Reparación endovascular de la aorta torácica, resultados a largo plazo / Endovascular repair of the thoracic aorta, long-term results

Resumen Introducción: Las diversas patologías de la aorta torácica descendente, representan una implícita amenaza para la vida, y son potencialmente tratables mediante reparación endovascular. Objetivo: Evaluar los resultados de la reparación endovascular de la aorta torácia descendente (TEVAR). Material y Método: Estudio observacional, retrospectivo y descriptivo, donde se analiza TEVAR, en un período de 10 años (2009 al 2019), en el Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Se realizó TEVAR en 31 pacientes, sexo masculino 74,2%, femenino 25,8%, edad promedio 67,8 años (rango 53-85), patologías asociadas: hipertensión arterial sistémica (77,4%), tabaquismo (67,7%) y dislipidemia (38,7%), las indicaciones para TEVAR fueron: el aneurisma de la aorta descendente (51,61%), la disección tipo B crónica complicada (29,03%), y la disección tipo B aguda complicada (19,35%), relacionado al procedimiento se evidenció: morbilidad cardiovascular (12,9%) y morbilidad neurológica (6,45%), complicaciones relacionadas a la endoprótesis (29,03%), incidencia de endofugas (19,35%), estancia hospitalaria promedio de 5,2 días (rango 3 a 17), seguimiento promedio de 47,3 meses (9-108), éxito técnico primario (100%), tasa de reintervención: 3,22%, tasa de supervivencia a 1, 3, 5 años del 96,77%, 93,54 y 90,32% respectivamente, no hubo mortalidad menor a 30 días. Discusión: La evidencia demuestra que TEVAR puede realizarse en forma segura y efectiva, cumpliendo estrictos criterios clínicos y condiciones anatómicas, representando la modalidad de elección para la reparación de las lesiones de la aorta descendente. Conclusión: Los resultados demuestran que TEVAR, representa una excelente estrategia terapeutica, menos invasiva, con baja morbilidad y mortalidad asociada.

Introduction: The pathological injuries of the descending thoracic aorta, represent an implicit threat to life, and are potentially treatable by endovascular repair. Aim: To evaluate the results of endovascular repair of the descending thoracic aorta (TEVAR) in the medium and long term. Material and Method: Observational, retrospective and descriptive study, where TEVAR is analyzed, over a period of 10 years (2009 to 2019), at the Dr. Eduardo Pereira Hospital in Valparaíso, Chile. Results: TEVAR was performed in 31 patients, male sex 74.2%, average age 67.8 years (range 53-85), symptomatic 64.5%, associated pathologies: systemic arterial hypertension (77.4%), smoking (67.7%) and dyslipidemia (38.7%), indications for endovascular repair were descending aortic aneurysm (51.61%), complicated Stanford type B chronic aortic dissection (29.03%), and complicated Stanford type B acute aortic dissection (19.35%), neurological morbidity (6.45%), cardiovascular morbidity (12.9%), complications related to the stent (29.03%), where endoleaks predominate (19.35%), average hospital stay of 5.2 days (range 3 to 17), average followup of 47.3 months (9-108), primary technical success (100%), survival rate at 1, 3, 5 years of 96.77%, 93.54 and 90.32% respectively, there was no mortality less than 30 days or reoperation. Discussion: the evidence shows that TEVAR can be performed safely and effectively, meeting strict clinical criteria and anatomical conditions, which represents the modality of choice for the repair of lesions in the descending aorta. Conclusion: The results show that TEVAR represents an excellent therapeutic strategy, less invasive, with low associated morbidity and mortality.

Fístula aorto-duodenal primaria: caso clínico / Primary aorto-duodenal fistula: clinical case

Resumen Introducción Las fístulas aorto-entéricas (FAE) son una causa infrecuente de hemorragia digestiva. El pronóstico, generalmente ominoso, depende de una alta sospecha clínica y diagnóstico oportuno. Caso clínico Reportamos el caso de una mujer de 66 años intervenida por un aneurisma sacular aórtico abdominal (AAA) yuxtarrenal, con rotura contenida, fistulizado al duodeno. Presentó una hemorragia digestiva en el preoperatorio; sin embargo, el diagnóstico de la fístula se hizo en el intraoperatorio. La paciente fue sometida a reparación quirúrgica urgente con instalación de una prótesis aórtica bifemoral y resección duodenal. En el postoperatorio inmediato presentó una trombosis parcial de las ramas de la prótesis aórtica e isquemia de extremidades, siendo reintervenida exitosamente. Discusión La FAE es una causa potencialmente fatal de hemorragia digestiva. El diagnóstico continúa siendo un desafío debido a su presentación inespecífica y siempre debiese ser considerado frente a una hemorragia digestiva sin causa aparente. Existen varias opciones para el enfrentamiento quirúrgico que deben ser analizadas caso a caso, sin retrasar la reparación de la fístula. Es preferible la resección duodenal ante la simple duodenorrafia.

