Outcomes and Economic Impact of Hypogastric Artery Management During Elective Endovascular Aortic Repair for Aorto-Iliac Aneurysms

Background: To analyze clinical outcomes and perform a macro-costing evaluation of endovascular aortic repair (EVAR) for aorto-iliac aneurysms. Methods: This is a retrospective, financially unsupported, physician-initiated observational cohort study. Patients with iliac artery involvement treated with EVAR between January 1st, 2014 and December 31st, 2021 were identified. Inclusion criteria were intact aneurysm, elective EVAR with at least 1 hypogastric artery (HA) treatment, use of bifurcated endograft (EG), and at least 6 months of follow-up. Primary outcomes of interest were overall survival, freedom from aneurysm-related mortality (ARM), freedom from EVAR-related reintervention, and overall EVAR(procedure)-related costs. Results: We studied 122 (9.1%) patients: 119 (97.5%) were male and 3 (2.5%) females. Median age of patients was 76 years (range, 68.75–81). Overall, 107 (87.7%) patients had both HAs preserved according to following strategy: 45 (36.9%) with flared limbs, 13 (10.6%) with bilateral branched device, and 49 (40.2%) with a combination of flared limb on 1 side and branched device on the contralateral side. Bilateral overstenting was performed in 15 (12.3%) patients. Estimated overall survival was not different between groups of EVAR (Log-rank, P = 0.561). There was only 1 (0.8%) ARM ascertained during the follow-up. Estimated freedom from EVAR-related reintervention was not different among groups (Log-rank, P = 0.464). During the follow-up, 9 (7.4%) patients developed buttock claudication (Society for Vascular Surgery (SVS) grade 1, n = 4, SVS grade 2, n = 5), more frequently in HA overstenting (hazard ratio (HR): 3.6; 95% confidence intervals (CIs): 0.96–13.5, P = 0.058). When all cots were included, branched EVAR still carried the highest burden (P = 0.001) in comparison with the mixed subgroup, the overstenting subgroup, and the flared limbs subgroup. Conclusions: Early mortality and pelvic ischemic syndromes rate were acceptably low in all techniques. Hypogastric artery preservation showed lower complication rate in comparison with HA overstenting which, however, appears to be safe an effective for option with similar overall costs for patients who are not candidates for HA preservation based on aortic anatomy

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Degenerazione aneurismatica dell'asse arterioso axillo-omerale conseguente a legatura di fistola arterovenosa per emodialisi

INTRODUZIONE/SCOPO DELLO STUDIO La legatura di una fistola arterovenosa per emodialisi pu\uf2 comportare la degenerazione aneurismatica a medio-lungo termine dell\u2019asse arterioso axillo-omerale, le cui complicanze costituiscono una minaccia per la vitalit\ue0 dell\u2019arto. Tale condizione, descritta sporadicamente in letteratura, occorre pi\uf9 frequentemente in pazienti sottoposti a terapia immunosoppressiva dopo trapianto renale. MATERIALE E METODI Dal 2006 ad oggi abbiamo osservato 3 casi di degenerazione aneurismatica dell\u2019asse axillo-omerale dopo chiusura di fistola arterovenosa per emodialisi, in pazienti in trattamento immunosoppressivo in esiti di trapianto renale. In un caso il paziente \ue8 giunto alla nostra osservazione per un quadro di ischemia acuta della mano ed embolizzazione acromiale. Gli altri due pazienti erano asintomatici ma si presentavano con riscontro obiettivo di tumefazione pulsante all\u2019arto. Tutti i pazienti sono stati sottoposti a esame ecocolorDoppler. I pazienti asintomatici hanno inoltre eseguito accertamenti diagnostici di secondo livello (AngioTC \u2013 AngioRM). In tutti e tre i casi abbiamo osservato la presenza di un aneurisma di diametro compreso tra 22 e 30 mm caratterizzati da abbondante apposizione trombotica endoluminale condizionante netta riduzione del lume residuo. RISULTATI I pazienti sono stati sottoposti a exeresi dell\u2019aneurisma e ricostruzione dell\u2019asse arterioso. La focale dilatazione aneurismatica dell\u2019arteria omerale ha consentito in un caso l\u2019innesto di un breve segmento protesico in PTFE. Negli altri due pazienti, l\u2019estesa degenerazione dell\u2019asse arterioso ne ha resa necessaria la sostituzione mediante confezionamento di innesto in vena grande safena autologa invertita. I pazienti eseguono follow-up annuale mediante ecocolorDoppler, che dimostra regolare perviet\ue0 degli innesti in assenza di complicanze. DISCUSSIONI/CONCLUSIONI E\u2019 auspicabile che i pazienti sottoposti a legatura di fistola per emodialisi, soprattutto se sottoposti a terapia immunosoppressiva, vengano periodicamente monitorati clinicamente, ed ecograficamente al sospetto di ectasia arteriosa, per riconoscere la patologia degenerativa aneurismatica dell\u2019asse axillo-omerale e prevenirne le temibili complicanze. Qualora indicato, il trattamento chirurgico di prima scelta \ue8 la sostituzione con vena autologa

Os Brachyura semiterrestres Crustacea, Decapoda de Ilha Comprida, SP., Brasil

This work aims to analyse the faunistic composition of ''Ilha Comprida, SP, Brasil, in relation to semiterrestrial crabs. The collects were done during one year. The animals were handy sampled, and the colleting area comprised from Cananeia proximities to Icapara bar, towards north, including beaches, sand banks and mangroves. After each sample the animals were identified. The results obtained were similar those presented for other estuarine regions in São Paulo north coast. With reference to the species from Parana coast, we have got 2 species more. The crabs recorded are distributed in 3 Decapod families: Grapsidae, Ocypodidae and Xanthidae