The evolution of management of type B aortic dissection in a series of 100 consecutive cases in a tertiary center.

INTRODUCTION AND OBJECTIVES: Management of aortic dissection is rapidly evolving. The present study aims to assess paradigm shifts in type B aortic dissection (TBAD) treatment modalities and their outcomes according to clinical presentation and type of treatment. We also aim to assess the impact of endovascular technology in TBAD management in order to define organizational strategies to provide an integrated cardiovascular approach. METHODS: We performed a retrospective review with descriptive analysis of the last 100 consecutive patients with TBAD admitted to the Vascular Surgery Department of Centro Hospitalar Universitário Lisboa Norte over a 16-year period. Results were stratified according to treatment modality and stage of the disease. The study was further divided into two time periods, 2003-2010 and 2011-2019, respectively before and after the introduction of a dedicated endovascular program for aortic dissections. RESULTS: A total of 100 patients (83% male; mean age 60 years) were included, of whom 59 were admitted in the acute stage (50.8% with complicated dissections). The other 41 patients were admitted for chronic dissections, most of them for surgical treatment of aneurysmal degeneration. Temporal analysis demonstrated an increase in the number of patients operated for aortic dissection, mainly due to an increase in chronic patients (33.3% in 2003-2010 vs. 64.4% in 2011-2019) and a clear shift toward endovascular treatment from 2015 onward. Overall in-hospital mortality was 14% and was significantly higher in the chronic phase (acute 5.1% vs. chronic 26.8%; OR 5.30, 95% CI 1.71-16.39; p=0.003) and in patients with aneurysmal degeneration, regardless of the temporal phase. Only one death was recorded in the endovascular group. CONCLUSION: Management of TABD carried an overall mortality of 14% during a 16-year period, but the appropriate use of endovascular technology has substantially reduced in-hospital mortality.

Predictive Factors for Aortic Graft Infection: A Case-Control Study.

BACKGROUND: Graft infections are one of the most serious complications in vascular surgery, with high mortality rates. Few studies addressed risk factors associated with a higher susceptibility to infection. The aim of this study is to identify perioperative factors associated with aortic graft infections (AGI). METHODS: We designed a retrospective, case-control study from patients subjected to open aortic repair between 2013 and 2019. Cases of AGI were defined according to the management of aortic graft infection collaboration (MAGIC) criteria and matched to controls without proven infection. Demographics, hospital complications, and laboratory workups were assessed. Predictors of AGI were identified through univariate and multivariate analysis. RESULTS: Most graft infections occurred in a late period (n = 17; 85%), after a median interval of 13.5 months interquartile range (IQR 1.5-36). Gram-negative bacteria were most frequently isolated in infected grafts, namely Enterobacteriaceae (n = 12). Cases had significantly lower postoperative serum albumin levels (1.9 g/dL vs. 2.4 g/dL; P = 0.002). Alcohol abuse, malignancy, prolonged lengths of stay, wound infection and dehiscence, in-hospital infection, postoperative heart failure or bowel ischemia were significantly correlated to the onset of AGI. In the multivariate analysis, prolonged hospital stays odds ratio (OR 1.05; P = 0.03), malignancy (OR 5.82; P = 0.03) and alcohol abuse (OR 42.41; P = 0.002) maintained a significant association. CONCLUSIONS: The risk of AGI seems to be higher in patients with concurrent malignancy, alcohol abuse or prolonged hospital stays. Strategies to mitigate this complication in these patients are of utmost importance.

Clinical outcomes of aortic arch hybrid repair in a real-world single-center experience.

