Surgical Repair of a Ruptured Giant Abdominal Aortic Aneurysm in a 16-Year-Old with Takayasu's Arteritis: Case Report and Etiological Review

Abstract Takayasu's arteritis is a type of primary systemic vasculitis that affects medium and large arteries, including the aorta and its main branches, as well as the pulmonary and coronary arteries. Although rare in children, it is the third most common vasculitis in the pediatric population, often with delayed diagnosis due to the nonspecific presentation of clinical symptoms in its initial phase. This is a case of a 16-year-old girl with a giant ruptured abdominal aortic aneurysm, who needed surgery on an emergency basis. The etiological aspects involved in aneurysms in young patients are also addressed.

Expression of MicroRNA-1281, C-Reactive Protein, and Renal Function in Individuals with Abdominal Aortic Aneurysm and their Clinical Correlation after Endovascular Repair.

INTRODUCTION: The treatment of infrarenal aortic aneurysms has changed in the last three decades. Endovascular aneurysm repair (EVAR) has become the primary treatment option in anatomically suitable patients with infrarenal aortic aneurysms. However, there is no serum biomarker to be used in EVAR follow-up. METHODS: This is a prospective single-centre study of 30 consecutive patients with abdominal aortic aneurysm (AAA) who underwent EVAR. Serum dosages of micro ribonucleic acid 1281 (miRNA-1281), creatinine, total cholesterol, triglycerides, and C-reactive protein (CRP) were evaluated and angiotomographic evaluations were performed preoperatively and six months after the intervention. RESULTS: There was a hyperexpression of miRNA-1281 in patients with AAA and a significant reduction of it after EVAR, from 1.66-fold before EVAR to 0.27 after the procedure (P<0.0001). MiRNA-1281 expression was not influenced by renal function (creatinine: 1.14±0.29, P=0.68), total cholesterol (179.9±59.9, P=0.22), or CRP (1.17±3.5; P=0.48). There is correlation between AAA size and CRP serum levels, however there was no statically significant reduction of CRP after EVAR. DISCUSSION: MiRNA-1281 expression may be influenced by cholesterol, triglycerides levels, and renal function. We found no difference in these markers before and six months after EVAR. However, miRNA-1281 presents a significant reduction in patients with no follow-up complications. We hypothesize that miRNA-1281 expression may be related to aortic wall stress or flow changes. CONCLUSION: MiRNA-1281 may contribute as a possible marker of EVAR follow-up.

Abdominal aortic aneurysms ruptured to the vena cava: a case series and literature review.

Ruptured abdominal aortic aneurysms (RAAA) evolving aortocaval fistula (AF) can have catastrophic hemodynamic effects. Surgical repair is imperative, but the optimal technical approach is still under debate. Our objective is to present 3 cases treated with endovascular repair (EVAR) at a University Hospital. Case #1, a 71-year-old man presenting a 7.1cm RAAA with AF, repaired with a monoiliac stent graft and femoral-femoral bypass; Case #2, a 76-year-old man presenting a 9.9cm RAAA with AF, repaired with a bifurcated stent graft; Case #3, a 67-year-old man with previous history of EVAR, presenting a type 3 endoleak with late rupture related to AF, repaired with a tubular stent graft. All cases unfolded with delayed recovery and significant complication rates, although AF symptoms had resolved by hospital discharge. EVAR techniques for AF may require secondary interventions but are feasible, despite the lack of consensus, considering the rarity of this RAAA presentation.

Aneurismas de aorta abdominal rotos (AAAR) com evolução para fístula aorto-cava (FAC) podem apresentar consequências hemodinâmicas catastróficas. A correção cirúrgica é mandatória, embora não haja consenso sobre a técnica operatória. Apresentamos uma série de três casos operados em hospital universitário pela técnica endovascular. No primeiro caso, um homem de 71 anos apresentou AAAR de 7,1 cm com FAC, submetido a correção por endoprótese monoilíaca e enxerto femoral cruzado. No segundo, um homem de 76 anos apresentou AAAR de 9,9 cm com FAC submetido a colocação de endoprótese bifurcada. O terceiro caso era de um homem de 67 anos com histórico de EVAR e endoleak tipo 3, com ruptura tardia para veia cava, tratado com extensão aórtica. Todos apresentaram evolução pós-operatória prolongada com significativas complicações, entretanto com boa resolução dos sintomas à alta hospitalar. A EVAR é uma técnica promissora para o tratamento de FAC, embora com taxa de reintervenção significativa.