Introduction Aorto-enteric fistulae (AEF) are a rare cause of gastrointestinal bleeding. The prognosis tends to be ominous, depending greatly in a high level of clinical suspicion and prompt diagnosis. Clinical case We report a case of a 66-year-old female with a saccular juxta-renal abdominal aortic aneurysm (AAA), with a contained rupture. The patient was urgently submitted to surgical repair using an bifemoral aortic prosthesis. A duodenal partial resection was performed. During the immediate postoperative time she presented partial thrombosis of prosthesis and ischemia of lower extremities so she was reoperated successfully. Discussion AEF is a potentially fatal cause of gastrointestinal bleeding. Diagnosis is still troublesome due to its vague presentation and it should always be considered when facing gastrointestinal haemorrhage with no apparent cause. There are several surgical approaches that should be pondered case to case without delaying the repair of the defect.

Endovascular treatment of the ascending aorta: is this the last frontier in aortic surgery?

Abstract Regardless the successful treatment of the descending aorta with endovascular prosthesis, for the ascending aorta segment, because of several anatomic and physiologic issues, this technique has been considered an alternative only for high-risk or inoperable patients. Despite restricted indications, hundreds of treatments have been performed worldwide, demonstrating its safety and reproducibility if it is done in high-quality centers. Therefore, understanding patients' selection criteria and technique limitations are critical to its application.

Reemplazo de arco aórtico y aorta descendente proximal por aneurisma o disección aórtica con prótesis Thoraflex / Aortic arch and proximal descending aorta replacement with the Thoraflex* prosthesis

Resumen: El compromiso simultáneo del arco aórtico y aorta descendente proximal, ya sea por disección o aterosclerosis, constituye uno de los mayores desafíos que puede enfrentar un cirujano cardiovascular. La prótesis híbrida Thoraflex, introducida en los últimos años, ha resultado ser una importante ayuda para el tratamiento quirúrgico de esta compleja y grave patología. Esta consiste en un tubo protésico de Dacron con 4 ramas, para el reemplazo del arco aórtico y sus troncos braquiocefálicos y perfusión corporal distal, y una endoprótesis que queda como "trompa de elefante suspendida" en la aorta descendente proximal. Presentamos en esta oportunidad nuestra experiencia inicial en 4 pacientes, 3 con disección aórtica crónica y una con un aneurisma aterosclerótico, usando la prótesis híbrida Thoraflex.

Abstract: Atherosclerotic aneurysm or dissection of the aortic arch and proximal descending thoracic aorta is one of the major challenges for a cardiovascular surgeon. The new hybrid prosthesis Thoraflex has become an important devise to simplify the surgical treatment of this very complex and technically demanding aortic pathology. This hybrid prosthesis consists of a 4-branched arch graft with a stent-graft at the distal end. The proximal part is a gelatin-coated woven polyester prosthesis. The stented section is a self-expanding endoprosthesis constructed of thin-walled polyester and nitinol ring stents that is left in the proximal descending aorta as a "frozen elephant trunk". We present our initial experience with the Thoraflex prosthesis in four patients, three of them with chronic aortic dissection and one with an atherosclerotic aneurysm.