OBJECTIVE: Aortic arch aneurysmal disease remains a therapeutic challenge. For patients unsuitable for standard open surgery, hybrid repair with debranching of the supra-aortic arteries followed by thoracic endovascular grafting has been shown to be an effective solution. The aim of this study was to report the clinical outcomes of a single-institution experience using hybrid aortic arch repair. METHODS: The cases of all consecutive patients submitted to hybrid aortic arch repair between January 2010 and June 2018 were prospectively collected and retrospectively analyzed. The outcomes of the study were 30-day mortality, perioperative complications, 2-year survival, endoleak, and reintervention rates. RESULTS: A total of 35 patients with a median age of 71 years (interquartile range, 62-77 years) were submitted to hybrid aortic arch repair, with a median follow-up of 26.9 months (interquartile range, 2.4-63.6 months). Ten procedures (28.6%) were performed urgently for contained rupture. The most common etiology was degenerative (n = 14 [40.0%]). The proximal landing zones according to the Ishimaru classification were zone 2 in 20 patients (57.1%), zone 1 in 12 patients (34.3%), and zone 0 in 3 patients (8.6%). Early endoleaks were observed in six patients (17.1%), equally distributed between type I and type II. Late endoleaks were identified in 4 of 24 patients (16.7%; type I, n = 2 [8.3%]; type II, n = 1 [4.2%]; and type III, n = 1 [4.2%]). Thirty-day mortality rate was 14.3% (n = 5) with an early death rate of 8.7% (2/23) in elective cases and 30.0% (3/10) in urgent cases (odds ratio [OR], 4.93; confidence interval [CI], 0.68-35.67; P = .128). Except in one patient, 30-day mortality was associated with landing zone 0 or zone 1 (26.7% vs 5.0%; OR, 6.91; CI, 0.68-69.86; P = .141). Three patients (8.6%) suffered a postoperative stroke, and no episodes of spinal cord ischemia were observed. Two-year survival rate was 67.8% (CI, 49.4%-80.8%). Survival rates were significantly lower with increasing age (hazard ratio [HR], 1.10; CI, 1.03-1.18; P = .004), urgent procedure (HR, 4.80; CI, 1.56-14.80; P = .003), zone 0 or zone 1 (HR, 6.34; CI, 1.73-23.18; P = .001), presence of arrhythmia (HR, 3.76; CI, 1.22-11.62; P = .013), and cerebrovascular disease (HR, 4.12; CI, 1.38-12.35; P = .006). A multivariate analysis identified age (HR, 1.11; P = .047) and zone 0 or zone 1 (HR, 4.93; P = .033) as the only predictors for overall mortality. CONCLUSIONS: Hybrid aortic arch repair seems to be an alternative for higher risk patients not suitable for open repair, but selection of patients is crucial and may benefit from further refinement. In this study, worse outcomes were seen in older patients and those who required more proximal landing zones.

Surgical Treatment of Post-Carotid Endarterectomy Carotid Pseudoaneurysm.

Post-endarterectomy pseudoaneurysms (PEPA) are a rare complication of carotid endarterectomy (CEA), but are associated with high morbidity risk. Therefore, once they are diagnosed, treatment is urgent to prevent possible complications such as rupture, embolisation, thrombosis, or airway and cranial nerve compression. In this video, the surgical procedure is shown in a case of PEPA 10 years after CEA with patch angioplasty, which was successfully managed by surgical excision and interposition of great saphenous vein graft. Follow up duplex examination at six months was normal, with patency of the vein graft. This case reiterates the importance of open surgery as the treatment of choice for this difficult clinical setting.

An Original Bailout Solution for Renal Artery Dissection after Fenestrated/Branched EVAR.

BACKGROUND: Renal artery (RA) dissection may occur during endovascular treatment of thoracoabdominal aneurysms. The aim of this paper is to report the use of kissing coronary stents in the renal bifurcation as a bailout solution for dissection after fenestraded/branched endovascular aortic repair (F/B-EVAR). METHODS/RESULTS: A 73-year-old male with an asymptomatic Crawford type 4 thoracoabdominal aneurysm and a concomitant right common iliac artery aneurysm was proposed for endovascular repair, consisting of thoracic endovascular aortic repair plus custom-made device F/B-EVAR, followed by staged bifurcated EVAR plus right-sided IBD. In the control angiogram of the first procedure, a distal occlusion of the left renal artery was observed and attributed to iatrogenic dissection. The 6F sheath was reintroduced and the two main branches of the RA were catheterized with 0.014 wires. Then, two coronary drug-eluting stents were used for a kissing stenting technique with good angiographic and clinical results. As planned, one week later the patient underwent an uneventful second stage procedure. Follow-up CTA at 1 year showed normal patency of the renal stents as well as aneurysm shrinking and no signs of endoleak. CONCLUSIONS: In the reported case, the use of coronary stents was a safe and long-lasting solution to rescue an iatrogenic renal artery dissection during F/B-EVAR.

