Hybrid Repair of Left Subclavian Artery Pseudoaneurysm With Vertebral Artery Revascularisation: A Solution for a Complex Case.

Introduction: Pseudoaneurysms of the subclavian artery are a rare complication. Surgical treatment is necessary to prevent potentially lethal complications. This needs adequate planning in cases that require vertebral artery revascularisation. Report: A 56 year old man with multiple systemic comorbidities underwent endovascular treatment using a balloon expandable bare metal stent for symptomatic subclavian Steal syndrome. During follow up, computed tomography angiography (CTA) revealed a pseudoaneurysm in the proximal segment of the left subclavian artery. The patient had criteria warranting left vertebral artery revascularisation. The patient underwent scheduled hybrid surgical treatment involving transposition of the vertebral artery to the common carotid artery, endarterectomy of the internal carotid artery, and endovascular therapy for pseudoaneurysm exclusion; all were performed on the left side. The post-operative period was without incident. After 12 months the patient remains asymptomatic, with adequate exclusion of the pseudoaneurysm, and patency of the procedures. Discussion: Hybrid surgery could offer a secure, feasible, and less invasive option for treating subclavian artery pseudoaneurysms that require vertebral artery revascularisation.

Tratamiento quirúrgico de aneurisma de aorta abdominal en paciente con riñón único de localización pélvica / Surgical treatment of abdominal aortic aneurysm with solitary pelvic kidney

Introducción: la presencia de riñón pélvico constituye una variante anatómica con escasa incidencia en la población general, y es todavía más infrecuente su asociación con aneurismas de aorta abdominal (AAA). Caso clínico: varón de 69 años con insuficiencia renal estadio 4, remitido por hallazgo ecográfico de AAA. La angioTC muestra un AAA de 56 mm de diámetro máximo con riñón único de localización pélvica, cuya arteria renal única surge de la bifurcación aórtica. El paciente se sometió a tratamiento quirúrgico de forma programada. Se realizó un bypass aortobiiliaco y bypass desde la rama derecha del injerto a la arteria renal con vena safena interna invertida. Como técnica de protección renal se administró manitol intravenoso previamente al clampaje renal y se realizó en primer lugar la anastomosis de la vena safena interna con la arteria renal para así infundir solución salina fría durante el tiempo de isquemia. El posoperatorio transcurrió sin incidencias exceptuando un discreto deterioro de la función renal que se resolvió mediante tratamiento médico. Discusión: el riñón pélvico implica un desafío en el tratamiento de la patología aórtica aneurismática asociada. Por un lado, supone una limitación a la hora de efectuar tratamientos endovasculares y por otro, la necesidad de minimizar el tiempo de isquemia renal durante el clampaje puede aumentar significativamente la complejidad del tratamiento quirúrgico.(AU)

Introduction: pelvic kidney is an anatomical variant with minimal incidence in the general population; its association with abdominal aortic aneurysm (AAA) is even more infrequent. Case report: a 69-year-old man with stage 4 renal failure, was referred due to an ultrasound finding of AAA. CT angiography shows a 56-mm AAA with a single pelvic kidney whose single renal artery arises from the aortic bifurcation. The patient underwent elective surgical treatment. An aorto-biiliac bypass and a bypass from the right branch of the graft to the renal artery with inverted great saphenous vein (GSV) were performed. The renal protection techniques consist on administrating intravenous mannitol prior to renal clamping and to perform the anastomosis of the GSV with the renal artery in first place in order to infuse cold saline solution during the time of ischemia. The postoperative period was uneventful except for a slight deterioration in renal function that was resolved with medical treatment. Discussion: the presence of a pelvic kidney in the treatment of aneurysmal aortic pathology can be challenging. On the one hand, it represents a limitation to endovascular techniques and on the other hand, the need to minimize the time of renal ischemia during clamping can significantly increase the complexity of the surgical treatment.(AU)

Fenestrated and chimney endovascular aneurysm repair versus open surgery for complex abdominal aortic aneurysms.

