Impact of Gradual Adoption of EVAR in Elective Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study from 2009 to 2015.

INTRODUCTION: The recommendations about the preferred type of elective repair of abdominal aortic aneurysm (AAA) still divides guidelines committees, even nowadays. The aim is to assess outcomes after AAA repair focusing on differences between endovascular aneurysm repair (EVAR) and open surgical repair (OSR). METHODS: The observational retrospective cohort study of consecutive patients submitted to elective AAA repair at a tertiary center, 2009-2015. Exclusion criteria were as follows: nonelective cases or complex aortic aneurysms. Primary outcomes were postoperative complications, length of hospital stay, survival, freedom from aortic-related mortality, and vascular reintervention. Time trends were assessed along the period under analysis. RESULTS: From a total of 211 included patients, those submitted to EVAR were older (74 ± 7 vs. 67 ± 9 years; P < 0.001), presented a higher prevalence of hypertension (83.5% vs. 68.5%, P = 0.004), obesity (28.7% vs. 14.3%, P = 0.029), previous cardiac revascularization (30.5% vs. 14.7%, P = 0.005), heart failure (17.2% vs. 5.2%, P = 0.013), and chronic obstructive pulmonary disease (32.8% vs. 13.3%, P = 0.002). Patients were followed during a median of 49 months. EVAR resulted in a significantly shorter length of hospital stay (median 4 and interquartile range 3 vs. 8 (9); P < 0.001), lower 30-day complications (10.6% vs. 22.8%, P = 0.017), lower aortic-related mortality, and similar reintervention after adjustment with a propensity score. Along the time under analysis, EVAR became the predominate type of repair (P = 0.024), the proportion of complications decreased (P = 0.014), and the 30-day mortality (P = 0.035). CONCLUSIONS: Although EVAR was offered to patients with more comorbidities, better and durable outcomes were achieved after EVAR, favoring its adoption for elective AAA repair.

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.

Outcomes After Catheter Direct Thrombolysis for Acute Limb Ischaemia - Single Center Experience.

INTRODUCTION: The aim of this study is to evaluate the outcome of catheter directed thrombolysis (CDT) in acute lower limb ischaemia depending on the underlying etiology. METHODS: Retrospective single center analysis of electronic clinical data on patients with acute lower limb ischaemia treated with CDT. Between January 2011 and September 2017, 128 procedures in 106 patients were included. The etiology of ischaemia was native artery thrombosis in 39 procedures (30,5%), PTFE graft thrombosis in 56 (43,8%), intra-stent thrombosis in 11 (8,6%), emboly in 9 (7%), popliteal aneurysm thrombosis in 9 (7%), vein graft thrombosis in 2 (1,6%) and popliteal artery entrapment in 2 (1,6%). RESULTS: Median follow-up time was 14 months [range: 6-31], during which 22% needed further intervention. The need for reintervention was 27,6% in native artery thrombosis group, 65,2% in PTFE graft thrombosis group, 18,2% in intra- stent thrombosis group. No reinterventions occurred neither in popliteal aneurysm group or emboly group. Amputation free survival was 83,3% (SE 4,6%) at 27 months and cumulative incidence of death was 10,1% (SE 5,2%) at 32 months, with no differences between the groups. CONCLUSION: Intra-arterial thrombolytic therapy achieves good mid-term clinical outcomes, reducing obviating the need to open surgical treatment in many patients. These results support the choice for CDT as a valid option in acute limb ischaemia of several etiologies.

Emergency Nightmares - Rupture of Type III Thoracoabdominal Aneurysm.