Ex-vivo Surgical Repair of a Renal Artery Aneurysm with Kidney Autotransplantation.

Renal artery aneurysms are rare. They are most commonly degenerative, congenital or due to medial fibroplasia. Proximal aneurysms can be repaired by endovascular and in-situ surgical techniques. However, aneurysms of the distal renal artery and its branches require ex-vivo surgical repair, also known as auto-transplantation: the kidney is removed, dissected and reconstructed in cold ischemia, and put back in place. A 69-year-old woman, with hypertension, presented with bilateral renal artery aneurysms with a diameter of 3.4 cm on the right kidney and 1 cm on the left kidney. The right renal artery aneurysm, which was due to medial fibroplasia, was successfully repaired using the ex-vivo surgical technique. Patency was confirmed by postoperative computed tomography angiography.

Aneurysm-related disseminated intravascular coagulation successfully treated by endovascular repair.

Aortic abdominal aneurysm (AAA) is an uncommon etiology of disseminated intravascular coagulation (DIC). The authors report a case of an 81-year-old male patient who presented with hematuria, intraoral hemorrhage, melaenas and ecchymosis of the lower back and of the abdominal wall, after being medicated with etoricoxib for a back pain. During the study, an abdominal aortic aneurysm, which prolonged to the left common and internal iliac artery, was discovered. The diagnosis of AAA induced DIC was made. After endovascular aneurysm repair (EVAR), the patient's hemorrhagic manifestations disappeared and the laboratory findings normalized. In conclusion, the state-of-the-art treatment of DIC is the elimination of the underlying disease; in this case, EVAR was proven to be effective in treating the aortic aneurysm and the AAA-related DIC.

Hybrid Surgery in Lower Limb Revascularization: A Real-World Experience from a Single Center.

BACKGROUND: Through the association of endovascular and open procedures, hybrid surgery for lower limb revascularization allows the treatment of multilevel occlusive disease with a lower risk when compared to extensive open interventions. The aim of this study is to evaluate the immediate and midterm clinical outcomes of hybrid techniques for lower limb revascularization in a cohort of patients with multilevel arterial disease. METHODS: Data from elective procedures between 2012 and 2017 were retrospectively collected regarding hybrid lower limb revascularization procedures. The outcomes of the study were categorical clinical improvement, patency rates, major amputation rates, and mortality. RESULTS: A total of 81 patients, 89 limbs, with a median age of 69 years (interquartile range [IQR] 61-73) were submitted to hybrid lower limb revascularization, with a median follow-up of 10.7 months (IQR 2.5-25.1). Treatment indications were chronic limb-threatening ischemia in 80.9% of the cases (rest pain in 18.0% and tissue loss in 62.9%). One-year primary, primary-assisted, and secondary patency rates were 78.28% (95% confidence interval [CI] 65.20-86.92), 85.12% (95% CI 72.96-92.09), and 90.19% (95% CI 79.13-95.54), respectively. Overall categorical clinical improvement was observed in 56.2%. Major amputation and mortality rates were 14.6% and 16.0%, respectively. Multilevel Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) C or D and stage IV Leriche-Fontaine classification were strongly associated with decreased categorical clinical improvement (adjusted odds ratio [aOR] 0.08, P < 0.0001 and aOR 0.25, P = 0.013, respectively). Multilevel TASC C or D was also related to higher amputation rates, contrary to clinical presentation (adjusted hazard ratio [aHR] 11.37, P = 0.002 and aHR 4.70, P = 0.091, respectively). Primary-assisted and secondary patency rates were associated with higher categorical clinical improvement (aOR 4.30, P = 0.036 and aOR 7.36, P = 0.021, respectively) and decreased major amputation rates (aHR 0.11, P = 0.003 and aHR 0.09, P = 0.001, respectively) but were not related to multilevel TASC and Leriche-Fontaine classifications. CONCLUSIONS: The present study reports a real-world experience with a large proportion of patients with chronic limb-threatening ischemia. Hybrid interventions for lower limb revascularization revealed to be a potential approach for patients with complex arterial disease that would beneficiate from less invasive procedures.