Expression of MicroRNA-1281, C-Reactive Protein, and Renal Function in Individuals with Abdominal Aortic Aneurysm and their Clinical Correlation after Endovascular Repair

Abstract Introduction: The treatment of infrarenal aortic aneurysms has changed in the last three decades. Endovascular aneurysm repair (EVAR) has become the primary treatment option in anatomically suitable patients with infrarenal aortic aneurysms. However, there is no serum biomarker to be used in EVAR follow-up. Methods: This is a prospective single-centre study of 30 consecutive patients with abdominal aortic aneurysm (AAA) who underwent EVAR. Serum dosages of micro ribonucleic acid 1281 (miRNA-1281), creatinine, total cholesterol, triglycerides, and C-reactive protein (CRP) were evaluated and angiotomographic evaluations were performed preoperatively and six months after the intervention. Results: There was a hyperexpression of miRNA-1281 in patients with AAA and a significant reduction of it after EVAR, from 1.66-fold before EVAR to 0.27 after the procedure (P<0.0001). MiRNA-1281 expression was not influenced by renal function (creatinine: 1.14±0.29, P=0.68), total cholesterol (179.9±59.9, P=0.22), or CRP (1.17±3.5; P=0.48). There is correlation between AAA size and CRP serum levels, however there was no statically significant reduction of CRP after EVAR. Discussion: MiRNA-1281 expression may be influenced by cholesterol, triglycerides levels, and renal function. We found no difference in these markers before and six months after EVAR. However, miRNA-1281 presents a significant reduction in patients with no follow-up complications. We hypothesize that miRNA-1281 expression may be related to aortic wall stress or flow changes. Conclusion: MiRNA-1281 may contribute as a possible marker of EVAR follow-up.

Diagnóstico precoz del aneurisma de la aorta abdominal asintomático en Pinar del Río / Early diagnosis of asymptomatic aortic abdominal aneurysm in Pinar del Rio

RESUMEN Introducción: el aneurisma de la aorta abdominal constituye una enfermedad con elevada mortalidad en la actualidad. Objetivo: caracterizar los pacientes con el diagnóstico de aneurisma de la aorta abdominal en la provincia de Pinar del Río. Métodos: se realizó un estudio descriptivo, prospectivo de corte longitudinal, a los pacientes con aneurisma de la aorta abdominal tratados en la consulta de angiología, durante el período 2013 al 2017. El universo estuvo formado por 70 pacientes que acudieron a realizarse ultrasonido abdominal, a los cuales se les diagnosticó un aneurisma de la aorta abdominal; se estudió la totalidad. Resultados: el 58,56 % de los pacientes fueron identificados por el departamento de imagenología. Predominó el sexo masculino (95,7 %), y como factores de riesgo los pacientes fumadores (90 %) e hipertensos (85,7 %). Se observó el crecimiento del saco aneurismático en relación con la hipertensión arterial; no existió aumento del diámetro en el 44,3 % de los pacientes. El 7,15 % fueron intervenidos quirúrgicamente, donde el 100 % fueron pacientes con un diámetro inicial mayor de 5 cm. Conclusiones: los aneurismas aórticos abdominales fueron comunes en pacientes masculinos pasadas la cuarta década de la vida, se presentó principalmente en pacientes fumadores e hipertensos. El departamento de radiología constituyó la principal fuente de remisión. La identificación precoz y tratamiento oportuno son elementos determinantes para un desenlace positivo de dicha enfermedad.

ABSTRACT Introduction: aortic abdominal aneurysm constitutes an entity with a high mortality rate in current times. Objective: to characterize the patients with the diagnosis of aortic abdominal aneurysm in Pinar del Rio province. Methods: a descriptive, prospective-longitudinal study was conducted with patients having aortic abdominal aneurysms treated in Angiology Service during the period 2013-2017. The target group comprised 70 patients who came for an abdominal ultrasound, they were diagnosed as aortic abdominal aneurysm carriers, and all of them were studied. Results: patients identified by Imaging Department reached the 58,56 %; male sex predominated (95,7 %), as risk factors prevailed smokers (90 %) and hypertensive patients (85,7 %). Aneurysmal sac growth was observed in relation to hypertension; and there was no increase in diameter in 44,3 % of patients; 7,15 % of the patients underwent surgery, 100 % were patients with an initial diameter greater than 5 cm. Conclusions: aortic abdominal aneurysms were common in male patients past the fourth decade of life, occurring mainly in smokers and hypertensive patients. Radiology department was the main source of referral. Early identification and timely treatment are determinant elements for a positive outcome of this disease.

