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.

[Aortic mural thrombus]. / Trombo aórtico mural.

Aortic mural thrombus is a rare clinical finding in the absence of aneurysm or atherosclerosis but an important source of noncardiogenic emboli with a difficult diagnosis and a high rate of complications, including high mortality. It appears to occur more frequently in young adults usually with underlying pro-thrombotic disorder. With the increasing use of high resolution imaging, the asymptomatic mural thrombus became an increasingly frequent finding, but its potential for embolization or the best treatment are still a matter of debate. The management of mural thrombus in non-atherosclerotic aorta represents a challenge because no guidelines are available, and should be individualized. The therapeutic approach should include the triple aspects of aortic mural thrombus: primary disease anticoagulation treatment, surgical thrombectomy to solve embolic complications and endovascular/classical surgery to exclude the thrombus from the aorta. Historically therapeutic anticoagulation was proposed as first-line therapy and surgical intervention was reserved for mobile thrombus, recurrent embolism and contraindication for anticoagulation. However, it is associated with a 25-50% embolic recurrence rate, thrombus persistence in 35% and secondary aortic surgery in up to 31% of the cases. Recent data suggest that endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with a low recurrence and re-embolization rates. In this article we review the published literature concerning this topic.

O trombo aórtico mural é uma entidade rara na ausência de doença aterosclerótica ou aneurismática, mas uma causa importante de embolia não cardioembólica, com diagnóstico de presunção difícil e alta incidência de complicações, incluindo mortalidade elevada. Afeta mais frequentemente o adulto jovem geralmente com um distúrbio pró-trombótico subjacente. Com o maior acesso a exames de imagem de alta resolução, o trombo mural assintomático tornou-se um achado crescente, sem que se saiba atualmente prever o seu potencial embolígeno ou melhor orientação terapêutica. O seu tratamento representa um desafio, dada a ausência de guidelines disponíveis, devendo este ser individualizado. A abordagem terapêutica deve incluir os aspetos tríplices do trombo mural aórtico: anticoagulação para tratamento do distúrbio primário, trombectomia cirúrgica para resolução das complicações embólicas e a cirurgia endovascular/clássica para excluir o trombo da aorta. Historicamente a anticoagulação foi proposta como terapêutica de primeira linha e a intervenção cirúrgica reservada para os casos de trombo móvel, embolia recorrente refratária ou contra-indicação da mesma. No entanto o uso da AC isolado está associada a recorrência embólica em 25-50% dos casos, persistência do trombo em 35% e necessidade de cirurgia aórtica secundária em até 31%. Dados recentes sugerem que a técnica endovascular, quando possível, parece ser um procedimento eficaz e seguro com baixa incidência de recorrência ou re-embolização. Este artigo visa realizar uma revisão da literatura publicada.

[The Impact of Patient Transfer After Rupture of an Abdominal Aortic Aneurysm]. / O Impacto da Transferência de Doentes após Rutura de Aneurisma da Aorta Abdominal.

OBJECTIVE: determine whether patient transfer adversely affects the survival of ruptured abdominal aortic aneurysm (rAAA) patients after conventional surgery. METHODS: We performed a retrospective review of all patients undergoing attempted repair of an rAAA at a tertiary center, over January 2008 and December 2014. Patients were divided into those presenting directly to our center and those transferred from another hospital. The main outcome variable was 24-hour or 30-day mortality, with secondary variables including time to surgical treatment, length of intensive care unit stay and total length hospitalization. RESULTS: 78 patients (88% men) underwent attempted open repair of an rAAA during this period, 69% (54 cases) were transferred from another institution. Both groups were similar in terms of demographic characteristics, comorbidities and hemodynamic stability. The overall mortality rate was 51% at 30 days. Transferred patients took twice as long as direct patients to get to the operating room (median 7,9 vs. 3,9 horas, p < 0,05), Although the difference for surgery treatment, there was no difference in 24-hour and 30-day mortality between the transferred group and direct group (26% e 50% vs. 29% e 58%, p < 0,05). Mean intensive care unit stay (median, 12 vs. 4 dias, p = 0,04) and total hospitalization (median 11 vs. 4 dias, p = 0,04) were sustantially superior in the transferred group. CONCLUSIONS: Transfer of patients with RAAA in this series results in a doubling of the time interval between initial patient presentation and arrival in the operating room. This, however, did not result in any disadvantage in the survival rate between the groups. The total length and resources consumption were higher in the transfer group. These results may be attributed to a pre-selection of patients (clinically stable) who are able to tolerate such a delay in surgical treatment, secondary to transfer.

