Using the Casper Stent in Carotid Angioplasty: A Single Center Experience

Objectives To establish the success rate in endovascular internal carotid artery (ICA) stenosis recanalization using the double-layer stent Casper-RX (Microvention, Inc 35 Enterprise, Aliso Viejo, California, United States of America) and to identify the main comorbidities in individuals with ICA stenosis, morphological characteristics of the stenosis, diagnostic methods, intraoperative complications, as well as morbidity and mortality within 30 days of the surgical procedure. Materials and Methods Retrospective analysis of 116 patients undergoing ICA angioplasty with a degree of stenosis > 70% using Casper-RX stenting who underwent this procedure from April 2015 to December 2019. Results Technical success was achieved in 99.1% of the patients. Three of them had postprocedural complications: one transient ischemic attack (TIA) and two puncture site hematomas. A cerebral protection filter was not used in only two procedures, as these consisted of dissection of the carotid. There was satisfactory recanalization and adequate accommodation of the stents in the previously stenosed arteries, with no restenosis in 99.4% of the cases. Conclusion The endovascular treatment of extracranial carotid stenoses using the Casper-RX stent showed good applicability and efficacy. Although only two cases of thromboembolic complications occurred during the procedure, fu

Preoperative Endovascular Embolization of Glomus Jugulare Tumors: A Retrospective Case Series of 22 Embolizations in 20 Patients and Literature Review

Objective Glomus jugulare tumors, or tympanojugular paragangliomas, are rare, highly vascularized skull base tumors originated from paraganglion cells of the neural crest. With nonabsorbable embolic agents, embolization combined with surgery has become the norm. The authors assess the profile and outcomes of patients submitted to preoperative embolization in a Brazilian tertiary care hospital. Methods The present study is a single-center, retrospective analysis; between January 2008 and December 2019, 22 embolizations were performed in 20 patients in a preoperative character, and their medical records were analyzed for the present case series. Results Hearing loss was the most common symptom, present in 50% of the patients, while 40% had tinnitus, 30% had dysphagia, 25% had facial paralysis, 20% had hoarseness, and 10% had diplopia. In 7 out of 22 embolization procedures (31%) more than a single embolic agent was used; Gelfoam (Pfizer, New York, NY, USA) was used in 18 procedures (81%), in 12 of which as the single agent, followed by Embosphere (Merit Medical, South Jordan, UT, USA) (31%), Onyx (Medtronic, Minneapolis, MN, USA) (9%), and polyvynil alcohol (PVA) and Bead Block (Boston Scientific, Marlborough, MA, USA) in 4,5% each. The most common vessel involved was the ascending pharyngeal artery, involved in 90% of the patients, followed by the posterior auricular artery in 15%, the internal maxillary artery or the occipital artery in 10% each, and the superficial temporal or the lingual arteries, with 6% each. Only one patient had involvement of the internal carotid artery. No complications from embolization were recorded. Conclusions Preoperative embolization of glomus tumors is safe and reduces surgical time and complications, due to the decrease in size and bleeding.

Tratamento híbrido para revascularização de membro inferior em paciente com infecção de prótese vascular: relato de caso / Hybrid treatment for lower limb revascularization in a patient with vascular graft infection: a case report

Resumo Pacientes portadores de doença arterial obstrutiva periférica com isquemia crítica do membro associada a infecção de prótese vascular apresentam elevadas taxas morbimortalidade e alto risco de perda do membro. Apresentamos o caso de um paciente masculino de 76 anos com isquemia crítica do membro inferior esquerdo associada a infecção de prótese vascular femoropoplítea. Utilizamos abordagem híbrida para o tratamento com acesso cirúrgico das regiões inguinais e poplíteas, sendo a prótese vascular utilizada como acesso endovascular para recanalização direta da artéria femoral superficial devido a obstrução longa e extensa calcificação, que impediram as tentativas iniciais de tratamento endovascular. Após a recanalização endovascular, a prótese infectada foi retirada. O avanço das técnicas e materiais endovasculares em associação com a cirurgia aberta permitem novas soluções para pacientes quando os procedimentos habituais falham.

Abstract Patients with severe arterial obstructive disease and critical limb ischemia associated with vascular graft infection have elevated morbidity and mortality rates and are at high risk of limb loss. We present the case of a 76-year-old male patient with left lower limb critical ischemia and a femoropopliteal vascular graft infection. We used a hybrid treatment approach with an open surgical approach to the inguinal and popliteal regions and used the vascular prosthesis as endovascular access for direct recanalization of the superficial femoral artery, because the long occlusion and extensive calcification had frustrated initial attempts at endovascular treatment. After endovascular recanalization, the infected graft was removed. Used in conjunction with open surgery, advances in endovascular techniques and materials offer new solutions for patients when usual procedures fail.