Introduction The rupture of thoracoabdominal aneurysms (rTAA) represents one of the major challenges to the vascular surgeon. Recent developments in the endovascular armamentarium and the high mortality from open surgery make endovascular treatment an attractive option. Devices to be used in an emergency environment should be "off-the-shelf" and include, among others, EVAR snorkel/chimney and branched endoprosthesis (T-branch, Cook®). METHODS: We describe the case of a 70-year-old patient who was admitted to the emergency room due continuous low back pain with 3 days of evolution. RESULTS: The tomographic computer angiography showed a type III thoracoabdominal aneurysm, with a transverse maximum diameter of 75x81mm in the infrarenal aorta and an exuberant hematoma in the left retroperitoneum, but no active extravasation of the contrast was observed (Figure 1). There was still marked tortuosity and moderate iliac calcification. It was decided to place a branched endoprosthesis (34 mm diameter at the top and 18 mm at the bottom). The branched endoprosthesis was extra-corporeally oriented, and introduced through a right femoral approach. The final position was verified with the digital subtraction angiography in anteroposterior incidence, ensuring that the distal border of each branch was 1.5 to 2 cm above the target vessel and that the stent marks presented the desired position. After the endoprosthesis was opened, the branches are catheterized by the left axillary access, however, it was verified that the endoprosthesis had an antero-posteriorly inverted implantation. It was possible to catheterize the superior mesenteric artery and the left renal artery (celiac trunk occlusion was documented intraoperatively); occlusion of the remaining endoprosthesis branches was performed with an Amplatzer. The patient evolved with multiorgan dysfunction and died at 24 hours post-operatively. CONCLUSION: Implantation of an off-the-shelf branched endoprosthesis requires specific anatomical criteria such as aortic diameter> 25mm to allow catheterization of the vessels, the possibility of incorporating each target vessel at a 90o angle in relation to each branch and visceral arteries with a diameter between 4 and 8 mm. Anatomy review is important to understand the lengths and positions of the branches. It should be borne in mind that it is possible that the device might have to be rotated during implantation to better align the marks and that both incidences (anteroposterior and profile) may be useful in confirming the position, something that should be thoroughly pursued to safeguard a correct implantation regardless of the initial stent position in your delivery system.

Endovascular Treatment of Proper Hepatic Artery Aneurysm - Case Report.

INTRODUCTION: Hepatic artery aneurysms (HAAs) are rare, representing about 0.1-2% of all arterial aneurysms. They are the second most common splanchnic aneurysms, after splenic artery aneurysms. They have the highest rate of rupture among all splanchnic artery aneurysms and frequently become symptomatic. METHODS: To present a case of a hepatic artery aneurysm treated by endovascular technique. RESULTS: A 65-year old man who had a medical history of hypertension, dyslipidemia and smoking, with an incidental finding on a CT imaging of a hepatic artery aneurysm (maximum diameter 75mm) was admitted for selective arteriography and treatment. He was asymptomatic. We proceeded to aneurysm exclusion with a self-expandable covered stent (Viabahn®) 6x100mm. Final angiography revealed permeability of right hepatic artery, splenic artery and gastroduodenal artery, and no visible endoleaks. He was discharged on the 4th postoperative day, asymptomatic and without analytic changes. On a 6 months follow-up, CT-angio confirmed a fully patent stent with no visible endoleaks and complete aneurysm exclusion. CONCLUSION: HAAs should be diagnosed before rupture. Abdominal pain, bleeding or compression may be the first symptoms. Exclusion by endovascular techniques, namely through covered- stent use, may be a good option.

True Brachial Artery Aneurysm after Arteriovenous Fistula for Hemodialysis - Case Report.

