Effect of Chronic Antiplatelet and Anticoagulant Medication in Neck Hematoma and Perioperative Outcomes after Carotid Endarterectomy.

BACKGROUND: A retrospective analysis of neck hematoma, stroke, and mortality after symptomatic and asymptomatic carotid endarterectomy (CEA) was conducted, to determine the most appropriate perioperative medication for these patients. Thirty-day outcomes of moderate and severe neck bleeding were also investigated. METHODS: Patients undergoing CEA in a Vascular Surgery department were analyzed (2015-2019). Preprocedure antithrombotic medication (from the 5 days prior to surgery) was identified. End point predictors were identified by univariate and multivariable analyses and adjusted for confounders. RESULTS: A total of 304 CEA were included. Almost half of the included patients (49.67%) were under low-dose aspirin, 17.55% other single antiplatelet agent, 12.59% dual antiplatelet therapy, 8.61% anticoagulation, and 10.92% no antithrombotic therapy. There was a 8.22% rate of important hematoma, including 4.93% severe (requiring surgical exploration) hematomas and a 30-day all-stroke incidence of 2.94% in symptomatic and 1.79% asymptomatic patients (P = 0.51). When compared to aspirin, severe hematoma was more prevalent with single clopidogrel or triflusal (relative risk [RR] 4.25, P = 0.11), dual antiplatelet group (RR 11.84, P = 0.002), and anticoagulation (RR 8.604, P = 0.02). Dual antiaggregation and anticoagulation did not confer postoperative stroke protection compared to single aspirin in either symptomatic or asymptomatic patients. Nonsignificant higher intrahospital mortality was noted in no medication, dual antiplatelet, and anticoagulation groups in contrast to aspirin. Severe neck bleeding was associated with increased congestive heart failure (9.26-fold, P = 0.03) and longer hospital stay (11.20 ± 24.69 days vs. 3.18 ± 4.79 with no bleeding, P < 0.001), with a tendency for higher hospital readmission at 30 days (4.66-fold, P = 0.13). Mortality and stroke rates were similar. CONCLUSIONS: Double antiaggregation and anticoagulation did not confer better perioperative outcomes after elective CEA in our study. These regimens were associated with an increased risk of neck hematoma, especially severe bleeding, with similar rates of neurologic events in both symptomatic and asymptomatic patients and no mortality benefit. Monotherapy with aspirin appears to be the safest perioperative antithrombotic regimen for elective CEA.

Determinants of Quality of Life in Patients with Post-Thrombotic Syndrome.

BACKGROUND: Chronic post-thrombotic syndrome (PTS) may develop in up to 50% of patients after deep vein thrombosis (DVT), and may reduce patients' quality of life (QoL). We aimed to evaluate the association of PTS severity with QoL in patients with proximal DVT submitted for medical treatment and also to identify modifiable and non-modifiable risk factors related to PTS. METHODS: Patients with iliac or femoropopliteal DVT observed in Vascular Surgery consultation in our institution from 1 year period with unilateral DVT were selected. Patients with total vein recanalization were excluded. Villalta scale was applied to assess PTS degree and VEINES-QoL/Sym questionnaire was used as a disease-specific QoL measure. Correlation between PTS degree and VEINES-QoL/Sym score and predictors of PTS were determined. RESULTS: Fifty-six patients were accepted to enter the study. From those, 66.1% were female, 64.3% (n = 36) had iliac and 35.7% (n = 20) femoropopliteal DVT. PTS was present in 52.8% of iliac and 65.0% of femoropopliteal DVT patients observed for consultation (P = 0.41). There was a significant correlation with PTS degree and both VEINES-QoL and VEINES-Sym scores (P < 0.01). Major depression (odds ratio OR = 5.63, P = 0.04) and regular wear of compressing stockings (OR = 4.69, P = 0.04) were the only independent factors associated with PTS. Patients with depression had lower QoL scores, while patients with PTS who wear compression stockings had similar QoL scores compared to patients without PTS. Ultrasound alterations (OR = 3.28, P = 0.17), age, gender, iliac DVT, multiple DVT and time after DVT (P > 0.20) were not associated with PTS syndrome. CONCLUSIONS: VEINES-QoL/Sym had moderate inverse correlation with PTS degree. Depression was associated with both PTS and lower QoL scores. Patients with PTS criteria compliant to wearing compressing stockings had similar QoL scores to patients without PTS.

