RESUMO

OBJECTIVE: Great efforts have been made to choose between bypass surgery and angioplasty as the first choice for revascularisation in chronic limb threatening ischaemia (CLTI). Endovascular therapy predominates despite limited evidence for its advantages. The purpose of this observational cohort study was to investigate outcomes after open and endovascular infrapopliteal revascularisation in extensive infrainguinal arterial disease. METHODS: The medical records of 1 427 patients who underwent infrainguinal revascularisation exclusively for CLTI in the period January 2014 to February 2019 were reviewed. After detailed analysis, only infrapopliteal revascularisations classified as GLASS stage II or III were considered, resulting in 326 procedures. In total, 127 patients underwent endovascular therapy and 199 patients underwent bypass graft surgery (BGS). The primary endpoints included amputation free survival (AFS) and overall survival (OS). Secondary endpoints included the analyses of multiple factors related to long term AFS. RESULTS: Regarding the primary endpoint, AFS was 75.2% and 65.2% at one and three years, respectively. OS at one and three years was 91.2% and 83.1%, respectively. In the univariable analysis, the hazard of the combined endpoint of major amputation or death was higher after bypass surgery than after endovascular therapy (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.13 - 2.89; p = .013). After either revascularisation method, TASC II femoropopliteal D was associated with a higher risk of amputation or death (HR 1.69, 95% CI 1.10 - 2.58; p = .015). Multivariable Cox regression analysis revealed no association between the variables analysed for AFS. CONCLUSION: Patients with CLTI submitted to infrapopliteal revascularisation and classified as GLASS II and III had satisfactory AFS and OS rates after an individualised team conference decision. Furthermore, the revascularisation modality (endovascular or open) did not influence the AFS results.

Assuntos

RESUMO

OBJECTIVES: The aim of the study was to evaluate mid- to late clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) with Acurate neo™ (Boston Scientific, Boston, MA). BACKGROUND: TAVR is an established treatment for aortic stenosis (AS). Few data exist on mid- to long-term outcomes and durability after new-generation valves. METHODS: All consecutive patients (n = 104) who underwent Acurate neo™ implantation from 2012 to 2018 were included. Follow-up was systematically performed at 1, 6, 12, and 24 months and yearly thereafter. Outcomes were reported according to VARC-2, and structural valve deterioration (SVD) or bioprosthetic valve failure defined accordingly to new definitions. RESULTS: Mean age was 82 ± 5.4 years, 56.7% were female and the Society of Thoracic Surgeons score for mortality was 5.9 ± 4%. Patients were followed for a median of 3 years (1,092 days; IQR 1.5-4 years), and the maximum follow-up was 7 years. All-cause mortality values at 1 and 5 years were 8.5% and 40.5%, respectively. No relevant changes in mean gradient and orifice area occurred (7.9 ± 3.8 mmHg and 1.9 ± 0.3 cm2 at 1 year; 6.6 ± 2.1 mmHg and 1.8 ± 0.3 cm2 at 5 years), and there was a significant rate of paravalvular leaks resolution at 1, 2, and 3 years (p = .004; p < .001; p < .001, respectively). None of the patients had leaflet thrombosis or endocarditis. One patient developed SVD at 84 months. CONCLUSIONS: Acurate neo™ was associated with sustained echocardiographic results. Reassuring mid- to long-term outcomes was observed in this cohort of elderly patients with severe AS.

Assuntos

RESUMO

Abstract Objectives: The aim of the study was to evaluate mid- to late clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) with A curate neo™ (Boston Scientific, Boston, MA). Background: TAVR is an established treatment for aortic stenosis (AS). Few data exist on mid- to long-term outcomes and durability after new-generation valves. Methods: All consecutive patients (n = 104) who underwent A curate neo™ implantation from 2012 to 2018 were included. Follow-up was systematically performed at 1, 6, 12, and 24 months and yearly thereafter. Outcomes were reported according to VARC-2, and structural valve deterioration (SVD) or bioprosthetic valve failure defined accordingly to new definitions. Results: Mean age was 82 ± 5.4 years, 56.7% were female and the Society of Thoracic Surgeons score for mortality was 5.9 ± 4%. Patients were followed for a median of 3 years (1,092 days; IQR 1.5­4 years), and the maximum follow-up was 7 years. All-cause mortality values at 1 and 5 years were 8.5% and 40.5%, respectively. No relevant changes in mean gradient and orifice area occurred (7.9 ± 3.8 mmHg and 1.9 ± 0.3 cm2 at 1 year; 6.6 ± 2.1 mmHg and 1.8 ± 0.3 cm2 at 5 years), and there was a significant rate of paravalvular leaks resolution at 1, 2, and 3 years (p = .004; p < .001; p < .001, respectively). None of the patients had leaflet thrombosis or endocarditis. One patient developed SVD at 84 months. Conclusions: A curate neo™ was associated with sustained echocardiographic results. Reassuring mid- to long-term outcomes was observed in this cohort of elderly patients with severe AS.