Revascularización endovascular compleja multinivel y multivaso a través de un bypass fémoro-poplíteo ocluído en paciente con isquemia crónica con amenaza para las extremidades inferiores / Complex multilevel and multivessel endovascular revascularization through an occluded femoral-popliteal bypass in a patient with chronic limb threatening ischemia

Resumen La isquemia crónica con amenaza para las extremidades inferiores (ICAEI) representa el estadio final de la enfermedad arterial periférica, un problema de prevalencia creciente que conlleva el aumento de los costos de salud en todo el mundo. La ICAEI es una enfermedad con elevada morbilidad, generando mortalidad significativa, pérdida de miembros, dolor y disminución de la calidad de vida. La principal causa de amputaciones no-traumáticas de miembros inferiores está relacionada a la diabetes y a la ICAEI. Entre un 2% y 3% de los pacientes con enfermedad arterial periférica se presentan con un caso grave de ICAEI, condición que se correlaciona con enfermedad arterial multinivel y multiarterial, calcificación y oclusiones totales crónicas. Se describieron varias estrategias técnicas para cruzar con éxito largas oclusiones en segmentos arteriales. Se puede realizar la recanalización utilizando técnicas endoluminales, subintimales y retrógradas. Relatamos un caso de revascularización endovascular compleja multinivel y multiarterial a través de un bypass fémoro-poplíteo en una paciente con ICAEI.

Abstract Chronic limb-threatening ischemia (CLTI) represents the end stage of peripheral artery disease, a problem of growing prevalence and increased health care costs around the globe. CLTI is a highly morbid disease, incurring significant mortality, limb loss, pain, and diminished health-related quality of life. The major cause of non-traumatic lower extremity amputation are related to diabetes and CLTI. Between 2% to 3% of patients with peripheral artery disease present with a severe case of CLTI, a condition that is correlated with multilevel and multivessel arterial disease, calcification, and chronic total occlusions. Multiple technical strategies to successfully cross long occlusions in arterial segments have been described. Recanalization can be performed using endoluminal, subintimal, and retrograde techniques. We report a case of complex multilevel and multivessel endovascular revascularization through an occluded femoro-popliteal bypass in a patient with CLTI.

Clinical outcomes following microsurgery and endovascular embolization in the management of spinal dural arteriovenous fistula: A meta-analysis study / 北京大学学报(医学版)

OBJECTIVE@#To compare the clinical effect of microsurgery and endovascular embolization in the treatment of spinal dural arteriovenous fistula (SDAVF) by meta-analysis.@*METHODS@#A systematic review was performed to retrieve all relevant literature about surgical treatment or endovascular embolization of SDAVF up to December 2019 through PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials Results, CNKI, Wanfang Data, and SinoMed. The Chinese and English key words included: "SDAVF", "spinal dural arteriovenous fistula", "spinal AVM", "spinal vascular malformation and treatment". The included studies were evaluated using the Newcastle-Ottawa scale. The early failure rate, long-term recurrence, neurological recovery, and complications were evaluated and the clinical effects of the two methods in the treatment of SDAVF were compared by using RevMan 5.3 software. And a further subgroup analysis of the therapeutic effect of endovascular embolization with different embolic agents was conducted.@*RESULTS@#A total of 46 studies involving 1 958 cases of SDAVF were included, in which 935 cases were treated by microsurgery and 1 023 cases were treated by endovascular embolization. The funnel plot demonstrated that there was no publication bias. The results of meta-analysis showed that the incidence of early surgical failure was lower than that of endovascular embolization (OR=0.20, 95%CI: 0.13-0.30, P < 0.05), and the long-term recurrence was also lower than that of endovascular embolization (OR=0.36, 95%CI: 0.22-0.58, P < 0.05). The improvement of neurological function in the surgical patients is significantly higher than that in the patients treated with endovascular embolization (OR=2.86, 95%CI: 1.36-5.99, P < 0.05). There was no significant difference in the occurrence of complications in these two groups (OR=1.52, 95%CI: 0.88-2.64, P=0.14). In the cases of endovascular embolization, the risk of treatment failure or recurrence was higher with Onyx glue than with n-butyl 2-cyanoacrylate (NBCA), and the difference was statistically significant (OR=4.70, 95%CI: 1.55-14.28, P < 0.05).@*CONCLUSION@#Although the treatment of dural arteriovenous fistulas by intravascular embolization has been widely used, the clinical effect of microsurgery is still better than that of endovascular embolization. Large scale and high-quality randomized controlled trials are required to validate the efficacy and safety of endovascular treatment in SDAVF patients.

Vein of Galen Aneurysmal Malformations in Pediatric Patients Submitted to Endovascular Treatment: Report of 3 Cases

Objective To report three cases of vein of Galen aneurysmalmalformation (VGAM) in pediatric patients treated at the hemodynamics lab of Hospital Santa Isabel (HSI) in Blumenau, state of Santa Catarina, Brazil, from 2006 to 2020. Clinical presentation, endovascular treatment, and postprocedure evolution to date are included. Case description Three children aged 5 to 12 months with cardiac, respiratory, or neurological damage in the neonatal stage, were referred to the neurosurgery service and diagnosed with VGAM. The three patients underwent endovascular embolization of themalformation, with different clinical evolution throughout outpatient follow-up. Conclusion Vein of Galen aneurysmal malformations are uncommon vascular abnormalities that, until the advent of endovascular embolization, were associated with high morbidity and mortality rates. Its prognosis is linked with initial clinic, early diagnosis, and timely surgical correction.