BACKGROUND: Many patients with complex abdominal aortic aneurysms are unfit for open repair. New endovascular technologies and bailout techniques are being used for managing these complex anatomies. The purpose of this study is to compare the results obtained with advanced endovascular aneurysm repair (a-EVAR) techniques (fenestrated and chimney endografts) to those obtained with open repair for the treatment of complex abdominal aortic aneurysms not anatomically suitable for standard endovascular exclusion (infrarenal neck <10 mm, juxtarenal, suprarenal and Crawford's type IV thoracoabdominal aneurysms). METHODS: All patients that underwent open surgery (OS cohort; historical, January 1994-December 2015) or a-EVAR (a-EVAR cohort; prospective, January 2006-December 2015) at our institution for complex abdominal aortic aneurysms that meet the anatomical criteria described above on the preoperatory contrast-enhanced computed tomography scan were included. Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (V-POSSUM) was employed for risk-assessment. RESULTS: A total of 108 patients were included, all of them male: 56 in the OS cohort and 52 in the a-EVAR cohort (mean age: 67.5±6.7 vs. 72.65±6.4 years, respectively; P=0.000). V-POSSUM predicted 4 deaths for the OS cohort and 3 deaths for the a-EVAR cohorts within the postoperative period and morbidity rates of 57% and a 44.4%, respectively. All-cause 30-day mortality rates were 9 patients (16%) for the OS cohort and 2 patients (3.8%) for the a-EVAR cohort (P=0.038). Thirty-day morbidity rates were 59% for the OS cohort and 44% for the a-EVAR cohort (P=0.09). Mean cost of treatment was € 15,707 per patient for the OS cohort (median: € 11,516; inter-quartilic range [IQR]: € 7901; min-max: € 5069-11,0052) and € 33,457 per patient for the a-EVAR cohort (median: € 29,663; IQR: € 5979; min-max: € 13,865-19,3536), P=0.000. CONCLUSIONS: A-EVAR is a feasible alternative to open surgery for complex abdominal aortic aneurysms at our institution, with lower 30-day mortality rates, yet increasing double the amount the total cost of the therapy.

A Rare Complication After Endovascular Aneurysm Repair: Disconnection of the Suprarenal Stent of a Zenith Endograft.

PURPOSE: To report a disconnection between the bare suprarenal stent and the main body of a Zenith endograft. CASE REPORT: A 79-year-old man with a history of successful endovascular repair of an aortic aneurysm presented a sudden episode of hypotension and hematuria. He had undergone implantation of a Zenith bifurcated device 8 years earlier in 2006. Plain abdominal radiography and computed tomography showed disconnection of the uncovered proximal stent, which led to endograft migration and type Ia endoleak. The patient also presented with distal endoleaks at the attachment sites in both common iliac arteries. The aneurysm sac diameter had increased from 52 to 96 mm. A proximal aortic cuff and bilateral iliac extensions were deployed via a common femoral artery access. Completion angiography did not show endoleak. CONCLUSION: After publication of a few such cases with the older Zenith device, the union between the suprarenal stent and main body was reinforced in 2002 to prevent this complication. Since modification of the device, this sequela had not been described. The reappearance of this complication underscores the need for continued surveillance, considering that these late events may require a reintervention to maintain the clinical success of the procedure.

Predictors of cervical bleeding after carotid endarterectomy.

BACKGROUND: The aim of this study is to determine the incidence of severe cervical bleeding requiring reintervention after carotid endarterectomy (CEA), to identify its predictive parameters, and to find out the influence of these on major complications. METHODS: This was a retrospective review of 502 CEAs carried out in 455 consecutive patients between 1995-2011 in our institution. The end points were: postoperative cervical bleeding that required reoperation and major postoperative complications (i.e., stroke, myocardial infarction, and death). Patients' demographics, antiplatelet and anticoagulant treatment, anaesthetic technique, surgical details, and perioperative management were registered. The end point predictors were univariate and multivariate analyzed. RESULTS: Neck bleeding after CEA occurred in 42 cases (8.4%), requiring reoperation in 28 cases (5.6%). In the univariate analysis, chronic anticoagulation and anticoagulation 24 hours before surgery were associated with reoperation for bleeding (16.6% vs. 4.8% [P = 0.02] and 17.8% vs. 4.7% [P = 0.014], respectively). The agent used for antiplatelet treatment before surgery was related to reoperation in the univariate analysis and was the only factor with statistical significance in the multivariate analysis: acetylsalicylic acid (ASA) 100 mg (2.4%), ASA 300 mg (1.5%), clopidogrel 75 mg (7.8%), ASA 100 mg associated with clopidogrel (3.3%), triflusal (5.5%), and ticlopidine (2.2%); there was a higher incidence of reoperation only in the group of patients who had taken clopidogrel 24 hours before CEA (4.7% vs. 1.05% [P = 0.06], respectively) but without statistical significance (odds ratio: 2; 95% confidence interval: 0.95-4.84). No reoperations were registered using vein patch compared to prosthetic patch (0% vs. 6.1% [P = 0.028]). Conversion to general anesthesia (22.2% vs. 4.9% [P = 0.014]) and noncontrollable postoperative hypertension (6.9% vs. 2.5% [P = 0.028]) were associated with a higher rate of reoperation. There were no statistically significant differences in the reoperation rates related to bleeding for anesthetic technique (local versus general), surgical procedure (classic endarterectomy versus eversion technique), type of prosthetic patch (Dacron/politetrafluoroethylene), use of shunt, intraoperative dose of heparin, protamine reversal, activated clotting time monitoring, or surgeon qualification level. The combined rate of stroke mortality was 2.6%. Reoperation for bleeding was not associated with an increased rate of thrombosis, stroke, death, or injury of cranial nerves. CONCLUSIONS: Postoperative severe bleeding after carotid surgery in our institution is not an uncommon complication. Its incidence is within the range reported in the literature, but it is not associated with major complications or mortality. Antiplatelet treatment with clopidogrel is the main risk factor associated with reintervention. Other factors, such as coagulation control, postoperative hypertension management, and the use of an autologous patch, could help reduce its incidence.

