Thoracic aortic aneurysms, a single center's 10-years experience and analysis of outcomes.

INTRODUCTION: Thoracic aortic aneurysms (TAAs) are an increasingly prevalent pathology with significant associated morbidity and mortality. Thoracic endovascular aortic repair (TEVAR) is the primary line of treatment. The purpose of this study was to analyse a single center's experience in the treatment of TAAs and identify possible risk factors for worse outcomes. METHODS: A retrospective review of our institutional database was done to identify all patients treated for TAAs in a 10-year period, from 1 January 2012 to 31 December 2022. Data were extracted from patients' medical records. Primary outcome was all-cause mortality and secondary outcomes were procedure related morbidity (vascular access complications, medullary ischaemia, stroke, endoleaks, migration, aneurysm sac enlargement >5 mm) and need for reintervention at 1-, 6- and 12-month follow-up. A descriptive and inferential analysis of the data was performed. Statistical analyses were conducted using the IBM Statistical Package for Social Sciences (SPSS) software. RESULTS: We identified 34 patients treated for TAAs in this period. Mean age was 68 years [47-87] and 79.4% of patients were male. Mean aneurysm diameter was 63 mm [35-100], 55.9% fusiform and 44.1% saccular. The majority (91.2%) were located at the descending thoracic aorta and 3 (8.8%) of them extended to the aortic arch. The most common aetiology was degenerative in 22 patients (64.7%), followed by aortic dissection in 8 patients (23.5%). Elective surgery was performed in 19 (61.3%) patients and 12 (38.7%) had urgent repair. TEVAR was the treatment of choice in 24 (77.4%) patients, and the remaining 7 (22.6%) were treated with hybrid surgery. Mean length of hospital stay was 10 days [2-80] (6 days for elective repair versus 16 days for urgent repair, p = .016). Follow-up period ranged from 1 month to 10 years. At 1 year follow-up, all-cause mortality was 15%, morbidity was 30% (with 6 (22%) patients having a type Ia endoleak) and need for reintervention was 22%. Aneurysm diameter was a significant risk factor for procedure related morbidity (median diameter of 73.5 mm versus 56.0 mm in patients with no morbidity; p = .027). The presence of type Ia endoleak was significantly associated with higher reintervention rates (p = .001), but not with higher mortality rates (p = .515). Age, female sex, aetiology and urgent repair weren't associated with any significant differences in the outcomes. CONCLUSIONS: TEVAR proved to be effective in the treatment of TAAs, with good outcomes at short and mid-term follow-up. TAAs should be diagnosed earlier and be promptly treated when meeting criteria to prevent worse outcomes.

Aneurysmal Degeneration of the Brachial Artery Following Chronic Arteriovenous Fistula Ligation.

Introduction: Arteriovenous fistulas (AVF) are currently considered to be the best vascular access option for patients with end stage chronic kidney disease requiring haemodialysis. In rare cases of patients with chronic AVF, thrombosis or ligation of the access can lead to the development of brachial artery aneurysms. Despite being uncommon, reports of this phenomenon have arisen in recent decades due to an increase in the number of patients undergoing dialysis worldwide. This case presented with a brachial aneurysm that developed after AVF ligation. Case report: A 62 year old male presented to the emergency department with swelling of the medial aspect of his left arm associated with pain, inflammatory signs, and finger paraesthesia. Swelling had started two months previously but had worsened within the last week. He had history of kidney transplant 20 years ago and a chronic functioning radiocephalic fistula that had not been used since, and which had been ligated in the past year due to the development of venous aneurysms. Physical examination revealed a pulsatile mass in his left arm and absent radial and ulnar pulses, without signs of hand ischaemia. There was significant venous collateralisation of the arm and chest and numbness of the left fingers, suggesting venous and neurological compression. Computed tomography angiography showed a large left brachial artery aneurysm (108 x 87 x 180 mm). The patient underwent aneurysm sac emptying and collateral ligation followed by great saphenous vein interposition, with clinical improvement. Conclusion: The presence of a chronic AVF can lead to progressive changes in the arterial wall. Sudden ligation or thrombosis of a functioning AVF causes increased blood pressure within the artery, which may further contribute to its aneurysmal degeneration. In addition, immunosuppressive therapy following kidney transplant has been described as a synergistic risk factor leading to aneurysm formation. Despite being a rare complication, patients with a chronic AVF should be monitored closely after vascular access ligation.