Change in Domains that Influence Quality of Life after Major Lower Limb Amputation in Patients with Peripheral Arterial Disease.

BACKGROUND: Recent guidelines raise the concept of the importance of health-related quality of life (QoL). Change in QoL after amputation in ischemic patients is not well described. We aim to evaluate the change in quality of life after major limb amputation in patients with peripheral arterial disease. METHODS: We retrospectively identified all patients submitted to above-knee amputation (AKA) and below-knee amputation in our vascular surgery department in a 2-year period. Trauma excluded. A vascular amputee adapted QoL questionnaire was administered comparing the last 2 weeks to the 2 weeks before amputation. It included subjective and objective questions adapted from WHOQoL-BREEF and SF-36 divided into specific domains of QoL (physical health, role physical, pain, social, and psychological health) that were compared to 2 global items (overall QoL and general health). Independent samples tests and linear correlations were calculated. RESULTS: A total of 106 patients were included, 30-day mortality rate 16.3% and 1-year 39.1%. Patients had an increase in mean total score after amputation of 14.35 out of 100 points, with an improvement of 52.1 points in pain and 11 points in social and psychological health out of 100 (P<0.001). Physical health and role physical scores decreased after amputation. Overall QoL was correlated with total score (P<0.001). Mean QoL total score after amputation was 79.0% ± 12.6. In general, amputees scored higher in the domains social and psychological health. Older people, women, AKA and bilateral amputees had lower physical health scores (P<0.05), prosthesis was correlated with improvement in physical health after amputation (P = 0.026). Elderly and married people had big improvement in overall QoL after amputation (P = 0.008 and P = 0.056, respectively). CONCLUSIONS: QoL does not seem to diminish in advanced ischemic patients after amputation. Older people value more a decrease in pain and family support over physical health. Therefore, patient oriented treatments should be preferred. Future research should be made to validate a disease-specific questionnaire for this population.

Aortic Anastomotic Aneurysm After Infra Renal Grafting.

An 87 year-old male presented with a 71mm proximal anastomotic aneurysm causing left renal artery displacement (Figures 1 and 2), 19 years after infra-renal aorto-aortic grafting for an infra-renal abdominal aortic aneurysm. Dilatation of visceral aorta was also observed. Management would be challenging but patient denied further intervention.

Hemodialysis Reliable Outflow graft: A valid option in patients with central venous stenosis.

INTRODUCTION: Central venous stenosis can be the main obstacle to the creation of an autologous vascular access in the upper limbs. The Hemodialysis Reliable Outflow graft was developed to provide an upper limb vascular access option to such patients, avoiding alternative, less advantageous options, such as lower limb vascular accesses or central venous catheters. Its advantages include catheter avoidance and, in case of lower limbs accesses, reduction of the ischemic risk and iliac vein thrombosis, potentially compromising a future kidney transplant. PATIENTS AND METHODS: Revision of the clinical files of the four patients who were placed a Hemodialysis Reliable Outflow device in our Center, including demographic variables, implantation technique characteristics, surgical complications, episodes of infection and thrombosis of the access, and need to place a transitory central venous catheter to undergo hemodialysis treatment. RESULTS: Four Hemodialysis Reliable Outflow grafts were placed, which resulted in a significant improvement in the dialysis efficacy in all patients, with a median raise in the Kt/V of 36.7%. Two cases needed thrombectomy, one of which was unsuccessful. The actual time of patency varies between 3 and 28 months. CONCLUSION: Our experience with the Hemodialysis Reliable Outflow device showed that it was a safe option for patients with central venous stenosis and was associated with good clinical and analytic outcomes.

Combined Endovascular Exclusion with Percutaneous Sac Aspiration and Thrombin Injection in the Management of Popliteal Artery Aneurysm.

BACKGROUND: Symptomatic popliteal artery aneurysms (PAAs) can be managed by open surgery or endovascular exclusion. METHODS: The authors describe a case of a 68-mm PAA causing compressive symptoms and managed by endovascular exclusion combined with percutaneous sac decompression. RESULTS: Endovascular exclusion allows sac pressure reduction. Additional percutaneous sac aspiration and thrombin injection promote sac shrinking and avoid persistent collateral flow. CONCLUSIONS: In challenging cases, matching different techniques can be helpful.

Endovascular Treatment of Femoral Anastomotic Aneurysm: Case Report and Review of Published Cases.