Historia natural de la estenosis carotídea de grado moderado en pacientes con enfermedad arterial periférica / Natural history of moderate-degree carotid stenosis in patients with peripheral artery disease

Fundamento y objetivo: Conocer la evolución de la estenosis carotídea moderada asintomática, losfactores que influyen en la progresión y la morbimortalidad relacionada. Pacientes y método: Estudio observacional retrospectivo de 133 pacientes con estenosis carotídea asintomática entre 50-69% en una o ambas carótidas entre 2002 y 2009. Se incluyen pacientes sometidos a cribado por enfermedad arterial periférica (EAP), patología aneurismática o soplo carotíeo. El seguimiento se realiza mediante ecodoppler anual. Se valora el grado de progresión, variables relacionadas con esta, la aparición de episodios neurológicos y mortalidad global y cardiovascular. Se ha realizado un estudio descriptivo, análisis univariante (ji al cuadrado y t de Student), análisis multivariante (regresión logística) y curvas de supervivencia (test de Log-Rank). Resultados: Con un tiempo medio (DE) de seguimiento de 30,8 (1,7) meses, se observó progresión de la estenosis en el 33% de los pacientes, con un tiempo medio de progresión de 31 3 (2,7) meses. Se registró una mayor tasa de progresión en el subgrupo de pacientes que asociaban EAP y cardiopatía isquémica (odds ratio [OR] 2,84, intervalo de confianza del 95% [IC 95%] 1,14-7,03). En el análisis multivariante tan solo la EAP se presenta como un factor de riesgo de progresión (p = 0,043). El grupo de pacientes con progresión presentó mayores tasas de episodios neurológicos (15 frente a 1,6%, p = 0,01), mayor mortalidad global (15 frente a 3%, p = 0,04) y mayor mortalidad cardiovascular (12,1 frente a 1,5%, p = 0,03). Conclusiones: La progresión de estenosis carotídea asintomática entre el 50-69% es frecuente en pacientes sometidos a cribado, especialmente en aquellos con antecedentes de cardiopatía isquémica y/o EAP. Esta progresión se asocia a una mayor tasa de complicaciones cardiovasculares. Por ello recomendamos el seguimiento clínico y ecográfico de estos pacientes (AU)

