the expression of thrombomodulin by HUVECs is significantly decreased (P < 0.05). The lipopolysaccharide inhibitor clearly inhibited the expression of E-selectin following incubation with OMVs, although its impact on TF and thrombomodulin expression was nominal. Incubation of whole blood with supernatant from HUVECs exposed to OVMs resulted in increased MPAs. CONCLUSIONS: This study demonstrates that, at the cellular level, OMVs from pathogenic bacteria play a complex role in endothelial activation. Although OMV-bound lipopolysaccharide modulates inflammatory proteins, including E-selectin, it has a negligible effect on the tested coagulation mediators. Additionally, endothelial activation by OMVs facilitates platelet activation as indicated by increased MPAs. By influencing the inflammatory and coagulation cascades, OMVs may contribute to the hypercoagulable response seen in sepsis.


Assuntos
Proteínas da Membrana Bacteriana Externa/imunologia , Coagulação Sanguínea/imunologia , Micropartículas Derivadas de Células/imunologia , Vesículas Citoplasmáticas/imunologia , Sepse/imunologia , Trombofilia/imunologia , Proteínas da Membrana Bacteriana Externa/farmacologia , Vesículas Citoplasmáticas/metabolismo , Selectina E/metabolismo , Escherichia coli/imunologia , Escherichia coli/metabolismo , Células Endoteliais da Veia Umbilical Humana , Humanos , Lipopolissacarídeos/imunologia , Lipopolissacarídeos/farmacologia , Monócitos/imunologia , Selectina-P/metabolismo , Ativação Plaquetária/imunologia , Sepse/metabolismo , Trombomodulina/metabolismo , Trombofilia/metabolismo , Tromboplastina/metabolismo
19.
J Surg Res ; 184(1): 458-66, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23800440

RESUMO

INTRODUCTION: Gram-negative bacteria release outer membrane vesicles (OMVs) during growth that contain various membrane components involved in eliciting an inflammatory response, including lipopolysaccharide and virulence factors. However, little is known about the role of OMVs in sepsis. The objective of this study was to determine how OMVs, derived from Escherichia (E.) coli, elicit the cellular responses involved in activating the inflammatory cascade, and to determine whether additional virulence factors in pathogenic OMVs augment the inflammatory response. METHODS: Human umbilical endothelial cells were inoculated with OMVs from non-pathogenic E. coli (npOMV) or pathogenic E. coli (pOMV) and analyzed for adhesion protein synthesis, cytokine production, and necrosis factor (NF)-κB translocation. RESULTS: Flow cytometry demonstrated that human umbilical vein endothelial cells exposed to npOMV or pOMV significantly increased expression of E-selectin and intercellular adhesion molecule, with a large population of cells demonstrating increased expression of both proteins. Interleukin-6 levels were significantly elevated by 4 h after exposure to npOMV and pOMVs. NF-κB translocation to the nucleus was shown to be induced by npOMV and pOMVs. However, the role of additional virulence factors associated with pOMVs remains undefined. CONCLUSIONS: Both npOMVs and pOMVs are capable of initiating the inflammatory cascade in endothelial cells. OMVs trigger NF-κB translocation to the nucleus, resulting in up-regulation of adhesion molecules and cytokines, presumably for the recruitment of leukocytes. By eliciting an inflammatory response, OMVs could facilitate the transition from a localized infection to a systemic response, and ultimately sepsis.


Assuntos
Proteínas da Membrana Bacteriana Externa/imunologia , Estruturas da Membrana Celular/imunologia , Células Endoteliais/imunologia , Infecções por Escherichia coli/imunologia , Escherichia coli/imunologia , Moléculas de Adesão Celular/metabolismo , Estruturas da Membrana Celular/microbiologia , Células Endoteliais/metabolismo , Células Endoteliais/microbiologia , Escherichia coli/patogenicidade , Fímbrias Bacterianas/imunologia , Citometria de Fluxo , Células Endoteliais da Veia Umbilical Humana , Humanos , Inflamação/imunologia , Inflamação/microbiologia , Interleucina-6/metabolismo , Lipopolissacarídeos/farmacologia , NF-kappa B/metabolismo , Sepse/imunologia , Sepse/microbiologia , Fatores de Virulência/imunologia
20.
Am Surg ; 78(7): 741-4, 2012 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22748530

RESUMO

Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.


Assuntos
Vértebras Cervicais/lesões , Imageamento por Ressonância Magnética , Exame Físico , Traumatismos da Coluna Vertebral/diagnóstico , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Traumatismos da Coluna Vertebral/etiologia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/etiologia , Adulto Jovem
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