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1.
Am J Cardiol ; 145: 143-150, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33460607

RESUMO

It is unknown whether endovascular intervention (EVI) is associated with superior outcomes when compared with surgical revascularization in octogenarian. National Inpatient Sample (NIS) database was used to compare the outcomes of limb revascularization in octogenarians who had surgical revascularization versus EVI. The NIS database's information on PAD patients ≥80-year-old who underwent limb revascularization between 2002 and 2014 included 394,504 octogenarian patients, of which 184,926 underwent surgical revascularization (46.9%) and 209,578 underwent EVI (53.1%). Multivariate analysis was performed to examine in-hospital outcomes. Trend over time in limb revascularization utilization was examined using Cochrane-Armitage test. EVI group had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.61 [95% CI: 0.58 to 0.63], myocardial infarction (aOR: 0.84 [95% CI: 0.81 to 0.87]), stroke (aOR: 0.93 [95% CI: 0.89 to 0.96]), acute kidney injury (aOR: 0.79 [95% CI: 0.77 to 0.81]), and limb amputation (aOR: 0.77 [95% CI: 0.74 to 0.79]) compared with surgical group (p < 0.001 for all). EVI group had higher risk of bleeding (aOR: 1.20 [95% CI: 1.18 to 1.23]) and vascular complications (3.2% vs 2.7%, aOR: 1.25 [95% CI: 1.19 to 1.30]) compared with surgical group (p < 0.001 for all). Within study period, EVI utilization increased in octogenarian patients from 2.6% to 8.9% (ptrend < 0.001); whereas use of surgical revascularization decreased from 11.6% to 5.2% (ptrend < 0.001). In conclusion, the utilization of EVI in octogenarians is increasing, and associated with lower risk of in-hospital mortality and adverse cardiovascular and limb outcomes as compared with surgical revascularization.


Assuntos
Procedimentos Endovasculares/tendências , Mortalidade Hospitalar , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Injúria Renal Aguda/epidemiologia , Idoso de 80 Anos ou mais , Amputação Cirúrgica/estatística & dados numéricos , Angioplastia/tendências , Aterectomia/tendências , Endarterectomia/tendências , Feminino , Humanos , Masculino , Infarto do Miocárdio/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Risco , Stents , Acidente Vascular Cerebral/epidemiologia , Enxerto Vascular/tendências , Procedimentos Cirúrgicos Vasculares/tendências
2.
Eur J Hosp Pharm ; 27(6): 337-340, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33097616

RESUMO

OBJECTIVE: High-dose tranexamic acid (TXA) can cause seizures in patients who have undergone pulmonary endarterectomy (PTE). Seizures secondary to TXA will resolve once the drug is excreted from the body, and the patients do not have to be on long-term anticonvulsants. The aim of the study is to find out if medication review in the hospital has led to deprescribing of anticonvulsants for TXA-associated seizures on discharge from the critical care unit (CCU) and hospital. METHODS: This is a single-centre retrospective study conducted at a tertiary cardiothoracic hospital between 2012 and 2017. The inclusion criteria consisted of all adult patients who have undergone PTE surgery. Patients who were started on anticonvulsants preoperatively or postoperatively for seizures secondary to organic causes were excluded. RESULTS: A total of 933 patients underwent PTE from January 2012 to August 2017. 25 patients had TXA-related seizures postoperatively and were started on anticonvulsant therapy, giving an incidence of 2.7%. 15 patients were discharged from the CCU without anticonvulsants. A further three patients had their anticonvulsants deprescribed in the ward before being discharged from the hospital. CONCLUSION: Deprescribing of anticonvulsants after benign seizures secondary to high-dose TXA is facilitated by verbal and written handover, which can be improved in our hospital. A detailed handover summary, as well as a discharge letter with clearly defined instructions for drug review, is needed to make deprescribing a more robust process.


Assuntos
Anticonvulsivantes/administração & dosagem , Antifibrinolíticos/efeitos adversos , Desprescrições , Convulsões/induzido quimicamente , Convulsões/tratamento farmacológico , Centros de Atenção Terciária , Antifibrinolíticos/administração & dosagem , Relação Dose-Resposta a Droga , Endarterectomia/tendências , Humanos , Artéria Pulmonar/cirurgia , Estudos Retrospectivos , Convulsões/epidemiologia , Centros de Atenção Terciária/tendências , Ácido Tranexâmico/administração & dosagem , Ácido Tranexâmico/efeitos adversos , Reino Unido/epidemiologia
3.
J Vasc Surg ; 72(3): 977-986.e1, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32067877

