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- Prevenção secundária com estatinas na patologia arterial periférica ateroscleróticaPublication . Pedro, Luís MThe use of statins for secondary prevention in patients with peripheral (extracoronary) arterial disease is not widespread. Their possible use has only relatively recently been studied and data in the literature are sometimes controversial or are not disclosed. The aim of this paper is to review the recent literature and to discuss possible reasons for using statins in patients with extracoronary atherosclerotic arterial involvement, focusing on the areas in which they have been investigated. The main conclusions are that statins should be prescribed with the objective of reducing coronary and cerebrovascular morbidity and mortality in patients with carotid disease, abdominal aortic aneurysm and lower limb occlusive disease. There is sufficient evidence to suggest a reduction in the perioperative risk of vascular surgery when statins are used, and in patients with carotid stenosis they also appear to reduce perioperative risk in endarterectomy. Nevertheless, there are insufficient data to recommend the use of statins to control post-endarterectomy restenosis. In patients with intermittent claudication, statins improve walking distance and may be used for this purpose. Finally, there is insufficient evidence to recommend statins to prevent restenosis in lower limb revascularization procedures, to control progression of abdominal aortic aneurysms, or to reduce the severity of renal artery stenosis or renal dysfunction.
- Outcomes of elective and non-elective fenestrated-branched endovascular aortic repair for treatment of thoracoabdominal aortic aneurysmsPublication . Dias-Neto, Marina; Vacirca, Andrea; Huang, Ying; Baghbani-Oskouei, Aidin; Jakimowicz, Tomasz; Mendes, Bernardo C.; Kolbel, Tilo; Sobocinski, Jonathan; Bertoglio, Luca; Mees, Barend; Gargiulo, Mauro; Dias, Nuno; Schanzer, Andres; Gasper, Warren; Beck, Adam W.; Farber, Mark A.; Mani, Kevin; Timaran, Carlos; Schneider, Darren B.; Pedro, Luís M; Tsilimparis, Nikolaos; Haulon, Stéphan; Sweet, Matthew P.; Ferreira, Emília; Eagleton, Matthew; Yeung, Kak Khee; Khashram, Manar; Jama, Katarzyna; Panuccio, Giuseppe; Rohlffs, Fiona; Mesnard, Thomas; Chiesa, Roberto; Kahlberg, Andrea; Schurink, Geert Willem; Lemmens, Charlotte; Gallitto, Enrico; Faggioli, Gianluca; Karelis, Angelos; Parodi, Ezequiel; Gomes, Vivian; Wanhainen, Anders; Habib, Mohammed; Colon, Jesus Porras; Pavarino, Felipe; Baig, Mirza S.; Gouveia e Melo, Ryan Eduardo Costeloe De; Crawford, Sean; Zettervall, Sara L.; Garcia, Rita; Ribeiro, Tiago; Alves, Gonçalo; Gonçalves, Frederico Bastos; Kappe, Kaj Olav; Mariko van Knippenberg, Samira Elize; Tran, Bich Lan; Gormley, Sinead; Oderich, Gustavo S.Objective: To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs). Background: FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described. Methods: Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006-2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair. Results: A total of 2603 patients (69% males; mean age 72±10 year old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2187 patients (84%) and non-elective repair in 416 patients [16%; 268 (64%) symptomatic, 148 (36%) ruptured]. Non-elective FB-EVAR was associated with higher early mortality (17% vs 5%, P <0.001) and rates of MAEs (34% vs 20%, P <0.001). Median follow-up was 15 months (interquartile range, 7-37 months). Survival and cumulative incidence of ARM at 3 years were both lower for non-elective versus elective patients (50±4% vs 70±1% and 21±3% vs 7±1%, P <0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio, 1.92; 95% CI] 1.50-2.44; P <0.001) and ARM (hazard ratio, 2.43; 95% CI, 1.63-3.62; P <0.001). Conclusions: Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment.