Coral Reef Aorta: Literature Review and Analysis of the Published Cases in the Last 20 Years.

BACKGROUND: Coral reef aorta (CRA) is defined by the presence of heavily calcified exophytic plaques that protrude into the aortic lumen. However, the exact causes and development of this condition are still not fully understood. When the aortic branches are affected, it can result in various symptoms. Despite ongoing research, there is currently no established consensus on the best treatment for CRA. This review aims to examine the latest findings regarding the clinical presentation and approach to treating patients with CRA. METHODS: We conducted a systematic electronic search of the literature using the PubMed and Embase databases. Throughout the search, we adhered to the guidelines outlined in the PRISMA framework. From the identified publications, we extracted information pertaining to patients' characteristics, symptoms, and types of treatment from a total of 124 cases reported over the past 20 years. The primary focus of our analysis was to assess the improvement of signs and symptoms, as well as to evaluate any postoperative complications. To achieve this, we performed both descriptive and inferential analyses on the collected data. Additionally, we conducted subgroup analyses based on treatment types and symptoms observed at presentation, presenting the findings in the form of odds ratios (ORs). RESULTS: After removing duplicate articles, we carefully screened the titles of 67 retrieved articles and excluded those that did not align with the purpose of our study. Subsequently, we thoroughly analyzed the remaining 41 articles along with their references, ultimately including 29 studies that were deemed most relevant for our systematic review. We examined a total of 124 cases of patients diagnosed with CRA, comprising 77 (62.1%) females and 48 (38.7%) males, with a mean age of 59 years (range: 37-84). The predominant signs and symptoms observed were intermittent claudication, reported in 57 (46.0%) patients, followed by refractory hypertension in 45 (36.3%) patients, intestinal angina in 28 (22.6%) patients, and renal insufficiency in 15 (12.1%) patients. Among the treated patients, 110 (88.7%) underwent open surgery repair (OSR), 11 (8.9%) received endovascular treatment, and 3 (2.4%) underwent laparoscopy. Postoperatively, a significant number of patients experienced substantial relief or complete resolution of their symptoms, as well as improved control of hypertension and renal function. In the group of patients treated with OSR, the inhospital stay mortality rate was 10.9%, the morbidity rate was 28.2%, and the reintervention rate was 15.5%. The high mortality rate during hospital stays in this group may be associated with such invasive procedures performed on patients who have substantial cardiovascular burden and multiple comorbidities. Conversely, no postoperative complications were reported in the group of patients treated with endovascular procedures or laparoscopic surgery. CONCLUSIONS: While coral reef aorta (CRA) is considered a rare condition, it is crucial for the medical community to remain vigilant about its diagnosis, particularly in patients presenting with symptoms such as intermittent claudication, refractory hypertension, renal impairment, or intestinal angina. Based on the findings of this review, both OSR and endovascular treatment have shown promise as viable therapeutic options. Although endovascular therapies may not always be feasible or may have reduced durability in these calcified bulky lesions, they should be considered in patients with multiple comorbidities, due to the high postoperative mortality rates associated with more invasive approaches. Additionally, these endoluminal procedures have demonstrated good patency rates during the 18-month follow-up period. It is essential to emphasize that the treatment strategy should be determined on a case-by-case basis, involving a multidisciplinary team to tailor it to the specific needs of each individual patient.

Host-Reaction Following Silicone Tube Implantation For Lower Limb Lymphoedema Mimicking Implant Infection.

