Nationwide Analysis of Ruptured Abdominal Aortic Aneurysm in Portugal (2000-2015).

OBJECTIVE: Ruptured abdominal aortic aneurysm (rAAA) is a lethal condition that requires acute repair to prevent death. This analysis aims to assess the nationwide trends in rAAA admission, repair and mortality in a country, Portugal, without national screening for AAA. METHODS: rAAA registered in the hospital administrative database of the National Health Service and all nationally registered deaths due to rAAA based on death certificate data were analysed. Three time periods (2000-2004, 2005-2009, and 2010-2015) were compared in patients ≥ 50 years old to assess the variations over time. RESULTS: A total of 2 275 patients ≥50 years old with rAAA were identified in the two databases from 2000 to 2015. The age standardised incidence of rAAA was 2.78 ± 0.24/100 000/year in 2000-2004, 3.17 ± 0.39/100 000/year in 2005-2009 and 3.21 ± 0.28/100 000/year in 2010-2015 (p < .001). When comparing the time periods 2000-2004 to 2005-2009, the age standardised rate of admission (n = 1460) increased from 1.57 ± 0.25/100 000/year to 2.24 ± 0.32/100 000/year (p < .001). The operative mortality rates decreased during this time period (from 55.3 ± 4.7% to 48.8 ± 4.7%, p < .001). In 2010-2015, the age standardised rate of admissions due to rAAA decreased (1.98 ± 0.22/100 000/year). Operative mortality remained stable (48.9 ± 6.2%). The rate of patient deaths outside the hospital decreased from the first to the second period (1.21 ± 0.10/100 000/year and 0.93 ± 0.29/100 000/year, respectively) but later increased (1.14 ± 0.22/100 000/year). This resulted in a higher overall rAAA related mortality in Portugal in the third period (2.20 ± 0.18/100 000/year, 2.21 ± 0.27/100 000/year and 2.26 ± 0.26/100 000/year in 2000-2004, 2005-2009, and 2010-2015, respectively, p < .001). CONCLUSION: Overall, the incidence of rAAA in Portugal has been stable over the past 10 years. The rates of admission, repair, and death due to rAAA repair seem to have reached an inflection point and are now decreasing. Mortality outside the hospital remains a matter of concern, warranting further planning of streamlined transfer networks and vascular surgical departments.

Vascular training does matter in the outcomes of saphenous high ligation and stripping.

OBJECTIVE: Varicose vein (VV) surgery is frequently performed by surgeons without formal vascular training. We aimed to compare the outcomes of the procedure based on the background of the surgeon. METHODS: All patients registered with VV surgery between 2004 and 2016 in Portuguese public hospitals were included in the study. Intrahospital outcomes were assessed from this administrative database. A random multicenter sample of 315 patients submitted to saphenous high ligation and stripping (175 patients from six vascular surgery departments and 140 patients from five general surgery divisions) were further queried over the phone, whereby additional nonregistered outcomes were evaluated: preoperative venous ultrasound, impact on quality of life by the 14-item Chronic Venous Insufficiency Quality of Life Questionnaire, visual analogue scale evaluation (score of 1 to 5) of the aesthetic results and general satisfaction, work absence days, and time to return to physical activities. RESULTS: In 13 years, there were 153,382 patients submitted to VV surgery. Of these, 49% were operated on by general surgeons and 40% by vascular surgeons; in 11%, it was not possible to identify the specialty performing the operation. Twenty-three deaths were registered (no differences between groups). In the general surgery group, 14% of patients were hospitalized for more than one night compared with 3% in the vascular group (P < .001). Reintervention rate during the period analyzed was significantly higher in the general surgery group (13.5% vs 8.2%; P < .001). Rate of outpatient surgery was higher in the vascular surgery group (60% vs 36%; P < .001). Phone query revealed similar overall satisfaction and improvement in quality of life in both groups (4.2 vs 4.0 [P = .275] and 35% vs 36% [P = .745], respectively). However, patients operated on by general surgeons reported worse surgical scars (2.8 vs 2.1; P = .007), higher number of residual VVs (2.4 vs 1.7; P = .006), and higher number of days absent from work (40 vs 27 days; P = .005) and took longer to resume physical activities (60 vs 41 days; P = .001). CONCLUSIONS: Despite that the majority of VV surgery in Portugal is executed by general surgeons, this study highlights important advantages when it is performed by surgeons with vascular training.