RESUMO

OBJECTIVE: Advances in technology have increased the use of endovascular therapy for lower extremity revascularization (LER), but the impact on hybrid surgery has not been studied. This study aims to (1) investigate the contemporary national trends in frequency of hybrid LER and (2) compare the outcomes of open bypass (BYP) and hybrid surgery for isolated femoropopliteal revascularization. METHODS: Using the national Vascular Quality Initiative database from 2010 to 2017, all patients receiving bypass or hybrid LER for PAD were identified. A trend of all hybrid LER compared with open LER was obtained. Next, only patients who underwent hybrid or open isolated femoropopliteal LER were identified. Patients treated with hybrid surgery underwent femoral endarterectomy and antegrade endovascular intervention of the femoropopliteal vessels (HYB), whereas patients treated with BYP underwent femoral endarterectomy and femoropopliteal bypass. These two groups of patients were matched based on age, gender, race, indication, ambulatory status, emergency status, diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, and hemodialysis. Patient characteristics and the perioperative and 1-year outcomes of the two groups were compared. RESULTS: The overall rate of hybrid LER procedures increased from 6.1% in 2010 to 32% in 2017 (P = .03). Hybrid LER was significantly more commonly used in patients with claudication (47%) and BYP surgery was used in patients with tissue loss (38.5%; P = .019). There were 456 HYB and 2665 BYP for isolated femoropopliteal revascularization. After propensity matching, the cohort comprised 425 patients in each group. HYB was associated with lower rate of myocardial infarction (1.9% vs 5.7%; P = .005) and renal complications (2.1% vs 6.7%; P = .003), length of stay (4.7 vs 6.1 days; P = .001), and higher rate of discharge to home (90.8% vs 81.4%; P < .001) compared with BYP. There was no significant difference in 30-day mortality (HYB 1.5% vs BYP, 2.5%; P = .44). The 1-year outcomes comparison suggested that patients in the BYP group had a higher likelihood of improvement in ambulatory status compared with patients in HYB group (16.7% vs 7.7%; P = .044). However, Kaplan-Meier analysis showed no difference in overall survival (P = .13) or amputation-free survival (P = .057) between the two groups. There was no statistical difference in graft patency, limb loss, or secondary interventions. CONCLUSIONS: Hybrid LER for PAD has been increasingly used and accounts for up to one-third of open LER in the Vascular Quality Initiative. Hybrid femoropopliteal revascularization improves perioperative outcomes compared with femoropopliteal bypass. However, the 1-year outcomes between the two procedures are comparable, suggesting that hybrid femoropopliteal revascularization should be favored in high-risk patients because of its perioperative advantages.


Assuntos
Endarterectomia/tendências , Procedimentos Endovasculares/tendências , Artéria Femoral/cirurgia , Doença Arterial Periférica/cirurgia , Artéria Poplítea/cirurgia , Enxerto Vascular/tendências , Idoso , Amputação Cirúrgica , Terapia Combinada/tendências , Bases de Dados Factuais , Endarterectomia/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/diagnóstico por imagem , Artéria Poplítea/fisiopatologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Grau de Desobstrução Vascular
4.
Int J Cardiol ; 300: 282-288, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31744721

RESUMO

BACKGROUND: Right ventricular (RV) afterload in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is associated with reduced myocardial contractility and ventriculoarterial coupling. The impact of increased afterload on RV myocardial deformation was assessed by comparing the characteristics of CTEPH patients to healthy controls at baseline, and by comparing characteristics of CTEPH patients before and 12 months after pulmonary endarterectomy (PEA). METHODS: Cardiac deformation and function of CTEPH patients (n = 20) and healthy controls (n = 20) were assessed by cardiac magnetic resonance (CMR). CTEPH patients were also examined with right heart catheterization before and 12 months after PEA. RESULTS: PEA resulted in significant improvement of invasive hemodynamics and normalization of RV hypertrophy and right atrial, RV and left ventricular dimensions and volumes. RV ejection fraction improved from 30 ±â€¯13% at baseline to 44 ±â€¯10% at 12 months (p < 0.0001) but remained decreased compared with control subjects (54 ±â€¯4%, p < 0.05). RV global circumferential strain (GCS) normalized 12 months after PEA, but RV global longitudinal strain (GLS) remained significantly lower in CTEPH patients than controls (baseline -12.9 ±â€¯3.3% vs. -16.5 ±â€¯3.6% at 12 months p < 0.01, vs. controls -19.3 ±â€¯3.2%, p < 0.05). RV mass changes were significantly correlated with RV-ejection fraction, RV-GLS, and RV-GCS. RV-pulmonary arterial coupling with the volume method improved at 12 months (0.49 ±â€¯0.30 vs. 0.84 ±â€¯0.31, p < 0.0005), but remained significantly reduced compared with healthy controls (1.19 ±â€¯0.20, p < 0.0005). CONCLUSION: RV global longitudinal and circumferential myocardial three-dimensional strain by CMR improved significantly in CTEPH patients 12 months after PEA. Improvements in myocardial deformation were associated with regression of RV hypertrophy and decrease in pulmonary artery pressure.