Estudo experimental de reconstrução da veia femoral com enxerto tubular do bipolímero de cana-de-açúcar / Experimental study of femoral vein reconstruction with sugarcane biopolymer tubular graft

RESUMO Objetivo: avaliar, através de dopplerfluxometria, de venografia, de histologia e de evolução clínica, o uso de enxertos tubulares de biopolímero de cana-de-açúcar (BP) na reconstrução de veias femorais em cães. Métodos: oito cães adultos foram submetidos à reconstrução de veia femoral, à esquerda com enxerto tubular de BP e à direita com veia autóloga. No período pós-operatório, os animais foram submetidos à avaliação clínica e dopplerfluxometria das veias femorais. Após 360 dias, os cães foram reoperados e submetidos à flebografia das veias femorais com contraste iodado. Os segmentos das veias femorais contendo os enxertos foram retirados e enviados para avaliação histopatológica. Resultados: os cães não apresentaram hemorragia, hematoma, infecção da ferida operatória ou edema dos membros operados. Um animal apresentou dilatação venosa superficial na região inguinal esquerda. A flebografia realizada 360 dias após a primeira cirurgia demonstrou que três (37,5%) enxertos de BP e sete (87,5%) do grupo controle (C) estavam pérvios. Na avaliação histopatológica foi encontrada uma reação inflamatória com neutrófilos e linfócitos na superfície externa de ambos os grupos. Na camada íntima de revestimento dos enxertos e na camada externa nos dois grupos, foi encontrada fibrose. Conclusão: com base nos resultados obtidos com o modelo experimental utilizado, conclui-se que a BP apresenta potencial para ser utilizado como enxerto tubular para revascularização venosa, porém novas pesquisas precisam ser realizadas para confirmar a sua eficácia na revascularização de veias de médio e grande calibre, o que poderia permitir o seu uso na prática clínica.

ABSTRACT Objective: to evaluate, through Doppler flowmetry, venography, histology and clinical evolution, the use of sugarcane biopolymer (BP) tubular grafts in the reconstruction of femoral veins in dogs. Methods: we submitted eight adult dogs to femoral vein reconstruction, on the left with BP tubular graft and on the right with autologous vein. In the postoperative period, the animals underwent clinical evaluation and femoral vein Doppler flowmetry. After 360 days, we reoperated the dogs and submitted them to femoral vein phlebography with iodinated contrast. We removed the segments of the femoral veins containing the grafts and sent them for histopathological evaluation. Results: the dogs did not present hemorrhage, hematoma, surgical wound infection or operated limb edema. One animal had superficial venous dilatation in the left inguinal region. Phlebography performed 360 days after the first surgery showed that three (37.5%) BP grafts and seven (87.5%) grafts from the control group (C) were patent. In the histopathological evaluation, we found an inflammatory reaction, with neutrophils and lymphocytes on the external surface of both groups. In the intimal layer of the grafts and in the outer layer in the two groups, we observed fibrosis. Conclusion: based on the results obtained with the experimental model used, BP presents potential to be used as a tubular graft for venous revascularization. However, new research must be performed to confirm its efficacy in the revascularization of medium and large diameter veins, which could allow its use in clinical practice.

Experimental implantation of an arterial substitute made of silicone reinforced with polyester fabric in rabbits

OBJECTIVES: The aim of this study was to analyze silicone tubes with an internal diameter of 4 mm as a possible material for vascular prostheses. METHODS: Grafts were implanted into the infrarenal aortas of 33 rabbits. Fluoroscopic examinations were performed within 150 days after surgical implantation. Sample grafts were analyzed via electron microscopy to evaluate the eventual endothelialization of the prostheses. RESULTS: The patency rates of the prostheses were 87% (±6.7%) after 30 days, 73% (±9.3%) after 60 days and 48% (±12%) after 120 days. The material presented characteristics that support surgical implantation: good tolerance promoted by polyester tear reinforcement, ease of postoperative removal and a lack of pseudoaneurysms. However, intimal hyperplasia was a limiting factor for the patency rate. CONCLUSIONS: We concluded that polydimethylsiloxane has limited potential as an alternative material for small vascular prostheses.

Hybrid approach of aortic diseases: zone 1 delivery and volumetric analysis on the descending aorta

Abstract Introduction: Conventional techniques of surgical correction of arch and descending aortic diseases remains as high-risk procedures. Endovascular treatments of abdominal and descending thoracic aorta have lower surgical risk. Evolution of both techniques - open debranching of the arch and endovascular approach of the descending aorta - may extend a less invasive endovascular treatment for a more extensive disease with necessity of proximal landing zone in the arch. Objective: To evaluate descending thoracic aortic remodeling by means of volumetric analysis after hybrid approach of aortic arch debranching and stenting the descending aorta. Methods: Retrospective review of seven consecutive patients treated between September 2014 and August 2016 for diseases of proximal descending aorta (aneurysms and dissections) by hybrid approach to deliver the endograft at zone 1. Computed tomography angiography were analyzed using a specific software to calculate descending thoracic aorta volumes pre- and postoperatively. Results: Follow-up was done in 100% of patients with a median time of 321 days (range, 41-625 days). No deaths or permanent neurological complications were observed. There were no endoleaks or stent migrations. Freedom from reintervention was 100% at 300 days and 66% at 600 days. Median volume reduction was of 45.5 cm3, representing a median volume shrinkage by 9.3%. Conclusion: Hybrid approach of arch and descending thoracic aorta diseases is feasible and leads to a favorable aortic remodeling with significant volume reduction.

