Use Of Endovascular Procedures Research Articles

Endovascular (stent-graft)-assisted open vascular anastomosis.

Endovascular and open surgical approaches are an integral part of treating patients with complex vascular disease and are often considered separately. In some situations, traditional open surgical techniques can be used to facilitate an endovascular approach, as example: iliac conduit use for EVAR/TEVAR, subclavian or axillary conduits for complex endovascular aortic repairs (chimney, B-FEVAR), and bypass to great vessels or visceral artery (celiac, superior mesenteric and renal arteries) debranching. As devices and techniques evolve, the open and endovascular approaches can be utilized in more complimentary fashion. This paper describes the use of endovascular procedures to assist difficult open surgical situations such as iliofemoral bypass, aortic arch debranching involving the left subclavian artery, and distal right iliac artery management during open thoracoabdominal aortic aneurysm (TAAA) repair.

Impact of the endovascular revolution on vascular training through analysis of national data case reports

BackgroundIn the last couple of decades, there has been a shift in use of endovascular procedures in vascular surgery. We aim to examine the impact of this endovascular shift on vascular trainees, determine whether the surgical experiences of trainees in the integrated residency and fellowship program changed over time, and identify differences between the two training paradigms. MethodsData were extracted from the Accreditation Council for Graduate Medical Education National Data Case Logs for the vascular surgery fellowship (1999-2021) and integrated residency (2012-2021) programs. Every procedure was categorized as open or endovascular, then designated into the following subcategories: thoracic aneurysm repairs, cerebrovascular, abdominal aneurysm repairs, venous, vascular access, peripheral arterial disease, visceral, or miscellaneous. We compared the prevalence of open and endovascular cases in the fellowship and integrated residency using data from overlapping years (2012-2021). In addition, we compared the mean number of cases per trainee per year within designated time intervals. The vascular surgery fellowship was grouped into three intervals: 1999 to 2006, 2006 to 2013, and 2013 to 2021; the integrated vascular surgery residency was grouped into two intervals: 2012 to 2017 and 2017 to 2021. Data were standardized to represent the average number of cases per trainee per year. ResultsWithin the fellowship, we found a 362.37% increase in endovascular procedures (mean, 56.80 ± 32.57 vs 262.63 ± 9.91; P < .001), although there was only a 32.47% increase in open procedures (220.19 ± 4.55 vs 291.68 ± 8.20) between the first and last time intervals. There was a decrease in abdominal aneurysm repair (24.46 ± 7.30 vs 13.85 ± 0.58; P < .001) and visceral (6.41 ± 0.44 vs 5.80 ± 0.42; P = .039) open procedures. For the integrated residency, there was an increase in open procedures by 8.52% (352.18 ± 8.23 vs 382.20 ± 5.84; P < .001). Residents had greater total, open, and endovascular procedures per year than fellows (all P < .001). Chief residents had approximately one-half as many cases as vascular fellows per year. Fellows performed more open abdominal aneurysm repair (14.04 ± 0.80 vs 12.40 ± 1.32; P = .007) and visceral (5.83 ± 0.41 vs 4.88 ± 0.46; P > .001) procedures than residents. Overall, 52% to 53% of cases performed by trainees per year were open procedures in both the fellowship and integrated residency (288.56 ± 12.10 vs 261.27 ± 10.13, 365.52 ± 17.23 vs 319.58 ± 6.62; both P < .001). Within the subcategories, only cerebrovascular, vascular access, and miscellaneous had more open procedures performed per trainee. ConclusionsVascular surgery training has incorporated new endovascular techniques and technologies while maintaining operative training in open procedures. Despite changes in vascular surgery training, trainees are still performing more open procedures than endovascular procedures per year. However, there are evolving deficits in specific types of procedures.