Objetivo: Determinar se a transferência inter-hospitalar afecta adversamente a sobrevida de doentes com rutura de aneurisma da aorta abdominal (rAAA), submetidos a cirurgia convencional. Métodos: Efetuamos uma análise retrospetiva dos rAAA tratados sequencialmente por cirurgia convencional, num centro de referenciação terciária, no período compreendido entre janeiro 2008 e dezembro de 2014. Os casos foram divididos entre os que se apresentram diretamente neste centro e os que foram alvo de transferência. Analisou-se a mortalidade às 24 horas, a mortalidade aos 30 dias e, como outcomes secundários, incluíram-se o tempo de chegada ao bloco operatório, duração de internamento na unidade de cuidados intensivos (UCI) e o tempo de internamento total. Resultados: Neste período, um total de 78 casos (88% do género masculino) foram submetidos a cirurgia convencional por rAAA, 69% (54 casos) transferidos de outra instituição. Ambos os grupos mostraram semelhanças nas características demográficas, bem como no perfil de comorbilidades e estadio de estabilidade hemodinâmica. A mortalidade global foi de 51% aos 30 dias. O tempo de chegada ao bloco operatório do grupo transferido foi 2 vezes superior (mediana 7,9 vs. 3,9 horas, p < 0,05). Apesar da diferença para início da prestração de cuidados cirúrgicos específicos, a mortalidade às 24 horas e aos 30 dias não diferiu entre entre o grupo transferido e o direto (26% e 50% vs. 29% e 58%, p < 0,05) respectivamente. O tempo de internamento na UCI (mediana, 12 vs. 4 dias, p = 0,04) e a duração total de internamento (mediana 11 vs. 4 dias, p = 0,04) foram substancialmente maiores para o grupo transferido. Conclusões: O resultado da transferência inter-hospitalar, nesta série de doentes, resultou numa duplicação do tempo de admissão no bloco operatório Contudo, não se verificou qualquer desvantagem em relação à sobrevida entre os grupos. A duração da hospitalização e consumo de recursos foi maior no grupo transferido. Estes resultados podem dever-se à possível seleção de doentes transferidos (clinicamente estáveis) que conseguem tolerar o atraso na instituição do tratamento cirúrgico, decorrente da transferência.

[Aneurysmal disease - a multifocal pathology with regard to a clinical case.] / Doença aneurismática ­ uma patologia multifocal a propósito de um caso clínico.

INTRODUCTION: True para-anastomotic aneurysms are a rare complication of arterial surgery. OBJECTIVE: This paper aims to describe the clinical case of a 73 years-old patient, with history of a left above-the- -knee amputation due to an occluded popliteal aneurysm, admitted for surgical treatment of a contralateral popliteal aneurysm. RESULTS: A bypass between the right distal superficial femoral artery (SFA) and the distal popliteal artery was performed using autologous vein. Two years after the index surgery, aneurysmatic degeneration of the native artery was found on ultrasound, with 1.7 cm at the proximal anastomosis, and 1.4 cm distally. We kept surveillance, however, 12 years after surgery, he had a proximal true para-anastomotic aneurysm of the SFA with 4.8 cm. So, resection with interposition of a prosthetic graft between the native artery and the venous conduit of the previous bypass was performed. At this time the popliteal artery at the distal anastomosis had, approximately, 1.8 cm, so we chose to remain vigilant. Seventeen years after surgery, it measured 3.2 cm, in computed tomographic angiography. Therefore, total aneurysmectomy was performed and, due to redundancy of the previous bypass venous conduit caused by progressive dilation restricted to the distal popliteal artery, we did a termino-terminal reanastomosis to the normal sized popliteal artery. After 20 months, he is asymptomatic, with distal pulses present, without clinical nor radiological signs of aneurysmal degeneration. DISCUSSION AND CONCLUSION: This work aims to highlight the relevance of the follow up, not only on a clinical basis but also radiological, since we are dealing with a diffuse pathology that can appear in any arterial segment without symptoms.

