Outcome Analysis Using the Modified Frailty Index-5 in Patients With Complex Aortoiliac Disease.

OBJECTIVES: Vascular surgery patients commonly have several comorbidities that cumulatively lead to a frailty status. The cumulative comorbidities disproportionately increase the risk of adverse events and are also associated with worsened long-term prognosis. In recent years, several tools have been elaborated with the objective of quantifying a patient's frailty. One of them is the modified frailty index-5 (mFI-5), a simplified and easy to use index. There is scarce data regarding its value as a prognostic factor in aortoiliac occlusive disease. The aim of this work is to validate mFI-5 as a potential postoperative prognostic indicator in this population. METHODS: From January 2013 to January 2020, 109 patients who underwent elective revascularizations, either endovascular or open surgery, having Trans-Atlantic Inter-Society Consensus II type D aortoiliac lesions in a tertiary and a regional hospital were selected from a prospective vascular registry. Demographic data was collected including diabetes mellitus, chronic heart failure, chronic obstructive pulmonary disease, arterial hypertension requiring medication and functional status. The 30-d and subsequent long-term surveillance outcomes were also collected including major adverse cardiovascular events (MACE), major adverse limb events (MALE) and all-cause mortality were assessed in the 30-d post-procedure and in the subsequent long-term surveillance period. The mFI-5 was applied to this population to evaluate the prognostic impact of this frailty marker on mortality and morbidity. RESULTS: In the long-term follow-up, mFI-5 was significantly associated with MACE (hazard ratio [HR] 2.469; 95% confidence interval [CI]: 1.267-4.811; P = .008) and all-cause mortality (HR 2.585; 95% CI: 1.270-5.260; P = .009). However, there was no significant association with 30-day outcomes. Along with the presence of chronic kidney disease, mFI-5 was the prognostic factor better able of predicting MACE. No prognostic value was found regarding short-term outcomes. CONCLUSION: The mFI-5 index may have a role in predicting long term outcomes, namely MACE and all-cause mortality, in the subset of patients with extensive aortoiliac occlusive disease. Its ease of use can foster its application in risk stratification and contribute for the decision-making process.

[The use of Onyx in the embolization of extracranial vascular malformations: efficacy and safety]. / Utilização de Onyx na embolização arterial de malformações vasculares extracranianas: eficácia e segurança.

OBJECTIVE: Presentation of Onyx outcomes in the embolization of extracranial vascular malformations, regarding the clinical efficacy and safety. MATERIAL AND METHODS: A 29 years old female patient, with a vascular malformation of the right upper thigh complicated with skin ulcer, healed in 2011, referred for light pain and tension at the site of the lesion. Physical examination revealed a scar of a previous ulcer, extensive venous collateral network and tenuous expandability of the malformation. Angiography revealed a high flow vascular malformation, with arterial and venous component, through branches of the internal iliac, common and profunda femoral arteries, involving the right thigh, from the root to the middle third, on the lateral side. Patient was proposed for arterial catheterization and endovascular embolization, which consisted in five embolization sessions with an interval of 3 weeks, through contralateral femoral catheterization, firstly with coils; in the remaining, it was decided to embolize with Onyx, through distal catheterization of the sinus with microcatheter. RESULTS: All sessions coursed without major complications, registering pain complains on the first post-procedure day which reversed with anti-inflammatory medication. There was no skin necrosis or significant elevation of tissue necrosis markers. Distal embolization of malformation sinus with Onyx was achieved in all sessions without significant reflux or recurrence of the embolized branch, with decreased of the sinus size, no pain complaints and the lack of expandability after the 5 sessions. CONCLUSION: Used primarily in intracranial vascular malformations, there is now a growing utilization of Onyx in the embolization of extracranial malformations, given the physical properties, with promising initial results, particularly in high-flow injuries. A recent study demonstrated a significant reduction of the malformation sinus, low rate of recanalization and re-expansion, with high clinical safety. The clinical result of this patient demonstrated the high efficacy and safety in the use of embolic agent, making its use promising in the treatment of a wide range of vascular malformations.