DIAGNOSIS AND TREATMENT OF PERIPHERAL ARTERIAL DISEASE IN PATIENTS WITH DIABETES MELLITUS

Patients with endocrine disorders often present with concomitant cardiovascular diseases. Peripheral arterial disease (PAD) in individuals with type 2 diabetes exhibits various clinical characteristics and diverse consequences. One of its primary manifestations is macrovascular complications. Although atherosclerosis is the primary cause, other contributory factors come into play. Notably, individuals with diabetes experience a more severe clinical course, marked by higher amputation rates and significant differences in mortality. The ankle-brachial index (ABI) is the standard diagnostic tool for identifying arterial diseases, while angiography is considered the gold standard for assessing anatomical aspects. Effective management of comorbidities including type 2 diabetes, hypertension, and dyslipidemia, has a substantial impact on clinical progression. Atherosclerotic disease manifests through the narrowing of affected vessels, resulting in reduced blood flow. The diagnosis of PAD requires the management of risk factors, medication-based therapies, and interventions for lower extremity issues. Physical exercise is also a valuable approach for alleviating PAD symptoms and extending pain-free walking distances. For patients with refractory conditions, surgical interventions are recommended. In cases where atherosclerotic arterial lesions are minor, pose minimal surgical risk, and have a high likelihood of successful intervention, percutaneous transluminal angioplasty should be considered. Early intervention is recommended in the presence of rest pain, ischemic ulcers, or necrosis. Balloon angioplasty and stent placement have shown efficacy in symptom relief for many PAD patients. Recent technological advancements have expanded the use of endovascular procedures, even before considering traditional "open" methods. Lesion location and length are essential factors for the long-term success of percutaneous vascular interventions.

Re-print: Treatment of Brachial Arterial Pseudoaneurysm and the Importance of Early Diagnosis with Doppler Ultrasonography

With the increased use of endovascular procedures, a rise in the number of cases of pseudoaneurysms has been seen. They have a low incidence, being its etiology traumatic or iatrogenic. Potential complications are edema, pain, hemorrhage and ischemia of the affected limb, which can even lead to loss of the fingers. We report a clinical case of a patient with brachial artery pseudoaneurysm after coronary angioplasty, which was resolved with Doppler ultrasound- guided puncture with thrombin injection.

Treatment of brachial arterial pseudoaneurysm and the importance of early diagnosis with Doppler ultrasonography

With the increased use of endovascular procedures, a rise in the number of cases of pseudoaneurysms has been seen. They have a low incidence, being its etiology traumatic or iatrogenic. Potential complications are edema, pain, hemorrhage and ischemia of the affected limb, which can even lead to loss of the fingers.We report a clinical case of a patient with brachial artery pseudoaneurysm after coronary angioplasty, which was resolved with Doppler ultrasound- guided puncture with thrombin injection.

Understanding the Basis of Radiation Protection for Endovascular Procedures: Occupational and Patients

IntroductionSome concepts of radiation protection are not well understood and must be refreshed periodically. The basic knowledge that a vascular surgeon must have about radiation protection for patients and staff is summarised.ReportDiagnostic reference levels are a form of investigation into the medical exposure of patients during diagnostic and endovascular procedures that help to optimise them. Radiological quantities such as dose area product, also known as kerma area product and cumulative dose, are the most relevant to the patient. Equivalent dose, in mSv, determines the dose limits for staff. The effective dose (related to absorbed dose), also in mSv, represents the global risk of cancer and hereditary effects. For patient protection, the most important factors are fluoroscopy time, collimation, magnification, keeping the patient as near as possible to the image detector and as far as possible away from the tube, and trying to work in fluoroscope mode. Regarding occupational protection, distance, shielding, and dosimetry are the most important.DiscussionWith the increased use of endovascular procedures, radiation protection is an issue that has grown in importance. Radiation protection is based on three principles: justification; optimisation; and dose limits. Every action focused on reducing a patient's radiation dose will also reduce the dose to staff. Basic principles such as “the further away the better”, “always use a lead apron, thyroid protector, and lead glasses”, and “do not forget to wear personal dosimeters” must be remembered at all times.