Anastomotic aneurysm is a possible complication after arterial reconstruction with highest incidence at femoral anastomosis; open surgery is the standard treatment, but endovascular exclusion can be useful in selected cases. The authors report a case of femoral anastomotic aneurysm, 19 years after aortobifemoral grafting, treated successfully using stent grafts, under local anesthesia and percutaneous brachial access. Review of published articles regarding endovascular management of femoral anastomotic aneurysm was performed. Endovascular exclusion of femoral anastomotic aneurysm is safe and feasible.

Endovascular Removal of Foreign Bodies.

INTRODUCTION: Intravascular or catheter embolization of a foreign body, either by fracture or migration, is a rare condition, occurring in approximately 1%. This study is focused on the migration of catheters since they represent the majority of cases of embolization. We present one of the largest published series of removal of foreign bodies with endovascular techniques. The objective of the present study is to demonstrate the different locations where foreign bodies, in most cases catheters, can reach, the technique used to remove them and the affected population. METHODS: This is a 9 years retrospective study in which we report the cases of foreign bodies removal performed by an endovascular approach between 2009 and 2017 in our institution. It includes 53 patients: 28 women and 25 men. The average age was 58 years (ranging from 15 to 87 years). The catheters were implanted by a heterogeneous group of professionals. RESULTS: Thirty three totally implantable catheters (Implantofix ®), sixteen peripheral inserted central catheter, three Guide Wires, one angioplasty balloon and one Amplazer vascular plug were extracted. The most common sites for the lodging of one of the ends of the intravascular foreign bodies were the right atrium (35,8%) the superior vena cava (11,3%) and the right ventricle (11,3%). In 98,1% of the cases, only one venous access was used for extraction of foreign bodies, and in 96,2% of the cases the right femoral access was used. The loop-snare technique was used in 45 cases (84,9%) and in 8 cases a basket was the option. The most common cause of catheter embolization was the disconnection between the catheter and the port during the surgery for its removal, which occurred in 55,1% of the cases. Fracture of totally implantable catheters occurred in 12,2%. The fracture of a peripheral inserted central catheter represents 32,7% of cases of embolization. Atrial fibrillation, occurred in 8 cases. The mortality rate during the procedure was zero. Technical performance was 100% successful. CONCLUSION: Percutaneous intervention for removal of intravascular foreign bodies is currently the best treatment option for patients. It is a minimally invasive, procedure, with low complication rates. Embolised material can be quite safely retrieved, and presents an attractive alternative to surgical removal of these devices. However, this work should serve as a consideration about the safety of the removal of catheters as well as their quality in order to reduce this type of complications.

Endovascular Treatment of Carotid Blowout Syndrome.

INTRODUCTION: Carotid blowout syndrome (CBS) is a life threatening complication associated with head and neck cancers (HNC) and its treatment. The mortality rate was reported to range from 3% to over 50% in the literature. Direct surgical repair of the ruptured internal carotid artery is often not technically possible due to the difficult anatomy and underlying poor co-morbid status. Endovascular techniques such as coil embolization and stent grafting offer an alternative to surgical ligation with better patient outcomes. METHODS: We describe the successful use of an endovascular approach in a case of emergent rupture of the common carotid artery (CCA) with massive bleeding in a patient submitted to radiotheraphy for the treatment of a neck malignancy. RESULTS: A 75-year-old man with a squamous cell carcinoma of the esophagus having undergone chemotherapy and radiotherapy, was admitted to the emergency room with haematemesis with approximately 1 hour of evolution. An angiogram revealed, in the right common carotid artery, contrast extravasation with a possible fistula communicating to the esophagus. A self-expandable covered stent was deployed in the right common carotid artery. Successful repair of the vessel was confirmed in the control angiogram. The patient was discharged 10 days later without neurological deficit or recurrent bleeding. Carotid blowout syndrome is one of the most complex bleeding complications that may occur in HNC patients. It is usually a life-threatening event and is accompanied with unexpectedly massive bleeding and high mortality/morbidity rates. Short and long term effects of radiation over arteries have been reported. Radiation can induce damage to the vasa vasorum of large arteries and it might lead to the rupture of arteries. In the HNC population with previous surgery or radiotherapy, a high index of suspicion must be maintained for CBS in patients presenting with any recent history of oral bleeding or haemorrhaging from an exposed neck wound. CONCLUSION: Current evidence shows that there was no significant difference in technical and hemostatic outcomes between the reconstructive and deconstructive endovascular methods. Permanent vessel occlusion resulted in higher immediately cerebral ischemia and stent grafting induced the more potentially delayed complications, such as infection, rebleeding, and stent thrombosis. In the present case, the endovascular management of CBS of the common carotid artery had high technical success and allowed immediate haemostasis. It has been suggested that self-expanding stent-grafts are useful for the initial control of carotid bleeding but are associated with more delayed complications.

