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Flow diversion treatment for acutely ruptured aneurysms.

急性破裂动脉瘤的分流治疗。

  • 影响因子:2.98
  • DOI:10.1136/neurintsurg-2019-015077
  • 作者列表:"Ten Brinck MFM","Jäger M","de Vries J","Grotenhuis JA","Aquarius R","Mørkve SH","Rautio R","Numminen J","Raj R","Wakhloo AK","Puri AS","Taschner CA","Boogaarts HD
  • 发表时间:2020-03-01
Abstract

BACKGROUND AND PURPOSE:Flow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms. METHODS:We conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0-2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up. RESULTS:At follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3-6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%). CONCLUSION:Flow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.

摘要

背景和目的: 在急性破裂的动脉瘤中,有时会使用导流器。然而,血栓栓塞和出血并发症令人担心,关于安全性的证据有限。因此,在这项多中心研究中,我们评估了急性破裂动脉瘤患者使用分流器治疗的并发症,临床和血管造影结果。 方法: 我们对6个中心的44例颅内动脉瘤破裂后15天内接受分流器治疗的患者进行了回顾性观察研究。主要终点是良好的临床结局,定义为改良Rankin量表评分 (mRS) 0-2。次要终点是随访时手术相关并发症和完全动脉瘤闭塞。 结果: 在随访 (中位3.4个月) 时,20例 (45%) 患者具有良好的临床结果。20例患者 (45%) 发生25例手术相关并发症。这些导致12例患者 (27%) 的永久性神经功能缺损。5例 (11%) 动脉瘤再次破裂。8例患者死亡,全因死亡率18%。手术相关并发症与不良临床结局相关 (mRS 3-6; OR 5.1(95% CI 1.0 to 24.9),p = 0.04)。大动脉瘤容易再次破裂,大小 ≥ 20  mm和 <20  mm的动脉瘤再出血率分别为60% (3/5) 和5% (2/39) (p = 0.01)。29例患者 (中位9.7个月) 的随访血管造影显示27例 (93%) 完全动脉瘤闭塞。 结论: 血流分流术治疗颅内破裂动脉瘤与包括动脉瘤再破裂在内的高手术相关并发症发生率相关。并发症与不良的临床结果相关。在有血管造影随访的患者中,观察到高闭塞率。

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影响因子:1.05
发表时间:2020-02-01
DOI:10.23736/S0021-9509.18.10206-0
作者列表:["Peters AS","Hatzl J","Bischoff MS","Böckler D"]

METHODS:BACKGROUND:Due to recent advances in endograft design and percutaneous access, technical success could be increased during endovascular aneurysm repair (EVAR). Beside EVAR, endovascular aneurysm sealing (EVAS) provides an alternative procedure to treat aneurysms. To compare the two methods, additional benchmark criteria should be evaluated: Screening time, dose area product (DAP), procedure time and contrast use. In this study these technical variables are analyzed for EVAS vs. EVAR in comparable patient cohorts. METHODS:It is a retrospective, single-center study. Only elective cases of infrarenal aortic aneurysms were included, all treated by the same surgeon (D.B.). Procedures were performed within the instructions for use without additional procedures. All operations were undertaken in a hybrid operating theatre. For EVAR, only the Medtronic Endurant® and the Gore C3 Excluder® were included. For EVAS the Nellix® from Endologix was used. RESULTS:Between 2012 and 2016, 67 patients were treated with EVAS and 40 with EVAR; of these 20 and 16 could be introduced into the study respectively. Median age was 73 and 72 years respectively (only men). The two groups were comparable in terms of BMI, GFR and ASA-status. Screening time was reduced for EVAS (10.6 vs. 14.5 min., P<0.01), while the DAP was not significantly different. Procedural time and contrast use were increased for EVAS (120 vs. 96 min., 120 vs. 79 mL, P<0.01). CONCLUSIONS:Especially the younger EVAS-procedure requires ongoing review in order to further reduce contrast agent. Reduced screening time for EVAS does not have a significant impact on radiation dose.