The Consequences of Negligence Claims in Arterial Surgery – An Analysis of Two Periods with an Increasing Use of Endovascular Treatment

Patient treatment within the Swedish medical service system can claim negligence injuries to the malpractice insurance review board and request financial compensation. The aim of this paper was to analyse the consequences of a negligence claim after arterial surgery between two periods with increasing use of endovascular treatment. This was a retrospective cohort study of the arterial surgery negligence claims from two three year periods 2005-2007 (Period A) and 2012-2014 (Period B) from the County Council's Mutual Insurance Company. The analysis was restricted to aortic, carotid, and lower limb arterial diseases. The magnitude of surgery for vascular diseases was obtained from the Swedish vascular register (Swedvasc). The number of patients undergoing arterial procedures increased from 16628 to 20709 (p=.01). There was an increase of 54% in the number of negligence claims between the periods. In Period A, the number of compensated claims was 22 out of 83 (29%) and in Period B 60 out of 151 (41%) (p=.06). Patients treated for aortic disorders and peripheral arterial surgery received compensation with increasing frequency whereas carotid diseases decreased. Claimants treated for aortic disorders were compensated in four out of 23 (17%) and 21 out of 54 (39%) in the two periods (p=.07), and after lower limb arterial surgery in six out of 34 (18%) and in 24 out of 71 (34%) (p=.09). After carotid surgery the corresponding figures were 12 out of 26 (46%) and 14 out of 25 (46%) (p=.48). The increasing use of endovascular procedures (but not in carotid artery surgery) did not seem to influence the pattern of negligence claims. Between the two three year periods there has been an increase in negligence claims but not in compensated ones. The increased use of endovascular procedures has not influenced the pattern of compensated negligence claims.

Recent developments in endovascular interventions to sustain vascular access patency in haemodialysis patients.

There is amassed evidence regarding the use of endovascular procedures for the treatment of vascular access stenosis and thrombosis. A review was conducted based on available randomized trials, cohort studies and retrospective analyses published after 2000 on endovascular treatment of dysfunctional and thrombosed vascular access, with an aim to illustrate the available device and procedural options. The use of paclitaxel-coated balloons, cutting balloons and covered stents is described in the field of vascular access stenosis. The broad spectrum of available devices and endovascular declotting procedures ranging from thrombolysis to thrombectomy is also discussed. Overall, in this review we demonstrate the increasing role of endovascular procedures in vascular access treatment and the improved patency outcomes provided by the implementation of novel endovascular devices. Moreover, the improvement of post-intervention primary patency rates after endovascular declotting procedures and the shift to more thrombectomy-dependent procedures over time is also highlighted. In conclusion, endovascular treatment of dialysis access stenosis and thrombosis has an established role, owing to the implementation of sophisticated devices, allowing, when needed, the simultaneous treatment of thrombosis and the underlying stenosis.

Survival trends after inferior vena cava and aortic injuries in the United States

ObjectiveRecent studies have demonstrated an increase in trauma mortality relative to mortality from cancer and heart diseases in the United States. Major vascular injuries such as to the inferior vena cava (IVC) and aortic injuries remain responsible for a significant proportion of early trauma deaths in modern trauma care. The purpose of this study was to explore patterns in epidemiology and mortality after IVC and aortic injuries in the United States. MethodsA 13-year analysis of the National Trauma Databank (2002-2014) was performed to extract all patients who sustained IVC, abdominal aortic, or thoracic aortic injuries. Demographics, clinical data, and outcomes were extracted. Patients were analyzed according to injury mechanism. ResultsA total of 25,428 patients were included in this analysis. Overall, the mean age was 39.8 ± 19.1 years, 70.3% were male, and 14.1% sustained a penetrating trauma. Although the incidence of all three injuries remained constant throughout the study period, for blunt trauma, mortality decreased over the study period (from 48.8% in 2002 to 28.7% in 2014; P < .001), in particular for thoracic aortic injuries (from 46.1% in 2002 to 23.7% in 2014; P < .001) and abdominal aortic injuries (from 58.3% in 2002 to 26.2% in 2014; P < .001). This decrease in mortality after blunt trauma was accompanied by an increase in endovascular procedures over the study period (from 1.0% in 2002 to 30.4% in 2014; P < .001), in particular for blunt thoracic aortic injuries (from 0.7% in 2002 to 41.4% in 2014; P < .001). When penetrating trauma patients were analyzed, overall there was an increase in mortality (from 43.8% in 2002 to 50.6% in 2014; P < .001), in particular after abdominal aortic injury (from 30.4% in 2002 to 66.0% in 2014; P < .001). Similar trends were observed for IVC injuries. No increase in endovascular use in penetrating trauma was identified (from 0.1% in 2002 to 3.4% in 2014; P < .001). ConclusionsThe present study demonstrates an overall decrease in mortality after blunt aortic injuries in the United States. This decrease was accompanied by an increase in the use of endovascular procedures. After penetrating trauma, however, despite contemporary advances in trauma care, mortality has increased over the study period, in particular after abdominal aortic injury. No increase in endovascular use in penetrating trauma was demonstrated.