Assuntos
Endarterectomia/tendências , Hipertensão Pulmonar/diagnóstico por imagem , Imagem Cinética por Ressonância Magnética/tendências , Embolia Pulmonar/diagnóstico por imagem , Disfunção Ventricular Direita/diagnóstico por imagem , Remodelação Ventricular/fisiologia , Idoso , Doença Crônica , Feminino , Seguimentos , Humanos , Hipertensão Pulmonar/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/cirurgia , Fatores de Tempo , Disfunção Ventricular Direita/cirurgia
5.
Int J Cardiol ; 278: 232-237, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30409735

RESUMO

BACKGROUND: Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). However, persistent pulmonary hypertension continues in 5-35% of patients after PEA. Recently, balloon pulmonary angioplasty (BPA) showed promise as a strategy for patients with non-operable CTEPH. Therefore, we investigated the usefulness of BPA for residual pulmonary hypertension after PEA. METHODS: Fifteen patients with residual pulmonary hypertension after PEA received 71 BPA sessions (4.7 ±â€¯1.4 sessions/patient). The mean time between the PEA and the first BPA session was 28.1 ±â€¯25.8 months. All patients underwent a comprehensive diagnostic work-up, including right heart catheterization, functional and laboratory tests, before, and 6-4 weeks after the BPA sessions. RESULTS: After BPA, the mean pulmonary arterial pressure decreased from 44.7 ±â€¯6.4 to 30.8 ±â€¯7.5 mm Hg (31% decline; p < 0.001). Pulmonary vascular resistance decreased from 551.9 ±â€¯185.2 to 343.8 ±â€¯123.8 dyn∗s/cm-5 (38% decline; p < 0.001). The 6-min walking distance increased from 383 ±â€¯104 to 476 ±â€¯107 m (mean change +93 m; p < 0.001). In two sessions (2.8%), serious periprocedural complications occurred. During a mean follow-up of 18 ±â€¯14.3 months, one patient died two months after the last BPA session. Fourteen patients survived. CONCLUSIONS: BPA could be a promising therapeutic strategy for persistent pulmonary hypertension after PEA in patients with CTEPH.


Assuntos
Angioplastia com Balão/tendências , Endarterectomia/tendências , Hipertensão Pulmonar/diagnóstico por imagem , Hipertensão Pulmonar/cirurgia , Adulto , Angioplastia com Balão/métodos , Débito Cardíaco/fisiologia , Endarterectomia/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Encaminhamento e Consulta/tendências , Estudos Retrospectivos , Resultado do Tratamento
6.
J Am Coll Cardiol ; 71(21): 2468-2486, 2018 05 29.
Artigo em Inglês | MEDLINE | ID: mdl-29793636

RESUMO

Chronic thromboembolic pulmonary hypertension (CTEPH), a rare consequence of an acute pulmonary embolism, is a disease that is underdiagnosed, and surgical pulmonary thromboendarterectomy (PTE) remains the preferred therapy. However, determination of operability is multifactorial and can be challenging. There is growing excitement for the percutaneous treatment of inoperable CTEPH with data from multiple centers around the world showing the clinical feasibility of balloon pulmonary angioplasty. Riociguat remains the only approved medical therapy for CTEPH patients deemed inoperable or with persistent pulmonary hypertension after PTE. We recommend that expert multidisciplinary CTEPH teams be developed at individual institutions. Additionally, optimal and standardized techniques for balloon pulmonary angioplasty need to be developed along with dedicated interventional equipment and appropriate training standards. In the meantime, the percutaneous revascularization option is appropriate for patients deemed inoperable in combination with targeted medical therapy, or those who have failed to benefit from surgery.