Assuntos

RESUMO

Objective: To investigate power of computed tomography venography (CTV) to identify and characterize iliac vein obstruction (IVO) compared with intravascular ultrasound (IVUS) examination in highly symptomatic patients with chronic venous disease (CVD). Methods: CVD CEAP C3-6 limbs with visual analog scale for pain score of greater than 3 and/or Venous Clinical Severity Scale of greater than 8 were prospectively investigated with CTV and IVUS examination. The segment of maximum IVO was verified and categorically classified: group I, 0% to 49%; group II, 50% to 79%; and group III, 80% or greater. The CTV's screening power to detect the point and degree of maximum IVO was compared with IVUS. Results: The CTV point of maximum IVO was 80% in the left limb, 10% in the right limb, 10% bilaterally; 2% in the inferior vena cava; 91% in the common iliac vein (CIV) confluence (41.6% below the CIV confluence, 34.5 at the CIV confluence, and 23.9% above the CIV confluence); 7% at the external iliac vein (kappa index 0.841; P < .001, when compared with IVUS). The distal venous segment considered free of obstruction was above inguinal ligament: 68% (CIV, 47%; external iliac vein, 21%) 32% below the inguinal ligament (common femoral vein, 26%; deep femoral vein, 6%) (kappa index 0.671; P » .023, when compared with IVUS). The power of CTV to detect an IVO of 50% or greater (groups II and III) when compared with IVUS achieved a sensitivity and specificity ratio of 94.0% and 79.2%, respectively. The positive predictive value was 94%, the negative predictive value was 79.1%, accuracy was 86.7% (kappa, 0.733), and interobserver agreement was 92.1% (95% confidence interval, 87.1-97.7; kappa, 0.899). Conclusions: CTV is a powerful screening method in determining the precise point of compression and classifying IVO in limbs with symptomatic CVD when compared with IVUS. The prevalence of an obstruction above the iliac vein confluence is significant and should be considered in iliac vein stenting treatment strategy. The tomographic classification system proposed here may help to define the optimum technique of treatment, prognosis, and comparison of outcome results. (J Vasc Surg: Venous and Lym Dis 2019;-:1-10.) Keywords: Iliac vein obstruction; Computed tomography Venography; Intravascular ultrasound; May-Thuner syndrome; Cockett syndrome; Classification

Assuntos

RESUMO

OBJECTIVE:Iliac vein stenting has emerged as the procedure of choice in the treatment of iliac vein obstruction (IVO). However, clinical outcomes have never been studied by a randomized clinical trial. Our purpose was to compare medical and endovascular treatment results in symptomatic chronic venous disease (CVD) patients with significant IVO documented by intravascular ultrasound (IVUS).METHODS:Patients with Clinical, Etiology, Anatomy, and Pathophysiology clinical class C3 to C6 and a visual analog scale for pain (VAS pain) score >3 were considered eligible. We randomly assigned limbs with ≥50% IVO on IVUS to undergo medical treatment alone or medical treatment plus iliac vein stenting. The patient and clinical physician were blinded. Primary outcomes included change from baseline in VAS pain score, Venous Clinical Severity Score, and 36-Item Short Form Health Survey quality of life questionnaire. Secondary outcomes included stent integrity, migration, and patency rates at 6 months.