Endovascular interventions decrease length of hospitalization and are cost-effective in acute mesenteric ischemia

ObjectiveAcute mesenteric ischemia (AMI) continues to be one of the most devastating diagnoses requiring emergent vascular intervention. There is a national trend toward increased use of endovascular procedures, with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed the treatment of AMI and the subsequent impact on length of hospitalization and hospitalization costs. MethodsWe identified all patients admitted for AMI from the National Inpatient Sample from 2004 to 2014 who received open surgical revascularization (OPEN) or an endovascular intervention (ENDO). Primary end points included length of hospital stay and cost of hospitalization. Our secondary end points included acute kidney injury (AKI), in-hospital mortality, and routine discharge. ResultsAmong 10,381 discharges identified in the data set, 3833 (37%; 97.5% confidence interval [CI], 35%-39%) were male patients with a mean age of 69 years (range, 18-98 years); 4543 (44%; 97.5% CI, 41%-47%) patients were treated ENDO, and 5839 (56%; 97.5% CI, 53%-59%) patients were treated OPEN. Although a higher proportion of patients in the ENDO group (28%; 97.5% CI, 24%-31%) vs the OPEN group (14%; 97.5% CI, 11%-16%) had a moderate to severe Charlson Comorbidity Index (P < .0001), ENDO was associated with a lower mortality rate (12.3% [97.5% CI, 9.8%-14.8%] vs 33.1% [97.5% CI, 29.9%-36.2%]; P < .0001) and a lower mean hospitalization cost ($41,615 [97.5% CI, $38,663-$44,567] vs $60,286 [97.5% CI, $56,736-$63,836]; P < .0001). After propensity-adjusted logistic regression analysis, OPEN retained a significant association with higher mortality than ENDO (odds ratio, 3.0; 97.5% CI, 2.2-4.1) and with higher costs (mean, $9196; 97.5% CI, $3797-$14,595). Patients in the OPEN group had higher risk for AKI (P < .0001) and discharge to a skilled nursing facility (P < .0001) rather than home. ConclusionsAlthough the rate of ENDO continues to rise nationally, it still has not surpassed OPEN revascularization in the face of AMI. Patients treated endovascularly demonstrated one-third the rate of in-hospital mortality (odds ratio, 3.0; 97.5% CI, 2.2-4.1), an increased hazard ratio for discharge alive (hazard ratio, 2.27; 97.5% CI, 2.00-2.58), and a cost saving of $9196 (97.5% CI, $3797-$14,595) per hospitalization. Furthermore, they were less likely to develop AKI and to be discharged home after hospitalization.

Improved mortality in treatment of patients with endovascular interventions for chronic mesenteric ischemia

ObjectiveChronic mesenteric ischemia (CMI) continues to be a devastating diagnosis. There is a national trend toward increased use of endovascular procedures with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed CMI patients' length of hospitalization and health care cost. MethodsWe identified all patients admitted for CMI from the National Inpatient Sample (NIS) from 2000 to 2014. Our primary end points included length of hospital stay (LOS) and cost of hospitalization (COH). Our secondary end points included mortality assessment of the CMI hospitalization. ResultsThere were 15,475 patients admitted for CMI. The mean age of patients was 71 years, and 4022 (26.0%) were male. There were 10,920 (70.6%) patients treated endovascularly (ENDO) and 4555 (29.4%) patients treated in an open fashion (OPEN). Although a higher proportion of patients in the ENDO (43.3%) group vs OPEN (33.1%) had a Charlson Comorbidity Index score of ≥2 (P < .0001), they had a lower mortality rate (2.4% vs 8.7%; P < .0001), lower mean LOS (6.3 vs 14.0 days; P < .0001), and lower COH ($21,686 vs $42,974; P < .0001). After adjusting for clinical and hospital factors, OPEN continued to demonstrate higher mortality than ENDO (odds ratio, 7.2; 95% confidence interval, 4.9-10.6; P < .0001), longer LOS (mean, +9.7 days; P < .0001), and higher COH (mean, +$25,834; P < .0001). ConclusionsThe rate of ENDO continues to rise nationally in the treatment of CMI patients. After adjusting for clinical and hospital factors, patients in the ENDO group tend to have lower in-hospital mortality of 2.4% and lower LOS by 10 days, and they incur a cost saving of >$25,000 compared with patients in the OPEN group. ENDO should be considered first line of therapy for patients with CMI.