Endovascular Treatment of a Complicated Type B Acute Aortic Dissection with 3-D ultrasound Control.

INTRODUCTION: Acute type B aortic dissection (ATBAD), identified within 2 weeks of symptom onset, accounts for 25%-40% of all aortic dissections. Approximately 25% of patients presenting with ATBAD are complicated at admission by malperfusion syndrome or hemodynamic instability, resulting in a high risk of early death when untreated. METHODS: We present a case of a patient with a complicated type B dissection treated by an endovascular technique with control of the sealing zone with transesophageal Echocardiogram (TEE) and 3-D images. RESULTS: A 56-year-old patient was admitted to the intensive care unit for having a type B aortic dissection complicated by persistent chest pain and uncontrolled hypertension. We perform a TEVAR (thoracic endovascular aortic repair) with a GORE® TAG® conformable thoracic stent graft with active control system to seal the primary entry tear, which covered the left subclavian artery. The origin of the left subclavian artery was covered by the stent graft and a vascular plug was put in place, to avoid endoleak. The procedure was performed with transesophageal echocardiogram with 3-D images to determine if the stent graft was in the true lumen. CONCLUSION: The treatment of acute, complicated type B aortic dissection has evolved in the past several years. Thoracic endovascular aortic repair when anatomy is suitable, has been regarded as the preferable treatment to seal the primary entry tear, redirect and re-establish adequate true lumen flow, and thereby promote aortic remodeling. The availability of TEVAR, albeit applied until recently as an off- -label treatment, has clearly produced better results than procedures such as open surgical or endovascular fenestration. However, the results of this treatment may improve when associated with other imaging tests. The TEE has a high performance in the diagnosis of this pathology, especially in regard to the detection of the flap and the two lumens, as well as for the calculation of the size of the entrance tear. It presents an added value in the endovascular treatment, since it helps in the implantation of the devices both for the location of the true lumen, its definitive position and the result of the procedure. TEVAR is the preferred treatment for acute, complicated type B aortic dissection with improved late survival and positive aortic remodelling. The efficacy of this treatment is significantly increased in association with other imaging techniques such as transesophageal echography.

Staged carotid and coronary surgery for concomitant carotid and coronary artery disease.

OBJECTIVE: To demonstrate that staged, consecutive, carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) are safe, perhaps preferable, alternative for the treatment of patients with severe carotid and coronary artery disease. METHODS: During an 8-year period ending December 1999, 77 (2.1%) of 3633 consecutive patients who were referred for isolated coronary surgery were found to have significant carotid disease and underwent CEA, and subsequently, CABG. The mean age was 65.2 +/- 5.9 years and 66 (85.7%) were males. The majority (84.4%) had triple vessel and 19.4% had left main disease. Carotid disease was unilateral in 71 patients (92.2%) and bilateral in six (7.8%), and 57 (74.0%) were neurologically asymptomatic. Only obstructions >70% were considered for endarterectomy. RESULTS: Eighty-three isolated CEAs were performed with direct clamping of the artery (mean 20.1 +/- 5.9 min) in all but one. There were no deaths. There were two strokes (2.4%) and three (3.6%) myocardial infarctions (MI). The mean admission time was 6.0 +/- 3.5 days. The staging interval was 32.4 days. During coronary surgery, a mean of 2.9 coronary grafts/patient was performed and all but one patient received at least one IMA graft. One patient (1.3%) died. There were two cases (2.6%) of MI and three patients (3.9%) had a stroke. Hence, the overall rates of perioperative mortality, MI and stroke were 1.3, 6.3 and 6.3%, respectively. The mean admission time was 8.3 +/- 6.0 days. CONCLUSIONS: Staging of carotid and coronary operations resulted in low global perioperative mortality and morbidity rates in these high-risk patients and is a good alternative therapeutic option.