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Query: UMLS:C0729233 (Thoracic)
 6,478 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Aneurysmal diseases of the thoracic aorta are life-threatening conditions. In such cases, stent-graft treatment has been proposed as an alternative to surgery. The morbidity and mortality associated with endovascular repair are significantly lower than those associated with open surgery. In the largest surgical series, the mortality ranged from 5% to 20%. In studies of endovascular repair, the 30-day mortality was 0%-20% and the periprocedural stroke rate was 0%-7%. Often, open surgery is prohibited in patients with these high-risk lesions; thus, in many cases endovascular treatment is the only alternative. Thoracic aortic diseases that can be treated with endovascular stent-graft placement include aneurysms, dissection, traumatic rupture, traumatic pseudoaneurysms, intramural hematoma, penetrating atherosclerotic ulcers, and aortic rupture. Thorough preprocedure imaging is essential for selecting patients, choosing the stent-graft devices, and planning the intervention. Prerequisites for endovascular stent-graft placement are an adequate neck for graft attachment and adequate vascular access. When the ascending aorta or aortic arch is involved, surgical and endovascular procedures can be combined and performed simultaneously, allowing treatment of a wider range of cases. An experienced interdisciplinary team is needed to manage such cases.
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PMID:Endovascular stent-graft treatment of thoracic aortic disease. 1622 93

Patent foramen ovale is considered as a potential risk factor for stroke owing to paradoxic embolism, leading to the question "to close or not to close the patent foramen ovale". We report a 26-year-old woman with chest pain, dyspnoea, sudden severe pain in both legs and paraplegia. Thoracic and abdominal computed tomography revealed massive pulmonary embolism and complete obstruction of the abdominal aorta. Interventional removal of the aortic thrombus was undertaken using the Fogarty catheter technique via the femoral arterial approach. As a result of worsening of cardiopulmonary function during the procedure, additional local thrombolysis, with a total of 50 mg recombinant tissue plasminogen activator, and fragmentation of the thrombus in the right pulmonary artery were performed via a femoral vein approach. Ultrasound studies revealed a patent foramen ovale of about 12 mm diameter with a significant right to left shunt. Under favourable conditions, a patent foramen ovale may allow the escape of a thrombus, sufficient to cause a potentially fatal pulmonary embolism, into the arterial system, where it can be removed by interventional manoeuvres.
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PMID:Patent foramen ovale as lifesaving purging valve. 1681 88

Seven percent of the United States population is diabetic. However, diabetics are two to five times more likely to develop cardiovascular disease and therefore populate 30% of open heart procedures in this country. In addition, it has been well documented that diabetic cardiac surgery patients are further disadvantaged with worse outcomes following those procedures. This has been termed the "Diabetic Disadvantage." To benchmark these specific disadvantages, we evaluated the short- and long-term outcomes for diabetics and nondiabetics undergoing coronary artery bypass graft (CABG), CABG/valve, and aortic or mitral valve replacement surgery before the broader acceptance and use of intravenous insulin infusions in this patient population in 2001. All such patient records (n = 1,369,961) from the Society of Thoracic Surgeons national database operated on between 1990 and 2000 were assessed for short-term outcomes. Ten-year survival was evaluated among 36,835 patients from the Northern New England Cardiovascular Disease Study Group longitudinal registry. The diabetic population was found to have higher rates of 30-day mortality, deep sternal wound infection, stroke, and longer length of stay than the nondiabetic population. In addition, diabetic patients had approximately two-fold worse 10-year survival. All differences were statistically significant (P < 0.001). In summary, The Diabetic Disadvantage in the pre-intravenous insulin era is characterized by worse short- and long-term outcomes for diabetic patients undergoing cardiac surgery in the United States and Canada.
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PMID:The diabetic disadvantage: historical outcomes measures in diabetic patients undergoing cardiac surgery -- the pre-intravenous insulin era. 1739 23

We report the case of a physically fit young man who presented with severe, life-threatening heat stroke after running a 10 km road race. He had previously received bilateral thoracic sympathectomy for axillary hyperhidrosis at another hospital, and was known to have upper body and limb anhidrosis. Thoracic sympathectomy can result in reduced sweating and disturbed peripheral vascular and heart rate responses. Patients should be warned that these mechanisms may play a role in the development of exertional heat stroke.
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PMID:Is previous thoracic sympathectomy a risk factor for exertional heat stroke? 1772 Apr 29