Increasing use of endovascular therapy in pediatric arterial trauma

BackgroundEndovascular therapy has been increasingly used for critically injured adults. However, little is known about the epidemiology and outcomes of endovascularly managed arterial injuries in children. We therefore aimed to evaluate recent trends in the endovascular management of pediatric arterial injuries and its association with early survival. MethodsAn 8-year analysis of the National Trauma Databank (2007-2014) was performed to extract all pediatric trauma patients (aged ≤16 years) with arterial injuries. Demographics, clinical data, interventions (endovascular vs open), and outcomes (in-hospital mortality and length of stay) were extracted. Patients undergoing endovascular or open procedures were compared for differences in clinical characteristics using bivariate analysis. Multivariable logistic regression analysis quantified the association between endovascular therapy and survival in the context of other variables predictive of survival on univariate analysis, with α ≤ .05. ResultsThere were 35,771 pediatric patients available for analysis. Overall, there was a significant increase in the use of endovascular procedures (from 7.8% in 2007 to 12.9% in 2014; P < .001), particularly among blunt trauma patients (5.8% in 2007 to 15.7% in 2014; P < .001). Conversely, a significant decrease was noted for open procedures (P < .001). There was a stepwise increase in the proportion of patients managed endovascularly as the Injury Severity Score (ISS) increased (highest in the ISS spectrum of 31-50). Angioembolization of internal iliac injury and thoracic aortic endograft placement were the two most common endovascular procedures (n = 88 [33.4%] and n = 60 [22.9%], respectively). There were 331 decedents (9.1% vascular injured children), 242 (73.1%) of whom were dead on arrival. After controlling for differences in demographics and clinical data, when outcomes were compared between patients who underwent endovascular and open procedures, there were no significant differences regarding in-hospital mortality (3.0% vs 3.6%; odds ratio, 0.7; 95% confidence interval, 0.1-6.1; P = .778). A logistic regression model identified Glasgow Coma Scale score ≤8, ISS ≥16, positive result of ethanol or drug screen, and systolic blood pressure <90 mm Hg on admission as independent risk factors for death. ConclusionsThe use of endovascular therapy in pediatric vascular arterial trauma has significantly increased, especially among severely injured blunt trauma patients. Despite this successful integration into care, there was no in-hospital survival advantage conferred by endovascular therapy compared with traditional open therapy. Approximately 10% of children with arterial injuries died during initial trauma assessment before therapy could be offered. Glasgow Coma Scale score ≤8, ISS ≥16, positive result of ethanol or drug screen, and systolic blood pressure <90 mm Hg on admission were identified as independent risk factors for death. As children are a population of vulnerable patients, long-term, multicenter studies are required to determine the most appropriate use of and indications for endovascular therapy in pediatric arterial trauma.

Trends and Outcomes in the Operative Management of Traumatic Vascular Injuries: A Comparison of Open versus Endovascular Approaches

