Acute Paraplegia Result from Spinal Ischemia Nine Years After Hybrid Total Arch Repair with Frozen Elephant Trunk: A Case Report

ABSTRACT Spinal cord ischemia due to decreased cord perfusion is a devastating complication in patients with thoracoabdominal dissection following frozen elephant trunk (FET) repair surgery. However, rare occurrence of spinal cord ischemia leading to paraplegia after long-term follow-up of FET repair has been reported. Here, we describe a case of spinal cord ischemia resulting in paraplegia nine years after hybrid total arch repair with FET. Cerebrospinal fluid drainage and serial treatment were utilized to decrease intraspinal pressure and increase blood flow to the spinal cord. Three months after the onset of paraplegia and with treatment and rehabilitation, the patient recovered to walk.

Direct and virtual measurements of abdominal aortic aneurysms: three-dimensional printed models / Medidas de aneurisma da aorta abdominal: modelos tridimensionais impressos e virtuais

Abstract Objective: To validate the use of a three-dimensional printing system for metric and volumetric analysis of the segments of an abdominal aortic aneurysm (AAA). Materials and Methods: In patients scheduled to undergo endovascular AAA repair, the computed tomography angiography (CTA) measurements obtained during the preoperative assessment of the patients were compared with those obtained by computed tomography of individualized three-dimensional biomodels. Results: The volumetric assessment showed a discrepancy of 3-12%, and the difference between the areas was 10-16%. Conclusion: Computed tomography measurements of 3D-printed biomodels of AAAs appear to be comparable to those of threedimensional CTA measurements of the same AAAs, in terms of the metric and volumetric dimensions.

Resumo Objetivo: Validar a aplicação do método de impressão tridimensional de biomodelos para aferição métrica e volumétrica de segmentos de aneurisma de aorta abdominal. Materiais e Métodos: Compararam-se as medidas obtidas por tomografia computadorizada dos biomodelos tridimensionais com as realizadas no planejamento pré-operatório de pacientes submetidos a correção endovascular de aneurisma de aorta abdominal. Resultados: A avaliação da volumetria demonstrou discrepância de 3% a 12% e a diferença entre as áreas foi de 10% a 16%. Conclusão: A tomografia computadorizada dos biomodelos impressos é compatível nas aferições métricas e volumétricas com as imagens tridimensionais da angiotomografia do paciente.

Comparison between arch zones in modified frozen elephant trunk procedure for complex thoracic aortic diseases

Abstract Introduction: The aim of this study is to compare postoperative outcomes and follow-up of two different modifications facilitating surgical technique of frozen elephant trunk (FET) procedure for complex thoracic aortic diseases - zone 0 (fixation with total arch debranching) and zone 3 (fixation with islet-shape arch repair). Methods: From May 2012 to December 2018, data were collected from 139 patients who had been treated with FET procedure for complex thoracic aortic diseases. According to Ishimaru arch map, patients with proximal anastomotic site of hybrid graft at zone 0 and zone 3 were grouped as Group A (n=58, 41.7%) and Group B (n=81, 58.3%), respectively. Mean age of study population was 54.7±11.4 years, and 111 patients were male (79.9%). Results: In-hospital mortality was observed in 20 (14.4%) patients (n=12, acute type A aortic dissection, and n=4, previous aortic dissection surgery). There was no significant difference between both groups in terms of in-hospital mortality. Four patients from Group A and three patients from Group B had permanent neurological deficit (P=0.32). Three patients from both groups had transient spinal cord ischemia (P=0.334). Although mean total perfusion time was longer in Group A, duration of visceral ischemia, when compared with Group B, was shorter (P<0.001). Five-year survival rate was 82.8% in Group A and 81.5% in Group B (P=0.876). Conclusion: FET procedure is a feasible repair technique in the treatment of complex aortic diseases, providing satisfactory early results. Because of its advantageous aspects, zone 0 fixation with debranching is the preferred technique in our clinic.

Transcaval access to the abdominal aorta: indications of interest to surgeons and a comprehensive literature review

Abstract We performed a review of the literature (until August 01, 2019) on the occasion of the first transcaval approach for transcatheter aortic valve implantation in our hospital. This review focuses mainly on the indications of this alternative access route to the aorta. It may be useful for vascular surgeons in selected cases, such as the treatment of endoleaks after endovascular aneurysm repair and thoracic endovascular aneurysm repair. We describe historical aspects of transcaval access to the aorta, experimental studies, available case series and outcomes. Finally, we summarize the most significant technical aspects of this little-known access.