The goal of this study was to compare outcomes of combined balloon aortic valvuloplasty (BAV) plus percutaneous coronary intervention (PCI) with BAV alone in a surgically high risk, older (>70 years) population with both aortic stenosis (AS) and coronary artery disease (CAD). The medical records, coronary angiograms, and procedural reports of 100 consecutive patients who underwent BAV and coronary angiography at our institution from July 2003 to November 2006 were reviewed. Seventeen patients (mean age 86.2+/-6.4 years) underwent combined (nonstaged) BAV and PCI with a calculated Society of Thoracic Surgery risk score of 13.5%+/-6.7; 13 of these underwent coronary stenting before BAV and 4 after BAV. All 17 patients were successfully treated with this combined strategy. The incidence of periprocedural mortality, myocardial infarction, and stroke was zero. An additional 25 patients (mean age 85.9+/-6.9) with CAD were identified who underwent BAV alone with a Society of Thoracic Surgery risk score of 12.6+/-5.7%. PCI in these patients was avoided primarily because of greater lesion complexity or a perceived low probability of symptomatic benefit. There was 1 procedural death, no myocardial infarction, and 1 postprocedural stroke in these 25 patients. The procedural duration and hospital length of stay for the combined BAV and PCI group was 98.8+/-17.6 minutes and 4.1+/-2.8 days, respectively, and for the BAV only group was 86.2+/-27.3 minutes and 3.3+/-2.1 days, respectively. In conclusion, with appropriate selection, BAV plus PCI was safely performed in this retrospective series of elderly, high-risk patients with severe AS and CAD.
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PMID:Comparison of outcomes in high-risk patients>70 years of age with aortic valvuloplasty and percutaneous coronary intervention versus aortic valvuloplasty alone. 1843 63

Thoracic aortic aneurysms and other thoracic aortic lesions may become life-threatening conditions if they remain untreated. Conventional open surgical reconstruction with placement of an interposition graft is regarded as a definitive form of treatment, but is associated with considerable operative morbidity and mortality. Thoracic aortic lesions involving the aortic arch require more complex surgical interventions necessitating cardiopulmonary bypass, and hypothermic circulatory arrest. Outcomes from this form of treatment have a reported early stroke and death rate of up to 25%. Thoracic endovascular aortic repair is a less invasive alternative for the treatment of many thoracic aortic lesions. The application of a thoracic endoprosthesis may be limited by the extent of involvement of the proximal thoracic aorta as coverage of arch vessel ostia may be necessary to obtain adequate proximal endograft fixation and aneurysm exclusion. In an effort to overcome proximal landing zone limitations imposed by arch vessel involvement, hybrid surgical-endovascular reconstructive and debranching bypass procedures have been performed to create a proximal landing zone of adequate length. Although these adjunctive techniques incorporate invasive surgical procedures, it is believed that minimizing the procedural invasiveness, by avoiding aortic cross-clamping and/or hypothermic circulatory arrest, morbidity and mortality outcomes can be improved especially in high-risk patients. Several surgical approaches and techniques have been described for various levels of aortic arch involvement with encouraging early and mid-term results, although the long-term durability of these hybrid surgical-endovascular procedures remains to be defined.
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PMID:Surgical bypass procedures to facilitate endovascular repair of aortic arch pathology. 1866 8

Thoracic endovascular aortic repair (TEVAR) may involve either planned or inadvertent coverage of aortic branch vessels when stent grafts are implanted into the aortic arch. Vital branch vessels may be preserved by surgical debranching techniques or by placement of additional stents to maintain vessel patency. We report our experience with a double-barrel stent technique used to maintain aortic arch branch vessel patency during TEVAR. Seven patients underwent TEVAR using the double-barrel technique, with placement of branch stents into the innominate (n = 3), left common carotid (n = 3), and left subclavian (n = 1) arteries alongside an aortic stent graft. Gore TAG endografts were used in all cases, and either self-expanding stents (n = 6) or balloon-expandable (n = 1) stents were utilized to maintain patency of the arch branch vessels. In three cases the double-barrel stent technique was used to restore patency of an inadvertently covered left common carotid artery. Four planned cases involved endograft deployment proximally into the ascending aorta with placement of an innominate artery stent (n = 3) and coverage of the left subclavian artery with placement of a subclavian artery stent (n = 1). TEVAR using a double-barrel stent was technically successful with maintenance of branch vessel patency and absence of type I endoleak in all seven cases. One case of zone 0 endograft placement with an innominate stent was complicated by a left hemispheric stroke that was attributed to a technical problem with the carotid-carotid bypass. On follow-up of 2-18 months, all double-barrel branch stents and aortic endografts remained patent without endoleak, migration, or loss of device integrity. The double-barrel stent technique maintains aortic branch patency and provides additional stent-graft fixation length during TEVAR to treat aneurysms involving the aortic arch. Moreover, the technique uses commercially available devices and permits complete aortic arch coverage (zone 0) without a sternotomy. Although initial outcomes are encouraging, long-term durability remains unknown.
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PMID:Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair. 1868 89