Controversy exists in vascular trauma regarding the best method of treatment-open versus endovascular techniques. Little has been published on this complex topic. Patients from 2005 to 2013 at a Level I trauma center with vascular injuries were identified via a prospectively trauma registry. Patient data, injury type/severity, treatment, and 30-day outcomes were obtained from the trauma registry and the chart review. Adverse events (limb loss, major disability, and death) were outcomes of interest. Univariate analysis and multivariate logistic regression were used to identify predictors of adverse events. In all, 346 patients were included (median age 34, range 1-93 years). Median Injury Severity Score (ISS) was 10 (1-59). Endovascular repairs (n = 52) increased from 0 per cent (2005) to 32 per cent (2013), and demonstrated equivalent outcomes to open approaches (P = 0.24). On multivariate analysis, higher ISS (P = 0.001), increasing age (P = 0.01), and lower extremity injuries (P = 0.001) were associated with adverse outcomes across the entire series. Endovascular approaches were most commonly used in vascular injuries of the chest/abdomen (39 of 52, 75% of all endovascular procedures in the series, P < 0.001), older patients (P = 0.003), blunt injury mechanism (P < 0.001), and patients with a higher ISS at presentation (P < 0.001). In conclusion, this large series, the use of endovascular procedures increased over time, and was associated with equivalent outcomes to open approaches, despite their higher usage in older patients, those with chest/abdominal injuries, and those with a higher ISS at presentation. Although these retrospective results are encouraging, further prospective study into the role of endovascular therapies in the treatment of vascular injuries.

The Role of Permissive and Induced Hypotension in Current Neuroanesthesia Practice.

Induced hypotension (IH) had been used for decades in neurosurgery to reduce the risk for intraoperative blood loss and decrease blood replacement. More recently, this method fell out of favor because of concerns for cerebral and other end-organ ischemia and worse treatment outcomes. Other contributing factors to the decline in its popularity include improvements in microsurgical technique, widespread use of endovascular procedures, and advances in blood conservation and transfusion protocols. Permissive hypotension (PH) is still being used occasionally in neurosurgery; however, its role in current anesthesia practice remains unclear. Our objective was to describe contemporary utilization of IH and PH (collectively called PH) in clinical practice among members of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC). A questionnaire was developed and distributed among SNACC members that addressed practice patterns related to the use of PH. The responses were analyzed based on the number of individuals who responded to each specific question. Of 72 respondents, 67.6% reported over 10 years of clinical experience, while 15.5% reported 5-10 years of post-training experience. The respondents admitted to providing anesthesia for 300 (median) neurosurgical cases per year. PH was applied most commonly during open interventions on cerebral aneurysms (50.8%) and arteriovenous malformations (46%). Seventy-three percent of respondents were not aware of any complications in their practice attributable to PH. PH is still being used in neuroanesthesia practice by some providers. Further research is justified to clarify the risks and benefits of PH in modern neuroanesthesia practice.

Trends and outcomes of endovascular therapy in the management of civilian vascular injuries

The rapid evolution of endovascular surgery has greatly expanded management options for a wide variety of vascular diseases. Endovascular therapy provides a less invasive alternative to open surgery for critically ill patients who have sustained arterial injuries. The purpose of this study was to evaluate recent trends in the management of arterial injuries in the United States with specific reference to the use of endovascular strategies and to examine the outcomes of endovascular vs open therapy for the treatment of civilian arterial traumatic injuries. A 9-year analysis of the National Trauma Data Bank was performed to identify all patients who sustained arterial injuries. Demographics, clinical data, interventions, and outcomes were extracted. Propensity scores were used to match endovascular patients to those undergoing open operation. Patient outcomes were compared according to treatment approach. A total of 23,105 patients were available for analysis. Overall, there was a significant increase in the use of endovascular procedures during 9years (from 0.3% in 2002 to 9.0% in 2010; P< .001), particularly among blunt trauma patients (from 0.4% in 2002 to 13.2% in 2010; P< .001). This increase was noteworthy and dramatic for injuries of the internal iliac artery (from 8.0% in 2002 to 40.3% in 2010; P< .001), thoracic aorta (from 0.5% in 2002 to 21.9% in 2010; P< .001), and common/external iliac arteries (from 0.4% in 2002 to 20.4% in 2010; P< .001). A significant decrease was noted for open procedures (49.1% in 2002 to 45.6%; P< .001), especially for blunt trauma (42.9% in 2002 to 35.8% in 2010; P< .001). There was a stepwise increase in the proportion of patients managed by endovascular therapy as the Injury Severity Score increased (highest in the spectrum Injury Severity Score 31-50). When outcomes were compared between matched patients who underwent endovascular and open procedures, patients who underwent endovascular procedures had significantly lower in-hospital mortality (12.9% vs 22.4%; odds ratio, 0.5; 95% confidence interval, 0.4-0.6; P< .001). Endovascular patients also had decreased rates of sepsis (7.5% vs 5.4%; odds ratio, 0.7; 95% confidence interval, 0.5-0.9; P= .025). The use of endovascular therapy in the United States has increased dramatically during the last decade, in particular among severely injured blunt trauma patients. Endovascular therapy was associated with improved in-hospital mortality and lower rates of sepsis.