Hybrid treatment with complete transposition of supra-aortic trunks versus conventional surgery for the treatment of aortic arch aneurysm

Abstract Objective: The disease of the aortic arch is traditionally approached by open surgical repair requiring cardiopulmonary bypass and circulatory arrest. This study performed a retrospective analysis comparing outcomes through primary hybrid patients submitted to aortic arch surgery without cardiopulmonary bypass with patients submitted to conventional open surgery. Methods: 25 patients submitted to the aortic arch surgery were selected in the period 2003-2012 at the Madre Teresa Hospital in the city of Belo Horizonte, Brazil; 13 of these underwent hybrid technique without cardiopulmonary bypass and 12 underwent conventional open surgery. Results: The mortality rate for the hybrid group was 23% and for the conventional surgery group was 17% (P=0.248). The postoperative complication rate was also similar in both groups, with no significant difference. Conclusion: Both techniques proved to be similar in mortality and morbidity. However, due to the small sample, more analytical studies with larger samples and long-term follow-up are needed to clarify this issue.

Thoracoabdominal aortic aneurysm in a hiv-positive patient

Abstract Advent of antiretroviral therapy has increased survival of patients with human immunodeficiency virus (HIV) infections, with the result that some of these patients now develop degenerative diseases, such as atherosclerotic aneurysms. Degenerative thoracoabdominal aortic aneurysm is rare in HIV patients. In this report, a 63-year-old male patient with HIV submitted to open repair of thoracoabdominal aortic aneurysm. The patient did not suffer any type of complication in the perioperative period and remained well in a 28-month follow-up period. In summary, open repair still remains a good alternative for aortic complex aneurysms even in HIV patients.

Experimental model for sutureless proximal anastomosis by the viabahn open revascularization technique (VORTEC)

Abstract Introduction: In the treatment of complex aneurysms, debranching is an extra-anatomical revascularization of visceral arteries followed by endograft coverage of the thoracoabdominal aorta. It eliminates the need for a thoracotomy and aortic clamping, but requires the performance of several technically demanding visceral anastomosis. In 2008, Lachat described visceral revascularization with the use of a sutureless distal anastomosis, performed by the telescoping of an endograft in the visceral branch, named VORTEC (Viabahn Open Revascularization TEChnique). Objective: An experimental model was created to test the feasibility and short term results of performing a telescoped proximal anastomosis to the abdominal aorta. Methods: Swine model. The abdominal aorta was dissected and ligated between the renal arteries and the iliac vessels. Three centimeters bellow the renal arteries a Viabahn endograft was telescoped for 2 cm into the proximal aorta. The other extremity was conventionally anastomosed to the distal aorta. Patency, sealing and tensile strength of the anastomosis were tested. Results: Time for performing the telescoped anastomosis was shorter (5.4±2.8 min versus 10.3±3.4 min, P<0.05). All grafts were patent and both types of anastomosis presented no bleeding. Immediate tensile strength showed a higher strength of the conventional suture (22.7 x 14.3 N, P<0.09). After 30 days there was no pseudo-aneurysms and the strength of the conventional and VORTEC anastomosis were similar (37.3 x 40.8 N, respectively, P=0.17). Conclusion: Telescoped proximal anastomosis by the technique of VORTEC is feasible. After 30 days the tensile strength of the both anastomosis were similar.