Background and objective: To understand the evolution of moderate asymptomatic carotid stenosis, the factors that influence its progression and the related morbimortality. Patients and methods: Retrospective observational study of 133 patients with asymptomatic carotid stenosis between 50-69% in one or both carotids between 2002 and 2009. Included patients were subjected to screening for peripheral arterial disease (PAD), aneurysmal disease or carotid bruit. The monitoring was carried out using an annual duplex scan. The rate of progression, the variables related to this, the appearance of neurological events, and global and cardiovascular mortality were evaluated. Descriptive studies, univariate analysis (chi-squared test and Student’s t-test), multivariate analysis (logistic regression), and survival curves (Log-Rank test) were carried out. Results: With an average time of monitoring: 30.8 1.7 months, stenosis progression was observed in 33% of the patients, with an average progression time of 31.3 2.7 onths. Greater progression was observed in the subgroup of patients with PAD and ischemic heart disease (odds ratio [OR] 2.84, confidence interval [CI] 95% 1.14-7.03). In the multivariate analysis only the PAD was identified as a risk factor for progression (P = .043). The group of patients with progression showed greater rates of neurological events: 15 vs. 1.6% (P = .01), greater global mortality: 15 vs. 3% (P = .04), and greater cardiovascular mortality: 12.1 vs. 1.5% (P = .03). Conclusions: The progression of asymptomatic carotid stenosis between 50-69% is common in patients subjected to screening, especially in those with a history of ischaemic heart disease and/or PAD. This progression is associated with an increased rate of cardiovascular complications. For this reason, we recommend clinical and echographic follow-up of these patients (AU)

[Natural history of moderate-degree carotid stenosis in patients with peripheral artery disease]. / Historia natural de la estenosis carotídea de grado moderado en pacientes con enfermedad arterial periférica.

BACKGROUND AND OBJECTIVE: To understand the evolution of moderate asymptomatic carotid stenosis, the factors that influence its progression and the related morbimortality. PATIENTS AND METHODS: Retrospective observational study of 133 patients with asymptomatic carotid stenosis between 50-69% in one or both carotids between 2002 and 2009. Included patients were subjected to screening for peripheral arterial disease (PAD), aneurysmal disease or carotid bruit. The monitoring was carried out using an annual duplex scan. The rate of progression, the variables related to this, the appearance of neurological events, and global and cardiovascular mortality were evaluated. Descriptive studies, univariate analysis (chi-squared test and Student's t-test), multivariate analysis (logistic regression), and survival curves (Log-Rank test) were carried out. RESULTS: With an average time of monitoring: 30.8 ± 1.7 months, stenosis progression was observed in 33% of the patients, with an average progression time of 31.3 ± 2.7 months. Greater progression was observed in the subgroup of patients with PAD and ischemic heart disease (odds ratio [OR] 2.84, confidence interval [CI] 95% 1.14-7.03). In the multivariate analysis only the PAD was identified as a risk factor for progression (P=.043). The group of patients with progression showed greater rates of neurological events: 15 vs. 1.6% (P=.01), greater global mortality: 15 vs. 3% (P=.04), and greater cardiovascular mortality: 12.1 vs. 1.5% (P=.03). CONCLUSIONS: The progression of asymptomatic carotid stenosis between 50-69% is common in patients subjected to screening, especially in those with a history of ischaemic heart disease and/or PAD. This progression is associated with an increased rate of cardiovascular complications. For this reason, we recommend clinical and echographic follow-up of these patients.

Endovascular repair of an iliac arteriovenous fistula secondary to perforation from a common iliac aneurysm in a patient with Ehler-Danlos syndrome.

BACKGROUND: Type IV Ehler-Danlos syndrome (EDS) patients are prone to life-threatening vascular complications. Surgical management of those complications is challenging owing to vessel wall fragility, which may result in hemorrhagic events and high mortality rates. Here we report a case of left common iliac aneurysm perforation of the ipsilateral iliac vein repaired using endovascular technique in a patient with EDS. METHOD AND RESULTS: A 54-year-old patient presented with heart failure symptoms that evolved over 1 week in association with left leg edema and steal syndrome due to a perforation of the left iliac vein caused by a left common iliac aneurysm. A thrombosed right common iliac aneurysm and several other visceral and peripheral aneurysms were discovered on computed tomographic scan at admission. An aortouniiliac stent graft was used to seal the fistula. After 18 months of follow-up, the patient remained asymptomatic. CONCLUSIONS: We suggest that endovascular therapy is useful to manage vascular complications in patients with EDS.

[Clinical and therapeutic characteristics of limb emboli]. / Características clínicas y terapéuticas de las embolias de extremidades.