Aneurisma de la arteria carótida interna como lesión compresiva de la vía visual / Internal carotid artery aneurysm as a compressive lesion of the visual pathway

El diagnóstico temprano de las lesiones compresivas del nervio óptico adquiere cada vez mayor importancia. La descompresión precoz de este o del quiasma puede resultar una mejora significativa de la función visual, mientras que el diagnóstico erróneo puede ocasionar pérdida visual irreversible, disfunción neurológica o la muerte. Las causas de la compresión de la vía visual anterior son increíblemente variadas. Los meningiomas, los tumores hipofisarios y los aneurismas son las lesiones comúnmente más identificadas como causa de neuropatía óptica compresiva sin edema del disco. Presentamos una paciente femenina de 50 años de edad, quien se sometió a la cirugía de catarata congénita del ojo izquierdo, sin mejoría de la función visual, a lo que se sumó el empeoramiento inespecífico de la calidad visual. La psicofísica visual, la campimetría automatizada y la tomografía de coherencia óptica aportaron hallazgos sugestivos de compresión de la vía visual intracraneal. Se indicó imagen por resonancia magnética de cráneo y órbitas para confirmar la sospecha diagnóstica. La angiografía cerebral demostró la presencia de un aneurisma de la arteria carótida interna, que se trató por vía endovascular con resultados satisfactorios(AU)

The importance of early diagnosis of compressive lesions of the optic nerve is on the increase. Timely decompression of the optic nerve or the optic chiasm may bring about significant visual function improvement, whereas erroneous diagnosis may result in irreversible visual loss, neurological dysfunction or death. The causes of compression of the anterior visual pathway are incredibly varied. Meningiomas, pituitary tumors and aneurysms are the lesions most commonly identified as causes of compressive optic neuropathy without disc edema. A case is presented of a female 50-year-old patient undergoing congenital cataract surgery of her left eye without visual function improvement, alongside unspecific visual quality worsening. Visual psychophysical testing, automated campimetry and optical coherence tomography contributed findings suggestive of intracranial visual pathway compression. Magnetic resonance imaging of the brain and orbits was indicated to confirm the diagnostic suspicion. Cerebral angiography revealed the presence of an internal carotid artery aneurysm which was treated by endovascular procedure with satisfactory results(AU)

Ablación por radiofrecuencia versus crosectomía safenofemoral más oclusión endovascular distal en pacientes con insuficiencia de la vena safena mayor / Radiofrequency ablation versus sapheno-femoral crosectomy plus distal

Introducción: Actualmente se prefieren procedimientos mínimamente invasivos como las técnicas endovasculares para el tratamiento de la insuficiencia de vena safena mayor que pueden ser por ablación térmica, química o mecánica. Éstos tienen la ventaja de ser ambulatorios, presentar menos complicaciones postoperatorias, una rápida incorporación laboral y mejores resultados estéticos. El objetivo de este estudio es evaluar los resultados del tratamiento con radiofrecuencia versus crosectomía safenofemoral más oclusión endovascular distal. Material y Métodos: Estudio descriptivo prospectivo que incluyó a todos los pacientes con diagnóstico de insuficiencia de la vena safena mayor de enero 2017 a octubre 2019. La elección de la técnica a utilizar se hizo al azar. Resultados: El 77% correspondió al género femenino, con edad media 49 años, el estadío C:2 de la clasificación clíica CEAP fue la más frecuente (57%) y el shunt tipo 3 (63%). La ablación por radiofrecuencia se realizó con mayor frecuencia (83%). El dolor y parestesias (fueron las complicaciones más frecuentes en ambos grupos sin diferencias estadísticamente significativas (p = 0.1470). No hubo diferencias estadísticamente significativo entre las dos técnicas quirúrgicas realizadas en resultado estético (p = 0.4456), el retorno de actividades cotidianas (p = 0.992) ni las laborales (p = 0.901). Conclusiones: Tanto la ablación por radiofrecuencia de la vena safena mayor como la crosectomía safenofemoral más oclusión endovascular distal se consideran dos métodos seguros y efectivos para tratar insuficiencia de vena safena mayor; ya que los resultados finales fueron similares para ambas técnicas quirúrgicas.

Introduction: Minimally invasive endovascular procedures like thermal, chemical or mechanical ablation are currently preferred for the treatment of the great saphenous vein insufficiency, because have the advantage of being outpatient, with minimal postoperative complications, a faster incorporation to work and better aesthetic results. This study persuit to evaluate the results of radiofrequency treatment versus sapheno-femoral crosectomy plus distal endovascular occlusion. Methods: The study included all the patients with a diagnosis of great saphenous vein insufficiency from January 2017 to October 2019. The technic was chosen randomly. Results: 77% of patients was female , with a mean age of 49 , the C2 stage of the CEAP classification is present in 57% and the type 3 shunt in 63%. Radiofrequency ablation was performed in 83% of the cases. Pain and paresthesia were the most frequent complications, without statistically signification between both technics (p = 0.1470). The aesthetic result, the return to daily activities (p = 0.992) and to work (p = 0.901) had not statistically significant differences between the two surgical techniques. Conclusions: Both, radiofrequency ablation of the greater saphenous vein and sapheno-femoral crosectomy plus distal endovascular occlusion are considered safe and effective methods to treat great saphenous vein insufficiency because the final results were similar for both surgical techniques.