INTRODUCTION: Brachial artery aneurysms are relatively uncommon and generally due to infectious, post-traumatic or iatrogenic etiology. They seem to affect 4.5% of arteriovenous fistula. The usual manifestation is an accidental finding of a pulsatile, painless, and asymptomatic mass. Complications include sac thrombosis, thromboembolic ischaemic events, and disruption with profuse bleeding. METHODS: The aim of this study is to present a case of true brachial artery aneurysm in end-stage renal disease patient after arteriovenous fistula creation. RESULTS: Sixty-six-year-old men with a past medical history of hypertension, dyslipidemia, smoking and poliquistic renal disease. He started a hemodialysis program in March 2006, using a brachiocephalic fistula on the left upper limb, built in February 2005. Submitted to kidney transplant in June 2010 and subsequent fistula ligation in December 2012. He goes to the emergency service in June 2016 with a pulsatile mass on the medial aspect of the left arm. Pain, redness and heat were present. Radial pulse was palpable. Inflammatory parameters were high and ultrasound revealed a fusiform aneurysm of the brachial artery with partial thrombosis and triphasic flow. An MRI was performed, documenting a brachial artery aneurysm, with 44mm greatest diameter and an extension of 17.5cm. Patient was hospitalized under antibiotic therapy and submitted to a reversed great saphenous vein interposition graft. Discharge from hospital occurred on the 7th postoperative day, with no sensitive or motor deficits and a present radial pulse. CONCLUSION: Arterial aneurysm is a rare, but significant complication long after the creation of a hemodialysis access. High flow, immunosuppression and increased resistance following ligation of the AV fistula may accelerate this process.

Strategies to prevent TEVAR-related spinal cord ischemia.

Spinal cord ischemia remains the Achilles' heel of thoracic and thoracoabdominal diseases management. Great improvements in morbidity and mortality have been obtained with the endovascular approach TEVAR (Thoracic Endovascular Aortic Repair) but this devastating complication continues to severely affect the quality of life, even if the primary success of the procedure - dissection/aneurysm exclusion - has been achieved. Several strategies to deal with this complication have been published in the literature over the time. Knowledge and technology have been evolving from identification of the risk factors associated with spinal cord ischemia, including lessons learned from open surgery, and from developments in the collateral network concept for spinal cord perfusion. In this comprehensive review, the authors cover several topics from the traditional measures comprising haemodynamic control, cerebrospinal drainage and neuroprotective drugs, to the staged-procedures approach, the emerging MISACE (minimally invasive selective segmental artery coil-embolization) and innovative neurologic monitoring such as NIRS (near-infrared spectroscopy) of the collateral network.

Perioperative Drainage of Cerebrospinal Fluid for Endovascular Aortic Surgery.

INTRODUCTION: Spinal cord ischemia (SCI) is a feared complication following thoracic endovascular aortic aneurysm repair (TEVAR). European Society for Vascular Surgery guidelines suggest lumbar drainage of cerebrospinal fluid (CSF) in high-risk patients. The institutional protocol proposes as indications for CSF drainage: coverage of Adamkiewicz artery origin (T9-T12), aortic length of coverage >15 cm, compromise of collateral arteries (left subclavian or internal iliac occlusion) and symptomatic SCI. The aim of this study is to demonstrate CSF drainage efficacy and safety in the prevention or treatment of TEVAR-related SCI. METHODS: Patients submitted to TEVAR with perioperative CSF drainage between May 2015 and April 2017 at our hospital were prospectively included. The primary outcome consisted of prevention or regression of neurological symptoms (efficacy). Other complications were recorded as secondary outcomes (safety). RESULTS: Nine patients, aged between 63 and 75 years, were included. Eight surgeries were elective and one was emergent. Eight lumbar catheters were placed before surgery and one in the postoperative period due to SCI symptomatology that reverted after CSF drainage. Of those placed preoperatively, 2 developed postoperative SCI symptoms that alleviated with increased drainage or haemoglobin optimization. All patients were submitted to general anaesthesia. The patient treated in the emergent setting progressed with multiorgan dysfunction and death 24 hours after surgery. There were no other complications. CONCLUSION: In this group of patients, CSF drainage was safe and effective in the prevention and treatment of TEVAR-related SCI.

