A single-center experience in the eversion femoral endarterectomy.

OBJECTIVES: Endarterectomy is the treatment of choice for arterial occlusive disease of the femoral bifurcation. Longitudinal arteriotomy and prosthetic patch angioplasty is the standard technique but, due to the increasing concerns with prosthetic-related infections and multidrug-resistant pathogens our group adopted an alternative approach. We present our experience with eversion femoral endarterectomy. METHODS: All patients submitted to eversion femoral endarterectomy in a single institution during 2016-2019 were retrospectively analyzed. Patient demographics, surgical data, and complications were captured from medical records. RESULTS: Nineteen patients, 84.2% male and a median age of 67 years (IQR 62-78) were submitted to eversion femoral endarterectomy with a median follow-up of 180 days (IQR 71-395). Seventeen (89.4%) patients were treated for chronic limb ischemia and the other two were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Most of the patients had smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). Only 3 patients (15.8%) were submitted exclusively to endarterectomy, 13 (68.4%) were submitted to endarterectomy as an adjuvant for peripheral endovascular treatment, 2 (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm, and 1 (5.3%) was complemented with thrombectomy of the femoro-popliteal sector. Primary patency rates were 100% and 87.5% (CI (38.7-98.1)) at 6 and 12 months, respectively. Primary-assisted and secondary patency rates were 100%. The 30-day mortality rate was 5.3% (n = 1) and complication rate 10.5% (n = 2). One patient complicated with acute renal disease related to rhabdomyolysis. Another patient developed a wound-related hematoma treated with surgical drainage, but died three days after consequent to ischemia-reperfusion injury. CONCLUSIONS: Eversion femoral endarterectomy is a safe and feasible technique, with good patency results and respecting the concept of leaving nothing behind. A careful control of the proximal and distal endpoints is essential for the success of the technique.

Hybrid Surgery in Lower Limb Revascularization: A Real-World Experience from a Single Center.

BACKGROUND: Through the association of endovascular and open procedures, hybrid surgery for lower limb revascularization allows the treatment of multilevel occlusive disease with a lower risk when compared to extensive open interventions. The aim of this study is to evaluate the immediate and midterm clinical outcomes of hybrid techniques for lower limb revascularization in a cohort of patients with multilevel arterial disease. METHODS: Data from elective procedures between 2012 and 2017 were retrospectively collected regarding hybrid lower limb revascularization procedures. The outcomes of the study were categorical clinical improvement, patency rates, major amputation rates, and mortality. RESULTS: A total of 81 patients, 89 limbs, with a median age of 69 years (interquartile range [IQR] 61-73) were submitted to hybrid lower limb revascularization, with a median follow-up of 10.7 months (IQR 2.5-25.1). Treatment indications were chronic limb-threatening ischemia in 80.9% of the cases (rest pain in 18.0% and tissue loss in 62.9%). One-year primary, primary-assisted, and secondary patency rates were 78.28% (95% confidence interval [CI] 65.20-86.92), 85.12% (95% CI 72.96-92.09), and 90.19% (95% CI 79.13-95.54), respectively. Overall categorical clinical improvement was observed in 56.2%. Major amputation and mortality rates were 14.6% and 16.0%, respectively. Multilevel Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) C or D and stage IV Leriche-Fontaine classification were strongly associated with decreased categorical clinical improvement (adjusted odds ratio [aOR] 0.08, P < 0.0001 and aOR 0.25, P = 0.013, respectively). Multilevel TASC C or D was also related to higher amputation rates, contrary to clinical presentation (adjusted hazard ratio [aHR] 11.37, P = 0.002 and aHR 4.70, P = 0.091, respectively). Primary-assisted and secondary patency rates were associated with higher categorical clinical improvement (aOR 4.30, P = 0.036 and aOR 7.36, P = 0.021, respectively) and decreased major amputation rates (aHR 0.11, P = 0.003 and aHR 0.09, P = 0.001, respectively) but were not related to multilevel TASC and Leriche-Fontaine classifications. CONCLUSIONS: The present study reports a real-world experience with a large proportion of patients with chronic limb-threatening ischemia. Hybrid interventions for lower limb revascularization revealed to be a potential approach for patients with complex arterial disease that would beneficiate from less invasive procedures.

Endovascular Repair of Bilateral Carotid Dissection in a Near Hanging Victim.

INTRODUCTION: There is much debate in the literature regarding the management of blunt cervical carotid injuries. This report describes a case of bilateral carotid artery dissection in the very uncommon case of a near hanging victim and the treatment controversies regarding its management. REPORT: A 50 year old male patient was admitted after attempted suicide through hanging, having been swiftly rescued by a bystander. On admission, six hours after the event there was no neurological deficit. There was evidence of soft tissue damage related to the rope position, subcutaneous emphysema, and neck swelling. The CT angiogram showed dissection of both common carotid arteries with significant luminal narrowing as well as fracture of the thyroid cartilage; brain injury was excluded. Heparin infusion was started and an endovascular repair with bilateral covered stent placement, requiring coverage of the external carotid artery on the left side, was performed. The vascular procedure was uneventful. The patient was discharged 36 days after the event, on dual antiplatelet drugs and under regular psychiatric and speech therapy care, and is currently alive and well 22 months after surgery with no neurological damage. DISCUSSION: The choice of treatment was not straightforward as there are no guidelines or consensus around its management. In this case, however, an endovascular repair seemed suitable and the result was optimal, with no neurological damage and a good result after 22 months.

[Large infectious thoracoabdominal aortic aneurysm in a chronic contained rupture, treated successfully using the "simplified technique"]. / Volumoso aneurisma infeccioso da aorta toracoabdominal em rotura contida tratado com sucesso pela "técnica simplificada"

The clinical case of a 72-years old male is reported, admitted into a Medical Department through the Emergency Service, with a clinical picture of heavy lumbar pain, with walking compromise and acute urinary retention, lasting for several hours. Laboratory analysis revealed a marked elevation of acute inflammatory parameters and a renal failure, expressed by 108 mg/dl of urea and 4.4 mg/dl of creatinine. The patient was admitted with the provisional diagnosis of acute prostatitis, pos-renal acute renal insufficiency and dorso-lumbar pathology of unknown etiology. Three consecutive and subsequent hemocultures allowed the isolation of a Streptococcus pneumonae strain and a CT dorso lumbar spine evaluation disclosed a D11 to D12 spondylodiscitis, with a partial destruction of the vertebral bodies and an extensive throracoabdominal aortic aneurysm adjacent to those vertebrae, with some characteristic features of an infectious aneurysm. Simultaneously, an hemothorax on the left chest was noticed, consequence of a chronic contained rupture of the aneurysm. Following an intensive and specific antibiotic therapy and with an almost completed recovery of the renal function, he underwent surgical management, consisting in the evacuation and drainage of the hemothorax, followed by resection of the aneurysm and extensive tissular debridmente, culminating in the vascular reconstruction utilizing the "simplified technique", introduced in 1984 by A. Dinis da Gama for the surgical management of thoracoabdominal aortic aneurysms. The patiente tolerated the procedure well, with no intercorrences or complications and the post operative course was unventfull. One month later, a CT-angio control disclosed the revascularization procedure working in excellent condition. Finally, an orthopedic artrodhesis of the injuried vertebrae was performed, allowing an easy and pain-free walking and he was discharged on day 60, under antibiotic treatment. The main features of this clinical case are emphasized and discussed, namely those aspects related to its pathogenesis, clinical presentation, diagnosis and surgical management.