Tratamiento endovascular de aneurismas de aorta con estrategia minimalista / Endovascular Treatment of Aortic Aneurysms with Minimalistic Approach

RESUMEN Introducción: Los aneurismas de aorta siguen siendo una patología frecuente, en especial aquellos localizados en la aorta abdominal. Desde 1990, gracias al avance en los dispositivos y las técnicas endovasculares, la cirugía convencional ha dejado de ser la única opción de tratamiento. Presentamos nuestros resultados en el manejo del aneurisma de aorta con técnica endovascular mínimamente invasiva. Objetivos: Analizar los resultados a 30 días del implante de endoprótesis en la aorta torácica y abdominal con una estrategia mínimamente invasiva. Material y métodos: Entre marzo de 2012 y abril de 2019 se realizaron 395 implantes consecutivos de endoprótesis de aorta; en 264 (67%) de los cuales se utilizó una técnica mínimamente invasiva (MIN-A). De este grupo 240 procedimientos (90,9%) fueron llevados a cabo para reparar la aorta abdominal (EVAR) y 24 (9,1%) la aorta torácica (TEVAR). Resultados: De 264 pacientes se logró éxito técnico (ET) del implante en el 99,6% y éxito clínico (EC) en el 97,7%. La mortalidad a 30 días fue del 1,1% dado por neumonía, insuficiencia cardíaca y EPOC. Ningún paciente presentó IAM, ACV o necesitó de conversión a reparación quirúrgica de urgencia. El tiempo promedio del procedimiento fue de 62 minutos (SD ± 17). Algunos pacientes requirieron conversión a cierre quirúrgico del acceso [20 (7%) durante los primeros 100 casos, y 7 (3%) en los últimos 164 pacientes p = 0,05)]. El sangrado mayor que requirió transfusión fue del 1,1%. El tiempo promedio para la deambulación fue de 18 horas (SD ± 10), que luego de los primeros 100 pacientes disminuyó en forma significativa a 13 horas (SD ± 2,9 p = 0,05). La estadía hospitalaria en promedio fue de 1,4 días (SD ± 1,14) con 5 casos externados el mismo día del procedimiento. Conclusiones: Los procedimientos de reparación endovascular de aneurismas de la aorta con una estrategia miniinvasiva fueron factibles y seguros, ya que permitieron convertir estos procedimientos en abordajes percutáneos, con bajas tasas de complicaciones asociadas al acceso, menor tiempo quirúrgico, rápida deambulación y menor estadía hospitalaria, sin modificar la seguridad global del procedimiento. La curva de aprendizaje permitió bajar la tasa de conversiones a cirugía, así como los tiempos de deambulación.

ABSTRACT Background: Aortic aneurysms, particularly of the abdominal aorta, are still common. Since 1990, conventional surgery is no longer the only treatment option due to advances in endovascular devices and techniques. We present our results in the management of aortic aneurysms with a minimally invasive endovascular technique. Objectives: The aim of this study was to analyze the 30-day outcomes of endograft implantation in the thoracic aorta and abdominal aorta using a minimally invasive approach. Methods: Between March 2012 and April 2019, 395 consecutive endografts were implanted in the aorta, and 264 (67%) were performed using a minimally invasive approach (MIN-A). Among this group, 240 (90.9%) corresponded to abdominal endo-vascular aortic repair (EVAR) and 24 (9.1%) to thoracic endovascular aortic repair (TEVAR). Results: Technical success (TS) of the implant was achieved in 99.6% of the 264 patients and clinical success (CS) in 97.7%. Thirty-day mortality was 1.1% due to pneumonia, heart failure and chronic obstructive pulmonary disease. There were no cases of myocardial infarction, stroke or need for conversion to urgent surgical repair. Mean duration of the procedure was 62 minutes (SD ± 17). Some patients required conversion to surgical closure of the access site [20 (7%) during the first 100 cases and 7 (3%) in the final 164 patients, p = 0.05]. Three (1.1%) patients presented major bleeding requiring transfusion. Mean time to ambulation was 18 hours (SD ± 10) that significantly decreased to 13 hours after the first 100 patients (SD ± 2.9; p= 0.05). Mean length of hospital stay was 1.4 days (SD ± 1.14) with 5 patients discharged on the same day of the procedure. Conclusions: Endovascular aortic aneurysm repair using a minimally invasive strategy was feasible and safe, turning this procedure into a percutaneous approach, with low access site-related complications, shorter operative time, rapid ambulation and shorter length of hospital stay, without modifying overall safety of the procedure. The learning curve resulted in reduced rate of conversion to surgery and earlier ambulation.