Introdução: A isquemia medular (IM) é uma complicação temida após correção endovascular de aneurismas da aorta torácica (TEVAR). As guidelines da Sociedade Europeia de Cirurgia Vascular recomendam drenagem lombar (DL) de líquido cefalorraquidiano em doentes de alto risco. O protocolo institucional considera como indicações para DL: cobertura da origem da artéria de Adamkiewicz (T9-T12), cobertura aórtica >15 cm, comprometimento de colaterais (oclusão da artéria subclávia esquerda ou ilíaca interna) e IM sintomática. O objetivo do trabalho foi demonstrar a eficácia e segurança da DL na prevenção ou tratamento da IM após TEVAR. Métodos: Doentes submetidos a DL no perioperatório de TEVAR entre maio de 2015 e abril de 2017 no nosso hospital foram prospetivamente incluídos. Outcome primário: prevenção e/ou reversão de sintomas neurológicos (eficácia). Outcome secundário: complicações relacionadas com a técnica (segurança). Resultados: Incluíram-se 8 doentes com aneurismas tóraco-abdominais e 1 com disseção aórtica tipo B, com idade entre 63-75 anos. Oito cirurgias foram eletivas e uma urgente. O cateter foi colocado previamente à cirurgia em 8 casos e no pós-operatório em 1 caso por sintomatologia de IM que reverteu após a colocação. Dos colocados pré-operatoriamente, 2 tiveram sintomas de IM no pós-operatório, que aliviaram com aumento da drenagem e optimização da hemoglobina. A TEVAR urgente resultou na perfusão insuficiente de ramos viscerais com disfunção multiorgânica e morte 24h após a cirurgia. Não se registaram outras complicações. Conclusão: A colocação de DL revelou-se segura e eficaz na prevenção e tratamento de IM após TEVAR.

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.

[Pelvic congestion syndrome - A clinical report]. / Síndrome de Congestão Pélvica - A Propósito de um Caso Clínico.

Pelvic congestion syndrome is a common disorder that occurs mainly in young multiparous women. It is characterized by a variable combination of chronic (up to 6 months) not cyclical pain, dyspareunia, dysmenorrhea, urinary symptoms and constipation, that may be associated to perineal and lower limbs varicose veins, with pelvic origin. We report the clinical case of a 26 year-old female, G0P0, with lower limbs varicose veins. During the investigation of chronic pelvic pain associated to pelvic heaviness and dyspareunia, a MR was performed and pelvic varicose veins were diagnosed. Findings were confirmed by venography. Imaging findings and symptoms severity mandated treatment and we proceeded to left ovaric vein embolization. Therapeutic success was then reached and patient remains asymptomatic 10 months after treatment.

[TEVAR: a strategy for the diversity of thoracic aorta disease. Series of cases and national prospect]. / Tevar: uma solução para a diversidade de patologias da aorta torácica: revisão institucional e panorama nacional.

OBJECTIVE: To assess endovascular treatment of thoracic aorta diseases in a national centre of angiology and vascular surgery. To quantify the national registry of TEVAR's. MATERIAL AND METHODS: This unicentric and retrospective study included patients submitted to TEVAR until the end of 2012. Twenty-seven patients were considered high-risk for conventional surgery: 14 degenerative thoracic aorta aneurysms or pseudoaneurysms (10 assymptomatic), 1 ruptured thoracoabdominal aneurysm, 5 aortabronchial/aortoesophageal fistulas, 3 complicated dissections, 2 penetrating atherosclerotic ulcer/intramural hematoma, 1 traumatic laceration and 1 embolization from aortic plaque. Eighteen (67%) were emergent/urgent procedures. RESULTS: At the institutional level, immediate technical success was achieved in all cases; average follow up was 24 months (0-97). Thirty days and 24 months global mortality was, respectively, 4% (6% for emergent/urgent procedures and 0% for elective procedures) and 13%. Aortic-related mortality was similar. One case of paraplegia and 2 of case of stoke were registered. Endoleak was present in 4 patients. Survival free from aneurysmal sac expansion (aneurysm, pseudoaneurysm or dissection, n=16) was 88% at 30 days. Survival free from aortic reintervention was 93% at 30 days and 81% at 24 months. Nationally, TEVAR registries triplicated from 2007 top 2010. CONCLUSION: These results favour the actual tendency to consider TEVAR as a first-line solution for several thoracic aortic diseases.

[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.