[Coronary-subclavian steal syndrome]. / Síndrome de roubo subclávio-coronário.

OBJECTIVE: Presentation of 3 consecutive cases of coronary-subclavian steal syndrome, with special attention to clinical evolution, diagnosis, treatment strategies and outcomes. MATERIAL AND METHODS: We present three consecutive cases of male patients, aged 60 to 69 years (average: 63 years) with hypertension, dyslipidemia, and smoking as the most prevalent cardiovascular risk factors. The 3 cases had a history of previous coronary revascularization using the left internal mammary artery to the anterior descending coronary, with an interval of 4 months to 4 years before the onset of symptoms, 2 of the cases with stable angina, 1 with V4 to V6 ST segment depression in the exercise test and 1 with myocardial infarction with no ST segment elevation. None of the patients had left upper limb claudication. In 2 patients, no left radio-cubital pulse was detected at rest being weak in the third. All patients had atherosclerotic obliteration of the left subclavian artery, 2 with occlusion and 1 with stenosis >90%. Cardiac catheterization was the diagnostic exame in all cases. The interval between diagnosis and intervention was 6 to 13 weeks (median of 9 weeks). We chose the endovascular treatment with balloon expandable stent. The preferred access route was the left humeral artery in 2 cases and the femoral artery in the third. RESULTS: In all patients the revascularization was achieved, without residual stenosis. Angiography after revascularization, disclosed antegrade flow in all patients through the left internal mammary artery. Recovery of the symmetry of pulses was noticed in all the patients, no signs or symptoms of myocardial ischemia were presented in two of them, with nonspecific pre-cordial symptoms remained in the third, after effort. All patients were discharged with dual antiplatelet therapy for a period not less than 3 months. CONCLUSION: The coronary-subclavian steal syndrome is a rare cause of myocardial ischemia after coronary revascularization (0.1% to 6%), as a result of proximal arterial occlusive disease, with subsequent hemodynamic, being atherosclerosis the main etiology. Although the surgical route has been the treatment of choice in the past, endovascular revascularization emerged nowadays as the first-line treatment, with recent studies demonstrating high patency at the 2nd and 5th year after angioplasty (100% and 85% to 95%) and low morbidity and mortality. Further doubts arise about the role of double antiplatelet therapy, having been chosen, in this series, treatment of at least 3 months.

[Endovascular managemente of an aorto-bronchial fistula secondary to a thoracic aortic aneurysm]. / Correcção endovascular de aneurisma da aorta torácica complicado por fístula aorto-brônquica primária.

OBJECTIVE: Presentation of a case of endovascular repair of aorto-bronchial fistula secondary to thoracic aortic aneurysm. MATERIAL AND METHODS: 67 years old male patient, former smoker, with a history of arterial hypertension, dyslipidemia, coronary artery disease, chronic renal insufficiency and carotid endarterectomy, followed in outpatient department with recent diagnosis of descending TAA. The patient presented to the emergency department due to 2 episodes of cough and self-limited abundant hemoptysis. The thoracic angio-CT revealed a rupture of the aneurysm, with 77mm, to the lung parenchyma with aorto-bronchial fistula to the left main bronchus. Patient was submitted to endovascular repair using a Valiant Thoracic endoprosthesis by Medtronic®, via right femoral approach. RESULTS: The procedure went without complications. There was no paraplegia or acute arterial lesion. Postoperatively, there were registed two episodes of self-limited hemoptysis and developed cough that progressively reversed after 2 months. The patient held antibiotic prophylaxis during hospitalization and for 2 months after discharge. 12 months after procedure, no complications were observed and patient remains asymptomatic. CONCLUSION: The advance of endovascular approach in the treatment of complicated AAT brought a new therapeutic solution, giving a reduction in morbidity and mortality (± 3%), particularly for control of active aorto-bronchial fistula. As regards to success rate and long-term antibiotic prophylaxis, present studies are inconclusive. Concerned to infection risk and fistula recurrence (± 10%), long-term antibiotic administration was the chosen treatment.