INTRODUCTION: Silicone tube implantation in lymphoedema reduces symptoms by improving fluid drainage. Although there are descriptions of implant host reaction that can be misdiagnosed as graft infections these are scarce. REPORT: A 34 year old female with lymphoedema of the lower limb, underwent silicone tube implantation. Ten months after surgery, the patient presented with fever and dermatolymphangioadenitis of the limb. Ultrasound suggested an abscess surrounding the tubes. Clinical improvement was achieved after a 6-day cycle of meropenem. She was discharged under oral cefuroxime and clindamycin for one week. After 1 month, CT-angiography was performed showing only residual inflammation surrounding the tubes, the patient was asymptomatic and limb diameter was normal. CONCLUSION: Sudden onset and improvement of the patient's condition after a short cycle of antibiotics without the need of tube removal supports a host-like reaction rather than an actual infection. Doctors should be aware of such complications avoiding unnecessary procedures.

Best Medical Treatment in Patients with Asymptomatic Carotid Stenosis: Myth or Reality?

BACKGROUND: Approximately 1.4 million strokes/year causing about 1.1 million deaths annually occur in Europe and 10%-15% of those strokes are result of thromboembolism from a previously significant asymptomatic carotid stenosis (ACS). Medical treatment has improved considerably in the last 15 years; however, its success depends on patient compliance. The aim of our study was to evaluate, in patients with ACS, the implementation and patient adherence to best medical treatment (BMT). Additionally, we sought to determine the "real-world" incidence of cerebrovascular/coronary events in a cohort of nonoperated ACS patients and weighing this risk against surgical complications in patients with ACS undergoing surgical treatment at our Department. METHODS: Patients with ACS ≥ 60% identified by a carotid ultrasound performed at our Department were retrospectively evaluated. Patients selected to BMT were excluded if the follow-up period was inferior to 2 years, as well as patients lost in follow-up, with missing clinical information and submitted to carotid stenting. Patients' data collection was supported by hospital reporting system and data were introduced into a database created for the purpose. Statistical analysis was performed using SPSS-25 software. RESULTS: After exclusion criteria were applied, the last 120 consecutive patients (60 with ACS submitted do carotid endarterectomy and 60 with ACS under BMT) were retrospectively evaluated. Twenty one patients had ipsilateral events for more than 6 months. Most patients had hypertension (n = 107; 89%), dyslipidemia (n = 101; 84%), 40% had diabetes, 33% diagnosed coronary disease, 32% were overweight or obese, and 17% were current smokers. Blood pressure control, normal weight, statin with/without ezetimibe association, and antiaggregant therapy were only achieved in 33 patients and only 5 had additionally low-density lipoprotein levels < 70 mg/dL, hemoglobin A1c < 7%, and were nonsmokers. Of the 60 patients assigned to medical treatment, 3 (5%) had a stroke at 2 years of follow-up, which was fatal in 1 patient. Among patients submitted to carotid endarterectomy, perioperative stroke was documented in 3% of the patients, none of them disabling or fatal. CONCLUSIONS: Although some recent studies report a risk of ipsilateral stroke of only 0.34% per year in patients with ACS ≥ 50% under BMT therapy in our everyday practice strict compliance to medical treatment fails in most patients. In consequence, we think that a "one-size-fits-all" guideline policy may not be appropriate for all patients and the management of specific ACS patients may need to be individualized.

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.

An Incidental Finding Of A Persistent Sciatic Artery - Case Report And Literature Review.

Persistent sciatic artery is a rare anatomic variation due to the lack of regression during fetal development, associated sometimes with abnormalities of the iliofemoral arterial axis and predisposing the patients to aneurysm formation and thromboembolism, which can compromise the limb. In our department, we assisted a 59-year-old male with an acute limb ischemia as result of an incidental finding of a thrombosed persistent sciatic artery aneurysm.

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.

Abdominal Aortic Aneurysms and Q Fever: An Odd Connection to Keep in Mind.

Abdominal aortic aneurysms (AAAs) secondary to Coxiella burnetii infections are rare but carry important implications. The diagnosis is difficult due to unspecific symptoms. To the authors' knowledge, this is the first AAA caused by chronic Q fever treated with an endoprosthesis.

COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes.