Assuntos
Endarterectomia/tendências , Fibrinolíticos/administração & dosagem , Hipertensão Pulmonar/diagnóstico por imagem , Hipertensão Pulmonar/terapia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/terapia , Doença Crônica , Ensaios Clínicos como Assunto/métodos , Ativadores de Enzimas/administração & dosagem , Humanos , Hipertensão Pulmonar/epidemiologia , Embolia Pulmonar/epidemiologia , Pirazóis/administração & dosagem , Pirimidinas/administração & dosagem
8.
Circulation ; 137(18): 1921-1933, 2018 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-29317447

RESUMO

BACKGROUND: The availability and diversity of lower limb revascularization procedures have increased in England in the past decade. We investigated whether these developments in care have translated to improvements in patient pathways and outcomes. METHODS: Individual-patient records from Hospital Episode Statistics were used to identify 103 934 patients who underwent endovascular (angioplasty) or surgical (endarterectomy, profundaplasty, or bypass) lower limb revascularization for infrainguinal peripheral artery disease in England between January 2006 and December 2015. Major lower limb amputations and deaths within 1 year after revascularization were ascertained from Hospital Episode Statistics and Office for National Statistics mortality records. Competing risks regression was used to estimate the cumulative incidence of major amputation and death, adjusted for patient age, sex, comorbidity score, indication for the intervention (intermittent claudication, severe limb ischemia without record of tissue loss, severe limb ischemia with a record of ulceration, severe limb ischemia with a record of gangrene/osteomyelitis), and comorbid diabetes mellitus. RESULTS: The estimated 1-year risk of major amputation decreased from 5.7% (in 2006-2007) to 3.9% (in 2014-2015) following endovascular revascularization, and from 11.2% (2006-2007) to 6.6% (2014-2015) following surgical procedures. The risk of death after both types of revascularization also decreased. These trends were observed for all indication categories, with the largest reductions found in patients with severe limb ischemia with ulceration or gangrene. Overall, morbidity increased over the study period, and a larger proportion of patients was treated for the severe end of the peripheral artery disease spectrum using less invasive procedures. CONCLUSIONS: Our findings show that from 2006 to 2015, the overall survival increased and the risk of major lower limb amputation decreased following revascularization. These observations suggest that patient outcomes after lower limb revascularization have improved during a period of centralization and specialization of vascular services in the United Kingdom.


Assuntos
Angioplastia/tendências , Endarterectomia/tendências , Extremidade Inferior/irrigação sanguínea , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Doença Arterial Periférica/cirurgia , Enxerto Vascular/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica/tendências , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Endarterectomia/efeitos adversos , Endarterectomia/mortalidade , Inglaterra/epidemiologia , Feminino , Humanos , Salvamento de Membro/tendências , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Melhoria de Qualidade , Fatores de Risco , Medicina Estatal , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
9.
J Cardiothorac Vasc Anesth ; 32(2): 771-778, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29310938

RESUMO

OBJECTIVE: Patients undergoing pulmonary endarterectomy (PEA) have impaired right ventricular function. The authors sought to assess the clinical utility of commonly used perioperative echocardiographic and right heart catheter measurements in patients undergoing PEA. DESIGN: A single-center prospective observational study. SETTING: The study was conducted in a quaternary care cardiac surgical center in the United Kingdom. PARTICIPANTS: Patients undergoing PEA between April 2015 and January 2016. INTERVENTIONS: Thermodilution cardiac index and echocardiography variables were measured at 3 time points: before sternotomy (T1), after pericardial incision (T2), and after sternal closure (T3). Six-month follow-up echocardiography and 6-minute walk (6-MWT) test were performed. MEASUREMENTS AND MAIN RESULTS: Fifty patients were recruited and complete data sets were available for 41 patients. Tricuspid annular plane systolic excursion declined after pericardial incision and cardiopulmonary bypass (T1: 15 ± 4 mm, T2: 13 ± 4 mm, T3: 7 ± 2 mm; p < 0.0001), returning to baseline 6 months postoperatively. Cardiac index (T1: 2.5 ± 0.7 L/min/m2, T2: 2.6 ± 0.6 L/min/m2, T3: 2.3 ± 0.5 L/min/m2; p = 0.07) and right ventricular fractional area change (T1: 36 ± 11%, T2: 40 ± 12%, T3: 40 ± 9%; p = 0.12) were preserved perioperatively. 6-MWT improved from baseline (294 ± 111 m) to follow-up (357 ± 107 m) (p < 0.001). Pulmonary vascular resistance at T3 correlated moderately with follow-up 6-MWT (R = -0.60). CONCLUSIONS: In patients undergoing PEA, invasive measurements and echocardiography assessment of right ventricular function are not interchangeable. Tricuspid annular plane systolic excursion is not a reliable measure of right ventricular function perioperatively. Pulmonary vascular resistance shows moderate correlation with postoperative functional capacity.


