Objective Thrombolysis and open surgical revascularization are current options for the treatment of acute limb ischemia (ALI). Despite the several randomized controlled trials comparing the two ...options, no single treatment can yet be recommended as a universal initial management of ALI. The purpose of this study was to evaluate contemporary endovascular and surgical revascularization for ALI. Methods Consecutive patients with ALI treated with endovascular revascularization (ER) or open revascularization (OR) between 2005 and 2011 were identified and reviewed. Procedural success and outcomes were compared between the two groups. Limb salvage and survival were assessed by time-to-event methods, including Kaplan-Meier estimation and competing-risks regression models. Results A total of 154 limbs were treated in 147 patients in the ER group, compared with 326 limbs in 296 patients in the OR group. The mean follow-up was 14 ± 18.5 months. The majority of patients presented with Rutherford II ischemia (83% for OR, 90% for ER). In Rutherford II patients, technical success was achieved in 90.7% of the OR group vs 79.9% of the ER group ( P = .002), with amputation rates of 10.0% vs 7.2% ( P = .35) at 30 days and 16.3% vs 13.0% ( P = .37) at 1 year, respectively. In Rutherford II patients with failed bypass graft, technical success rate was 95.0% (OR) vs 75.0% (ER) ( P = .001), whereas the amputation rate was 6.3% vs 15.38% ( P = .13) at 30 days and 24.1% vs 23.1% ( P = .90) at 1 year, respectively. The overall 30-day mortality rate was 13.2% (OR) and 5.4% (ER) ( P = .012). Overall amputation rates were 13.5% (OR) vs 6.5% (ER) at 30 days ( P = .023) and 19.6% (OR) vs 13.0% (ER) at 1 year ( P = .074). The primary patency rate was 57% (OR) and 51% (ER) at 1 year ( P = .74). Predictors of limb loss by life-table analysis included coronary artery disease (hazard ratio HR, 2.0; P = .007) and Rutherford category III (HR, 19.0; P < .001). Predictors of death by life-table analysis included age (HR, 1.03; P < .001), end-stage renal disease (HR, 7.28; P < .001), cancer (HR, 1.65; P = .005), and chronic obstructive pulmonary disease (HR, 1.61; P = .005). Conclusions In patients presenting with class II ALI, ER or surgical OR resulted in comparable limb salvage rates. Although technical success is higher with OR for patients presenting with failed bypass grafts, the amputation rates are comparable. Overall mortality rates are significantly higher at 30 days and 1 year in the OR group.
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients ...with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for the treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were reported. Since the 2011 guidelines, several studies and a few systematic reviews comparing CEA and CAS have been reported, and the role of medical management has been reemphasized. In the present publication, we have updated and expanded on the 2011 guidelines with specific emphasis on five areas: (1) is CEA recommended over maximal medical therapy for low-risk patients; (2) is CEA recommended over transfemoral CAS for low surgical risk patients with symptomatic carotid artery stenosis of >50%; (3) the timing of carotid intervention for patients presenting with acute stroke; (4) screening for carotid artery stenosis in asymptomatic patients; and (5) the optimal sequence of intervention for patients with combined carotid and coronary artery disease.
A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (grades of recommendation assessment, development, and evaluation) approach, as was used for other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low-risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin scale score, 0-2), carotid revascularization is considered appropriate for symptomatic patients with >50% stenosis and should be performed as soon as the patient is neurologically stable after 48 hours but definitely <14 days after symptom onset. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients with an increased risk of carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. For patients with symptomatic carotid stenosis of 50% to 99%, who require both CEA and coronary artery bypass grafting, we suggest CEA before, or concomitant with, coronary artery bypass grafting to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on the clinical presentation and institutional experience.
Catheter directed thrombolysis (CDT) and pharmacomechanical thrombectomy in various technical combinations have been the main driver of acute deep venous interventions for over a decade. While the ...majority of high-level evidence was based on it, CDT requires longer procedural care and is associated to a small but not negligible bleeding risk. Contemporary DVT intervention, following the paradigm shift in myocardial infarction and stroke management, has steadily migrated towards minimizing or eliminating thrombolytics due to the introduction of mechanical/aspiration thrombectomy. Mechanical thrombectomy (MT) devices are undoubtedly improving our ability to remove thrombus more efficiently in a single session without the adverse events and complex logistics related to the use of thrombolytics.
Abstract Objective Endovascular popliteal artery aneurysm repair (EPAR) is increasingly used over open surgical repair (OPAR). The purpose of this study was to analyze the available literature on ...their comparative outcomes. Methods The PubMed and Embase databases were searched to identify studies comparing OPAR and EPAR. Studies with only one treatment and fewer than five patients were excluded. Demographics and outcomes were collected. Bias risk was assessed using a modified version of the Newcastle-Ottawa Scale. Results were computed from random-effects meta-analyses using the DerSimonian-Laird algorithm. Results A total of 14 studies were identified encompassing 4880 popliteal artery aneurysm repairs (OPAR, 3915; EPAR, 1210) during the last decade. OPAR patients were younger (standard mean difference, −0.798 −0.798 to −1.108; P < .001) and more likely to have worse tibial runoff (odds ratio OR, 1.949 (1.15-3.31); P = .013) than EPAR patients. OPAR had higher odds of wound complications (OR, 5.182 2.191-12.256; P < .001) and lower odds of thrombotic complications (OR, 0.362 0.155-0.848; P < .001). OPAR had longer length of stay (standardized mean difference, 2.158 1.225-3.090; P < .001) and fewer reinterventions (OR, 0.275 0.166-0.454; P < .001). Primary patency was better for OPAR at 1 year and 3 years (relative risk, 0.607 P = .01 and 0.580 P = .006, respectively). There was no difference in secondary patency at 1 year and 3 years (0.770 P = .458 and 0.642 P = .073, respectively). Conclusions EPAR has a lower wound complication rate and shorter length of hospital stay compared with OPAR. This comes at the cost of inferior primary patency but not secondary patency out to 3 years. Studies reporting long-term outcomes are lacking and necessary.
