Journal of vascular surgery
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Randomized Controlled Trial Comparative Study
Improving aneurysm-related outcomes: nationwide benefits of endovascular repair.
Endovascular aneurysm repair (EVAR) has changed the practice of abdominal aortic aneurysm (AAA) surgery. We examined a national Medicare database to establish the effect of EVAR introduction into the United States. ⋯ EVAR is replacing open surgery without an increase in overall case volume. EVAR is responsible for overall decrease in operative mortality even in ruptured aneurysms while decreasing utilization variables. Reimbursement to hospitals is shrinking, however.
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Popliteal artery aneurysm (PAA) is uncommon. The clinical presentation of PAA includes rupture, embolism, and thrombosis. In this article, we evaluate the results of our 20-year experience with surgical management of PAAs, analyzing the role of anatomic, clinical, and surgical factors that potentially affect early and long-term results. ⋯ Results of surgery on asymptomatic PAAs are good-significantly better than those for symptomatic ones. Elective surgical intervention should be performed in patients with a low surgical risk and a long life expectancy when the correct indication exists. In thrombosed aneurysms, intra-arterial thrombolysis may represent an alternative to emergent surgical management. Our data demonstrated that results are similarly good in claudicants, and this fact confirms that only acute ischemia due to PAA thrombosis represents a real surgical challenge. In selected patients with focal lesions, a posterior approach seems to offer better long-term results. The runoff status and the site of distal anastomosis affect long-term patency as well.
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A rapidly increasing number of thoracic aortic lesions are now treated by endoluminal exclusion by using stent grafts. Many of these lesions abut the great vessels and limit the length of the proximal landing zone. Various methods have been used to address this issue. We report our experience with subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. ⋯ Subclavian revascularization procedures can be performed with relatively low risk. Complications are rare, and patient recovery is rapid. Although this is not necessary in all cases, we advocate subclavian to carotid transposition when the aortic lesion is within 15 mm of the left subclavian orifice to prevent type II endoleak or perfusion of a dissected false lumen when the ipsilateral vertebral artery is patent and dominant or when coronary revascularization using an ipsilateral internal mammary artery is anticipated and in cases that necessitate extensive coverage of intercostals that contribute to spinal cord perfusion. Carotid to subclavian artery bypass should be reserved for patients with a patent internal mammary artery conduit perfusing a coronary vessel and should be combined with proximal subclavian ligation.
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Randomized Controlled Trial Multicenter Study Comparative Study
Perioperative myocardial ischemic injury in high-risk vascular surgery patients: incidence and clinical significance in a prospective clinical trial.
The purpose of this study was to assess prospectively the incidence, health care resource utilization, and economic burden associated with perioperative myocardial ischemic injury (PMII) in high-risk patients undergoing noncardiac vascular surgery. ⋯ In modern vascular surgery practice, PMII remains common despite the availability of beta-blockers and other preventative strategies. PMII is associated with dramatic increases in resource utilization and cost. The increase in resource utilization associated with PMII resulted in an estimated incremental cost per patient of dollar 9980.00. If 250,000 high-risk open vascular operations are performed annually in the United States, the economic burden of PMII in these procedures alone approximates dollar 444 million. Strategies to decrease PMII incidence and severity should be evaluated in large-scale prospective trials.
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Patients undergoing vascular surgery comprise a group at elevated risk of fatal and nonfatal perioperative cardiovascular events. In four recent longitudinal studies, the 30-day incidence of death in such patients was 3% to 6%, and the incidence of myocardial infarction was 5% to 14%. Growing evidence suggests that beta-adrenergic receptor antagonists prevent cardiovascular morbidity and mortality in high-risk patients undergoing noncardiac surgery, including those undergoing vascular surgery. This article reviews the available evidence concerning beta-blockers and provides guidance for their use in the perioperative setting.