First Population-Based Screening of Abdominal Aortic Aneurysm in Portugal.

BACKGROUND: The incidence of abdominal aortic aneurysm (AAA) repairs in Portugal is one of the lowest mentioned in the literature. This phenomenon can be justified either by a low prevalence of the disease or by its low detection rate. To date, the prevalence of the pathology is unknown. The objective of the study was to estimate the prevalence of AAA and its associated risk factors, in men aged ≥65 years and to evaluate the population's disease awareness. METHODS: All males aged ≥65 years registered in a Portuguese primary health care unit were invited to participate. The abdominal aorta was measured by ultrasound (inner to inner method). Concomitant risk factors and patient's AAA awareness were also assessed. An aortic diameter >30 mm was considered aneurysmatic. RESULTS: Nine hundred thirty-three patients were invited for the screening. Of these, 715 participated in the study (participation rate of 76.6%). The AAA prevalence in this sample was 2.1%. Eighty-five percent of the evaluated patients had never heard of the disease before. The mean age of the assessed population was 72.3 years; Multiple logistic regression analysis showed a positive association between AAA and history of smoking (odds ratio [OR] 8.8, P = 0.037) and history of dyslipidemia (OR 9.6, P = 0.035). A negative association was found between diabetes and AAA (OR 0.33, P = 0.045). CONCLUSIONS: The found prevalence shows that a significant number of potentially fatal AAAs remains to be diagnosed in Portugal. These results highlight the need for an effective program of AAA detection in Portugal. The lack of awareness in the Portuguese population for this pathology should also prompt reflexion.

Simplified hybrid repair with true lumen recycling for retrograde renovisceral perfusion in a complex chronic aortic dissection.

A 59-year-old man was referred with complicated chronic type B aortic dissection. Despite the false lumen's being dominant in terms of caliber and limb perfusion, visceral arteries originated in a 9-mm true lumen. A staged approach was performed: open aortobi-iliac bypass with preservation of both lumens to the infrarenal aorta, with reinforcement of the aorta and anastomosis with Dacron (wrap technique); exclusion of the dissection by endografting all of the false lumen with three successive thoracic endoprostheses; and maintenance of true lumen perfusion using two periscopes with self-expanding nitinol stents. The patient remains asymptomatic after 1 year of follow-up.

[Occlusion of peripheral bypass--changing of an institutional paradigm]. / OCLUSÃO DE BYPASS PERIFÉRICO. MUDANÇA DE PARADIGMA INSTITUCIONAL.

OBJECTIVES: Compare the results of surgical thrombectomy (ST) and catheter directed thrombolysis (CDT) in the treatment of acute ischemia due to peripheral prosthetic bypass occlusion. METHODS: Retrospective single center analysis of the electronic clinical data on two groups of patients with acute lower limb ischemia due to prosthetic bypass occlusion: in one ST was performed (data collected between June-2006 ahd September-2011) and the other was treated with CDT Qui2 test (categorical variables) and independent samples t test (continuous variables) were used for comparisons between groups. The Kaplan-Meier method was used to estimate rates of freedom from reintervention and limb salvage, with the Log Rank test used for comparisons. RESULTS: Twenty-six bypass were included in the ST group and 11 bypass were included in the CDT group. There were no statistically significan differences between groups regarding gender age and type of occluded bypass. The median time for freedom from reintervention was 275 days for the CDT group and three days for the ST group (p = 0.0029 when comparing survival curves). The median time for limb salvage was 468 days for the CDT group and 17 days for the ST group (p = 0.03 when comparing survival curves). CONCLUSION: These results support the choice for CDT as the local first line therapy for acute ischemia due to bypass occlusion, despite the limitations arising from the sample size. The results of ST need to be urgently addressed.