- Hybrid surgery in lower limb revascularization : a real-world experience from a single centerPublication . Soares, Tony; Manuel, Viviana; Amorim, Pedro; Martins, Carlos; Melo, Ryan; Ministro, Augusto; Sobrinho, Gonçalo; Silvestre, Luís; Fernandes E Fernandes, Ruy; Pedro, Luís MBackground Through the association of endovascular and open procedures, hybrid surgery for lower limb revascularization allows the treatment of multilevel occlusive disease with a lower risk when compared to extensive open interventions. The aim of this study is to evaluate the immediate and midterm clinical outcomes of hybrid techniques for lower limb revascularization in a cohort of patients with multilevel arterial disease. Methods Data from elective procedures between 2012 and 2017 were retrospectively collected regarding hybrid lower limb revascularization procedures. The outcomes of the study were categorical clinical improvement, patency rates, major amputation rates, and mortality. Results A total of 81 patients, 89 limbs, with a median age of 69 years (interquartile range [IQR] 61–73) were submitted to hybrid lower limb revascularization, with a median follow-up of 10.7 months (IQR 2.5–25.1). Treatment indications were chronic limb-threatening ischemia in 80.9% of the cases (rest pain in 18.0% and tissue loss in 62.9%). One-year primary, primary-assisted, and secondary patency rates were 78.28% (95% confidence interval [CI] 65.20–86.92), 85.12% (95% CI 72.96–92.09), and 90.19% (95% CI 79.13–95.54), respectively. Overall categorical clinical improvement was observed in 56.2%. Major amputation and mortality rates were 14.6% and 16.0%, respectively. Multilevel Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) C or D and stage IV Leriche-Fontaine classification were strongly associated with decreased categorical clinical improvement (adjusted odds ratio [aOR] 0.08, P < 0.0001 and aOR 0.25, P = 0.013, respectively). Multilevel TASC C or D was also related to higher amputation rates, contrary to clinical presentation (adjusted hazard ratio [aHR] 11.37, P = 0.002 and aHR 4.70, P = 0.091, respectively). Primary-assisted and secondary patency rates were associated with higher categorical clinical improvement (aOR 4.30, P = 0.036 and aOR 7.36, P = 0.021, respectively) and decreased major amputation rates (aHR 0.11, P = 0.003 and aHR 0.09, P = 0.001, respectively) but were not related to multilevel TASC and Leriche-Fontaine classifications. Conclusions The present study reports a real-world experience with a large proportion of patients with chronic limb-threatening ischemia. Hybrid interventions for lower limb revascularization revealed to be a potential approach for patients with complex arterial disease that would beneficiate from less invasive procedures.
- Incidence and prevalence of thoracic aortic aneurysms: a systematic review and meta-analysis of population-based studiesPublication . Melo, Ryan; Duarte, Gonçalo Silva; Lopes, Alice; Alves, Mariana; Caldeira, Daniel; Fernandes E Fernandes, Ruy; Pedro, Luís MThoracic aortic aneurysms (TAA) may grow asymptomatically until they rupture, with a mortality over 90%. The true incidence and prevalence of this condition is uncertain and epidemiologic data is scarce, understudied and dispersed. Therefore, we aimed to conduct a systematic review and meta-analysis of the incidence and prevalence of TAAs in population-based studies. We searched MEDLINE, EMBASE and CENTRAL from inception to October 2020 for all population-based studies reporting on incidence and/or prevalence of TAAs. Data were pooled using a random effects model. The main outcome was the overall available worldwide incidence and prevalence of TAAs. The secondary outcomes were to evaluate the incidence of ruptured TAAs, differences in the location of these aneurysms (either ascending, arch or descending aorta) and differences in prevalence/incidence across different study designs. Twenty-two studies were included in the review and meta-analysis. The pooled incidence and prevalence of TAAs was 5.3 per 100,000 individuals/year (95% confidence interval [CI]: 3.0; 8.3) and 0.16% (95% CI: 0.12; 0.20), respectively. The pooled incidence of ruptured aneurysms was 1.6 per 100,000 individuals/year (95% CI: 1.3; 2.1). We found a significant difference of the prevalence in autopsy-only studies, which was 0.76% (95% CI: 0.47; 1.13) and the prevalence of TAAs dropped down to 0.07% (95% CI: 0.05;0.11) when these studies were excluded from the overall analysis. The current epidemiologic information provided serve as a base for future public-health decisions. The lack of well-design population-base studies and the limitations encountered serve as calling for future research in this field.
- Fiber optic realshape in endovascular aneurysm repair: following the light into a future with less radiation exposurePublication . Melo, Ryan; Pedro, Luís MKlaassen et al. conducted a retrospective observational matched cohort study comparing patients undergoing endovascular aneurysm repair (EVAR) with or without the use of Fiber Optic RealShape (FORS) technology. They compared the use of FORS during contralateral gate cannulation in 27 cases matched (age, sex, and body mass index) with 27 patients using regular (fluoroscopy only) EVAR. The results indicated a reduction in cumulative air kerma, air kerma area product, and fluoroscopy time during gate cannulation. However, no significant differences were observed in overall cannulation time, total procedure time, or total procedure radiation exposure. Their study builds on previous research on FORS in endovascular procedures, including in pre-clinical models and human trials.