Uso do doppler colorido das carótidas no diagnóstico de um paciente com fístula carotideocavernosa direta / Use of color doppler of carotids in the diagnosis of a patient with direct carotid-cavernous fistula

Adulto jovem de 18 anos que evoluiu após traumatismo craniencefálico leve com fístula carotídea direta. Apresentou zumbido e exoftalmia, ambos de característica pulsátil e à esquerda. Foi submetido a estudo com Doppler das carótidas, que mostrou elevadas velocidades do fluxo sanguíneo e índices de resistência reduzidos nas artérias carótidas comum e interna esquerdas, compatíveis com fístula carotídea direta. A angiotomografia computadorizada cerebral confirmou a fístula carotídea. Foi encaminhado para tratamento endovascular por embolização, com sucesso. O Doppler de carótidas pode ter papel importante no diagnóstico das fístulas carotídeas diretas e acompanhamento de pacientes submetidos à terapêutica endovascular.(AU)

Retroperitoneal iliac conduits as an alternative access site for endovascular aortic repair: a tertiary care center experience / Condutos ilíacos retroperitoneais como local de acesso alternativo para reparo endovascular de aneurisma: experiência em centro de atenção terciária

Abstract Background Retroperitoneal open iliac conduits (ROIC) are used in patients with hostile iliac anatomy undergoing endovascular aortic repair (EVAR). Objectives We hereby report our experience of ROIC in patients subjected to EVAR. Methods This was a retrospective evaluation of 8 patients out of a total of 75 patients (11%) who underwent EVAR in the last 10 years. Pre-procedure computed tomography angiography was used to assess the dimensions of iliac and femoral arteries. Patients who had small arterial dimensions (i.e. smaller than the recommended access size for the aortic endograft device) were subjected to ROIC. Results The mean age of the 3 males and 5 females studied was 45.7 ± 15.2 years. The indication for ROIC was the small caliber ilio-femoral access site in 7 patients and atherosclerotic disease in 1 patient. All external grafts were anastomosed to the right common iliac artery except one which was anastomosed to the aortic bifurcation site because of a small common iliac artery. The procedural success rate was 100%. Local access site complications included infection (n=1), retroperitoneal hematoma (n=1), and need for blood transfusion (n=3). The median post-intervention hospital stay was 10 days. All patients had favorable long-term outcomes at a median follow-up of 18 months. Conclusions Female patients require ROIC during EVAR more frequently. Adjunctive use of iliac conduit for EVAR was associated with favorable perioperative and short-term outcomes.

Resumo Contexto Os condutos ilíacos abertos retroperitoneais são utilizados em pacientes submetidos a reparo endovascular de aneurisma (REVA) com anatomia ilíaca hostil. Objetivos Relatamos a nossa experiência com os condutos ilíacos em pacientes submetidos a REVA. Métodos Trata-se de uma avaliação retrospectiva de oito pacientes, de um total de 75 (11%), os quais foram submetidos a REVA nos últimos 10 anos. Foi realizada angiotomografia computadorizada antes do procedimento para avaliar as dimensões das artérias ilíaca e femoral. Os pacientes com dimensões arteriais menores, abaixo do tamanho de acesso recomendado para o dispositivo de endoprótese aórtica, foram submetidos a condutos ilíacos. Resultados A média de idade dos participantes foi de 45,7±15,2 anos, sendo três do sexo masculino e cinco do sexo feminino. As indicações para condutos ilíacos foram local de acesso ilíaco femoral de pequeno calibre, para sete pacientes, e doença aterosclerótica, para um paciente. Todas as próteses externas foram anastomosadas na artéria ilíaca comum direita, com exceção de uma, que foi anastomosada no local da bifurcação aórtica por apresentar artéria ilíaca comum menor. A taxa de sucesso do procedimento foi de 100%. As complicações no local de acesso incluíram infecção (n = 1), hematoma retroperitoneal (n = 1) e necessidade de transfusão de sangue (n = 3). O tempo mediano de internação hospitalar pós-intervenção foi de 10 dias. Todos os pacientes apresentaram desfechos de longo prazo favoráveis no seguimento mediano de 18 meses. Conclusões As pacientes do sexo feminino necessitaram de condutos ilíacos durante REVA com maior frequência. O uso adjuvante de condutos ilíacos com REVA foi associado a desfechos perioperatórios e de curto prazo favoráveis.

Unibody design for aortic disease with a narrow aortic bifurcation: tips and tricks for success / Design unimodular para doença da aorta com bifurcação aórtica estreita: dicas para o sucesso

Abstract Background Surgical management of patients with abdominal aortic diseases associated with distal narrowing is a challenging situation. Objectives To evaluate outcomes of unibody bifurcated endovascular stent graft repair. Methods This is a retrospective, observational, multi-institutional database study of a cohort of consecutive cases, approved by the local Ethics Committee. Records were reviewed of patients diagnosed from 2010 to 2020 with "shaggy" aorta, saccular aneurysm, penetrating aortic ulcer, and isolated aortic dissection located in the infrarenal abdominal aorta. All patients were treated with a unibody bifurcated stent graft. Main outcomes were technical success, procedure complications, long-term patency, and mortality in the follow-up period up to 5 years. Data on demographics, comorbidities, surgical management, and outcomes were analyzed. Results Twenty-three patients were treated with unibody bifurcated stent graft repair, including 7 cases of "shaggy" aorta, 3 isolated dissections of the abdominal aorta, 4 penetrating aortic ulcers, and 9 saccular aneurysms. Immediate technical success was achieved in 100% of cases. At follow-up, all stent grafts remained patent and there were no limb occlusions. The patients were symptom-free and reported no complications related to the procedure. There were 5 deaths during the follow-up period (median= 4 years), but none were related to the procedure and there were no aorta-related deaths. Conclusions The present study shows that unibody bifurcated stent grafting is safe and effective in this group of patients with narrow distal abdominal aorta and complex aortic pathology. The results were similar for both infrarenal aortic aneurysms and aorto-iliac atherosclerotic disease.