Aortic Dissection Repair Using the STABILISE Technique Associated with Arch Procedures: Report of Two Cases.

INTRODUCTION: The stent assisted balloon induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique is being increasingly used for the treatment of complicated aortic dissections. However, as it is a fairly recent technique, the scientific information is limited. REPORT: In this paper we report two cases of the STABILISE technique associated with procedures in the ascending aorta and supra-aortic trunks, consisting of a "frozen elephant trunk" procedure in one case and in the other, a carotid endarterectomy associated with reimplantation of the vertebral artery and partial arch debranching. DISCUSSION: In conclusion, while acknowledging the need for longer follow up and greater experience to support the safety and efficacy of this procedure, the two cases reported confirm that the STABILISE technique is a valid endovascular alternative in the treatment of complicated aortic dissections.

Posterior Gastric Artery Aneurysm.

INTRODUCTION: Aneurysms of small abdominal vessels are extremely rare; however, even minor aneurysmal accessory arteries can rupture, leading to potentially fatal consequences. The purpose of this paper is to report a case of coil embolisation of an aneurysmal posterior gastric artery. CASE PRESENTATION: The authors describe the case of a 66 year old female patient with an aneurysm of the posterior gastric artery. Coil embolisation was performed. The six month follow up computed tomography angiogram revealed exclusion of the aneurysm. DISCUSSION: The presented case is exceedingly rare. This type of aneurysm has to be kept in mind as a possible cause of bleeding, despite the limited information regarding their natural history. CONCLUSION: Owing to the safety and applicability of the endovascular technique, it is nowadays probably the best treatment alternative for this type of aneurysm.

Restenosis of Aorto-renal Venous Grafts: Report of Two Patients Treated by Endovascular Stenting.

INTRODUCTION: Renal venous graft restenosis is an uncommon event usually associated with significant clinical impact. Its treatment by endovascular stenting is seldom reported in the literature. REPORT: Two cases of successful stenting for restenosis in aorto-renal venous grafts are described, detailing the technique and in one case reporting for the first time the use of a covered stent in this condition. DISCUSSION: Technical success may be achieved with proper material selection for the patient's anatomy and with dilation at relatively high pressures. The use of a covered stent may provide extra safety when treating vein grafts.

Implantación de endoprótesis para el tratamiento del síndrome de vena cava superior maligno: serie de 56 pacientes de un solo centro / Stent Placement for the Treatment of Malignant Superior Vena Cava Syndrome-A Single-Center Series of 56 Patients

Objetivo: Presentar una serie de intervenciones de implantación de endoprótesis para tratar el síndrome de vena cava superior (VCS) maligno. Material y métodos: En una revisión del periodo comprendido entre octubre de 2005 y julio de 2013 se identificaron 56 pacientes consecutivos tratados por un síndrome de VCS maligno sintomático mediante implantación de endoprótesis. Resultados: La implantación de endoprótesis en la VCS se intentó en 56 pacientes (46 varones, 10 mujeres) de 34-84 años de edad (media 59,3). La tasa de éxitos fue de 49/57 (86%). El éxito se asoció al tipo de obstrucción agrupada de la siguiente forma: grupo 1 (a: estenosis de VCS, o b: oclusión de vena innominada unilateral con estenosis de vena innominada contralateral y VCS normal), grupo 2 (oclusión de VCS y exclusión de oclusión de vena innominada bilateral) y grupo 3 (oclusión de vena innominada bilateral con independencia del estado de la VCS). Las tasas de éxito fueron del 100% (39/39), del 75% (9/12) y del 16,6% (1/6), respectivamente. Estas diferencias eran significativas: grupo 1 frente a grupo 2 + 3 (p < 0,001) y grupo 2 frente a grupo 3 (p = 0,032). Se produjeron complicaciones agudas en 9 pacientes. Los pacientes en los que se dieron las complicaciones agudas fueron de mayor edad que los demás (67,8 frente a 57,6 años, p = 0,019). Hubo muertes relacionadas con la intervención en el 3,5% (n = 2). Se produjo una oclusión de la endoprótesis en el 3,5% (n = 2). La supervivencia de los pacientes fue baja (mediana 2,6; rango < 1-29,6 meses) e independiente del éxito de la implantación de endoprótesis. Conclusiones: La implantación de endoprótesis para el síndrome de VCS maligno proporciona un alivio sintomático inmediato y sostenido que persiste hasta la muerte en este grupo de pacientes con una esperanza de vida corta y restablece el acceso venoso central para la administración de quimioterapia. El fallo técnico se asoció a oclusiones de la VCS y sobre todo a una oclusión de la vena innominada bilateral