Assuntos
Ecocardiografia Transesofagiana/normas , Endarterectomia/normas , Monitorização Intraoperatória/normas , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/cirurgia , Função Ventricular Direita/fisiologia , Ecocardiografia Doppler de Pulso/normas , Ecocardiografia Doppler de Pulso/estatística & dados numéricos , Ecocardiografia Doppler de Pulso/tendências , Ecocardiografia Transesofagiana/estatística & dados numéricos , Ecocardiografia Transesofagiana/tendências , Endarterectomia/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/estatística & dados numéricos , Monitorização Intraoperatória/tendências , Estudos Prospectivos , Resistência Vascular/fisiologia
10.
Asian Cardiovasc Thorac Ann ; 25(5): 345-349, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28457173

RESUMO

Background Surgical pulmonary thromboendarterectomy has been established as the treatment of choice for chronic thromboembolic pulmonary hypertension. We conducted a survey among Asia-Pacific cardiothoracic surgeons to examine their current practice demographics and reflect their views on the future prospects for pulmonary thromboendarterectomy surgery. Methods All cardiothoracic surgeons who were registered on the CTSNet.org website and based in the Asia-Pacific region were invited to participate in an online survey. The electronic questionnaire was completed by 172 (6.3%) surgeons. Responses were recorded anonymously and tabularized as absolute figures and fractions. Results Pulmonary thromboendarterectomy surgery has been performed by few Asia-Pacific surgeons and in small numbers of patients, but survival rates and functional outcomes were satisfactory in most experiences. Failures were thought to have resulted primarily from the difficulty in selecting suitable candidates for surgery. The need for greater clinical experience was clear, yet this might be hampered by the limited recognition of pulmonary thromboendarterectomy surgery as a potential cure for chronic thromboembolic pulmonary hypertension. Most surgeons considered that this procedure should be restricted to designated expert centers, and acknowledged the need to organize dedicated regional meetings where clinical practice guidelines can be established and updated as appropriate for regional healthcare facilities. Conclusions Although much effort is needed before pulmonary thromboendarterectomy surgery becomes widely adopted in the Asia-Pacific region, many surgeons and centers are already seeking its implementation. Designating expert centers, bringing together a regional working group on pulmonary thromboendarterectomy, and establishing clinical practice guidelines as appropriate for regional healthcare facilities were recommended.


Assuntos
Endarterectomia/tendências , Hipertensão Pulmonar/cirurgia , Padrões de Prática Médica/tendências , Artéria Pulmonar/cirurgia , Cirurgiões/tendências , Ásia , Austrália , Endarterectomia/efeitos adversos , Endarterectomia/mortalidade , Europa (Continente) , Pesquisas sobre Atenção à Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/fisiopatologia , Nova Zelândia , Complicações Pós-Operatórias/etiologia , Artéria Pulmonar/fisiopatologia , Resultado do Tratamento
11.
Ann Vasc Surg ; 42: 111-119, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28359796

RESUMO

BACKGROUND: It is unknown whether increased endovascular treatment of chronic mesenteric ischemia has led to decreases in open surgery, acute mesenteric ischemia, or overall mortality. The present study evaluates the trends in endovascular and open treatment over time for chronic and acute mesenteric ischemia. METHODS: We identified patients with chronic or acute mesenteric ischemia in the Nationwide Inpatient Sample and Center for Disease Control and Prevention database from 2000 to 2012. Trends in revascularization, mortality, and total deaths were evaluated over time. Data were adjusted to account for population growth. RESULTS: There were 14,810 revascularizations for chronic mesenteric ischemia (10,453 endovascular and 4,358 open) and 11,294 revascularizations for acute mesenteric ischemia (4,983 endovascular and 6,311 open). Endovascular treatment increased for both chronic (0.6-4.5/million, P < 0.01) and acute mesenteric ischemia (0.6-1.8/million, P < 0.01). However, concurrent declines in open surgery did not occur (chronic: 1-1.1/million, acute: 1.8-1.7/million). Among patients with acute mesenteric ischemia, the proportion with atrial fibrillation (18%) and frequency of embolectomy (1/million per year) remained stable. In-hospital mortality rates decreased for both endovascular (chronic: 8-3%, P < 0.01; acute: 28-17%, P < 0.01) and open treatment (chronic: 21-9%, P < 0.01; acute: 40-25%, P < 0.01). Annual population-based mortality remained stable for chronic mesenteric ischemia (0.7-0.6 deaths per million/year), but decreased for acute mesenteric ischemia (12.9-5.3 deaths per million/year, P < 0.01). CONCLUSIONS: Population mortality from acute mesenteric ischemia declined from 2000 to 2012, correlated with dramatic increases in endovascular intervention for chronic mesenteric ischemia, and in spite of a stable rate of embolization. However, open surgery for both chronic and acute ischemia remained stable.


