A Delphi Consensus Study on Undergoing Carotid Endarterectomy: Patient Reported Outcome Measures.

OBJECTIVE: Currently, evidence is lacking for disease specific patient reported outcome measures (PROMs) for use in atherosclerotic carotid artery stenosis (either symptomatic or asymptomatic) submitted to carotid endarterectomy (CEA). This study aimed to obtain expert consensus on the most important items to include in a PROM designed to capture the impact of atherosclerotic carotid artery stenosis and its treatment on health related quality of life. METHODS: A three round modified Delphi consensus study was performed. A mixed expert Delphi panel of doctors (international panel of dedicated vascular surgeons and neurologists) and patients (either symptomatic or asymptomatic patients meeting criteria for carotid artery revascularisation) was implemented. The aim was to obtain pre-defined consensus on items in four pre-defined domains: generic, quality of life, symptom related, and treatment related. Consensus was reached in rounds two and three with > 70% overall expert agreement. RESULTS: The experts agreed on 23 items (out of 49) which were distributed as follows: five in the generic, six in the quality of life, six in the symptom, and six in the treatment related domain. Interestingly, comparing the items that reached consensus in this study, with the generic and disease specific PROMs previously used in carotid artery disease investigation, the only constant items were "difficulty with walking" and "ability to perform daily activities" included in the symptom domain. Considering the items that reached expert consensus in the additional domains, emphasis was given to the impact of the diagnosis, treatment and follow up, and to fear or concern "about the future" and "about severe stroke". In the treatment domain emphasis was also attained on the side effects, long term patient satisfaction, and on the information provided regarding treatment options. DISCUSSION: As hard clinical outcomes become increasingly rare, assessment of the impact of CEA becomes increasingly difficult. The consensus reached provides a newly defined disease specific PROM that warrants independent validation in specific populations in the future.

Critical analysis of the literature and standards of reporting on stroke after carotid revascularization.

OBJECTIVE: Mechanisms of procedural stroke after carotid endarterectomy (CEA) or carotid artery stenting are surprisingly underresearched. However, understanding the underlying mechanism could (1) assist in balancing the choice for revascularization vs conservative therapy, (2) assist in choosing either open or endovascular techniques, and (3) assist in taking appropriate periprocedural measures to further decrease procedural stroke rate. The purpose of this study was to overview mechanisms of procedural stroke after carotid revascularization and establish reporting standards to facilitate more granular investigation and individual patient data meta-analysis in the future. METHODS: A systematic review was conducted according to the PRISMA statement. RESULTS: The limited evidence in the literature was heterogeneous and of low quality. Thus, no formal data meta-analysis could be performed. Procedural stroke was classified as hemorrhagic or ischemic; the latter was subclassified as hemodynamic, embolic (carotid embolic or cardioembolic) or carotid occlusion derived, using a combination of clinical inference and imaging data. Most events occurred in the first 24 hours after the procedure and were related to hypoperfusion (pooled incidence 10.2% [95% confidence interval (CI), 3.0-17.5] vs 13.9% [95% CI, 0.0-60.9] after CEA vs carotid artery stenting events, respectively) or atheroembolism (28.9% [95% CI, 10.9-47.0]) vs 34.3 [95% CI, 0.0-91.5]). After the first 24 hours, hemorrhagic stroke (11.6 [95% CI, 5.7-17.4] vs 9.0 [95% CI, 1.3-16.7]) or thrombotic occlusion (18.4 [95% CI, 0.9-35.8] vs 14.8 [95% CI, 0.0-30.5]) became more likely. CONCLUSIONS: Although procedural stroke incidence and etiology may have changed over the last decades owing to technical improvements and improvements in perioperative monitoring and quality control, the lack of literature data limits further statements. To simplify and enhance future reporting, procedural stroke analysis and classification should be documented preemptively in research settings. We propose a standardized form enclosing reporting standards for procedural stroke with a systematic approach to inference of the most likely etiology, for prospective use in registries and randomized controlled trials on carotid revascularization.

Pre-operative Neutrophil to Lymphocyte Ratio is Associated With 30 Day Death or Amputation After Revascularisation for Acute Limb Ischaemia.