Thoracic endografting is emerging as an alternative option in the surgical management of patients who have thoracoabdominal aortic aneurysms (TAAA) or aortic dissection. Due to the high morbidity and mortality rates associated with open TAAA repair, vascular surgeons are searching for innovative methods to repair such aneurysms. A combined endovascular and open approach, otherwise known as the hybrid repair, involves aortic "debranching" (renal and mesenteric revascularization) to create a landing zone for the endograft. Although operative mortality with hybrid is equivalent to mortality found with open repair, reported paralysis rates are reduced. Limited data regarding hybrid graft patency and durability are available. Vascular nurses play a vital role in patient education pre and postoperatively; therefore, they should know the risks and benefits associated with both open and hybrid TAAA repair as well as the risk associated with TAAA rupture. Nurses caring for patients after hybrid repair should possess astute assessment skills in monitoring for postoperative complications. Close observation for stroke, paralysis, renal insufficiency/failure, bowel ischemia/dysfunction, lower extremity ischemia and basic hemodynamics is essential for favorable outcomes. Vascular nurses should provide surgery-specific instruction regarding lengths of stay, expected outcomes, activity restrictions, CT-scan follow-up and possible complications after surgery, including warning signs. In the evolving field of endovascular surgery, vascular nurses must remain current on new innovative techniques being used, such as thoracic endografting.
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PMID:Hybrid repair of thoracoabdominal aneurysms: a combined endovascular and open approach. 1902 68

In Japan, the intravenous tissue plasminogen activator (t-PA) Alteplase (0.6 mg/kg) administration of the within 3 h of the onset of acute ischemic stroke was approved for therapeutic use in the year 2006. t-PA induces thrombolysis in patients with acute ischemic stroke, and this method has gradually gained recognition among physicians and the general population. However, the number of patients who were treated using Alteplase is low (4,000-5,000 patients/year), and this figure accounts for only 2-3% of the annual number of cases of ischemic stroke. There is little doubt that Alteplase treatment is a potentially effective modality for some patients with acute ischemic stroke. The post-marketing surveillance of 4,749 Japanese patients treated using Alteplase showed that 33% of the patients had modified Rankin scale (mRS) scores of 0-1, 17% of patiens died and 4.5% presented with symptomatic intracerebral hemorrhage (ICH); these results were comparable to those from other countries. The expansion of the therapeutic time window has been a matter of concern. The investigators of the European Cooperative Acute Stroke Study (ECASS) have reported that there was significant improvement in the clinical outcomes of patients with acute ischemie stroke when Alteplase was administered 3-4.5 h after the onset of the symptoms. Mismatches in perfusion- and diffusion-weighted (DW) magnetic resonance imaging (MRI) images have been used for selecting patients 3 h after the onset of symptoms, and the findings from MRI, dwimages (DWI) and MR angiography are practical predictors of t-PA therapy within 3 h of onset. The Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) Japan study showed that local intra-arterial fibrinolysis is effective in patients with embolic MCA occlusion within 6 h of the onset of symptoms. Combining the initiation of intravenous t-PA administration with further intra-arterial fibrinolysis or mechanical thrombolectomy may improve the recanalization rate. Thrombolysis in combination with ultrasound-enhanced clot lysis is another attractive therapy. In Japan the neuroprotective agent edaravone (radical scavenger) is commonly used in combination with t-PA, and it is expected to decrease the hemorrhagic transformation after t-PA administration. Acute cerebral ischemic symptoms may occasionally precede thoracic aortic dissection. Thoracic aortic dissection after t-PA administration may prove to be fatal, and it is an important disorder that must be differentially diagnosed.
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PMID:[Thrombolysis by intravenous tissue plasminogen activator (t-PA)--current status and future direction]. 1917 6

We report the case of a systemic air embolism occurring during pulmonary radiofrequency ablation. At the end of the procedure, the patient experienced a sudden myocardial infarction, complicated by ventricular fibrillation, cardiac arrest, and cerebral infarction. Thoracic computed tomography showed an air-blood level inside the left atrium and ventricle, the aortic arch, and the coronary arteries. Cerebral computed tomography showed an infarct in the frontoparietal area. Myocardial infarction and stroke responded to resuscitation measures, including hyperbaric oxygenation. The occurrence of this life-threatening event confirms the need to train experienced anesthesiologists in these new invasive approaches to cancer treatment.
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PMID:Massive systemic air embolism during percutaneous radiofrequency ablation of a primary lung tumor. 1960 23


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