Assuntos
Procedimentos Endovasculares/tendências , Isquemia Mesentérica/mortalidade , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/mortalidade , Oclusão Vascular Mesentérica/cirurgia , Padrões de Prática Médica/tendências , Procedimentos Cirúrgicos Vasculares/tendências , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Bases de Dados Factuais , Embolectomia/tendências , Embolização Terapêutica/tendências , Endarterectomia/tendências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Isquemia Mesentérica/diagnóstico , Oclusão Vascular Mesentérica/diagnóstico , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Enxerto Vascular/tendências , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
12.
Int J Cardiol ; 225: 87-90, 2016 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-27716556

RESUMO

OBJECTIVES: To describe our single center experience with the use of laser endartherectomy assisted balloon angioplasty in popliteal and infrapopliteal arterial disease. BACKGROUND: Peripheral arterial disease (PAD) carries significant morbidity to patients. Some patients may have multiple comorbid conditions potentially limiting therapeutic options for PAD. Endovascular interventions are aimed at decreasing arterial disease symptoms, improve wound healing and ultimately limb salvage. There is limited data on below the knee PAD and simultaneous laser endartherectomy use in this anatomic location. METHODS: The cohort comprised 41 patients that underwent laser assisted balloon angioplasty from 2010 to 2013. All patients had popliteal and infrapopliteal arterial disease. Outcomes evaluated were limb salvage and symptom relief 12months following the procedure. A comparison between the patients that underwent amputation and those with limb salvage was also performed. RESULTS: All the patients had TASC II (Trans Atlantic Inter-Society Consensus) type D lesions. Most patients reported persistent PAD symptoms by six months, with 17% remaining symptom free by 12months. Affected limb salvage was 69%. Five patients (12%) died and one third of the patients had a new peripheral angiogram. In the repeat angiogram, most patients showed initial target vessel occlusion. No statistically significant differences were found between the patients that preserved their limb to those who underwent amputation. CONCLUSIONS: Laser assisted balloon angioplasty use for complex popliteal and infrapopliteal arterial disease is a therapeutic option when limb salvage is the goal. Despite this, symptom recurrence and the need for repeated angiography continue to be high.


Assuntos
Angioplastia com Balão a Laser/tendências , Endarterectomia/tendências , Salvamento de Membro/tendências , Doença Arterial Periférica/cirurgia , Artéria Poplítea/cirurgia , Idoso , Angioplastia com Balão a Laser/métodos , Angioplastia com Balão a Laser/mortalidade , Estudos de Coortes , Endarterectomia/métodos , Endarterectomia/mortalidade , Feminino , Seguimentos , Humanos , Salvamento de Membro/mortalidade , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Artéria Poplítea/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução Vascular/fisiologia
13.
Ann Am Thorac Soc ; 13 Suppl 3: S255-8, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-27571007

RESUMO

In looking toward the future of chronic thromboembolic pulmonary hypertension, the following four clinical questions deserve careful consideration: (1) What is inoperable disease, and how is it defined? (2) Is there a role for targeted medical therapy in technically operable, proximal disease? (3) Where does balloon pulmonary angioplasty fit into the treatment algorithm? (4) How should we approach patients with symptomatic chronic pulmonary thromboembolism without pulmonary hypertension? The search for these answers will continue to propel this field forward. Consequently, the crossroads we find ourselves at signal opportunity and hope for future advances.


Assuntos
Gerenciamento Clínico , Hipertensão Pulmonar/terapia , Embolia Pulmonar/complicações , Embolia Pulmonar/terapia , Angioplastia com Balão/tendências , Doença Crônica , Terapia Combinada/tendências , Endarterectomia/tendências , Humanos , Hipertensão Pulmonar/etiologia
15.
Circulation ; 133(18): 1761-71, 2016 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-27052413