Risk factors for severe complications after total aortic arch replacement / 中华麻醉学杂志

Objective To determine the risk factors for severe complications after total aortie areh replacement.Methods Patients with acute type A aortic dissection of both sexes,scheduled for elective total aortic areh replacement,were selected.According to whether or not postoperative severe complications occurred during hospitalization,the patients were divided into either postoperative severe complications group or non-postoperative severe complication group.Factors including age,gender,body mass index,preoperative complications (Marfan syndrome,hypertension and diabetes mellitus),preoperative left ventricular ejection fraetion,levels of serum N-terminal pro-brain natriuretic peptide,hemoglobin and serum alanine aminotransferase,aspartate aminotransferase and creatinine,international normalized ratio,operation time,cardiopulmonary bypass time,selective antegrade cerebral perfusion time,regional cerebral oxygen saturation (rSO2),etc.were recorded.The risk factors of which P values were less than 0.05 would enter the multivariate logistie regression analysis to stratify postoperative severe complications-related risk factors for this type of patients.Results A total of 98 patients were enrolled in this study.Of the 98 patients,28 patients developed posloperative severe complications,and the incidence was 29c％.The results of logistic regression analysis showed that age＞60 yr,△rSO2-min＜80％ throughout the surgery and △rSO2-min＜80％ during hemostasis were independent risk factors for severe complications after total aortie arch replacement.Conclusion Age ＞60 yr,△rSO2-min＜80％ throughout the surgery and △rSO2-min＜80％ during hemostasis are independent risk factors for severe complications after total aortic arch replacement.

Stent-graft relining in a patient with acute aortic aneurysm and a completely migrated endograft

Abstract Stent-graft migration and type I endoleaks are associated with a higher rate of reintervention and increased mortality and morbidity. This article describes a patient presented with an infrarenal aortic stent-graft which had migrated into the aortic sac with loss of all aortic neck attachment. The acutely expanding abdominal aortic aneurysm was treated by placing a second modular endograft within and above the migrated stentgraft. The patient returned 36 months later, with features of an acute myocardial infarction, severe bilateral lower limb ischemia, and renal failure. He was too ill for intervention and demised within 48 hours.

Crossed Renal Ectopia and Aorto-Occlusive Disease: A Management Strategy

We present a rare case of a patient with aortoiliac occlusive disease on the background of type A crossed renal ectopia, for whom open surgical intervention was required. Aortic exposure in patients with concomitant crossed renal ectopia can present technical challenges to the vascular surgeon. The knowledge of variations in the ectopic renal blood supply is of paramount importance when performing surgery to treat this condition and affects the choice of surgical exposure. We present and discuss the operative details of our patient and outline an approach to this subset of patients.

Tratamento híbrido das doenças do arco aórtico / Hybrid treatment of aortic arch disease

Introdução: O manejo das doenças da aorta torácica que envolvem a aorta ascendente, arco aórtico e aorta torácica descendente constituem um desafio técnico e é uma área em constante desenvolvimento e inovação. Objetivo: Analisar os resultados iniciais e a médio prazo do tratamento híbrido das doenças do arco aórtico. Métodos: Estudo retrospectivo de procedimentos realizados no período de janeiro de 2010 a dezembro de 2012, em que foram analisados o sucesso técnico e terapêutico, a morbimortalidade, os desfechos neurológicos, a taxa de vazamentos e de reintervenções. Resultados: Em um total de 95 pacientes tratados por doenças da aorta torácica no período, 18 realizaram o tratamento híbrido e adentraram neste estudo. A idade média foi de 62,3 anos. O sexo masculino esteve presente em 66,7%. O sucesso técnico e terapêutico foi de 94,5% obe 83,3%, respectivamente. A mortalidade perioperatória foi de 11,1%. Não houve óbito durante o acompanhamento de 1 ano. A taxa de reintervenção foi de 16,6%, devido a 2 casos de endoleak tipo Ia e um caso de endoleak tipo 2. Não foi observada oclusão dos enxertos anatômicos ou extra-anatômicos durante o período de seguimento. Conclusão: O tratamento híbrido das doenças do arco aórtico demonstrou ser uma alternativa viável à cirurgia convencional. As taxas de sucesso terapêutico e de reintervenções demonstram a necessidade do seguimento clínico rigoroso desses pacientes a longo prazo. .