Resumo Contexto O manejo cirúrgico de pacientes com doenças da aorta abdominal associadas ao estreitamento distal é desafiador. Objetivos Avaliar os desfechos do reparo endovascular com endoprótese bifurcada do tipo monobloco. Métodos Foi realizado um estudo retrospectivo, de coorte observacional, de banco de dados multi-institucional, com casos consecutivos, após aprovação pelo Comitê de Ética local. Foram analisados prontuários de pacientes com diagnóstico de shaggy aorta, aneurisma sacular, úlcera penetrante da aorta e dissecção isolada da aorta localizados na aorta abdominal infrarrenal entre 2010 e 2020; todos os pacientes foram tratados com endoprótese bifurcada do tipo monobloco. Os principais desfechos foram sucesso técnico, complicações relacionadas ao procedimento, perviedade de longo prazo e mortalidade no seguimento de até 5 anos. Foram incluídos dados demográficos, comorbidades, manejo cirúrgico e desfechos. Resultados Vinte e três pacientes foram tratados com endoprótese bifurcada do tipo monobloco, incluindo 7 casos de shaggy aorta, 3 dissecções isoladas da aorta abdominal, 4 úlceras penetrantes da aorta e 9 aneurismas saculares. Sucesso técnico imediato foi obtido em 100% dos casos. No seguimento, todas as endopróteses permaneceram pérvias e não houve oclusões de membros. Os pacientes estavam sem sintomas e não relataram complicações relacionadas ao procedimento. Ocorreram 5 óbitos durante o seguimento (mediana = 4 anos), mas nenhum relacionado ao procedimento ou à aorta. Conclusões O presente estudo mostra que a endoprótese bifurcada do tipo monobloco é segura e eficaz neste grupo de pacientes com estreitamento distal da aorta abdominal e patologia aórtica complexa. Os resultados foram semelhantes para aneurismas da aorta infrarrenal e doença aterosclerótica aortoilíaca.

Customização intraoperatória de endoprótese para correção de fístula aortoentérica em contexto de urgência: um relato de caso / Intraoperative endoprosthesis customization for repair of an aortoenteric fistula in an emergency context: a case report

Resumo A fístula aortoentérica é uma grave condição clínica, e seu manejo permanece sendo um grande desafio técnico aos cirurgiões. A abordagem por cirurgia convencional nesses casos está relacionada a altos índices de morbimortalidade. A cirurgia endovascular apresenta-se como uma ótima alternativa nesses casos; contudo, por não se tratar de aorta nativa, a anatomia pode não ser compatível com os dispositivos endovasculares comercialmente disponíveis, fazendo-se necessário, em casos de urgência, a utilização de dispositivos modificados pelo cirurgião. O caso relatado reporta uma fístula aortoentérica secundária, tratada em situação de urgência por técnica endovascular com dispositivo modificado.

Abstract Aortoenteric fistula is a severe clinical condition and its management remains a major technical challenge for surgeons. In these cases, the conventional surgical approach is associated with high rates of morbidity and mortality. Endovascular surgery is an excellent option in these cases, but considering that the aorta has been treated previously, anatomy may not be compatible with commercially available endovascular devices and so physician-modified endografts may be needed in urgent cases. The case reported involves a secondary aortoenteric fistula, treated on an emergency basis with endovascular techniques, using a physician-modified endograft.

Endovascular revascularization of chronic total arterial occlusion of the lower limb using the SAFARI technique / Revascularização endovascular utilizando a técnica SAFARI em casos de oclusão arterial total do membro inferior

Abstract The SAFARI technique or Subintimal Arterial Flossing with Antegrade-Retrograde Intervention is an endovascular procedure that allows recanalization of Chronic Total Occlusive (CTO) lesions when conventional subintimal angioplasty is unsuccessful. Retrograde access is usually obtained through the popliteal, anterior tibial, dorsalis pedis artery, or posterior tibial arteries and may potentially provide more options for endovascular interventions in limb salvage. The case of an 81-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and dyslipidemia is presented. He presented with a cutaneous ulcer on the right lower limb with torpid evolution and poor healing. The Doppler ultrasound and arteriographic study revealed a CTO lesion of the popliteal artery that was not a candidate for antegrade endovascular revascularization, but was successfully treated using the SAFARI technique. The patient had no perioperative complications, the wound showed better healing, and he was discharged with an indication of daily dressings and control by an external outpatient clinic.