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翻译标题与摘要 下载文献
影响因子:4.91
发表时间:2020-04-01
来源期刊:Annals of surgery
DOI:10.1097/SLA.0000000000003050
作者列表:["Karthaus EG","Vahl A","van der Werf LR","Elsman BHP","Van Herwaarden JA","Wouters MWJM","Hamming JF"]

METHODS:OBJECTIVE:To evaluate reasons to deviate from aneurysm diameter thresholds, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. BACKGROUND:Guidelines recommend surgical treatment for asymptomatic abdominal aortic aneurysms (AAAs) with a diameter of at least 55 mm for men and 50 mm for women. We evaluate reasons to deviate from these guidelines, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. METHODS:All patients undergoing elective AAA repair between 2013 and 2016 registered in the Dutch Surgical Aneurysm Audit (DSAA) were included. Surgery at diameters of <55 mm for men and <50 mm for women were considered guideline deviations. National deviation and hospital variation in deviation were evaluated over time. Questionnaires were distributed among all Dutch VSUs, inquiring for acceptable reasons for guideline deviation. VSUs were asked to estimate the guideline deviation percentage in their hospital which was then compared with their DSAA percentage. RESULTS:In all, 9039 patients were included. In 15%, we found guideline deviation, varying from 2% to 40% between VSUs. Over time, 21 VSUs were identified with a lower percentage of deviation than the national mean each year and 8 VSUs with a higher percentage. 44/60 VSUs completed the questionnaire. Most commonly reported reasons to deviate were concomitant large iliac diameter (91%) and saccular aneurysm (82%). The majority of the VSUs (77%) estimated their guideline deviation to be <5%. Eleven VSUs (25%) estimated their deviation concordant with their DSAA percentage, but 75% of VSUs underestimated their deviation. CONCLUSIONS:Dutch VSUs regularly deviate from the guidelines regarding aneurysm diameter, with variation between VSUs. Consensus exists amongst VSUs on acceptable reasons for guideline deviations; however, the majority underestimates their actual deviation percentage.

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影响因子:1.05
发表时间:2020-04-01
DOI:10.23736/S0021-9509.18.10639-2
作者列表:["Kodama H","Takahashi S","Okazaki T","Morita S","Go S","Watanabe M","Yamane Y","Katayama K","Kurosaki T","Sueda T"]

METHODS:BACKGROUND:Spinal cord ischemia (SCI) and paraplegia are complications of surgery for type A acute aortic dissection (TAAAD). Since the segmental arteries play a key role in SCI, this study evaluated the association between SCI and false lumen segmental arteries (FLSAs: segmental arteries originating from the false lumen). METHODS:The study included 101 consecutive TAAAD patients (mean age, 66±13; range, 34-89 years) who underwent surgery from January 2011 to April 2017. The diagnosis of TAAAD and the number of FSLAs were determined by preoperative computed tomography (CT). Patients were divided into two groups according to the number of FLSAs at the Th9-L2 level: Group A (N.=13), ≥8 FLSAs; and group B (N.=88), ≤7 FLSAs. Preoperative, perioperative, and postoperative findings were compared between the groups, and risk factors for SCI were evaluated. RESULTS:The frequency of preoperative paralysis was significantly higher in Group A than Group B (P=.0070). The overall incidence of postoperative SCI was 8% (8/101) and significantly higher in Group A than Group B (5/13 [45%] vs. 3/88 (4%), P<0.0001). Hospital mortality was 8% (8/101) and significantly higher in Group A than Group B (3/13 [23%] vs. 5/88 [6%], P=.0302). Multivariate analysis showed that the independent risk factors for SCI were ≥8 FLSAs at Th9-L2 (odds ratio [OR], 20.4; 95% confidence interval [95% CI], 3.34-124.9, P=0.0011) and diabetes mellitus (OR, 22.3; 95% CI, 1.69-294.5; P=0.0184). CONCLUSIONS:In patients who underwent surgery for TAAAD, ≥8 FLSAs at the Th9-L2 levels on preoperative CT was a risk factor for SCI.

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动脉瘤方向

动脉瘤是由于动脉壁的病变或损伤,形成动脉壁局限性或弥漫性扩张或膨出,以膨胀性、搏动性肿块为主要表现,可以发生在动脉系统的任何部位,而以肢体主干动脉、主动脉和颈动脉较为常见。

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