Introduction: The management of thoracic aortic disease involving the ascending aorta, aortic arch and descending thoracic aorta are technically challenging and is an area in constant development and innovation. Objective: To analyze early and midterm results of hybrid treatment of arch aortic disease. Methods: Retrospective study of procedures performed from January 2010 to December 2012. The end points were the technical success, therapeutic success, morbidity and mortality, neurologic outcomes, the rate of endoleaks and reinterventions. Results: A total of 95 patients treated for thoracic aortic diseases in this period, 18 underwent hybrid treatment and entered in this study. The average ages were 62.3 years. The male was present in 66.7%. The technical and therapeutic success was 94.5% e 83.3%. The perioperative mortality rate of 11.1%. There is any death during one-year follow- up. The reoperation rates were 16.6% due 2 cases of endoleak Ia and one case of endoleak II. There is any occlusion of anatomic or extra anatomic bypass during follow up. Conclusion: In our study, the hybrid treatment of aortic arch disease proved to be a feasible alternative of conventional surgery. The therapeutic success rates and re- interventions obtained demonstrate the necessity of thorough clinical follow-up of these patients in a long time. .

Fechamento do Canal Arterial Persistente Tipo Janela Com o Oclusor Septal AMPLATZER® / Percutaneous Closure of Window-Type Patent Ductus Arteriosus With the AMPLATZERTM Septal Occluder

Há vários anos, a oclusão percutânea do canal arterial persistente é uma técnica factível e eficaz na maioria das variantes morfológicas descritas por Krishenko. O tipo B, em janela, caracterizado por ser curto, permanece um desafio, devido ao maior risco de embolizações das próteses e das oclusões incompletas. Descrevemos aqui o uso bem-sucedido de oclusores septais AMPLATZER® em três pacientes com canal arterial em janela, dois casos tratados com dispositivos de 5 mm e um com o de 7 mm. O dispositivo AMPLATZER® desenhado para a oclusão da comunicação interatrial mostrou-se eficaz para o tratamento percutâneo dessa variante morfológica de canal arterial persistente.

For several years the percutaneous closure of patent ductus arteriosus has been a reliable and effective technique for most of the morphologic variants described by Krichenko. Type B, or window-type, patent ductus arteriosus remains a challenge due to the higher risk of device embolizations and incomplete occlusions. We report the successful use of AMPLATZERTM septal occluder in three patients with window-type patent ductus arteriosus, two cases treated with a 5-mm device and one case with a 7-mm device. The AMPLATZERTM device designed for the occlusion of atrial septal defects is effective for the percutaneous treatment of this morphological variant of patent ductus arteriosus.

Flow-diverting stent for the treatment of intracranial aneurysms / 国际脑血管病杂志

Flow-diverting stent that appears in recent years is a new method for the treatment of complex intracranial aneurysms.This article reviews the principles,composition,development,advantages and disadvantages,indications,main complications and some problems of flow-diverting stent.

Ruptured Abdominal Aortic Aneurysm with Antecedent Endovascular Repair of Abdominal Aortic Aneurysm

Late aortic rupture following successful endovascular repair of abdominal aortic aneurysm still does occur. It represents the ultimate failure of endovascular aortic repair of abdominal aortic aneurysm (EVAR) and subjects patients to equivalent risk of death as de novo rupture. Unfortunately, it is difficult to identify patients at risk for post-EVAR rupture as many present with aortic rupture in the absence of any endograft-related complications. Continued surveillance and timely intervention are of paramount importance to assure rupture-free survival, the ultimate goal of any aneurysm treatment modality. The vascular surgeon needs to be prepared to provide the optimal therapy, whether open or endovascular, for this challenging cohort of patients.

Tratamento endovascular de aneurisma de aorta abdominal em paciente com rim em ferradura: relato de caso / Endovascular treatment of abdominal aortic aneurysm in patient with horseshoe kidney: a case report

O rim em ferradura é uma das anomalias urológicas congênitas mais comuns e está presente em cerca de 0,12% dos pacientes com aneurisma de aorta abdominal. O reparo cirúrgico convencional está associado a dificuldades técnicas que provavelmente aumentam a morbidade e a mortalidade, mas que podem ser evitadas com o tratamento endovascular. Relatamos um caso de um paciente de 64 anos com rim em ferradura e aneurisma de aorta abdominal, que foi submetido ao reparo endovascular do aneurisma com sucesso.