Acute pulmonary embolism (PE) is a leading cause of cardiovascular mortality. Systemic anticoagulation is the standard of care, and treatment can be escalated in the setting of massive or submassive ...PE, given the high mortality risk. A secondary consideration for intervention is the prevention of late-onset chronic thromboembolic pulmonary hypertension. Treatment options include systemic thrombolysis, catheter-directed interventions, and surgical thromboembolectomy. Whereas systemic thrombolysis seems to be beneficial in the setting of massive PE, it appears to be associated with a higher rate of major complications compared with catheter-directed thrombolysis as shown in recent randomized trials for submassive PE. The hemodynamic and clinical outcomes continue to be defined to determine the indications for and benefits of intervention. The current review summarizes contemporary evidence on the role and outcomes of catheter-directed therapies in the treatment of acute massive and submassive PE.
Type II endoleaks Avgerinos, Efthymios D., MD; Chaer, Rabih A., MD; Makaroun, Michel S., MD
Journal of vascular surgery,
11/2014, Letnik:
60, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Type II endoleaks after endovascular aneurysm repair are the most common type of endoleak and generate the majority of secondary interventions. Their natural history is mostly benign, but they can ...occasionally lead to sac expansion and eventual rupture. Three-phase computed tomography angiography is the “gold standard” for diagnosis, but duplex ultrasound with or without contrast enhancement and magnetic resonance angiography offer an alternative for endoleak detection or surveillance. Whereas there are concerns as to whether sac expansion can be a dependable marker for risk of rupture, it is currently the best surrogate available and guides the indication for intervention. Obliteration of type II endoleaks can be challenging, and a variety of techniques, endovascular, open, and laparoscopic, have been proposed. The most common approaches are transarterial and translumbar embolization, and they are usually successful, provided the operator is experienced and persistent, targeting both the branches and the nidus of the endoleak. Recurrences and subsequent reinterventions should be anticipated, and on continuing sac expansion, repeated endovascular or open surgical and laparoscopic alternatives may be required.
Asymptomatic carotid stenosis has been associated with a progressive decline in neurocognitive function. However, the effect of carotid endarterectomy (CEA) on this process is poorly understood. We ...aimed to evaluate preoperative and postoperative cognitive function changes in asymptomatic patients after CEA.
A systematic review of the existing reports in PubMed/MEDLINE, Embase, and Cochran databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement recommendations. All original retrospective or prospective studies (including cohort, cross-sectional, case-control, pilot studies, etc) and clinical trials that compared pre and postoperative neurocognitive function in asymptomatic patients with carotid stenosis after CEA, which were published from January 2000 to April 2021 were identified and considered eligible for inclusion in the study.
Thirteen studies (502 CEAs) comparing cognitive function changes before and after CEA were identified. In 7 studies with a total 272 patients, a mean age range of 67.3 ± 4.8 to 76.35 years old, and follow-up ranging between 1 and 12 months, overall cognitive function improved after CEA. However, in 6 studies with a total sample of 230, a mean age range of 68.6 ± 6.9 to 74.4 ± 6.1 years, and follow-up ranged from 24 hours to 3 years, showed no change or decline in overall cognitive function after procedures.
The lack of standardization of specific cognitive tests and cognitive function assessment timing after CEA does not allow for definite conclusions to be made. However, improving brain perfusion with a combination of CEA and statin therapy may be a protective strategy against cognitive function decline.
Objective Lower extremity arterial injury may result in limb loss after blunt or penetrating trauma. This study examined outcomes of civilian lower extremity arterial trauma and predictors of delayed ...amputation. Methods The records of patients presenting to a major level I trauma center from 2004 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry, and outcomes were reviewed. Standard statistical methods were used for data analysis. Results We identified 149 patients (86% male; mean age, 33 ± 14 years,). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral artery, 26 (17%) superficial femoral artery, 50 (33%) popliteal, and 54 (36%) tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) underwent ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Delayed amputation was eventually required in 24 patients (17%): 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. Delayed amputation rates were 26% for popliteal, 20% for tibial, and 4.4% for common/superficial femoral artery injury. The delayed amputation group had significantly more ( P < .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), and fasciotomy (75% vs 43%), and a higher mangled extremity severity score (6.1 ± 1.8 vs 4.3 ± 1.6). Predictors of delayed amputation included younger age, higher injury severity score, popliteal or multiple tibial injury, blunt trauma, and pulseless examination on presentation. Conclusions Individualized decision making based on age, mechanism, pulseless presentation, extent of musculoskeletal trauma, and location of injury should guide the intensity of revascularization strategies after extremity arterial trauma. Although patients presenting with vascular trauma in the setting of multiple negative prognostic factors should not be denied revascularization, expectations for limb salvage in the short-term and long-term periods should be carefully outlined.
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