Direct and virtual measurements of abdominal aortic aneurysms: three-dimensional printed models.

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.

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.

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.

Abdominal aortic aneurysms ruptured to the vena cava: a case series and literature review / Aneurismas de aorta abdominal rotos para a veia cava: uma série de casos e revisão de literatura

Abstract Ruptured abdominal aortic aneurysms (RAAA) evolving aortocaval fistula (AF) can have catastrophic hemodynamic effects. Surgical repair is imperative, but the optimal technical approach is still under debate. Our objective is to present 3 cases treated with endovascular repair (EVAR) at a University Hospital. Case #1, a 71-year-old man presenting a 7.1cm RAAA with AF, repaired with a monoiliac stent graft and femoral-femoral bypass; Case #2, a 76-year-old man presenting a 9.9cm RAAA with AF, repaired with a bifurcated stent graft; Case #3, a 67-year-old man with previous history of EVAR, presenting a type 3 endoleak with late rupture related to AF, repaired with a tubular stent graft. All cases unfolded with delayed recovery and significant complication rates, although AF symptoms had resolved by hospital discharge. EVAR techniques for AF may require secondary interventions but are feasible, despite the lack of consensus, considering the rarity of this RAAA presentation.

Resumo Aneurismas de aorta abdominal rotos (AAAR) com evolução para fístula aorto-cava (FAC) podem apresentar consequências hemodinâmicas catastróficas. A correção cirúrgica é mandatória, embora não haja consenso sobre a técnica operatória. Apresentamos uma série de três casos operados em hospital universitário pela técnica endovascular. No primeiro caso, um homem de 71 anos apresentou AAAR de 7,1 cm com FAC, submetido a correção por endoprótese monoilíaca e enxerto femoral cruzado. No segundo, um homem de 76 anos apresentou AAAR de 9,9 cm com FAC submetido a colocação de endoprótese bifurcada. O terceiro caso era de um homem de 67 anos com histórico de EVAR e endoleak tipo 3, com ruptura tardia para veia cava, tratado com extensão aórtica. Todos apresentaram evolução pós-operatória prolongada com significativas complicações, entretanto com boa resolução dos sintomas à alta hospitalar. A EVAR é uma técnica promissora para o tratamento de FAC, embora com taxa de reintervenção significativa.

Nuevas tecnologías de imágenes para el diagnóstico y tratamiento de los aneurismas de aorta complejos / New Imaging Technologies for the Diagnosis and Treatment of Complex Aortic Aneurysms

RESUMEN La tecnología en imágenes desempeña un papel fundamental como guía en el tratamiento endovascular del aneurisma de aorta, especialmente en la aorta compleja toracoabdominal. Las salas quirúrgicas combinan imágenes de alta calidad con un entorno estéril y funcional, lo que permite, además de mejores resultados, una reducción del contraste a utilizar y la exposición a la radiación de pacientes y operadores. Esta presentación tiene como objetivo describir el uso actual de dicha tecnología, combinando angiotomografía y tomografía computarizada de haz cónico intraoperatoria, la "fusión"de imágenes y la ecografía intravascular, para guiar procedimientos y así mejorar la tasa de éxito intraoperatorio y reducir la necesidad de reintervenciones. Por otro lado, se describe un procedimiento para crear plantillas personalizadas 3D con las imágenes de alta definición de la anatomía arterial del paciente, que sirven como guías específicas para confeccionar en quirófano endoprótesis fenestradas. Estas plantillas de fenestración personalizadas podrían ampliar el número de pacientes con aneurismas complejos tratados en forma mínimamente invasiva.