Assuntos

RESUMO

Introdução: Doppler Ecografia (DE) é largamente utilizada no diagnóstico das estenoses carotídeas. Em 2003, a Sociedade Americana de Radiologia divulgou um consenso propondo critérios para graduação das estenoses da Artéria Carótida Interna (ACI). Em 2009, um grupo do Reino Unido apresentou recomendações para realização da DE das artérias carótidas.Objetivo: Avaliar a acurácia dos critérios velocimétricos utilizados na graduação das estenoses da artéria carótidainterna por Doppler Ecografia comparados à arteriografia.Métodos: Em 73 pacientes (146 ACI), foram avaliados: Pico de Velocidade Sistólica (PVS), Velocidade DiastólicaFinal (VDF) da ACI e razão PVS ACI/Artéria Carótida Comum (ACC), para detecção de estenoses < 50%, 50% - 69% (PVS: 125 - 230 cm/s), 70% - 99% (PVS > 230 cm/s). A correlação entre DE e arteriografia foi feita pelo método de Spearman e p < 0,05 considerado estatisticamente significativo. Resultados: A idade média dos pacientes foi 69 anos, 47 (64%) homens, 27 (37%) com acidente vascular encefálico, e 13 (18%)ataque isquêmico transitório. O melhor critério para estenoses de 50% - 69% foi PVS ACI ≥ 141 cm/s (sensibilidade: 94%, especificidade: 90%, acurácia: 93%) (AUC 0,97). Para estenoses entre 70% ‑ 99%, PVS ACI ≥ 176 cm/s mostrou sensibilidade: 92%; especificidade: 87%; acurácia: 90%; PVS ACI ≥ 230 cm/s teve sensibilidade: 89%; especificidade: 89%; acurácia:89% (AUC 0,96); e a razão PVS ACI/ACC≥ 4,0 teve sensibilidade: 70%; especificidade: 100%; e acurácia: 81% (AUC 0,96). Seis oclusões de ACI foram detectadas à DE e arteriografia. A correlação DE e arteriografia foi: PVS (0,81 – p < 0,001); VDF (0,78 – p < 0,001) e razão PVS ACI/ACC (0,81 – p < 0,001). Conclusões: Doppler Ecografia é um método confiável na detecção das estenoses carotídeas, correlacionando-se bem com a arteriografia, sendo importante validar os critérios DE que melhor se aplicam a cada serviço.

Introduction: The Doppler Ultrasonography (DU) is largely used to diagnose carotid stenoses. In 2003, the American Society of Radiology issued a consensus establishing criteria for gradating the stenoses of the Internal Carotid Artery (ICA). In 2009, a group in the United Kingdom presented recommendations for performing DU of carotid arteries. Objective: Evaluating the accuracy of the velocimetric criteria used to gradate internal carotid artery stenoses by Doppler Ultrasonographycompared to arteriography. Methods: We evaluated 73 patients (146 ICA): Peak Systolic Velocity (PSV), End-Diastolic Velocity (EDV) of ICA and the ICA/Common Carotid Artery (CCA) PSV ratio to detect stenoses < 50%, 50% - 69% (PSV: 125-230 (cm/s), 70% - 99% (PSV > 230 (cm/s). The correlation between DU and arteriography was ascertained with the Spearman’s method and p < 0.05 deemed statistically significant.Results: The patients’ average age was 69 years, 47 (64%) men, 27 (37%) with cerebrovascular accident, and 13 (18%), transient ischemic attack.The best criterion for stenoses of 50% - 69% was ICA PSV ≥ 141 cm/s (sensitivity: 94%, specificity: 90%, accuracy: 93%) (AUC 0.97). For stenoses between 70% - 99%, ICA PSV ≥ 176 cm/s presented sensitivity: 92%; specificity: 87%; accuracy: 90%; ICA PSV ≥ 230 cm/s presented sensitivity:89%; specificity: 89%; accuracy: 89% (AUC 0.96); and ICA/CCA PSV ratio ≥ 4.0 presented sensitivity: 70%; specificity: 100%; and accuracy:81% (AUC 0.96). Six ICA occlusions were detected by DU and arteriography. The DU and arteriography correlation was: PSV (0.81 – p < 0.001);EDV (0.78 – p < 0.001) and ICA/CCA PSV ratio (0.81 – p < 0.001).Conclusions: The Doppler Ultrasonography is a reliable method for detecting carotid stenoses, having a good correlation with arteriography.In this respect, validating the DU criteria which better suit each service is important.