RESUMO

BACKGROUND: Chronic thromboembolic pulmonary hypertension results from incomplete resolution of pulmonary emboli. Pulmonary endarterectomy (PEA) is potentially curative, but residual pulmonary hypertension following surgery is common and its impact on long-term outcome is poorly understood. We wanted to identify factors correlated with poor long-term outcome after surgery and specifically define clinically relevant residual pulmonary hypertension post-PEA. METHODS AND RESULTS: Eight hundred eighty consecutive patients (mean age, 57 years) underwent PEA for chronic thromboembolic pulmonary hypertension. Patients routinely underwent detailed reassessment with right heart catheterization and noninvasive testing at 3 to 6 months and annually thereafter with discharge if they were clinically stable at 3 to 5 years and did not require pulmonary vasodilator therapy. Cox regressions were used for survival (time-to-event) analyses. Overall survival was 86%, 84%, 79%, and 72% at 1, 3, 5, and 10 years for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the perioperative period were not attributable to right ventricular failure (chronic thromboembolic pulmonary hypertension). At reassessment, a mean pulmonary artery pressure of ≥30 mm Hg correlated with the initiation of pulmonary vasodilator therapy post-PEA. A mean pulmonary artery pressure of ≥38 mm Hg and pulmonary vascular resistance ≥425 dynes·s(-1)·cm(-5) at reassessment correlated with worse long-term survival. CONCLUSIONS: Our data confirm excellent long-term survival and maintenance of good functional status post-PEA. Hemodynamic assessment 3 to 6 months and 12 months post-PEA allows stratification of patients at higher risk of dying of chronic thromboembolic pulmonary hypertension and identifies a level of residual pulmonary hypertension that may guide the long-term management of patients postsurgery.


Assuntos
Endarterectomia/tendências , Hipertensão Pulmonar/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Endarterectomia/mortalidade , Feminino , Seguimentos , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco/métodos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Reino Unido/epidemiologia , Adulto Jovem
16.
Vestn Khir Im I I Grek ; 174(2): 47-51, 2015.
Artigo em Russo | MEDLINE | ID: mdl-26234064

RESUMO

The article presents an analysis of treatment results of 91 patients with iliac-femoral segment artery occlusion at the period from 2008 to 2014. Patients were divided into 2 groups: main group (n=30) consisted of patients who undergoing a half-closed loop endarterectomy with following implantation of stent-grafts in this area and control group (n=61) had patients whom were performed routine half-closed loop endarterectomy. The II degree of ischemia of lower extremities was in 88 (96,7%) patients and III degree had 3 (3,3%) patients. The areas of abnormalities of intravascular pattern were detected in 100% of cases in intraoperative angiography. They were modified using stent-grafts. A primary vascular patency was 100% in the first group and it numbered 65% in the second group during 5 years. The intraoperative angiography control with stent-graft implantation to the area of endarterectomy allowed reliable improvement of treatment results.


Assuntos
Arteriopatias Oclusivas/cirurgia , Endarterectomia/tendências , Artéria Femoral/cirurgia , Artéria Ilíaca/cirurgia , Extremidade Inferior/irrigação sanguínea , Angiografia , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/fisiopatologia , Endarterectomia/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução Vascular
17.
J Am Coll Cardiol ; 65(9): 920-7, 2015 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-25744009

RESUMO

BACKGROUND: Peripheral vascular intervention (PVI) is an effective treatment option for patients with peripheral artery disease (PAD). In 2008, Medicare modified reimbursement rates to encourage more efficient outpatient use of PVI in the United States. OBJECTIVES: The purpose of this study was to evaluate trends in the use and clinical settings of PVI and the effect of changes in reimbursement. METHODS: Using a 5% national sample of Medicare fee-for-service beneficiaries from 2006 to 2011, we examined age- and sex-adjusted rates of PVI by year, type of procedure, clinical setting, and physician specialty. RESULTS: A total of 39,339 Medicare beneficiaries underwent revascularization for PAD between 2006 and 2011. The annual rate of PVI increased slightly from 401.4 to 419.6 per 100,000 Medicare beneficiaries (p = 0.17), but the clinical setting shifted. The rate of PVI declined in inpatient settings from 209.7 to 151.6 (p < 0.001), whereas the rate expanded in outpatient hospitals (184.7 to 228.5; p = 0.01) and office-based clinics (6.0 to 37.8; p = 0.008). The use of atherectomy increased 2-fold in outpatient hospital settings and 50-fold in office-based clinics during the study period. Mean costs of inpatient procedures were similar across all types of PVI, whereas mean costs of atherectomy procedures in outpatient and office-based clinics exceeded those of stenting and angioplasty procedures. CONCLUSIONS: From 2006 to 2011, overall rates of PVI increased minimally. However, after changes in reimbursement, PVI and atherectomy in outpatient facilities and office-based clinics increased dramatically, neutralizing cost savings to Medicare and highlighting the possible unintended consequences of coverage decisions.