Objective: To report a series of stenting procedures for the treatment of malignant superior vena cava (SVC) syndrome. Material and methods: A review conducted from October 2005 to July 2013 retrieved 56 consecutive patients treated for symptomatic malignant SVC syndrome with stenting. Results: SVC stenting was attempted in 56 patients (46 males, 10 females), aged 34-84 years (mean 59.3). The success rate was 49/57 (86%). Success was associated with the type of obstruction and was classified as follows: group 1 (a-SVC stenosis, or b-unilateral innominate vein occlusion with contralateral innominate vein stenosis and normal SVC), group 2 (SVC occlusion excluding bilateral innominate vein occlusion) and group 3 (bilateral innominate vein occlusion irrespective of SVC status). Success rates were 100% (39/39), 75% (9/12) and 16.6% (1/6), respectively. These differences were significant for group 1 versus group 2 + 3 (P < .001) and for group 2 versus group 3 (p = 0.032). Acute complications occurred in 9 patients. Patients in whom acute complications occurred were older than the others (67.8 vs 57.6 years, p = .019). Procedure-related death rate was 3.5% (n = 2). Stent occlusion occurred in 3.5% (n = 2). Patient survival was poor (median 2.6 months; range < 1-29.6 months), independent of the success of stenting. Conclusions: Stenting for malignant SVC syndrome provides immediate and sustained symptomatic relief that lasts until death in this set of patients with a short life expectancy and restores the central venous access for administration of chemotherapy. Technical failure was associated with SVC occlusions and primarily with bilateral innominate vein occlusion

[Endovascular management of an infectious and ruptured abdominal aortic aneurysm. Clinical report]. / Tratamento endovascular de um aneurisma infeccioso da aorta abdominal em rotura - Caso Clínico.

Infectious aneurysms are about 1-3% of all aneurysms of the infrarenal aorta. Its treatment is challenging and the best strategy is far from consensual. The authors report a case of a HIV + patient with multiple other co-morbidities, which was seen in the emergency department with fever and left back pain. These symptoms would prove to be in relation to a ruptured infectious aneurysm of the abdominal aorta. Facing this situation it was decided to select an endovascular technique with implantation of an aorto uni - iliac stent graft with a right-left femoro-femoral cross-over using a 8 mm PTFE graft and exclusion of the left common iliac . The patient didn't have any complication from the situation or the procedure, but died 18 months postoperatively because of a pneumonia caused by Pneumocystis jiroveci. Although it is not the ideal solution for the treatment of infectious elective aneurysms, we believe that endovascular treatment seems to be a viable option and should be taken into account in a subgroup of patients that for their co-morbidities are not good candidates for conventional surgery and for those in rupture, either as a bridge or as a final solution.

Stent placement for the treatment of malignant superior vena cava syndrome - a single-center series of 56 patients.