ABSTRACT Imaging technology plays a key guiding role in the endovascular treatment of aortic aneurysms, especially in the complex thoracoabdominal aorta. The operating rooms combine high quality imaging with a sterile and functional environment, allowing for better outcomes, a reduction of the contrast agent to be used and of patients' and operators' exposure to radiation. The aim of this presentation is to describe the current use of imaging technology, combining intraoperative cone beam computed tomography (CBCT) and computed tomography angiography (CTA), image "fusion" and intravascular ultrasound, to guide the procedures and improve the intraoperative success rate, and to reduce the need for reinterventions. Furthermore, a procedure to create custom 3D templates with high definition images of the patient's arterial anatomy is described, which serve as specific guides for making fenestrated stent-grafts in the operating room. These custom fenestration templates could increase the number of patients with complex aneurysms treated with a minimally invasive approach.

Transcaval Access to the Abdominal Aorta: indications of Interest to Surgeons and a Comprehensive Literature Review.

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.

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.

Complicaciones venosas centrales asociadas al aneurisma de aorta abdominal roto / Central Venous Complications Associated with Ruptured Abdominal Aortic Aneurysm

RESUMEN La ruptura del aneurisma de aorta abdominal (AAA) representa una verdadera emergencia quirúrgica. Asociada con dolor abdominal, hipotensión e incluso shock, exige una transferencia inmediata a una sala de operaciones adecuadamente equipada para tratar el aneurisma en forma efectiva y sin demora. Ocasionalmente puede manifestarse como resultado de su relación con estructuras adyacentes. Dos complicaciones venosas asociadas con el AAA roto son la fístula aortocava y la compresión de la vena cava inferior (VCI). Los autores informan casos particulares de fístula aortocava y compresión de VCI con trombosis venosa profunda (TVP) por AAA roto. Los cuatro pacientes fueron tratados mediante reparación endovascular. Además de discutir las circunstancias asociadas con las complicaciones venosas por AAA, los autores también discuten la estrategia de tratamiento adoptada y las posibles alternativas.

ABSTRACT Ruptured abdominal aortic aneurysms (rAAAs) represent a real surgical emergency. In the presence of abdominal pain, hypotension or even shock, patients require emergency transfer to an operating room adequately equipped to treat the aneurysm effectively and without delay. Occasionally, symptoms are the consequence of involvement of the adjacent structures, Aortocaval fistula and compression of the inferior vena cava (IVC) are venous complications associated with rAAAs. We report cases of aortocaval fistula and IVC compression with deep venous thrombosis (DVT) due to rAAA. The four patients underwent endovascular repair. The circumstances associated with the venous complications of rAAA, the treatment strategy used and the therapeutic options are described.

Abdominal aortic aneurysms that have ruptured or are at imminent risk of rupture.

The rupture of an abdominal aortic aneurysm (AAA) is considered a high-risk surgical emergency, given the catastrophic consequences and high mortality rate. The objective of this pictorial essay is to illustrate the radiological signs that indicate rupture or imminent rupture. To that end, we describe cases treated at our facility and present a brief review of the literature on the topic. The clinical diagnosis of imminent AAA rupture can be difficult, because patients are usually asymptomatic or have nonspecific pain complaints. In the subsequent follow-up, it is possible to identify radiological signs that indicate instability or rupture itself and thus change the prognosis. Computed tomography is the modality of choice for evaluating an AAA and abdominal pain in the emergency setting. It is therefore essential that the radiologist immediately identify the imaging findings that indicate AAA rupture or the imminent risk of such rupture.

A ruptura de aneurisma da aorta abdominal (AAA) é considerada uma emergência cirúrgica de altíssimo risco, pelas consequências catastróficas e pelo alto índice de mortalidade. Este ensaio iconográfico tem como objetivo ilustrar os sinais radiológicos que indiquem ruptura ou a sua iminência. Utilizamos casos atendidos no nosso serviço e apresentamos breve revisão bibliográfica acerca do tema. O diagnóstico clínico da iminência de ruptura de AAA pode ser difícil, visto que os pacientes são normalmente assintomáticos ou apresentam queixas álgicas inespecíficas. No controle evolutivo, podem ser identificados sinais radiológicos que indiquem instabilidade ou a própria ruptura e, dessa forma, mudar o prognóstico do paciente. Como a tomografia computadorizada é a modalidade de escolha para a avaliação dos AAAs e da dor abdominal no cenário da emergência, torna-se imprescindível o reconhecimento precoce pelo radiologista dos achados de imagem que indiquem aneurismas rotos ou com risco iminente de ruptura.