- Synchronous and metachronous thoracic aortic aneurysms in patients with abdominal aortic aneurysms : a systematic review and meta‐analysisPublication . Melo, Ryan; Duarte, Gonçalo Silva; Lopes, Alice; Alves, Mariana; Caldeira, Daniel; Fernandes, Ruy Fernandes e; Pedro, Luís MBackground: The prevalence of thoracic aortic aneurysms (TAA) in patients with known abdominal aortic aneurysms (AAA) is not well known and understudied. Our aim was to conduct a systematic review and meta‐analysis of the overall prevalence of synchronous and metachronous TAA (SM‐TAA) in patients with a known AAA and to understand the characteristics of this sub‐population. Methods and Results: We searched MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) from inception to November 2019 for all population‐based studies reporting on the prevalence of SM‐TAAs in a cohort of patients with AAA. Article screening and data extraction were performed by 2 authors and data were pooled using a random‐effects model of proportions using Freeman‐Tukey double arcsine transformation. The main outcome was the prevalence of SM‐TAAs in patients with AAAs. Secondary outcomes were the prevalence of synchronous TAAs, metachronous TAAs, prevalence of TAAs in patients with AAA according to the anatomic location (ascending, arch, and descending) and the differences in prevalence of these aneurysms according to sex and risk factors. Six studies were included. The pooled‐prevalence of SM‐TAA in AAA patients was 19.2% (95% CI, 12.3–27.3). Results revealed that 15.2% (95% CI, 7.1–25.6) of men and 30.7% (95% CI, 25.2–36.5) of women with AAA had an SM‐TAA. Women with AAA had a 2‐fold increased risk of having an SM‐TAA than men (relative risk [RRs], 2.16; 95% CI, 1.32–3.55). Diabetes mellitus was associated with a 43% decreased risk of having SM‐TAA (RRs, 0.57; 95% CI, 0.41–0.80). Conclusions: Since a fifth of AAA patients will have an SM‐TAA, routine screening of SM‐TAA and their clinical impact should be more thoroughly studied in patients with known AAA.
- Incidence of acute aortic dissections in patients with out of hospital cardiac arrest: a systematic review and meta-analysis of observational studiesPublication . Melo, Ryan; Machado, Carolina; Caldeira, Daniel; Alves, Mariana; Lopes, Alice; Serrano, Maria; Fernandes E Fernandes, Ruy; Pedro, Luís MObjectives: Acute Aortic dissection (AAD) may present as out-of-hospital cardiac arrest (OHCA). However, the incidence of this presentation is not well known. Our aim was to perform a systematic review and meta-analysis of all observational studies reporting on the incidence of AAD in patients with OHCA. Methods: We searched MEDLINE, CENTRAL, PsycInfo, Web of Science Core Collection and OpenGrey databases from inception to March-2021, for observational studies reporting on the incidence of AAD in patients with OHCA. Data was pooled using a random-effects model of proportions. The primary outcome was the incidence of AAD in OHCA patients. Secondary outcomes were the incidence of type A aortic dissections (TAAD) and type B aortic dissections (TBAD) in OHCA patients, overall mortality following AAD-OHCA and risk of death in AAD-OHCA patients compared to risk of death of non-AAD-OHCA patients. Results: Fourteen studies were included. The pooled calculated incidence of OHCA due to AAD was 4.39% (95 %CI: 2.55; 6.8). Incidence of OHCA due to TAAD was 7.18% (95 %CI: 5.61; 8.93) and incidence of OHCA due to TBAD was 0.47% (95 %CI: 0.18; 0.85). Overall mortality following OHCA due to AAD was 100% (95 %CI: 97.62; 100). The risk of death in AAD-OHCA patients compared with non-AAD-OHCA patients was 1.10 (95 %CI: 0.94; 1.30). Conclusion: AAD as a cause of OHCA is more frequent than previously thought. Prognosis is dire, as it is invariably lethal. These findings should lead to a higher awareness of AAD when approaching a patient with OHCA and to future studies on this matter.