The horseshoe kidney is one of the most common urologic anomalies and is present in about 0,12% of the patients with abdominal aortic aneurysm. The conventional surgical repair is associated with technical difficulties that probably increase morbidity and mortality, but can be averted by the endovascular treatment. We report a case of a 64-year-old patient with horseshoe kidney and abdominal aortic aneurysm, who underwent endovascular repair with success.

Hybrid procedure without deep hypothermic circulatory arrest for DeBakey type Ⅰ aortic dissection / 中华胸心血管外科杂志

Objective Some major procedures for DeBakey type Ⅰ aortic dissection used to be performed with deep hypothermic circulatory arrest, which had been associated with more complications than seen with standard extracorporeal circulation. We reviewed the cases who received the treatment for DeBakey type Ⅰ aortic dissection by hybrid procedure without deep hypothermic circulatory arrest. The procedure consisted of ascending aorta replacement, ascending aorta-aortic arch branch vascular bypass reconstruction and endovascular graft exclusion. Methods From January 2009 to June 2010, 39 patients [mean age (55 ±16) years] who had DeBakey Ⅰ aortic dissection underwent hybrid procedure without deep hypothermic circulatory arrest. The femoral artery and right axillary artery were cannulated for perfusion. The ascending aorta and/or aortic valves were replaced under conventional extracorporeal circulation with Bentall procedure or Wheat procedure. The aortic arch branch vessels were dissected and the proximal part was sealed. Then the ascending aorta-aortic arch branch vascular bypasses were constructed with 4-bifurcation vascular grafts, Y-shape bifurcated vascular grafts or artificial vessels. Finally the endovascular grafts were deployed via the femoral incisions monitored dynamically with DSA, or via the ascending aortic bifurcated vessels monitored with transesophageal echocardiography. Results The operation succeeded in all 39 patients. Eight patients underwent ascending aorta replacement without aortic valve replacement or prosthesis, 20 patients underwent Bentall procedure ( Carbrol procedure were used in 11 cases), and 11 underwent Wheat procedure. For ascending aorta-aortic branch vascular bypass reconstruction, sequential anastomoses were performed in 8, Y-shaped bifurcated grafts were used in 15, and 4-bifurcated grafts were employed in 16 patients. The endovascular stent grafts were deployed via the former femoral incisions in 36 patients and via ascending aortic bifurcated vessels in 3. The cardiopulmonary bypass time was (61 ±22) minutes, the aortic crossclamp time was (48 ±18) minutes, and the post-operative intubation time was (30 ±9) hours. The thoracic drainage from each patient was less than 300 ml in 24 hours. No complication, such as hemiplegia, paraplegia, severe infections, renal failure or coagulation disorder, was observed. The duration of hospitalization was (21 ±6) days. No hospital death occurred. Follow-up was performed 1 to 15 months [mean (8.4 ±7.2) months] postoperatively. All patients survived without any organ dysfunction at follow up. The CTA examination 3 months after operation revealed that the false lumens had been closed in 91.2% of the patients. Conclusion Our findings indicated that the hybrid procedure, which combining ascending aorta replacement,ascending aorta-aortic arch branch vascular bypass reconstruction and endovascular graft exclusion under conventional extracorporeal circulation, may be an option for avoiding the possible complications associated with profound hypothermic circulatory arrest. The novel hybrid operation may improve the surgical outcomes and provide a simplified surgical approach for the treatment of DeBakey Ⅰ aortic dissection.

The early and midterm results of total aortic arch replacement for aortic aneurysm without cardiopulmonary bypass / 中华胸心血管外科杂志

