Co-existence of Abdominal Aortic Aneurysm with Urologic Neoplasm: Which Should Be Treated First in the Endovascular Era?

INTRODUCTION: Prevalence of Abdominal Aortic Aneurysm (AAA) with concomitant malignancy rounds 3-13%. Considering only urological neoplasms the prevalence is around 3.6%. Survival at 5 years of bladder carcinoma without extravesical invasion (stage II) rounds 63%. Endovascular Aneurysm Repair (EVAR), due to its minimally invasive profile, is an option for treatment of AAA prior to urological surgery as it does not require laparotomy not conditioning the delay of oncologic surgery. METHODS: Male, 62 years old. History of smoking and coronary artery disease and urothelial carcinoma of the bladder (T2N0M0). In the abdominal CT scan used for neoplasm staging a para-renal AAA with 50 mm of maximum diameter was firstly detected. This aneurysm presented only 5 mm of proximal neck length, insufficient for a safe proximal sealing with standard endografts. In consequence the treatment of choice was a tetra-fenestrated endograft (F-EVAR). RESULTS: F-EVAR occurred without complications: no endoleaks, access complications or branch thrombosis. Three months after F-EVAR, the patient underwent radical cystectomy with jejunocystoplasty, which also occurred without intercurrences. Two days after FEVAR patient was discharged home. After one year of follow-up, abdominal CT scan did not reveal any complications related to the endovascular procedure. The patient died 18 months after the intervention as a consequence of metastatic evolution of bladder primary neoplasm. CONCLUSION: The coexistence of AAA with neoplastic urologic pathology although rare is not negligible. In the above case, the patient presented AAA with about 5 cm (1-11% risk of rupture per year), associated with T2N0M0 bladder urothelial carcinoma (survival at around 63% at 5 years). Given the need for treatment of both pathologies, the doubt persisted about which procedure should be performed first: aneurysm repair or cystectomy. Prior to the advent of EVAR, AAA repair would require laparotomy with a potentially greater risk of complications in the subsequent urologic procedure, prosthesis infection and significant delay of the cystectomy. With the emergence of endovascular techniques, AAA repair occurs without conditioning postponement or significant complications during a subsequent urological procedure and then "EVAR first" was the decision. Two days after FEVAR patient was discharged home and three months latter cystectomy was performed also without complications. IN CONCLUSION: in case of concomitant AAA and abdominal malignancy balance between risk of rupture and progression of the neoplastic disease need to be weighted. With the advent of endovascular disease EVAR prior to the oncologic surgery represents an efficient, prompt and safe solution.

Quality of life and aortobifemoral bypass: The importance of hypogastric arteries.

INTRODUCTION: The aortobifemoral bypass (AFB) is one of the best options to revascularize patients with Aortoiliac Occlusive Disease (AIOD). The impact of this procedure in sexual function (SF) is unpredictable, with 0 to 80% of the patients reporting sexual dysfunction (SD) after surgery. The aim of this study was to evaluate SD after AFB and to assess the importance of patent hypogastric arteries before the procedure. METHODS: The study includes only male population submitted to AFB due to AIOD from between January 2013 and March 2016 in Centro Hospital São João (CHSJ). Patients with major amputations after the surgery or dead were excluded. The development of SD was evaluated by phone call. The quality of life before and after the procedure was evaluated by a standardized index score questionnaire (15D). Pre-operative patency of hypogastric arteries was appraised by assessing the patients imaging file. The arteries with direct anterograde flow were considered patent. RESULTS: Of a total of 53 patients, 40 were included in the study - 37% reported worsening, 26% improved and 37% didn't notice any change in SF after surgery. Exclusion causes were intrahospital death (5.7%), natural cause death (9.4%) and major amputation (11.3%). If at least one of the hypogastric arteries was patent before surgery, 51.1% described worsening in SF compared to only 7.1% in the group with no sustained anterograde flow to the hypogastric arteries (p<0.001). The majority of the group (92.1%), wasn't warned of the possibility of SD after surgery, being that 26.3% of these would have refused the procedure if they knew. CONCLUSION: SD is a prevalent and often overlooked complication after open aortoiliac revascularization and it remains a major taboo in the surgeon/patient relation. The existence of at least one hypogastric artery with preserved anterograde flow before surgery can strongly predict a higher risk of SD after surgery.

Introdução: O bypass aortobifemoral (BABF) é uma das melhores opções para revascularizar doentes com patologia aorto-ilíaca oclusiva. O impacto deste procedimento na função sexual é particularmente imprevisível, com 0 a 80% dos doentes a relatar deterioração após a cirurgia. Este trabalho tem como objectivo determinar a evolução da função sexual após BABF e avaliar a importância da permeabilidade pré-operatória das artérias hipogástricas. Métodos: No estudo estão incluídos apenas os doentes do sexo masculino que realizaram BABF por patologia aorto-ilíaca oclusiva entre Janeiro de 2013 e Março de 2016 no Centro Hospitalar São João (CHSJ). Foram excluídos os doentes submetidos a amputação major após a cirurgia. A evolução da função sexual foi avaliada por contacto telefónico. A evolução da qualidade de vida, antes e após a cirurgia, foi avaliada por um questionário padronizado (15D). A permeabilidade pré-operatória das artérias hipogástricas foi avaliada por consulta do processo clínico. Foram consideradas patentes as artérias com fluxo anterógrado directo. Resultados: Foram incluídos no estudo 40 doentes de um total de 53 ­ 37% reportaram agravamento, 26% melhoria e 37% não referiram qualquer alteração da função sexual após a cirurgia. As causas de exclusão foram morte intra-hospitalar (5,7%), morte de causas naturais (9,4%) e amputação major (11,3%). Dos doentes que apresentavam no mínimo uma artéria hipogástrica permeável antes da cirurgia, 57,1% agravou a função sexual, em comparação com apenas 7,1% dos doentes em que nenhuma hipogástrica apresentava fluxo anterógrado preservado (p<0,001). A maior parte dos doentes (92,1%) não foi alertado para o facto da sua função sexual poder deteriorar-se após a cirurgia, sendo que 26,3% teria recusado o procedimento caso tivessem obtido essa informação. Conclusão: A disfunção sexual após a cirurgia de revascularização aorto-ilíaca permanece um tema tabu na relação entre o doente e o cirurgião vascular. A existência de pelo menos uma artéria hipogástrica com fluxo anterógrado preservado antes da cirurgia poderá antever um risco significativamente maior de agravamento da disfunção sexual após o procedimento.

[Complications of Hypogastric Arteries Embolization in EVAR]. / Complicações Secundárias à Embolização da Artéria Ilíaca Interna no EVAR.

OBJECTIVE: The aim of this paper is dedicated to assess the risks of the embolization of the hypogastric arteries following the endovascular management of aorto-iliac aneurysms, looking at the incidence and nature of the most common complications, in the unilateral "versus" bilateral embolization with coils. METHODS: A systematic review of the literature was made on the subject, including the outcome of patients who underwent unilateral versus bilateral embolization of hypogastric arteries with coils in the EVAR. RESULTS: The most common complications were buttock claudication and erectile disfunction, with an estimation respectively of 28% and 15%, independently of the unilateral or bilateral procedure. Less commonly, colonic ischemia was found in 2%, as well as spinal cord ischemia, also found in 2%. CONCLUSIONS: The embolization of the hypoastric arteries may extend the field of utilization of the EVAR, however it cannot be regarded as an innocuous procedure. This systematic review suggests that more complications can be expected in patients who underwent bilateral versus unilateral embolization, namely related to buttock claudication. However, a similar evidence could not be demonstrated with erectile disfunction.