- A catastrophic seronegative anti-phospholipid syndrome: case and literature reviewPublication . Pinto, Vanda; Ministro, Augusto; Carreira, Nuno; Cardoso, Ana; Gonçalves, Catarina Sousa; Henriques, Mickael; Rato, João; Silva, Emanuel; Pedro, Luís MBackground: Antiphospholipid Syndrome (APS) is a multisystemic autoimmune disease characterized by arterial and venous thrombosis and / or obstetric morbidity in the presence of at least one circulating anti-phospholipid antibody. The spectrum of vascular events varies from deep venous thrombosis to catastrophic APS, a rare form characterized by acute multiorgan thrombosis and high mortality. Case report: We present the case of a 32-week pregnant woman arriving in the hospital emergency room with bilateral acute lower limb ischemia. In the obstetric evaluation, fetal death was declared. Computerized Tomography angiography showed pulmonary embolism of both pulmonary arteries, areas of splenic and right renal infarction and multiple arterial and venous thrombosis. The patient underwent urgent caesarean section and axillary-bifemoral bypass. No events registered. In the postoperative period, in an intensive care unit, treatment with rituximab and plasmapheresis were added to anticoagulant therapy. The laboratorial investigation was negative for thrombophilia and autoimmune diseases. Conclusion: Catastrophic APS develops quickly, with multiorgan involvement and high mortality rate. The presented case poses a multidisciplinary challenge, with the surgical approach of extra-anatomical revascularization being less invasive and guaranteeing immediate perfusion of the lower limbs. Although the serological tests were negative for anti-phospholipid antibodies, this case hardly fits into another diagnosis. Therefore, it was treated as a catastrophic APS, having shown a favorable evolution.
- Clinical aspects and present challenges of the seat belt aortaPublication . Melo, Ryan; Amorim, Pedro; Soares, Tony; Fernandes E Fernandes, Ruy; Ministro, Augusto; Garrido, Pedro; Fernandes e Fernandes, José; Pedro, Luís MObjective: Seat belt aorta is rare and difficult to manage. The lack of data and follow-up increases the complexity of treating such patients. We aimed to create a decision algorithm by reviewing our current experience and analyzing the presentation and management of our patients. Methods: We performed a descriptive case series based on retrospective analysis of all consecutive patients admitted with the diagnosis of seat belt aorta from 2008 to 2018. Seat belt aorta was defined as any blunt abdominal aortic lesion resulting from a seat belt compression mechanism after a car accident. Results: Nine consecutive patients were admitted with the diagnosis of seat belt aorta, all of whom developed lesions in the infrarenal aorta. Eight patients were assessed in the acute phase and one patient presented with late-onset symptoms. Associated injuries were present in all acute patients, and seat belt sign and small bowel injury were present in 88%. One patient presented with a small intimal tear and was treated conservatively. All other patients diagnosed with large intimal flaps (seven patients) and pseudoaneurysm (one patient) underwent open repair in five cases and endovascular repair in three cases. In-hospital mortality for the acute cases was 38%, with no mortality seen during follow-up. Two patients submitted to endovascular repair required reinterventions. Conclusions: Seat belt aorta is a deadly condition, frequently associated with blunt thoracoabdominal trauma with concomitant injuries; the presence of a seat belt sign or lower limb ischemia must lead to a high diagnostic suspicion. Management must take into account the other concomitant injuries. Follow-up is crucial as most patients are young; they may develop complications and subsequently require further intervention.
- A single-center experience in the eversion femoral endarterectomyPublication . Soares, Tony; Amorim, Pedro; Manuel, Viviana; Lopes, Alice; Fernandes E Fernandes, Ruy; Martins, Carlos; Pedro, Luís MObjectives: Endarterectomy is the treatment of choice for arterial occlusive disease of the femoral bifurcation. Longitudinal arteriotomy and prosthetic patch angioplasty is the standard technique but, due to the increasing concerns with prosthetic-related infections and multidrug-resistant pathogens our group adopted an alternative approach. We present our experience with eversion femoral endarterectomy. Methods: All patients submitted to eversion femoral endarterectomy in a single institution during 2016-2019 were retrospectively analyzed. Patient demographics, surgical data, and complications were captured from medical records. Results: Nineteen patients, 84.2% male and a median age of 67 years (IQR 62-78) were submitted to eversion femoral endarterectomy with a median follow-up of 180 days (IQR 71-395). Seventeen (89.4%) patients were treated for chronic limb ischemia and the other two were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Most of the patients had smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). Only 3 patients (15.8%) were submitted exclusively to endarterectomy, 13 (68.4%) were submitted to endarterectomy as an adjuvant for peripheral endovascular treatment, 2 (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm, and 1 (5.3%) was complemented with thrombectomy of the femoro-popliteal sector. Primary patency rates were 100% and 87.5% (CI (38.7-98.1)) at 6 and 12 months, respectively. Primary-assisted and secondary patency rates were 100%. The 30-day mortality rate was 5.3% (n = 1) and complication rate 10.5% (n = 2). One patient complicated with acute renal disease related to rhabdomyolysis. Another patient developed a wound-related hematoma treated with surgical drainage, but died three days after consequent to ischemia-reperfusion injury. Conclusions: Eversion femoral endarterectomy is a safe and feasible technique, with good patency results and respecting the concept of leaving nothing behind. A careful control of the proximal and distal endpoints is essential for the success of the technique.
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