INTRODUCTION: To treat an extremity embolus seems to be a simple and safe procedure. However, it is not exempt from potentially serious complications. We review our experience of treating acute peripheral arterial occlusion due to emboli. PATIENTS AND METHOD: We retrospectively analyzed the data of 127 embolectomies performed during the last five years, in 120 extremities in 116 patients. The mean age of the patients was 80 years and 66% were female. All cases were presented as acute threatened limb ischemia grades IIA or IIB, and the mean evolution time was 27 hours. The patency, limb salvage and morbidity-mortality rates in the postoperative period and the salvage and survival rates in the follow-up were analyzed. RESULTS: Of the embolectomies, 55% were femoral and 30% brachial. Although 90% of the cases improved, only 75% of them recovered distal pulses. In the postoperative period the patency, limb salvage, morbidity and mortality rates were 90%, 96%, 13% and 6.4%, respectively. The mean follow-up was 24 months. Up until this time, the patency and survival rates are 91% and 61%, respectively. The only factor related with an increase in the amputation rate was a clinical presentation, such as a threatened immediate ischemia. The factors related with an increase in survival rate were appropriate cardiological treatment and control, and long-term anticoagulation treatment. CONCLUSIONS: Suffering an embolus of the extremities and its treatment causes considerable morbidity-mortality and limb amputation rates. The extremity salvage is associated with the clinical presentation at the time of the treatment. Long-term anticoagulation treatment and appropriate cardiological control increase the survival of these patients.

Características clínicas y terapéuticas de las embolias de extremidades / Clinical and therapeutic characteristics of limb emboli

Introducción. Tratar una embolia arterial de las extremidades resulta un procedimiento sencillo, seguro y resolutivo. Sin embargo, no es un proceso exento de complicaciones potencialmente graves. Material y método. Se han analizado retrospectivamente las 127 embolectomías realizadas, en los últimos 5 años, en 120 extremidades de 116 pacientes. La media de edad fue 80 años y el 66% eran mujeres. La mayoría se manifestó como isquemias agudas con amenaza de la extremidad, de una media de 27 h de evolución. Se han analizado las tasas de permeabilidad, salvamento y morbimortalidad postoperatorias y de salvamento y supervivencia a medio plazo en el seguimiento. Resultados. El 55% de las embolectomías fueron femorales y el 30%, humerales. El 90% de los casos mejoraron clínicamente, aunque sólo el 75% recuperó pulsos distales. En el postoperatorio los resultados fueron: permeabilidad del 90%, salvamento del 96%, morbilidad del 13% y mortalidad del 6,4%. El seguimiento medio fue 24 meses. Al final del seguimiento medio, los resultados fueron: salvamento de extremidad del 91% y supervivencia del 61%. El único factor relacionado con un incremento en la tasa de amputación fue la presentación clínica como una isquemia aguda con amenaza inmediata (frente a amenaza inicial). Los factores relacionados con una mejor supervivencia fueron unos adecuados tratamiento y control cardiológico y una anticoagulación prolongada a dosis ajustadas. Conclusiones. Sufrir una embolia de extremidades y su tratamiento mediante embolectomía producen tasas de morbimortalidad y amputación no desdeñables. El salvamento de la extremidad está relacionado con la clínica en el momento del tratamiento. La anticoagulación prolongada y el control cardiológico aumentan la supervivencia de estos pacientes (AU)

Introduction. To treat an extremity embolus seems to be a simple and safe procedure. However, it is not exempt from potentially serious complications. We review our experience of treating acute peripheral arterial occlusion due to emboli. Patients and method. We retrospectively analyzed the data of 127 embolectomies performed during the last five years, in 120 extremities in 116 patients. The mean age of the patients was 80 years and 66% were female. All cases were presented as acute threatened limb ischemia grades IIA or IIB, and the mean evolution time was 27 hours. The patency, limb salvage and morbidity-mortality rates in the postoperative period and the salvage and survival rates in the follow-up were analyzed. Results. Of the embolectomies, 55% were femoral and 30% brachial. Although 90% of the cases improved, only 75% of them recovered distal pulses. In the postoperative period the patency, limb salvage, morbidity and mortality rates were 90%, 96%, 13% and 6.4%, respectively. The mean follow-up was 24 months. Up until this time, the patency and survival rates are 91% and 61%, respectively. The only factor related with an increase in the amputation rate was a clinical presentation, such as a threatened immediate ischemia. The factors related with an increase in survival rate were appropriate cardiological treatment and control, and long-term anticoagulation treatment. Conclusions. Suffering an embolus of the extremities and its treatment causes considerable morbidity-mortality and limb amputation rates. The extremity salvage is associated with the clinical presentation at the time of the treatment. Long-term anticoagulation treatment and appropriate cardiological control increase the survival of these patients (AU)