Outcomes of surgery for patients with Behcet's disease causing aortic pseudoaneurysm: a shift from open surgery to endovascular repair

OBJECTIVES: Behcet’s disease is a form of systematic vasculitis that affects vessels of various sizes. Aortic pseudoaneurysm is one of the most important causes of death among patients with Behcet’s disease due to its high risk of rupture and associated mortality. Our study aimed to investigate the outcomes of Behcet’s disease patients with aortic pseudoaneurysms undergoing open surgery and endovascular aortic repair. METHODS: From January 2003 to September 2014, ten consecutive patients undergoing surgery for aortic pseudoaneurysm met the diagnostic criteria for Behcet’s disease. Endovascular repair was the preferred modality and open surgery was performed as an alternative. Systemic immunosuppressive medication was administered after Behcet’s disease was definitively diagnosed. RESULTS: Eight patients initially underwent endovascular repair and two patients initially underwent open surgery. The overall success rate was 90% and the only failed case involved the use of the chimney technique to reach a suprarenal location. The median follow-up duration was 23 months. There were 7 recurrences in 5 patients. The median interval between operation and recurrence was 13 months. No significant risk factors for recurrence were identified, but a difference in recurrence between treatment and non-treatment with preoperative immunosuppressive medication preoperatively was notable. Four aneurysm-related deaths occurred within the follow-up period. The overall 1-year, 3-year and 5-year survival rates were 80%, 64% and 48%, respectively. CONCLUSIONS: Both open surgery and endovascular repair are safe and effective for treating aortic pseudoaneurysm in Behcet’s disease patients. The results from our retrospective study indicated that immunosuppressive medication was essential to defer the occurrence and development of recurrent aneurysms.

Dacron graft intussusception technique for treatment of type a aortic dissections: technical notes and preliminary results

Abstract Introduction: Optimal surgical management for acute type A aortic dissection (AAAD) remains unclear. The in-hospital mortality rate is still high (15%), and the intraoperative bleeding is an independent risk factor for hospital mortality. Objective: The aim of our study was describe a new method for aortic anastomosis in the repair of AAAD and report the hospital mortality and bleeding complications. Methods: Between January 2008 and November 2014, 24 patients, 16 male, median age 62 years, underwent surgical treatment of AAAD. The surgical technique consisted of intussusception of a Dacron tube in the dissected aorta, which is anastomosed with a first line of 2-0 polyester everting mattress suture and a second line of 3-0 polypropylene running suture placed at the outermost side. Open distal anastomosis was performed with bilateral selective antegrade cerebral perfusion in 13 (54.1%) patients. Results: Cardiopulmonary bypass and aortic clamping time ranged from 75 to 135 min (mean=85 min) and 60 to 100 min (mean=67 min), respectively. The systemic circulatory arrest ranged from 29 to 60 min (mean=44.5 min). One (4.1%) patient required reoperation for bleeding, due to the use of preoperative clopidogrel. The postoperative bleeding was 382-1270 ml (mean=654 ml). We used an average of 4.2 units of red blood cells/patient. There were two (8.3%) hospital deaths, one due to intraoperative bleeding and another due to mesenteric ischemia. The average length of stay in the intensive care unit and hospital was 44 hours and 6.7 days, respectively. Conclusion: This new method for surgical correction of AAAD was reproducible and resulted in satisfactory clinical outcomes.

Dilatation of common iliac arteries after endovascular infrarenal abdominal aortic repair with bell-bottom extension

Abstract Objective: Endovascular techniques to treat abdominal aortic aneurysms results in lower morbidity and mortality rates. However, dilation of the common iliac arteries prevents adequate distal sealing, which compromises the procedure success. The aim of this study is report the long-term outcomes of patients with abdominal aortic aneurysms associated with aneurysm of the common iliac artery following endovascular repair using a bifurcated bell-bottom stent graft. Methods: This is a retrospective study that evaluated patients treated with bifurcated bell-bottom extension stent grafts to repair an infrarenal abdominal aortic aneurysm and who had at least one common iliac artery with dilatation > 1.5 cm for at least 12 months after the endovascular intervention. Results: Thirty-eight patients with a mean age of 70.4±8.2 years were included. Stent graft placement was followed by dilation of the common iliac artery aneurysms in 35.3% of cases; endoleak and reoperation rates were 17.6% and 15.7%, respectively. Younger patients showed a higher rate of artery diameter increase following the procedure. The average arterial dilation was 16% in the first year, 29% in the second year, 57% in the third year and 95% from the fourth year until the end of follow-up. Conclusion: Repair of infrarenal abdominal aortic aneurysms with bifurcated bell-bottom type stents when there is common iliac artery dilation is a good therapeutic option to preserve hypogastric flow. The rate of endoleak was 17.6%, and 15.7% of cases required reoperation. Younger patients are more likely to experience dilation of the common iliac artery after the procedure.