Assuntos

RESUMO

AIMS: To demonstrate the feasibility and efficacy of the novel InSeal VCD for the closure of large puncture holes following percutaneous structural interventions. METHODS AND RESULTS: Prospective, non-randomised, single-arm, single-centre study with a series of patients submitted to endovascular treatment of abdominal and thoracic aortic aneurysm as well as transcatheter aortic valve implantation in whom the InSeal VCD was used to close the access site. These patients were followed up for one year with clinical examination, ankle-brachial index and Doppler ultrasound. The primary endpoint was the occurrence of major vascular complications at the puncture site. From a total of nine patients screened, seven were selected to receive the InSeal VCD. Technical and therapeutic successes were achieved in all cases. The sheath profiles used in these procedures ranged from 18 Fr to 25 Fr. No major vascular complications were observed during the follow-up period. Average ankle-brachial index pre-intervention and at one-month follow-up were 0.85 and 0.82, respectively. CONCLUSIONS: The InSeal VCD was shown to be effective in achieving acute and chronic haemostasis after usage of higher profile endovascular devices in this study. These results translated into no clinical complications up to one-year clinical follow-up.

Assuntos

RESUMO

AIMS:To demonstrate the feasibility and efficacy of the novel InSeal VCD for the closure of large puncture holes following percutaneous structural interventions.METHODS AND RESULTS:Prospective, non-randomised, single-arm, single-centre study with a series of patients submitted to endovascular treatment of abdominal and thoracic aortic aneurysm as well as transcatheter aortic valve implantation in whom the InSeal VCD was used to close the access site. These patients were followed up for one year with clinical examination, ankle-brachial index and Doppler ultrasound. The primary endpoint was the occurrence of major vascular complications at the puncture site. From a total of nine patients screened, seven were selected to receive the InSeal VCD. Technical and therapeutic successes were achieved in all cases. The sheath profiles used in these procedures ranged from 18 Fr to 25 Fr. No major vascular complications were observed during the follow-up period. Average ankle-brachial index pre-intervention and at one-month follow-up were 0.85 and 0.82, respectively.CONCLUSIONS:The InSeal VCD was shown to be effective in achieving acute and chronic haemostasis after usage of higher profile endovascular devices in this study. These results translated into no clinical complications up to one-year clinical follow-up.

Assuntos

RESUMO

Introdução: O implante por cateter de prótese aórtica (TAVI, do inglês transcatheter aortic valve implantation) constitui tratamento alternativo para pacientes com estenose aórtica de alto risco cirúrgico ou inoperáveis. Para adquirir competência, o grupo multidisciplinar deve receber treinamento específico e acumular experiência na execução do TAVI. Contudo, sua curva de aprendizado não está bem estabelecida. Nosso objetivo foi analisar o impacto da curva de aprendizado na seleção de pacientes, nos aspectos técnicos e nos resultados clínicos do TAVI. Métodos: Estudo observacional e prospectivo dos primeiros 150 pacientes submetidos a TAVI por via femoral, entre janeiro de 2009 e dezembro de 2013 divididos em tercis (n = 50) de acordo com a data do procedimento. Os desfechos foram definidos conforme os critérios Valve Academic Research Consortium-2 (VARC-2). Resultados: A idade foi de 82,5 ± 6,7 anos, sendo 44% homens e 75% em classe NYHA III/IV. O EuroSCORE (24,2 ± 13% vs. 21,2 ± 10,8% vs. 23,4 ± 14,3%) e o STS Score (5,9 ± 2,9% vs. 6,7 ± 4,3% vs. 5,8 ± 3,1%) foram similares entre os grupos. Observou-se redução gradativa nos tempos do procedimento (107,2 ± 48,1 minutos vs. 90,3 ± 42,2 minutos vs. 76,6 ± 37,7 minutos; p < 0,01) e de fluoroscopia (31,3 ± 9,6 minutos vs. 25,4 ± 8,7 minutos vs. 17,2 ± 6,2 minutos; p = 0,01), e no ...