Assuntos
Assistência Ambulatorial/economia , Medicare/economia , Doença Arterial Periférica/economia , Doença Arterial Periférica/terapia , Sistema de Pagamento Prospectivo , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/estatística & dados numéricos , Angioplastia/economia , Angioplastia/tendências , Aterectomia/economia , Aterectomia/tendências , Endarterectomia/economia , Endarterectomia/tendências , Planos de Pagamento por Serviço Prestado , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Stents/economia , Stents/tendências , Estados Unidos
18.
J Vasc Surg ; 58(5): 1331-8.e1, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23810297

RESUMO

OBJECTIVE: Optimal management of renal artery stenosis (RAS) remains unclear. Recent randomized controlled trials have shown no clear benefit with percutaneous transluminal angioplasty with or without stenting (PTRA/S) over medical management. We hypothesize that interventions for RAS are decreasing nationally. METHODS: The Nationwide Inpatient Sample, 1988-2009, was used to identify patients with a diagnosis of renal artery atherosclerosis undergoing open surgical repair (bypass or endarterectomy) or PTRA/S. The rate of interventions, in-hospital death, and perioperative outcomes were analyzed over time. Additionally, we used individual state inpatient and ambulatory databases to better understand the influence of outpatient procedures on current volume and trends. RESULTS: We identified 308,549 PTRA/S and 33,147 open surgical repairs. PTRA/S increased from 1.9/100K adults in 1988 to 13.7 in 2006 followed by a decrease to 6.7 in 2009. Open surgical repair steadily decreased from 1.3/100K adults in 1988 to 0.3 in 2009. In 2009, PTRA/S procedures (6.4/100K adults) greatly outnumbered procedures done by open repair alone (0.1/100K), combined open renal and aortic repair (0.2/100K), and combined PTRA/S and endovascular aneurysm repair (0.3/100K). From 2005 to 2009 33,953 patients underwent PTRA/S in the states of New Jersey Maryland, Florida, and California combined. The total number of PTRA/S performed in the outpatient setting remained stable from 2005 (3.8/100K) to 2009 (3.7/100K), whereas the total number of inpatient procedures mirrored the national trend, declining from 2006 (7.9/100K) to 2009 (4.2/100K). PTRA/S had lower in-hospital mortality (0.9% vs 4.1%; P < .001) compared with open repair. PTRA/S patients were more likely to be discharged home (86.2% vs 76.3%; P < .001) and had a shorter length of stay (4.4 vs 12.3 days; P < .001). Mortality was higher after combined open renal and open aortic surgery compared to open repair alone (6.5% vs 4.1%; P < .001). Mortality was similar for combined PTRA/S and endovascular aneurysm repair compared with PTRA/S alone (1.2% vs 0.9%; P = .04). CONCLUSIONS: The performance of PTRA/S procedures for the management of RAS has decreased significantly after 2006. An increasing proportion of these procedures are performed in the outpatient setting. PTRA/S remains the dominant revascularization procedure for RAS with lower in-hospital mortality and morbidity than surgery.


Assuntos
Angioplastia/tendências , Obstrução da Artéria Renal/terapia , Stents/tendências , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/tendências , Angioplastia/efeitos adversos , Angioplastia/instrumentação , Angioplastia/mortalidade , Distribuição de Qui-Quadrado , Terapia Combinada , Endarterectomia/tendências , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/mortalidade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
19.
J Thorac Cardiovasc Surg ; 144(1): 100-7, 2012 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22498087

RESUMO

OBJECTIVE: An increasing number of elderly patients are referred for pulmonary endarterectomy. The distinction between operable and inoperable lesions has been challenged over time. Hence, we developed alternative cardiopulmonary bypass management and cerebral protection strategies to obtain satisfactory surgical results according to the changing patient features. METHODS: From April 1994 to March 2011, 347 pulmonary endarterectomies were performed at our center. We began with the technique championed by the San Diego Group, adopting a single period of deep hypothermic circulatory arrest for each side (group A). Since 2003, we began to perform short periods of intermittent deep hypothermic circulatory arrest followed by periods of reperfusion (group B). We then adopted moderate, instead of deep, hypothermia (group C). Finally, we modified our technique further performing shorter (5-7-minute) periods of circulatory arrest (group D). RESULTS: The hemodynamic results after surgery were excellent in all 4 groups. The patients' age increased significantly. A trend toward an increase in the number of Jamieson type 3 lesions was observed. Associated with our protocol changes, we observed better postoperative respiratory function, a reduction in the length of mechanical ventilation and postoperative infections, and a remarkable improvement in uneventful postoperative courses. Despite the increased total circulatory arrest time, a trend toward a reduction in the incidence of transient neurologic events was observed, and operative mortality was not affected. CONCLUSIONS: In our experience, our alternative strategy resulted in a better combination of surgical accuracy and cerebral protection and improved outcomes.


Assuntos
Endarterectomia/tendências , Hipertensão Pulmonar/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Estudos de Casos e Controles , Doença Crônica , Feminino , Hemodinâmica , Humanos , Hipotermia Induzida , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
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