Resumo A técnica SAFARI, ou Subintimal Arterial Flossing with Antegrade-Retrograde Intervention, é um procedimento endovascular que permite a recanalização de lesões por oclusão total crônica (OTC) em caso de fracasso da angioplastia subintimal convencional. O acesso retrógrado é geralmente obtido através da artéria poplítea, tibial anterior, pediosa ou tibial posterior e pode fornecer mais alternativas de intervenções endovasculares para o salvamento do membro. É apresentado o caso de um homem de 81 anos com histórico de hipertenção não controlada, diabetes melito e dislipidemia. Ele apresentava uma lesão ulcerativa cutânea no membro inferior direito com evolução tórpida e má cicatrização. O ultrassom Doppler e o estudo arteriográfico revelaram uma lesão por OTC na artéria poplítea. O paciente não era candidato a revascularização endovascular anterógrada; sendo assim, esta foi realizada com successo utilizando a técnica SAFARI. O paciente não apresentou complicações perioperatórias e recebeu alta com indicação de cuidados diários com a ferida e controle em um ambulatório externo. Além disso, a ferida apresentou melhor cicatrização.

Prenatal Diagnosis of Vein of Galen Aneurysmal Malformation Allows Early Transumbilical Endovascular Treatment

Neonates with vein of Galen aneurysmal malformation (VGAM) presenting with severe cardiac failure and pulmonary hypertension represent a challenge for endovascular therapy.When early treatment is required, the small femoral arteries in this population are usually difficult to cannulate. Alternatively, the umbilical vessels offer a natural pathway to reach the lesion. Therefore, prenatal diagnosis of VGAM allows for delivery planning, perinatal management, and embolization through umbilical approach, thus leading to better outcomes.

Reparación endovascular de aneurisma de arteria ilíaca común asociado a fístula arterio-venosa ílio-ilíaca: reporte de caso / Endovascular repair of common iliac artery aneurysm associated with ilio-iliac arteriovenous fistula: case report

Resumen Introducción: Los aneurismas aislados de arteria ilíaca común son una patología infrecuente y habitualmente el diagnóstico es incidental. Su manejo solía ser por vía abierta, pero con el advenimiento de la cirugía endovascular, se han identificado mejores desenlaces en los pacientes llevados a este tipo de procedimientos, reservando la reparación abierta en los casos agudos y rupturas. La asociación entre estos aneurismas con fístulas ílio-ilíacas son infrecuentes y su manejo endovascular se ha reportado en solo una ocasión. Objetivo: Se presenta un caso de un paciente masculino de 82 años, con esta asociación, en el cual se decidió llevar de manera electiva a manejo endovascular de su patología. Discusión: En la literatura el manejo endovascular es ampliamente recomendado por su perfil de seguridad, sin embargo, no existe suficiente evidencia ante la presencia de una fístula ílio-ilíaca de manera concomitante, por ser una condición infrecuente. Conclusión: En el presente caso, abordamos de manera endovascular esta relación, obteniendo resultados favorables, con adecuado control de la patología, sin presentación de complicaciones.

Introduction: The isolated aneurysms of the common iliac artery correspond to an infrequent pathology; and the diagnosis of this entity is usually incidental. Its management is usually by open route, but with the advent of endovascular surgery, better outcomes have been identified in patients taken to this kind of procedure, reserving open repair for the urgent cases, like ruptures. The association between these aneurysms with ilio-iliac fistula is uncommon and their endovascular management has been reported only in one case in the literature. Aim: A case of an 82-year-old male patient will be presented, with this association, who was taken to an endovascular repair of his pathology, with good postoperative results. Discussion: In the literature, endovascular management is recommended by its safety profile, however there is insufficient evidence in the presence of an ilio-iliac fistula concomitantly, because it is an infrequent condition. Conclusion: In the present case, we address this relationship endovascularly, obtaining favorable results, with adequate control of the pathology, without presenting any complications.

Ataque cerebrovascular isquémico agudo de territorio anterior: Tratamiento endovascular / Acute ischemic stroke in anterior territory: endovascular treatment

La terapia endovascular (TEV) es el tratamiento estándar del ataque cerebrovascular isquémico (ACVi) con oclusión de gran vaso (OGVC). Aún no se conoce si esos resultados pueden generalizarse a la práctica diaria. Se describen los resultados de la TEV en pacientes con ACVi por OGVC dentro de las 24 horas, en un análisis retrospectivo entre enero 2013 y diciembre 2017 que incluyó 139 casos consecutivos con ACVi y OGVC en arteria cerebral media (ACM), hasta 24 horas del inicio de los síntomas, que recibieron TEV en nuestra institución. El resultado primario medido fue la escala de Rankin modificada (mRS) ≤ 2 a 90 días. Se evaluaron también: reperfusión exitosa, según la escala modificada de trombólisis en infarto cerebral (mTICI) 2b/3, hemorragia intracraneal sintomática (HIS) y mortalidad a 90 días. La edad media: 67.5 ± 15.0, siendo el 51.8% mujeres. La mediana basal de National Institute of Health Stroke Scale (NIHSS) fue 14 (IIC 8-18); la mediana del tiempo desde inicio de síntomas hasta punción inguinal: 331 min (IIC 212-503). El 45.3%, 63 pacientes, fueron tratados > 6 horas después del inicio de síntomas. La tasa de mRS ≤ 2 fue 47.5%. Se logró una reperfusión exitosa en el 74.8%. La tasa de mortalidad a 90 días fue del 18.7% y la HIS del 7.9%. Nuestro registro de pacientes de la vida real con ACVi por OGVC tratados con TEV dentro de las 24 horas mostró altas tasas de reperfusión, buenos resultados funcionales y pocas complicaciones, acorde con las recomendaciones internacionales.