Lyophilized allografts without pre-treatment with glutaraldehyde are more suitable than cryopreserved allografts for pulmonary artery reconstruction

Various methods are available for preservation of vascular grafts for pulmonary artery (PA) replacement. Lyophilization and cryopreservation reduce antigenicity and prevent thrombosis and calcification in vascular grafts, so both methods can be used to obtain vascular bioprostheses. We evaluated the hemodynamic, gasometric, imaging, and macroscopic and microscopic findings produced by PA reconstruction with lyophilized (LyoPA) grafts and cryopreserved (CryoPA) grafts in dogs. Eighteen healthy crossbred adult dogs of both sexes weighing between 18 and 20 kg were used and divided into three groups of six: group I, PA section and reanastomosis; group II, PA resection and reconstruction with LyoPA allograft; group III, PA resection and reconstruction with CryoPA allograft. Dogs were evaluated 4 weeks after surgery, and the status of the graft and vascular anastomosis were examined macroscopically and microscopically. No clinical, radiologic, or blood-gas abnormalities were observed during the study. The mean pulmonary artery pressure (MPAP) in group III increased significantly at the end of the study compared with baseline (P=0.02) and final [P=0.007, two-way repeat-measures analysis of variance (RM ANOVA)] values. Pulmonary vascular resistance of groups II and III increased immediately after reperfusion and also at the end of the study compared to baseline. The increase shown by group III vs group I was significant only if compared with after surgery and study end (P=0.016 and P=0.005, respectively, two-way RM ANOVA). Microscopically, permeability was reduced by ≤75% in group III. In conclusion, substitution of PAs with LyoPA grafts is technically feasible and clinically promising.

Developing a new endograft for the treatment of juxtarenal aortic aneurysms: definition and experimentation

OBJECTIVES: To analyze angiotomographic parameters of juxtarenal aneurysms to assess the applicability of an endograft model to patients and to create in vitro and in vivo models to assess the new endograft. METHODS: A total of 49 patients with juxtarenal aneurysms were submitted to angiotomographic evaluation, and parameters such as the aortic diameter, the length of the neck, and the angulations of the celiac trunk, superior mesenteric artery and renal arteries; the distances between them; and anatomic variations were analyzed. Based on these parameters, an endograft model was developed and tested in a newly created in vitro model of juxtarenal aneurysm. An experimental model of juxtarenal aneurysm was then established in six pigs weighing 50-60 kg to assess the new endograft model. RESULTS: The angiotomographic parameters of juxtarenal aneurysm measured in this study were similar to those reported in the literature and allowed the development of an endograft based on the hourglass concept, which was applicable to 85.8% of the patients. The in vitro model of juxtarenal aneurysm evidenced good radiopacity and functionality and permitted adjustments in the new device and technical improvements in the procedures for treating these aneurysms. In addition, the porcine model of juxtarenal aneurysm was successfully created in all six animals using a bovine pericardial patch, and use of the new endograft in three pilot procedures evidenced its feasibility. CONCLUSIONS: The Hourglass endograft was rendered applicable to treatment of the majority of patients with juxtarenal aneurysms simply by changing its diameter. Moreover, the new in vitro and in vivo models were shown to be effective for assessing both the presented endograft and experiments assessing the endovascular treatment of juxtarenal aneurysms. .

Surgical treatment of complex aneurysms and thoracic aortic dissections with the Frozen Elephant Trunk technique / Tratamento cirúrgico dos aneurismas complexos e dissecções da aorta torácica utilizando a técnica "Frozen Elephant Trunk"

Abstract Objective: Report initial experience with the Frozen Elephant Trunk technique. Methods: From July 2009 to October 2013, Frozen Elephant Trunk technique was performed in 21 patients (66% male, mean age 56 ±11 years). They had type A aortic dissection (acute 9.6%, chronic 57.3%), type B (14.3%, all chronic) and complex aneurysms (19%). It was 9.5% of reoperations and 38% of associated procedures (25.3% miocardial revascularization, 25.3% replacement of aortic valve and 49.4% aortic valved graft). Aortic remodeling was evaluated comparing preoperative and most recent computed tomography scans. One hundred per cent of complete follow-up, mean time of 28 months. Results: In-hospital mortality of 14.2%, being 50% in acute type A aortic dissection, 8.3% in chronic type A aortic dissection, 33.3% in chronic type B aortic dissection and 0% in complex aneurysms. Mean times of cardiopulmonary bypass (152±24min), myocardial ischemia (115±31min) and selective cerebral perfusion (60±15min). Main complications were bleeding (14.2%), spinal cord injury (9.5%), stroke (4.7%), prolonged mechanical ventilation (4.7%) and acute renal failure (4.7%). The need for second-stage operation was 19%. False-lumen thrombosis was obtained in 80%. Conclusion: Frozen Elephant Trunk is a feasible technique and should be considered. The severity of the underlying disease justifies high mortality rates. The learning curve is a reality. This approach allows treatment of more than two segments at once. Nonetheless, if a second stage is made necessary, it is facilitated. .