Background: Transcatheter aortic valve implantation (TAVI) is an alternative treatment for high-risk or inoperable patients with aortic stenosis. The multidisciplinary team must undergo specific training and accumulate experience to achieve optimal results. However, its learning curve is not well established. Our objective was to investigate the impact of learning curve on patient selection, technical aspects and clinical outcomes of TAVI. Methods: Observational, prospective analysis of the first 150 patients undergoing transfemoral TAVI between January 2009 and December 2013. Patients were divided into tertiles (n = 50), according to the procedure date. Outcomes were defined according to Valve Academic Research Consortium-2 (VARC-2) criteria. Results: Mean age was 82.5 ± 6.7 years, 44% were male and 75% were in NYHA class III/IV. EuroS-CORE (24.2 ± 13% vs. 21.2 ± 10.8% vs. 23.4 ± 14.3%) and STS Score (5.9 ± 2.9% vs. 6.7 ± 4.3% vs. 5.8 ± 3.1%) were similar between groups. A gradual decrease was observed in procedure times (107.2 ± 48.1 minutes vs. 90.3 ± 42.2 minutes vs. 76.6 ± 37.7 minutes; p < 0.01), fluoroscopy times (31.3 ± 9,6 minutes vs. 25.4 ± 8.7 minutes vs. 17.2 ± 6.2 minutes; p = 0.01) and contrast volume (145.5 ± 70.9 mL vs. 123.2 ± 87.8 mL vs. 101.1 ± 50 mL; p = 0.01). Mortality decreased gradually (20% vs. 10% vs. 4%; p = 0,047), and lower bleeding and moderate-to-severe aortic regurgitation were ...

RESUMO

Introdução: Os aneurismas da artéria renal são raros e constituem um desafio ao tratamento endovascular. Nosso objetivo foi descrever e analisar as técnicas e táticas no tratamento endovascular do aneurisma da artéria renal, verificando os resultados a curto e médio prazos de uma série consecutiva de casos. Métodos: Estudo retrospectivo, de procedimentos realizados no período de janeiro de 2010 a dezembro de 2013, em que foram analisados: o sucesso técnico e terapêutico, a morbimortalidade, e a taxa de vazamentos e de reintervenções. Resultados: Em um total de seis pacientes tratados, a idade média foi de 41 ± 5 anos e todos eram do sexo feminino. A maioria apresentou aneurismas saculares tipo II (83,3%). Foram utilizadas técnicas de remodelamento com uso de stent e molas em quatro casos, embolização segmentar renal em um caso e tratamento com endoprótese Multilayer® em outro. O sucesso técnico e terapêutico foi de 100 e 83,3%, respectivamente. Em um paciente, houve isquemia de polo superior renal, que evoluiu para hematúria e dor incontrolável, necessitando de nefrectomia. Não ocorreram óbitos e nem oclusão das artéria renais nativas e de seus ramos durante o acompanhamento de 1 ano. Conclusões: O tratamento endovascular do aneurisma de artéria renal demonstrou ser uma alternativa viável à cirurgia convencional com baixa morbidade. O estudo detalhado da vascularização renal e da localização do aneurisma determina a escolha da técnica endovascular a ser utilizada. O aneurisma da artéria renal do tipo II foi a morfologia mais frequentemente encontrada e pode ser tratado com sucesso por técnicas de remodelamento com o uso de stent e mola.

Background: Renal artery aneurysms are rare and constitute a challenge to endovascular treatment. Our objective was to describe and analyze the techniques and strategies for the endovascular treatment of renal artery aneurysms verifying short and medium-term results in a consecutive series of cases. Methods: Retrospective study of procedures performed from January 2010 to December 2013, analyzing technical and therapeutic success, morbidity and mortality, the rate of endoleaks and reinterventions. Results: In a total of six patients treated, mean age was 41± 5 years and all patients were female. The majority of the patients had type 2 saccular aneurysms (83.3%). Remodeling techniques using stent and coils were used in four cases, embolization of renal polar branch was used in one case and treatment with a Multilayer® endoprosthesis in another case. Technical and therapeutic success rates were 100% and 83.3%, respectively. In one patient there was upper renal pole ischemia, which progressed to uncontrollable hematuria and pain, requiring nephrectomy. There were no deaths or occlusion of the native renal artery and its branches during the 1-year follow-up. Conclusions: Endovascular treatment of renal artery aneurysm proved to be a feasible alternative to conventional surgery with low morbidity. A detailed study of renal vasculature and aneurysm location determines the choice of the endovascular technique to be used. Type II renal artery aneurysm was the most frequent morphology observed and may be successfully treated by remodeling techniques using stents and coils.

Assuntos