Objective Study the early and midterm results of a technique-total aortic arch replacement without using extracorporeal circulation or aortic bypass for the treatment of aortic aneurismal disease involving the transverse aortic arch and proximal descending aorta. Methods Between April and November 2004, 7 consecutive patients with true (n = 3) or false (n =4) aortic aneurysm underwent this procedure. The mean follow-up was 6. 6 years. The median age at operation was 57years ( range 23 to 75 years). Normothermia general anesthesia and median sternotomy combined with left anterior thoracotomy were administered. A partially occluding clamp was placed on ascending aorta and a longitude aortic incision was made. Anastomosis of a branched graft to ascending aorta in an end-to-side fashion was commenced. The descending aorta distal to the aneurysm was occluded and transected, and anastomosed to the distal end of the branched graft in an end-to-end fashion. Finally,the arch vessels were divided and anastomosed to the branches of the graft and the aneurysm excised. Results The average cross-clamp time of descending aorta, left common carotid artery, and innominate artery was (13.6 ±5.6)min, (5.7 ±0.8)min, and (7.8±2.5) min respectively. The mean intubation time was (12.3 ±4.1) hours. There were no adverse outcomes or neurologic complications in this series. All patients survived and recovered completely. The mean follow-up time was (79.7 ±2.1) months. All patients lead a normal life. There was no late death. CT follow-up study 6 years after surgery reveals no abnormal image. Conclusion Total aortic arch replacement without cardiopulmonary and aortic bypass is a feasible and effective method for the aortic aneurismal disease involving the transverse aortic arch and proximal descending aorta in selected patients.

Type I Endoleak Five Year after Endovascular Repair of Abdominal Aortic Aneurysm / 대한혈관외과학회지

Endovascular aneurysm repair (EVAR) surgery has become a more prevalent in recent years, as it is less invasive and requires a shorter hospital stay and recovery time, in addition to resulting in lower mortality. However, EVAR has the disadvantage of increased numbers of reintervention incidents, need of regular follow up, and uncertainty of long-term stability. Type II endoleak is the most common endoleak, but it mostly seals without intervention. Type I endoleak is a sealing failure around the graft and proximal neck or distal landing zone and usually occurs during the initial procedure, which can be corrected by ballooning, an additional stent (bare or graft), or surgery. Late type I endoleak can develop by migration of the graft or shrinkage or progression of aneurysm. Here we report a case of distal type I endoleak found 5 years after EVAR which was corrected by additional endovascular grafts.

Tratamento híbrido das doenças complexas da aorta torácica / Hybrid procedures for complex thoracic aortic diseases

INTRODUÇÃO: O tratamento híbrido das lesões complexas da aorta torácica (LCAT) requer a revascularização de uma ou mais artérias supra-aórticas, seguida do implante de endoprótese, com morbidade e mortalidade presumidamente mais baixas que a cirurgia convencional. OBJETIVOS: Avaliar a técnica e resultados do tratamento híbrido das LCAT. MÉTODOS: Durante dois anos, 12 pacientes com LCAT foram submetidos a procedimentos híbridos, incluindo aneurismas do arco aórtico e dissecções aórticas agudas Stanford A e B. Todos possuíam indicação de tratamento invasivo, além de zona de ancoragem proximal inadequada (menor que 20 mm). Metade era do sexo masculino e a média de idade de 55,5 anos (42 a 78). Pelo menos três fatores de risco cardiovascular estavam presentes em 75 por cento dos pacientes. A média de seguimento foi de 10,9 meses (2 a 25), com acompanhamento clínico e tomográfico. RESULTADOS: O sucesso técnico inicial foi alcançado em 10 pacientes. Todas as derivações dos vasos supra-aórticos foram realizadas em ambiente cirúrgico e os procedimentos endovasculares em sala de radiologia vascular. A "técnica do varal" foi empregada em seis casos. Dois óbitos ocorreram nos primeiros 30 dias do procedimento. Nenhuma migração da endoprótese foi observada. Nenhum paciente apresentou paraplegia, acidente vascular cerebral, insuficiência renal, hemorragia ou coagulopatia, conversão cirúrgica eletiva ou de emergência. CONCLUSÃO: O tratamento híbrido das LCAT é viável, especialmente em pacientes de alto risco. Uma adequada integração das técnicas cirúrgica e endovascular, além do acompanhamento clínico e radiológico adequado, tornam esta técnica uma ótima opção à cirurgia convencional.

