Giant Sac Growth: A Hybrid Approach to Treat a Misdiagnosed Late Type IIIb Endoleak.

Introduction: Endoleaks are a common complication following endovascular aneurysm repair, yet type IIIb are rare, especially with newer devices, and associated with high morbidity due to repressurisation of the sac. As endografts are used in patients with longer life expectancy, late type IIIb endoleaks are to be expected. This is a report of a giant common iliac aneurysm resulting from a misdiagnosed type IIIb endoleak. Report: An 85 year old man with history of right common iliac artery aneurysm, treated in 2003 with an EXCLUDER AAA Endoprosthesis (WL Gore, Flagstaff, AZ, USA) with iliac limb extension into the external iliac artery, presented at the emergency department with abdominal pain, hypotension, and syncope. He had a known endoleak, unsuccessfully treated by relining the right iliac stent graft overlap zones for a suspected type IIIa endoleak (2009), coil embolisation, and computed tomography (CT) guided thrombin injection of the aneurysmatic sac for a type II (2010), none of which managed to treat the cause with continuous aneurysm growth. The patient refused further treatments, but agreed to maintain surveillance. At admission, CT angiography showed common iliac aneurysm (185 × 134 mm) sac rupture without a visible endoleak. Resuscitative endovascular balloon occlusion of the aorta (REBOA) technique was performed to obtain haemodynamic control, then the aneurysm was approached through a midline incision. A type IIIb endoleak was identified due to a fabric tear on the right iliac limb extension. Suture was attempted without success, then relining of the lesion with an Endurant II Limb (Medtronic, Minneapolis, MN, USA) was performed, which managed to repair the endoleak. Discussion: Type IIIb endoleaks are uncommon and underdiagnosed due to fabric defects being too small or leaking intermittently. They can mimic other types of endoleaks and may cause aneurysm growth and rupture. One should consider this type of endoleak if previous treatments for other types were unsuccessful.

Prognostic Value of Charlson Comorbidity Index in Acute Embolic Lower Limb Ischaemia Patients.

INTRODUCTION: Charlson Comorbidity Index (CCI) is commonly used in outcome studies to adjust for patient comorbid conditions but has not been specifically validated for use in acute embolic lower limb ischaemia (AELLI). OBJECTIVES: The aim of this study was to access whether a high CCI score unadjusted (CCIu) and adjusted (CCIa) by age relates to major amputation and mortality after a first episode of AELLI. METHODS: The last 100 patients presenting with the first event of AELLI submitted to embolectomy at our Vascular Surgery Department were retrospectively evaluated. Patient characteristics, pre- and post-operative period variables were collected and CCIu and CCIa calculated. Survival predictors were analyzed using Cox regression. The area under the curve of the receiver operating characteristic curves was calculated to validate and determine the discriminating ability of CCIu and CCIa in predicting amputation rate and 30-day mortality. Youden index was used to determine the critical value. Survival analysis was performed with Kaplan-Meier method and differences between survival curves were tested with Log-Rank test. A P value of <0.05 was considered statistically significant. RESULTS: The mean age was 80.03±10.776 years and the mean follow-up 19.28±7.929 months. Amputation rate was 16%, 30-day mortality 21% and long-term mortality 42%. Patients with CCIu≥3 compared with patients with CCIu<3 had higher amputation rate (37.5% vs. 1.7%; OR:35.400), 30-day mortality (47.5% vs. 3.3%; OR:35.400) and global mortality (P=0.00). Also, patients with CCIa≥6 compared with patients with CCIa<6 had higher amputation rate (34.1% vs. 1.8%; OR:28.488), 30-day mortality (47.7% vs. 0.0%) and global mortality (P=0.00). Multivariate analysis showed that both CCIu and CCIa were independent predictors of amputation rate and 30-day mortality. CONCLUSION: CCIu and CCIa have proven to be good predictors of amputation rate and survival, thus being a valuable prognostic factor in patients presenting with the first event of AELLI.

Innominate artery post-traumatic pseudoaneurysm presenting with Horner's syndrome.

Isolated innominate artery trauma after blunt thoracic contusion is rare and occurs mostly at its origin. We report a case of a post-traumatic distal innominate artery pseudoaneurysm presenting with Horner's syndrome treated by conventional surgical approach.

Impact of Total Psoas Area and Lean Muscular Area on Mortality after Endovascular Aortic Aneurysm Repair.

BACKGROUND: Sarcopenia has assumed growing relevance as a morbimortality predictor after major abdominal surgery. The aim of this study is to access total psoas muscle area (TPA) and lean muscle area (LMA) impact in morbimortality after elective endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Asymptomatic patients submitted to aortic endoprosthesis implantation between January 1, 2014 and December 31, 2018 at our vascular surgery department were retrospectively evaluated. After exclusion criteria were applied, 105 patients were included in the study; preoperative computed tomography scans were evaluated using OSIRIX software (Bernex, Switzerland). Two observers independently calculated TPA at the most caudal level of the L3 vertebra and respective density, therefore calculating LMA. Patients were separated by tertiles with the lowest being considered sarcopenic and with higher muscle steatosis and compared with the higher tertiles. Patient demographics and intraoperative and postoperative period variables were collected. Charlson comorbidity index was calculated and surgical complications classified according to Clavien-Dindo. The intraclass correlation coefficient and Bland-Altman plot were made to characterize interobserver variability. Survival analysis was performed with the Kaplan-Meier method, and differences between survival curves were tested with the log-rank test. The effect of sarcopenia on patient survival was assessed using Cox proportional hazard models. RESULTS: Considering TPA, univariate analyses revealed that patients in the lower tertile had inferior survival (P = 0.03), whereas multivariate analyses showed increased likelihood of mortality (P = 0.039, hazard ratio (HR) 3.829). For LMA, univariate analyses revealed that patients in the lower tertile had inferior survival (P = 0.013), whereas multivariate analyses showed increased likelihood of mortality (P = 0.026, HR 4.153). When analyzing patients in the lowest tertile of both TPA and LMA, both univariate (P = 0.002) and multivariate (P = 0.018, HR 4.166) analyses reveled inferior survival. CONCLUSIONS: Our study reveals reduced survival in patients with low TPA and low LMA submitted to elective EVAR; these factors should probably be taken into consideration in the future for preoperative risk evaluation and surgical planning.