Resumo Objetivo: Relatar experiência inicial com a técnica "Frozen Elephant Trunk". Métodos: Entre julho de 2009 e outubro de 2013, 21 pacientes, 66% homens, média de idade de 56±11 anos, 66,7% portadores de dissecção da aorta tipo A de Stanford (9,6% agudas e 57,1% crônicas), tipo B (14,3%, todas crônicas) e aneurismas complexos (19%), foram operados pela técnica Frozen Elephant Trunk. Foram 9,5% de reoperações e 38% com procedimentos associados (25,3% revascularizações do miocárdio, 25,3% troca da valva aórtica e 49,4% tubos valvulados). Remodelamento da aorta foi avaliado com a comparação de angiotomografia pré-operatória e pós-operatória mais recente. Seguimento 100% dos pacientes, tempo médio de 28 meses. Resultados: Mortalidade hospitalar de 14,2%, sendo 50% nas dissecções do tipo A agudas, 8,3% nas tipo A crônicas, 33,3% nas tipo B crônicas e 0% nos aneurismas complexos. Tempos médios de CEC (152±24min), isquemia miocárdica (115±31min) e perfusão cerebral seletiva (60±15min). Principais complicações pós-operatórias foram sangramento (14,2%), acidente vascular encefálico (4,7%), paraplegia (9,5%), intubação>72h (4,7%) e insuficiência renal aguda (4,7%). Houve necessidade de complementação do tratamento (distal ao stent) em 19%. Houve trombose da falsa luz em 80%. Conclusão: Frozen Elephant Trunk é opção técnica a ser utilizada. A gravidade e extensão da doença justificam mortalidade mais elevada. A curva de aprendizado é uma realidade. Esta abordagem permite abordar mais de dois segmentos de aorta em um estágio, mas se necessário segundo estágio, este é facilitado. .

Balloon-Supported Passage of a Stent-Graft into the Aortic Arch

A 62-year-old man was admitted, and thoracic endovascular aortic repair (TEVAR) procedure was performed to treat an accidentally detected aortic aneurysm, which was 63 mm in diameter. While performing TEVAR, the passage of the stent-graft introducer system was impossible due to the prolapse of the introducer system into a wide-necked aneurysm; this aneurysm was located at the greater curvature of the proximal descending thoracic aorta. In order to advance the introducer system, a compliant balloon was inflated. Thus, we created an artificial wall in the aneurysm with this inflated balloon. Finally, we were able to advance the introducer system into the target zone.

Uso combinado de endoprótese GORE TAG® e Gore Exculder® para tratamento de aneurisma de aorta abdominal com angulação extrema / Combined use of GORE TAG® and Gore Exculder® endografts for treatment of abdominal aortic aneurysm with severe angulation

O avanço tecnológico da cirurgia endovascular no tratamento de aneurismas de aorta vem permitindo que uma maior quantidade de pacientes, antes considerados inaptos para essa abordagem, beneficie-se dessa modalidade terapêutica. Apesar da atual disponibilidade de endopróteses com alta conformabilidade, casos com anatomia desfavorável permanecem um desafio para os cirurgiões. Descrevemos um caso anatomicamente desfavorável, resolvido com sucesso pela técnica endovascular, utilizando-se uma manobra não convencional.

The advances in endovascular surgery for treatment of aortic aneurysms have allowed a greater number of patients, who were previously considered unsuitable for the approach, to benefit from this therapeutic modality. Despite the current availability of highly comfortable endografts, cases with unfavorable anatomy remain a challenge for surgeons. We report a case with difficult anatomy that was successfully managed using an unconventional endovascular technique.