BACKGROUND: Hybrid procedures for the treatment of complex thoracic aortic diseases (CTAD) require the revascularization of one or more supra-aortic arteries, followed by the deployment of one or more aortic endoprosthesis, with lower morbidity and mortality compared to conventional surgery. OBJECTIVES: To evaluate the technique and results of hybrid procedures for CTAD. METHODS: During two years, 12 patients with CTAD underwent hybrid procedures, including aortic arch aneurysms and acute Stanford A and B aortic dissections. All patients had formal indications to invasive treatment, and inadequate proximal landing zone (less than 20 mm). Half were male and the mean age was 55.5 years (42 to 78). At least three cardiovascular risk factors were present in 75 percent of patients. The average follow-up was 10.9 months (2 to 25), with periodic consultations and CT scans. RESULTS: The initial technical success was achieved in 10 patients. Bypasses of supra-aortic vessels were performed in a surgical environment and endovascular procedures in an interventional radiology facility. "Through-and-through" technique was used in six patients. Two deaths occurred in the first 30 days after the procedure. No endoprosthesis migration was observed. No patient had paraplegia, stroke, renal failure, bleeding or coagulopathy, elective or emergency surgical conversion. CONCLUSION: Hybrid treatment of CTAD is feasible, especially in high risk patients. Proper integration of surgical and endovascular techniques, in addition to clinical and radiological surveillance, makes this technique a great alternative to conventional surgery.

Aortic aneurysm surgery: problems and innovations

A long way was traveled since the first surgery was performed for the treatment of abdominal aortic aneurysm. Throughout this time, several innovations have been created in order to reduce the invasiveness of the surgical procedures and to improve their safety and durability. This review discusses the major and recent advances on aortic aneurysm interventions, including, the endovascular aortic repair, the laparoscopic aortic surgery, the conventional hybrid and endovascular techniques, combined laparoscopic and endovascular techniques, as well as future prospects for both thoracic and abdominal aorta. Faced with so many changes and developments, modern vascular surgeons must keep their minds open to innovations and should develop comprehensive training with different techniques, to provide the best therapeutic option for their patients.

Um longo caminho foi percorrido desde as primeiras intervenções cirúrgicas feitas para o tratamento do aneurisma de aorta abdominal. Ao longo deste tempo, várias inovações foram criadas, no sentido de reduzir a invasividade dos procedimentos e melhorar sua segurança e durabilidade. Nesta revisão, são discutidos os principais e recentes avanços em intervenções sobre aneurismas aórticos, incluindo a restauração aórtica endovascular, a cirurgia aórtica videolaparoscópica, as técnicas híbridas convencionais e endovasculares, as técnicas combinadas videolaparoscópicas e endovasculares, bem como as perspectivas futuras, tanto para aorta torácica como abdominal. Diante de tantas transformações e evolução, o cirurgião vascular moderno terá que ter sua mente aberta para as novidades e desenvolver capacitação ampla com diferentes técnicas para proporcionar a melhor opção terapêutica para seus pacientes.

Endovascular Aortic Aneurysm Repair in a Renal Transplant Recipient:a Case Report

Endovascular aneurysm repair (EVAR) has gained increasing acceptance and success. We report here on a case of EVAR in a patient with renal allograft. EVAR was performed using an aorto-biiliac endovascular graft system in a 65-year-old man who underwent kidney transplantation in the right iliac fossa. The donor renal artery was anastomosed to the recipient' s internal iliac artery. The preoperative renal function was normal. The size of the aneurysm was 5.5 cm in transverse diameter and the length of the distal neck was 2 cm to the right internal iliac artery. After the procedure, the completion angiogram demonstrated the good position of the endograft; however, we found a type II endoleak from the IMA. The postoperative renal function was not changed and the patient was discharged home after an uneventful hospital course. At the 6 month follow-up, the type II endoleak was noted to have decreased on the CT angiogram and the patient has remained well with a stable allograft renal function.

Correção endovascular de aneurisma de aorta abdominal em paciente com rim em ferradura: relato de caso / Endovascular repair of an abdominal aortic aneurysm in patient with horseshoe kidney: a case report

O rim em ferradura é uma anomalia congênita rara que pode causar várias dificuldades técnicas durante a correção convencional de aneurisma de aorta abdominal. Relatamos o caso de uma paciente de 68 anos com rim em ferradura, aneurisma de aorta abdominal sintomático e disfunção renal leve. A paciente foi submetida a correção endovascular, sendo utilizada uma endoprótese bifurcada. O pós-operatório foi livre de complicações. O diagnóstico e a técnica endovascular são discutidos, assim como a literatura revisada.

Horseshoe kidney is a rare congenital anomaly that may cause various technical problems during conventional repairs of abdominal aortic aneurysms. We report the case of a 68-year-old woman with a horseshoe kidney, symptomatic abdominal aortic aneurysm and mild renal failure. The patient underwent endovascular repair using a bifurcated endoprosthesis. The postoperative was uneventful. We describe the diagnosis and the endovascular technique and literature review.