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke (AIS) with proximal large vessel occlusions (LVO). However, it is still unknown whether these results can be generalized to clinical practice. We aimed to perform a retrospective review of patients who received EVT up to 24 hours, and to assess safety and efficacy in everyday clinical practice. We performed a retrospective analysis, from January 2013 to December 2017, on 139 consecutive patients with AIS for anterior circulation LVO strokes up to 24 h from symptoms onset, who received EVT in our institution. The primary outcome measured was a modified Rankin scale (mRS) ≤ 2 at 90 days. Secondary outcomes included successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, mortality rate at 90 days and symptomatic intracranial hemorrhage (sICH). The mean age was 67.5 ± 15.0, with 51.8% female patients. Median baseline National Institute of Health Stroke Scale (NIHSS) was 14 (IQR 8-18); median time from symptom onset to groin puncture was 331 min (IQR 212-503). Sixty-three patients (45.3%) were treated beyond 6 hours after symptoms onset. The rate of mRS ≤ 2 was 47.5%. Successful reperfusion was achieved in 74.8 %. Mortality rate at 90 days was 18.7 % and sICH was 7.9 %. Our registry of real-life patients with AIS due to LVO who received EVT within 24 hours showed high reperfusion rates, and good functional results with few complications, according to international recommendations.

Síndrome de Klipper-Trenaunay-Weber con compromiso vesical y uterino tratado por vía endoscópica y endovascular / Klippel-Trenaunay-Weber syndrome with vesical and uterine involvement treated by endoscopic and endovascular routes

El síndrome de Klippel-Trenaunay-Weber (SKTW) es una rara malformación venosa que, en general afecta a los miembros inferiores y, más raramente, a los superiores. Se caracteriza por formaciones angiomatosas cutáneas, várices e hipertrofia del miembro afectado. El compromiso genitourinario es sumamente infrecuente. Se presenta el caso de una paciente de 14 años. Ingresó por hematuria macroscópica de 48 h de evolución y metrorragia con grave compromiso hemodinámico. Se encontraba en estudio por presentar un hemangioma en el miembro inferior izquierdo que se extendía hasta la región pelviana. La uretrocistofibroscopía demostró la presencia de múltiples lesiones angiomatosas diseminadas en forma amplia en la vejiga, algunas de ellas con sangrado activo. La angioresonancia mostró una voluminosa formación hipervascularizada en contacto con la pared vesical a la cual desplazaba y fístulas arteriovenosas a nivel pelviano y en el miembro inferior izquierdo confirmando el diagnóstico etiológico. Se realizó una embolización arterial selectiva de los territorios ilíacos interno y externo e inmediatamente después una endocoagulación láser de los focos angiomatosos sangrantes. La hematuria remitió completamente en las 24 h posteriores al procedimiento. La metrorragia asociada al SKTW fue controlada mediante la utilización de análogos LHRH y progestágenos.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare venous malformation that generally affects the lower limbs and, more infrequently, the upper limbs. It is characterized by cutaneous angiomatous formations, varicose veins and hypertrophy of the affected limb. The involvement of the genitourinary tract is extremely infrequent. We expose the case of a 14 years old female patient who was admitted for macroscopic hematuria of 48 hours of evolution and metrorrhagia with severe hemodynamic decompensation. The patient was under study for presenting a hemangioma in the lower left limb that extended to the pelvic region. Urethrocystofibroscopy showed the presence of multiple wide-spread angiomatous lesions in the bladder, some of them with active bleeding. The angio-resonance showed a voluminous hypervascular formation in contact with the bladder wall showing several arteriovenous fistulas at the pelvic level and in the left lower limb confirming the etiological diagnosis. A selective arterial embolization of the internal and external iliac territories was performed and then, a laser endocoagulation of the bleeding angiomatous foci was carried out. The hematuria completely stopped within 24 hours later of the procedure. The metrorrhagia associated with KTWS was controlled by the use of LHRH analogs and progestogens.

Stents in the femoropopliteal territory: prevalence of fractures and their consequences / Stents no território fêmoro-poplíteo: prevalência de fraturas e suas consequências

ABSTRACT Endovascular treatment for femoropopliteal arterial disease has made revascularization procedures less invasive, but the self-expanding stents used can suffer great wear in arteries with extreme mobility. Objective: to evaluate the prevalence of fractures in stents implanted in the femoropopliteal segment, to identify predisposing factors and consequences on arterial patency. Method: between March and June 2019, thirty patients previously operated for femoropopliteal obstruction underwent stent X-rays in anteroposterior and lateral views to detect fractures and Doppler to analyze arterial patency. Results: we observed 12 cases with fractures (33.3%): 1 type I (2.8%), 3 type II (8.3%), 5 type III (13.9%), 3 type IV (8.3%) and no type V. According to the TASC II we had 1 in group B (8.3%), 6 in group C (50%) and 5 in group D (41.6%) p <0.004. The number of stents per limb was 3.1 (± 1.3) in cases of fracture versus 2.3 (± 1.3) in cases without fracture (p = 0.08). The extension was 274.17mm (± 100.94) in cases of fracture and 230.83mm (± 135.44) in cases without fracture (p = 0.29). On Doppler we had: 17 patients (47.2%) without stenosis, 9 patients (25%) with stenosis> 50% and 10 patients (27.8%) with occlusion (p = 0.37). There was no correlation between fracture and arterial obstruction (p = 0.33). Conclusion: stent fractures are a frequent finding in the femoropopliteal area (33.3%), being more prevalent in cases of more advanced disease (C and D). There was no association between the finding of fracture and arterial obstruction.