Introdução: Aneurismas para-anastomóticos verdadeiros constituem uma complicação rara da cirurgia arterial. Objetivo: Este trabalho pretende descrever o caso de um doente de 73 anos, com antecedentes de amputação pela coxa do membro inferior esquerdo por aneurisma poplíteo trombosado, admitido para tratamento cirúrgico de aneurisma poplíteo contralateral. Resultados: O doente foi submetido a exclusão do mesmo com construção de bypass femoro-poplíteo curto infragenicular com veia grande safena. Dois anos após a cirurgia índice, em controlo ecográfico, foi identificada ectasia de ambas as anastomoses com 1,7cm e 1,4cm de diâmetro máximo nas anastomoses proximal e distal, respetivamente. Manteve-se vigilância e aos 12 anos de seguimento apresentava aneurisma para-anastomótico verdadeiro na anastomose proximal com 4,8cm de diâmetro máximo. Foi submetido, então, a ressecção de aneurisma com interposição de enxerto protésico entre artéria nativa e o conduto venoso prévio. A artéria poplítea distal nesta altura apresentava, aproximadamente, 1,8cm de diâmetro, tendo-se optado por manter vigilância. Aos 17 anos de seguimento, a artéria poplítea justa anastomose distal atingiu 3,2cm em angiotomografia computorizada. Foi, portanto, submetido a abordagem poplítea distal e, devido a redundância do conduto venoso prévio provocada por uma dilatação progressiva da artéria poplítea distal, foi possível proceder a aneurismectomia total e reanastomose termino-terminal de conduto venoso à artéria poplítea distal de calibre normal. Aos cerca de 20 meses de seguimento, apresenta-se assintomático, com pulsos distais presentes, sem sinais clínicos ou radiológicos de degenerescência aneurismática. Discussão e Conclusão: Este trabalho pretende realçar a relevância do seguimento destes doentes, não só em termos clínicos, mas também radiológicos, pois estamos perante uma patologia de carácter difuso que pode surgir em qualquer segmento arterial de forma assintomática.

Popliteal artery aneurysm surgical repair: Retrospective unicenter analysis.

BACKGROUND: Popliteal artery aneurysm (PAA) thromboembolic complications may result in limb loss. We review our experience reporting outcomes in terms of complications and early and long-term patency rates. METHODS: From 2004 to 2013, 116 PAA required surgical repair at Coimbra Hospital and Universitary Centre, Portugal. Outcomes were analyzed using Kaplan-Meier method with log-rank tests, X2, and Cox proportional hazards models. RESULTS: A total of 116 PAAs with a mean diameter of 3.3 cm (1.5 to 10 cm) were followed. 40% limbs were asymptomatic and 27% presented with acute ischemia. 97% underwent medial bypass procedure (venous in 66%). Early mortality was 0.9% (1/116). 30-day and five-year cumulative limb salvage was 94.0% and 87%, respectively. There was no limb loss in asymptomatic patients and 1-3 Rutherford chronic ischemia. 62% early amputations were performed in acute ischemia, half of them with functioning bypass. 30-day primary and secondary patency rates were 91% and 97% respectively, higher with GSVs (96% and 99%) than PTFE (58% and 95%, P < .05; Fig 1). The 5-year primary and secondary patency rates were 68.1% and 73,5%, respectively, higher with GSVs (83% and 87%) than PTFE (37% and 43%, P < .05). Two recurrent PAAs (1,7%) required reintervention. Predictors for both amputation and loss of primary patency were PTFE bypass (p =0,002), and emergent surgery (p = 0,005). Acute ischemia was also predictor for amputation (p = 0,026), but not for loss of primary patency. CONCLUSIONS: Results of surgery on asymptomatic PAAs are good - significantly better than those from symptomatic PAAs. The results are similarly good in claudicants. The risks of early and late amputation were higher with prosthetic grafts and in an emergent settings.