OBJECTIVE: To report a series of stenting procedures for the treatment of malignant superior vena cava (SVC) syndrome. MATERIAL AND METHODS: A review conducted from October 2005 to July 2013 retrieved 56 consecutive patients treated for symptomatic malignant SVC syndrome with stenting. RESULTS: SVC stenting was attempted in 56 patients (46 males, 10 females), aged 34-84years (mean 59.3).The success rate was 49/57 (86%). Success was associated with the type of obstruction classified as: group1 (a -SVC stenosis, or b -unilateral innominate vein occlusion with contralateral innominate vein stenosis and normal SVC), group2 (SVC occlusion excluding bilateral innominate vein occlusion) and group3 (bilateral innominate vein occlusion irrespective of SVC status). Success rates were 100% (39/39), 75% (9/12) and 16.6% (1/6), respectively. These differences were significant for group1 versus group2+3 (p<0.001) and for group2 versus group3 (p=0.032). Acute complications occurred in 9 patients. Patients in whom acute complications occurred were older than the others (67.8 vs. 57.6 years, p=0.019). The procedure-related death rate was 3.5% (n=2). Stent occlusion occurred in 3.5% (n=2). The patient survival was poor (median 2.6; range <1-29.6months), independently of the success of stenting. CONCLUSIONS: Stenting for malignant SVC syndrome provides immediate and sustained symptomatic relief that lasts until death in this set of patients with a short life expectancy and restores the central venous access for administration of chemotherapy. Technical failure was associated with SVC occlusions and primarily with bilateral innominate vein occlusion.

[Complications of vascular access for hemodialysis - limits, imagination and commitment]. / Complicações dos acessos vasculares para hemodiálise - limites, imaginação e empenho.

Terminal chronic kidney disease courses with high mortality and is a serious public health problem on a global scale. In Portugal, it involves about 14,000 patients of whom 5,000 are transplanted. The remaining require permanent renal replacement techniques. Every year, there are 2,200 new cases and the mortality rate is around 20%. One of the most important determinants for the survival of hemodialysis patients is the quality of vascular access. The role of the vascular surgeon is to planify and to do the best access possible, monitoring and fight for its patency and thereby improve not only the quality of life but also to combat mortality associated with complications of vascular access - first cause of hospital admission of these patients. The authors report 10 clinical cases in which the limits of the hemodialysis surgery were tested and where it was necessary commitment and imagination to prevent the vascular access loss. The management of some complications is a challenge for the vascular surgeon and currently it is necessary to find hybrid/complementary solutions. Examples of some complications and challenges are steal syndromes, venous hypertension, vascular access in unusual places and 'total' failure of vascular access. Focusing on maintaining vascular access working improves the quality of dialysis, quality of life for patients, saves vascular capital for future access and in extreme cases, saves lifes.

[Some reflections on the Klippel Trenaunay syndrome: A single entity or an association of vascular malformations]. / Algumas considerações sobre o syndrome de klippel trenaunay: uma entidade única ou um conjunto de malformações vasculares?

The author started in the year 2000, in the St Marta Hospital, a consultation for congenital vascular malformations, that was extrapolated to the Pulido Valente Hospital - CHLN where he continues to see multiple patients with this type of pathology, mainly located to the extremities.The Klippel Trenaunay syndrome, which was described as a set of anomalies constituted by the presence of a cutaneous angiomatous malformation ( port wine stain ), varicose veins and gigantism of the limbs, is undoubtedly the most common malformations that he is asked to treat. So he thought that it would be interesting to undertake an actual review of this pathology.After analyzing the various components in question he concludes that the condition is undoubtedly a set of malformations ranging from a cutaneous component, to the venous and lymphatic malformations and clear the osseous component, that causes the bone dysmorphic appearance, and that is essential a multidisciplinary approach to achieve a final satisfactory therapeutic result.

[Cubital artery aneurysm and hypothenar hammer syndrome. Report of an unusual case]. / Aneurisma da artéria cubital e síndrome do martelo hipotenar. Considerações sobre um caso clínico pouco frequente.

Hypothenar hammer syndrome (HHS) is a rare condition and is a term used to described an aneurysm or thrombosis of the ulnar artery. It is considered an occupational or recreational injury and usually results of repetitive trauma to the hypothenar region, where th unique anatomy after the artery leaves the Guyon canal, allows the arterial injury. Clinical manifestations are more often unilateral, involving the dominant hand. However, some authors report the existence of a previous arteriopathy, predisposing to the injury, after repetitive palmar trauma.The authors report the clinical case of a 60 year-old woman, with an ulnar aneurysm in the non dominant hand, without evident existence of repetitive trauma. The pathological examination of the artery revealed muscular hyperplasia, without the characteristics of muscular fibrodysplasia. The authors believe that this case, once again, demonstrates the existence of an autonomous and "previous" arteriopathy associated to the traumatic lesion.