RESUMO Os tratamentos endovasculares para a doença arterial obstrutiva fêmoro-poplítea tornaram os procedimentos de revascularização menos invasivos, porém os stents metálicos autoexpansíveis utilizados podem sofrer grande desgaste em artérias com extrema mobilidade. Objetivo: avaliar a prevalência de fraturas em stents implantados no segmento fêmoro-poplíteo, identificar fatores predisponentes e possíveis consequências sobre a patência arterial. Métodos: entre março a junho de 2019, trinta pacientes previamente operados por obstrução fêmoro-poplítea realizaram RX dos stents em incidências ântero-posterior e perfil para detectar fraturas e eco Doppler para analisar a patência arterial. Resultados: observamos 12 casos com fraturas (33,3%): 1 do tipo I (2,8%), 3 do tipo II (8,3%), 5 do tipo III (13,9%), 3 do tipo IV (8,3%) e nenhuma tipo V. Segundo a classificação TASC II, tivemos 1 no grupo B (8,3%), 6 no grupo C (50%) e 5 no grupo D (41,6%) p<0,004. O número de stents por membro foi de 3,1 (±1,3) nos casos de fratura contra 2,3 (±1,3) nos casos sem fratura (p = 0,08). A extensão tratada foi 274,17mm (±100,94) nos casos de fratura e 230,83mm (±135,44) nos casos sem fratura (p=0,29). No Doppler tivemos: 17 pacientes (47,2%) sem estenose, 9 pacientes (25%) com estenose>50% e 10 pacientes (27,8%) com oclusão (p=0,37). Não houve correlação entre fratura e obstrução arterial (p=0,33). Conclusão: as fraturas de stents são um achado frequente no setor fêmoro-poplíteo (33,3%) sendo mais prevalentes nos casos de doença mais avançada TASC II C e D. Não houve associação entre o achado de fratura e obstrução arterial.

Tratamento endovascular de dissecção traumática de aorta torácica - série de 16 casos / Endovascular treatment of traumatic dissection of the thoracic aorta - series of 16 cases

Resumo Contexto As lesões de aorta nos traumatismos torácicos fechados possuem alta mortalidade pré-hospitalar e no serviço de emergência. O tratamento endovascular é um método de escolha para o tratamento dessas lesões; entretanto, muitos resultados em relação a essa abordagem permanecem desconhecidos. Objetivos O objetivo deste trabalho é descrever a experiência no tratamento endovascular de lesões traumáticas de aorta torácica em um centro de referência em trauma. Métodos Este trabalho trata-se de estudo descritivo realizado através da revisão de prontuários eletrônicos de pacientes vítimas de trauma contuso de aorta torácica, atendidos em um hospital de referência em trauma na cidade de Curitiba (Paraná, Brasil). Resultados Dezesseis pacientes foram incluídos no estudo. Todos os pacientes foram vítimas de acidente de trânsito, sendo que 75% dos acidentes ocorreram por colisão entre veículos. As lesões de aorta variaram de Grau I a IV, e a maioria dos pacientes apresentou lesão de grau II (50%). Todos os pacientes foram submetidos a terapia endovascular com implante de endoprótese sendo realizado em média 71 horas após o trauma. Dois pacientes evoluíram a óbito, porém de causas não relacionadas à lesão de aorta. Durante o seguimento, apenas dois pacientes apresentaram complicações (endoleak e progressão da dissecção). Conclusões O método endovascular é uma alternativa viável no tratamento de lesões de aorta torácica por trauma contuso. São necessários estudos randomizados e controlados a fim de reforçar a indicação desse método como terapia para esse tipo de lesão.

Abstract Background Aortic injuries caused by blunt chest traumas have high pre-hospital and emergency mortality. The endovascular approach is one option for treatment of these injuries, but many outcomes related to this approach remain unknown. Objectives The aim of this study is to describe a specialist trauma center's experience with endovascular treatment of cases like these. Methods This is a descriptive study based on review of the electronic medical records of patients who had suffered from blunt thoracic aorta trauma and were seen at a hospital specializing in trauma cases in the city of Curitiba (Paraná, Brazil). Results Sixteen patients were included in the study. All patients were traffic accident victims and 75% of the accidents were the result of vehicle collisions. Aortic lesions ranged from grade I to IV and the majority had grade II lesions (50%). All patients underwent endovascular treatment with endografts, an average of 71 hours after the trauma. Two patients died, both from causes unrelated to their aortic injuries. During follow-up, only two patients presented complications (endoleak and progression of the dissection). Conclusions The endovascular method is a viable alternative for treatment of blunt trauma thoracic aortic injuries. Randomized and controlled studies are needed to provide evidence to support indication of this method to treat this type of injury.