A 67-year-old male diabetic patient with systemic arterial hypertension was admitted to the emergency department with a necrotic ulcer in the left external malleolus and no palpable popliteal or pedal pulses. Arterial Duplex ultrasound identified femoropopliteal occlusion, with popliteal refilling below the knee and a patent peroneal artery. An endovascular procedure was performed, requiring retrograde access to the popliteal artery to re-establish blood flow and deploy a popliteal stent. Technical success was achieved and the patient underwent debridement of the wound. Two days later, about 48 hours after the operation, the patient began to exhibit respiratory symptoms, with coughing and dyspnea. He immediately underwent a chest CT that identified ground glass opacities, the crazy-paving pattern, and bilateral air bronchogram in the lungs. A reverse transcription - polymerase chain reaction (RT-PCR) test was positive for SARS-Cov-2. The patient was moved to an intensive care unit and put on mechanical ventilation. Both hydroxychloroquine and azithromycin were administered. Despite appropriate treatment, the patient died 4 days after he was diagnosed with COVID-19.

Paciente do sexo masculino, 67 anos, diabético, hipertenso, foi admitido no pronto-socorro com histórico de úlcera necrótica no maléolo externo esquerdo, sem pulsos poplíteos e distais palpáveis. A ultrassonografia Doppler arterial identificou oclusão femoropoplítea, com reenchimento da artéria poplítea infragenicular e perviedade da artéria fibular. Foi realizado procedimento endovascular, com necessidade de acesso retrógrado na artéria poplítea para restabelecer o fluxo sanguíneo e realizar implante de stent poplíteo. O sucesso técnico foi alcançado e, em seguida, o paciente foi submetido ao desbridamento da ferida. No segundo dia, cerca de 48 horas de pós-operatório, o paciente apresentou quadro respiratório com tosse e dispneia. Foi submetido a uma tomografia computadorizada do tórax, que identificou opacidades em vidro fosco e broncograma aéreo bilateralmente nos pulmões, com teste de reverse transcription ­ polymerase chain reaction (RT-PCR) positivo para SARS-Cov-2. O paciente foi transferido para uma unidade de terapia intensiva, necessitando de ventilação mecânica. Recebeu hidroxicloroquina e azitromicina. Apesar do tratamento em suporte intensivo, o paciente morreu 4 dias após o diagnóstico de COVID-19.

COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes / Diagnóstico de COVID-19 em paciente com isquemia crítica do membro: complicações e desfechos clínicos

Abstract A 67-year-old male diabetic patient with systemic arterial hypertension was admitted to the emergency department with a necrotic ulcer in the left external malleolus and no palpable popliteal or pedal pulses. Arterial Duplex ultrasound identified femoropopliteal occlusion, with popliteal refilling below the knee and a patent peroneal artery. An endovascular procedure was performed, requiring retrograde access to the popliteal artery to re-establish blood flow and deploy a popliteal stent. Technical success was achieved and the patient underwent debridement of the wound. Two days later, about 48 hours after the operation, the patient began to exhibit respiratory symptoms, with coughing and dyspnea. He immediately underwent a chest CT that identified ground glass opacities, the crazy-paving pattern, and bilateral air bronchogram in the lungs. A reverse transcription - polymerase chain reaction (RT-PCR) test was positive for SARS-Cov-2. The patient was moved to an intensive care unit and put on mechanical ventilation. Both hydroxychloroquine and azithromycin were administered. Despite appropriate treatment, the patient died 4 days after he was diagnosed with COVID-19.

Resumo Paciente do sexo masculino, 67 anos, diabético, hipertenso, foi admitido no pronto-socorro com histórico de úlcera necrótica no maléolo externo esquerdo, sem pulsos poplíteos e distais palpáveis. A ultrassonografia Doppler arterial identificou oclusão femoropoplítea, com reenchimento da artéria poplítea infragenicular e perviedade da artéria fibular. Foi realizado procedimento endovascular, com necessidade de acesso retrógrado na artéria poplítea para restabelecer o fluxo sanguíneo e realizar implante de stent poplíteo. O sucesso técnico foi alcançado e, em seguida, o paciente foi submetido ao desbridamento da ferida. No segundo dia, cerca de 48 horas de pós-operatório, o paciente apresentou quadro respiratório com tosse e dispneia. Foi submetido a uma tomografia computadorizada do tórax, que identificou opacidades em vidro fosco e broncograma aéreo bilateralmente nos pulmões, com teste de reverse transcription - polymerase chain reaction (RT-PCR) positivo para SARS-Cov-2. O paciente foi transferido para uma unidade de terapia intensiva, necessitando de ventilação mecânica. Recebeu hidroxicloroquina e azitromicina. Apesar do tratamento em suporte intensivo, o paciente morreu 4 dias após o diagnóstico de COVID-19.