Abdominal aortic aneurysms that have ruptured or are at imminent risk of rupture / Aneurismas de aorta abdominal rotos e com risco iminente de ruptura

Abstract The rupture of an abdominal aortic aneurysm (AAA) is considered a high-risk surgical emergency, given the catastrophic consequences and high mortality rate. The objective of this pictorial essay is to illustrate the radiological signs that indicate rupture or imminent rupture. To that end, we describe cases treated at our facility and present a brief review of the literature on the topic. The clinical diagnosis of imminent AAA rupture can be difficult, because patients are usually asymptomatic or have nonspecific pain complaints. In the subsequent follow-up, it is possible to identify radiological signs that indicate instability or rupture itself and thus change the prognosis. Computed tomography is the modality of choice for evaluating an AAA and abdominal pain in the emergency setting. It is therefore essential that the radiologist immediately identify the imaging findings that indicate AAA rupture or the imminent risk of such rupture.

Resumo A ruptura de aneurisma da aorta abdominal (AAA) é considerada uma emergência cirúrgica de altíssimo risco, pelas consequências catastróficas e pelo alto índice de mortalidade. Este ensaio iconográfico tem como objetivo ilustrar os sinais radiológicos que indiquem ruptura ou a sua iminência. Utilizamos casos atendidos no nosso serviço e apresentamos breve revisão bibliográfica acerca do tema. O diagnóstico clínico da iminência de ruptura de AAA pode ser difícil, visto que os pacientes são normalmente assintomáticos ou apresentam queixas álgicas inespecíficas. No controle evolutivo, podem ser identificados sinais radiológicos que indiquem instabilidade ou a própria ruptura e, dessa forma, mudar o prognóstico do paciente. Como a tomografia computadorizada é a modalidade de escolha para a avaliação dos AAAs e da dor abdominal no cenário da emergência, torna-se imprescindível o reconhecimento precoce pelo radiologista dos achados de imagem que indiquem aneurismas rotos ou com risco iminente de ruptura.

Ruptured abdominal aortic aneurysm with a suprarenal tumor

Abstract This paper presents a case study of a patient that underwent surgery for a ruptured abdominal aneurysm. The postoperative course was complicated by resistant hypertension and tachycardia. A suprarenal mass was detected in the computed tomography scan with radiological suspicion of pheochromocytoma. Few cases of pheochromocytoma coexisting with aneurysms have been reported. Management of cardiovascular stability is crucial in such cases. Despite the lack of evidence, pheochromocytomas might have a role in the etiology of aortic aneurysms.

Quality of life after open surgical versus endovascular repair of abdominal aortic aneurysms

Abstract Objective: This study aims to compare open surgical and endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms in terms of their effects on quality of life, using Short Form-36 (SF-36). Methods: A total of 133 consecutive patients who underwent EVAR or open surgical repair for infra-renal abdominal aorta aneurysm between January 2009 and June 2014 were included in the study. Twenty-six (19.5%) patients died during follow-up and were excluded from the analysis. Overall, 107 patients, 39 (36.4%) in the open repair group, and 68 (63.6%) in the EVAR group, completed all follow-up visits and study assessments. Quality of life assessments using SF-36 were performed before surgery and at post-operative months 1, 6, and 12. Results: The mean duration of follow-up was 29.55±19.95 months. At one month, both physical and mental domains of the quality of life assessments favored EVAR, while the two surgical approaches did not differ significantly at or after six months postoperatively. Conclusion: Despite anatomical advantages and acceptable mid-phase mortality in patients with high- or medium-risk for open surgery, EVAR did not exhibit a quality of life superiority over open surgery in terms of physical function and patient comfort at or after postoperative six months.

Traditional and ultrasound physical examinations: a hybrid approach to improve clinical care

SUMMARY Point-of-care ultrasonography, which is performed at the bedside by physicians who are not specialists in imaging, has become possible thanks to recent technological advances that have allowed for a device with greater portability while maintaining image quality. The increasing use of point-of-care ultrasonography in different specialties has made it possible to expand physical examinations, make timely decisions about the patients and allows the performance of safer medical procedures. In this review, three cases from our experience are presented that highlight the use of point-of-care ultrasonography by clinicians. Bedside ultrasonography is a convenient modality used in a clinical setting to aid in early diagnosis of several common conditions. It is suggested that a hybrid approach of physical examination and point-of-care ultrasonography in the everyday clinical practice is an inevitable change of paradigm that is improving quality of care in a variety of clinical settings.

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.