Evolución del uso de técnicas endovasculares para revascularización infrainguinal de miembros inferiores en el periodo 2005-2011. Experiencia de nuestro centro

IntroductionThere is a growing trend in the number of infrainguinal endovascular revascularisations being performed in recent years. ObjectiveThe primary aim of this study is to describe the development of the use of endovascular procedures for infrainguinal revascularisation in a hospital centre since its introduction in 2005 to the present date. Material and methodsA study was conducted on the 391 infrainguinal revascularisations performed out of a total of 6.867 procedures. A cross-sectional study was performed by reviewing surgery records, surgical protocols, and medical histories, and sorting them into endovascular and open surgery. Clinical compromise and morphological technical success were analysed in the endovascular procedures group in order to compare them over the study period. ResultsA large majority (81.32%) presented as critical limb ischaemia. An increasing trend was observed in the number infrainguinal revascularization procedures performed, mainly at the expense of the endovascular group, which increased both in absolute numbers and proportionally compared to open surgery procedures (23.4% to 58,5%; P<.05). A slight increase in the rate of technical success was also noted when comparing the beginning and the end of the period, although this was not statistically significant (P=0.37). ConclusionsThe use of endovascular techniques in lower limb revascularisation in our institution has experienced a marked growth in recent years, with a tendency to increase further. Although we do not have the necessary data to ensure this, we believe that the use of these procedures may be an important factor in the increasing number of candidates for the lower limb revascularisations observed in our series.

PS94. Do Women Have Worse Amputation-Free Survival than Men following Endovascular Procedures for Peripheral Arterial Disease? An Evaluation of the California State-Wide Database

In recent years, use of endovascular procedures for peripheral arterial disease (PAD) has exceeded use of bypass procedures. Previously, it has been demonstrated that female gender negatively affects the outcomes of PAD interventions. This study examined gender disparities in outcomes of endovascular procedures in a contemporary large population based study. We used the Patient Discharge Data (PDD) from California's Office of Statewide Health Planning and Development (OSHPD) to identify all patients >35 years of age who underwent PAD interventions during 2005-2009. Cox proportional hazard regression was used to compare amputation-free survival and logistic regression was used to compare 12-month re-intervention rate adjusting for age, race, insurance status, severity of illness, and co-morbidities. Two-sided Fisher's exact test was used for comparison of critical limb ischemia between the sexes. During 2005-2009, 41,407 individuals underwent PAD interventions, 25,635 (61.9%) of whom had endovascular procedures (11,389 women (44.2%) and 14,246 men). Women were more likely than men (34.5% versus 30.1.%, P <.0001) to present with critical limb ischemia. Although 12-month re-intervention rate in women was similar to men (OR 0.961(95% CI 0.91-1.01, P = .146), amputation-free survival was better among women than men (HR 0.841, 95% CI 0.761-0.93, P = .007) following endovascular procedures. Sex was not statistically associated with amputation-free survival following open procedures (HR 1.04, 95% CI 0.94-1.151, P = .444). Despite presenting more frequently with critical limb ischemia, women had better amputation-free survival than men following endovascular PAD procedures in this contemporary population-based study. Further research is essential to help guide current practices of PAD management and address if these outcomes favor one type of PAD treatment modality in women.

Vascular Injury Accompanying Displaced Proximal Humeral Fractures: Two Cases and a Review of the Literature

We present two cases in which displaced proximal humeral fractures are accompanied by vascular injury. These Injuries are very rare but severe and the accompanying vascular impairment can have great clinical consequences. Therefore, we try to emphasize on the importance of thorough and accurate diagnostics, because it is obligatory for early diagnosis and improving the eventual outcome of these injuries. The specific order in treatment (internal fixation first or vascular repair first) depends on the severity of the accompanying vascular injury. The increasing use of endovascular procedures to treat vascular lesions is a very interesting development with several advantages, especially in elderly and multimorbid patients.