Aspectos psicológicos dos pacientes com câncer de colo de útero, relacionado à prática radioterápica / Psychological aspects of patients with cervical cancer radiotherapy: related practice

Radioterapia é um dos tratamentos instituídos para o combate ao câncer de colo uterino e provoca um forte impacto orgânico e psicológico nos pacientes. Ao destacar a importância do acompanhamento psicológico, realizou-se uma pesquisa com o objetivo de investigar as percepções e estratégias de enfrentamento à radioterapia. Trata-se de uma pesquisa qualitativa, com sujeitos encontrados a partir do método “Bola de Neve”, aos quais se aplicou uma entrevista aberta, posteriormente realizada sua Análise de Conteúdo. A Análise de Conteúdo compreendeu que a informação e a acolhida são fatores inerentes a melhoria da qualidade de vida do paciente. Percebeu-se que o apoio das redes sociais e equipe de saúde influencia positivamente no enfrentamento da enfermidade e auxilia a elaborar as idéias de finitude e a passividade quanto ao tratamento e o curso da doença. Assim, o estar informado e sentir-se acolhido e apoiado em seu sofrimento são situações que podem auxiliar o paciente no tratamento, reabilitação e convívio social.

Radiotherapy is a treatment instituted to combat uterine cancer and causes a strong physical and psychological impact on patients. Highlighting the importance of monitoring psychological, research was done in order to investigate the perceptions and strategies of confrontation to radiotherapy. It is a qualitative research with individuals found by the method “Snowball”, who participated in an open interview, which had its analysis of content performed before. The analysis of content understood that the information and the reception are inherent factors that improve the patient quality of life. It was realized that the support of social networks and health team have a positive influence in combating the disease and help to develop the ideas of finitude and passivity in relation to the treatment and course of the disease. Thus, to be informed and feel welcome and supported in their grief are situations that can assist the patient in treatment, rehabilitation and social life.

Aspectos psicológicos dos pacientes com câncer de colo de útero, relacionado à prática radioterápica / Psychological Aspects of Patients with Cervical Cancer Radiotherapy – Related Practice

Radioterapia é um dos tratamentos instituídos para o combate ao câncer de colo uterino e provoca um forte impacto orgânico e psicológico nos pacientes. Ao destacar a importância do acompanhamento psicológico, realizou-se uma pesquisa com o objetivo de investigar as percepções e estratégias de enfrentamento à radioterapia. Trata-se de uma pesquisa qualitativa, com sujeitos encontrados a partir do método “Bola de Neve”, aos quais se aplicou uma entrevista aberta, posteriormente realizada sua Análise de Conteúdo. A Análise de Conteúdo compreendeu que a informação e a acolhida são fatores inerentes a melhoria da qualidade de vida do paciente. Percebeu-se que o apoio das redes sociais e equipe de saúde influencia positivamente no enfrentamento da enfermidade e auxilia a elaborar as idéias de finitude e a passividade quanto ao tratamento e o curso da doença. Assim, o estar informado e sentir-se acolhido e apoiado em seu sofrimento são situações que podem auxiliar o paciente no tratamento, reabilitação e convívio social.(AU)

Radiotherapy is a treatment instituted to combat uterine cancer and causes a strong physical and psychological impact on patients. Highlighting the importance of monitoring psychological, research was done in order to investigate the perceptions and strategies of confrontation to radiotherapy. It is a qualitative research with individuals found by the method “Snowball”, who participated in an open interview, which had its analysis of content performed before. The analysis of content understood that the information and the reception are inherent factors that improve the patient quality of life. It was realized that the support of social networks and health team have a positive influence in combating the disease and help to develop the ideas of finitude and passivity in relation to the treatment and course of the disease. Thus, to be informed and feel welcome and supported in their grief are situations that can assist the patient in treatment, rehabilitation and social life.(AU)