Seminars in vascular surgery
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Review Comparative Study
Renal protection: preconditioning for the prevention of contrast-induced nephropathy.
As the numbers of interventional procedures are rising exponentially, identification of those patients at risk for renal complications has become even more important. Renal complications have been associated with increased morbidity and mortality after interventions. ⋯ Hydration and medications have been studied as protective measures to decrease risk of renal complications. Preconditioning patients with intravenous hydration has been found to be the most helpful in circumventing postprocedural contrast-induced nephropathy.
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With the introduction of retrievable inferior vena cava filters, the number being placed for protection from pulmonary embolism is steadily increasing. Despite this increased usage, the true incidence of complications associated with inferior vena cava filters is unknown. This article reviews the known complications associated with these filters and suggests recommendations and techniques for inferior vena cava filter removal.
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Thoracoabdominal aortic aneurysm (TAAA) is a life-threatening condition with a potentially high risk of rupture (46% to 74%) when left untreated. Mean elective surgical mortality rate is 6.6% at best, rising to 47% for emergency operations. Standard thoracic endovascular repair alone is not currently considered an adequate approach to treat TAAA because of the visceral arteries involved by the aneurysm sac. ⋯ Three transient renal function impairments (20%) and one type III endoleak (11%), which sealed spontaneously at the 1-month assessment, were detected. Sandwich technique for TAAA repair is a safe, well-tolerated, feasible alternative using ready-to-use endoprosthesis to provide efficient visceral revascularization in types I, II, III, and IV TAAAs. The sandwich technique appears to be a promising tool in the endovascular repair of TAAA, but more experience with the method is warranted.
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Diabetic neuropathy is common and it has been estimated that around 40% of older type 2 diabetic patients have risk factors for foot ulceration. It is the loss of the "gift of pain" that results in the development of what should be preventable foot lesions in many patients. As neuropathy is silent in up to 50% of patients, all diabetic patients should receive an annual screening by careful examination of the lower limbs for evidence of any sensory loss or peripheral vascular disease. Similarly, it must be remembered when treating neuropathic foot lesions that patients will willingly weight-bear on plantar ulcers: suitable offloading is therefore the first-line treatment for such lesions.
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Increased intra-abdominal pressure (IAP) and abdominal compartment syndrome (ACS) are important clinical problems after repair of ruptured abdominal aortic aneurysms and are reviewed here. IAP >20 mm Hg occurs in approximately 50% of patients treated with open abdominal aortic aneurysm repair after rupture, and approximately 20% develop organ failure or dysfunction, fulfilling the criteria for ACS. Patients selected for endovascular aneurysm repair are often more hemodynamically stable, perhaps related to not handling the viscera or more favorable anatomy, resulting in less bleeding and, consequently, decreased risk of developing ACS. ⋯ In addition, it should prevent lateralization of the bowel wall and adhesions between the intestines and the bowel wall. Enteroatmospheric fistulae must be prevented. Many alternative methods have been suggested, but we prefer the combination of vacuum-assisted wound closure with mesh-mediated traction, which will be described.