Patterns of treatment for peripheral arterial disease in the United States: 1996-2005

Endovascular procedures are increasingly used in the treatment of peripheral arterial disease (PAD). Whether this new procedural approach translates to clinical outcomes equivalent or superior to open surgical revascularization is a subject of debate. We sought to analyze population-based rates of major amputations for PAD during a time period in which the use of endovascular surgical procedures increased dramatically. We used the 1996-2005 Nationwide Inpatient Sample (NIS) to analyze rates of amputations and vascular interventions, and also to characterize the treatment of patients admitted acutely for PAD. Vascular interventions were designated based on International Classification of Diseases (ICD) procedure codes as open bypass, endovascular intervention, or major amputation (disarticulation at ankle or higher amputation). Population-based age-adjusted incidence rates of treatment were calculated by combining procedure rates with census data. Our analysis included 97,000 acute admissions for PAD, 83,000 major amputations, 77,500 endovascular procedures, and 171,000 open vascular bypass operations. Between 1996 and 2005, population-based rates of acute admissions for PAD decreased by 4.3% per year, open procedures by 6.6% per year, and major amputations by 6.4% per year, whereas endovascular procedures increased by 4.8% per year. Of patients acutely admitted for PAD, the likelihood of undergoing an amputation decreased (30.2% to 21.8%), the likelihood of undergoing an open vascular procedure decreased (34.5% to 26.3%), and the likelihood of undergoing an endovascular operation increased (12.7% to 28.3%). All of these changes were statistically significant at P < .05. The last decade has seen a significant increase in the use of endovascular procedures and a decrease in rates of major amputation. These trends are seen both for patients admitted with acute PAD, as well as in the population in general. While our study was not designed to demonstrate a causal relationship, our findings suggest an association between increased application of endovascular technology and reduced rates of amputation in patients with PAD.

Interventions for Deep Vein Thrombosis: Reemergence of a Promising Therapy

Venous thromboembolism (VTE) is a highly prevalent disorder with an incidence of nearly 1 million cases per year in the United States. In recent years, endovascular techniques that enable rapid venous thrombus removal or inferior vena cava (IVC) interruption have undergone major refinements, yet have not been readily welcomed by the physician community. Clinical reports and publications by different subspecialists and their professional societies reflect wide inconsistencies in the use of endovascular procedures and fail to reflect a contemporary understanding of the health consequences of deep vein thrombosis (DVT). This article updates physicians on key treatment considerations, including the use of endovascular interventions, that should influence clinical decision-making for acute DVT. Postthrombotic syndrome (PTS) occurs in 25% to 50% of patients with proximal DVT receiving standard anticoagulant therapy. PTS often leads to chronic lifestyle-limiting symptoms, work disability, major quality of life impairment, and high costs to patients and society. Although evidence from observational and randomized control studies has shown that early thrombus removal is likely to prevent PTS, bleeding complications remain a significant concern with thrombolytic therapy. For these reasons, the use of adjunctive endovascular thrombolysis should be accepted as appropriate for patients with life-threatening, limb-threatening, or organ-threatening complications of DVT, as well as for patients who fail to exhibit an acceptable response to initial anticoagulant therapy if they do not have additional risk factors for bleeding and such an approach is consistent with their preferences. Based on available evidence, the first-line use of endovascular thrombolysis should routinely be offered to patients with acute iliofemoral DVT who do not have risk factors for bleeding. A randomized controlled trial of permanent IVC filters added to the information available about these devices, but the data from this study have been susceptible to widely varying interpretations. The advent of retrievable IVC filters has resulted in greater utilization, but better studies are needed to determine the proper indications for their use. Endovascular therapy shows great promise for improving DVT outcomes, but its proper utilization remains uncertain. This uncertainty may be rooted in the absence of a US-based randomized controlled trial that challenges existing paradigms of DVT treatment. To reinvent and reorient DVT clinical practice patterns, physicians should (1) include PTS prevention as a key goal of initial DVT therapy; (2) recognize that iliofemoral DVT is a distinct clinical entity; (3) recognize the health significance of PTS in interpreting DVT trial results; and (4) embrace a new concept of health impairment caused by DVT with recognition of a broad range of DVT treatments and treatment outcomes.