OBJECTIVE: Inflammation is an early feature of acute limb ischaemia (ALI), hence the potential prognostic significance of inflammatory biomarkers. This study aimed to assess the value of pre-operative inflammatory biomarkers, specifically the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR), for predicting an adverse outcome after revascularisation for ALI. METHODS: All patients submitted to lower limb revascularisation for Rutherford IIa or IIb ALI at the authors' institution between 2009 and 2019 were screened retrospectively. Pre-operative NLR and PLR were analysed, along with other known prognostic factors. Primary outcome was the composite endpoint of 30 day death or amputation. RESULTS: A total of 345 patients were included, 84 of whom suffered the primary outcome (24.3%). The median follow up was 23.1 months (3.1 - 52.2). Higher age (OR 1.05 per year increase, 95% CI 1.01 - 1.09), diabetes (OR 2.63, 95% CI 1.14 - 6.06), Rutherford grade IIb vs. IIa (OR 5.51, 95% CI 2.11 - 14.42), higher NLR (OR 1.28 per unit increase, 95% CI 1.12 - 1.47), and fasciotomy need (OR 3.44, 95% CI 1.14 - 10.34) were independently associated with 30 day death or amputation, whereas pre-operative statin or anticoagulant medication were associated with a risk reduction (OR 0.23, 95% CI 0.53 - 0.96 and OR 0.20, 95% CI 0.05 - 0.84, respectively). PLR did not show an independent effect on this population. Pre-operative NLR presented a good discriminative ability (AUC 0.86, 95% CI 0.82 - 0.90). A cut off NLR level ≥ 5.4 demonstrated a 90.5% sensitivity and 73.6% specificity for 30 day death or amputation. Kaplan-Meier analysis showed that patients with pre-operative NLR ≥ 5.4 had significantly lower 30 day, six month and one year amputation free survival when compared with those with NLR < 5.4 (64.8 ± 4.0%, 44.1 ± 4.1%, and 37.5 ± 4.1% vs. 98.5 ± 0.9%, 91.9 ± 2.0%, and 85.9 ± 2.5%, log rank p < .001). CONCLUSION: In this study, higher pre-operative NLR was associated with 30 day death or amputation following intervention for Rutherford grade IIa or IIb ALI. NLR potentially stands as a simple, widely available and inexpensive biomarker that can refine decision making and possibly contribute to ALI morbidity and mortality reduction.

Incidental abdominal aortic aneurysms are largely undocumented and unmonitored.

BACKGROUND: In countries without organized population screening, incidental detection remains the major form of abdominal aortic aneurysm (AAA) diagnosis. Despite the presumed homogeneity in AAA prevalence, its rate of repair is highly variable, with Portugal treating 2 to 6 times fewer AAA per habitant than other western countries. OBJECTIVES: To evaluate the detection rate and monitoring of incidental AAA in a multicentre cohort from Portuguese hospitals. METHODS: All abdominal CT scans performed in men ≥ 65 years old in three major Portuguese hospitals between January and June 2018 were selected for review. CT scans prescribed by the Vascular Surgery or Emergency Departments were excluded. Patients with previously known AAA were also excluded. Subjects with newly detected aneurysms were assessed for the two primary outcomes: the description of the finding by the radiologist in the written report; the effective follow-up recommendations by the prescriber of the CT or by the general practitioner (GP). Patients with newly found AAA that met criteria for monitoring or treatment and failed to be given guidance were contacted and included in surveillance programs. RESULTS: Overall, 3292 abdominal CT scans were selected for review. A total of 133 newly found aneurysms were detected (4.2% prevalence in the cohort). Of those, 48 cases (36%) were not described by the radiologist in the written report. Further 42 patients (32%) were not successfully oriented by the ordering physician or GP, despite having had their AAA mentioned. Overall, only 32% (n = 42) of the newly diagnosed AAA were correctly identified and referred to monitoring. CONCLUSIONS: Incidental AAA is a common occurrence in in-hospital abdominal CTs. A significant number is not documented by the radiologist and the vast majority is not referred to monitoring. This could be a major reason for the low elective treatment rate of AAA in Portugal.

Penetrating Trauma To The Axillary Artery.

Axillary artery injuries due to penetrating trauma are relatively uncommon. Management of these injuries is challenging due to the complex local anatomy, rigid chest walls, and associated injuries. Open exposure with direct open vascular repair has been the mainstay of operative management. We report a clinical case of a 51-year-old man victim of penetrating trauma to the axillary artery caused by a chain-saw and repaired by open surgery with a great saphenous vein interposition graft.

Differences In Anthropometric Measures Between Critical Limb Threatening Ischaemia And Intermittent Claudication In Patients Undergoing Aorto Bifemoral Bypass.

OBJECTIVE/BACKGROUND: Peripheral artery disease (PAD) is an important manifestation of systemic atherosclerosis. Obesity is a risk factor for atherosclerosis and for cardiovascular events. However, the relationship between obesity and PAD is unclear. We hypothesized that anthropometric measures of adiposity, in particularly of central obesity will be associated with PAD severity, in patients undergoing aorto-bifemoral bypass. METHODS: A prospective observation study was conducted. From 2009 and 2012 a total of 46 males who underwent aorto-bifemoral bypass were enrolled prospectively. 17 with intermittent claudication (IC) and 29 with chronic limb threatening ischemia (CLTI). They were followed for 5 years. The anthropometric measures, weight, body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and the seric levels of hemoglobin, triglycerides, and albumin were recorded. The mortality and cardiovascular events in following five years were also registered. RESULTS: The groups did not differ in the mean age (IC 60.69±7.46 versus CLTI 64.51 ±8.42 years, p=0.712), diabetes (IC 18% versus CLTI 45%, p=0.06), hypertension (IC 70% versus CLTI 52%, p=0.21), hypercholesterolemia (IC 18% versus CLTI 45%, p=0.47) and smoking habits prevalence (IC 100% versus CLTI 86%, p=0.11). The anthropometric measures: weight, WC and WHR were significant lower in CLTI compared to IC patients (IC 72.74±9.84 Kg versus CLTI 65.92±10.89 Kg, p=0.043; IC 98.65±8.19 cm versus CLTI 89.38±15.91 cm, p=0.017; IC 1.06±0.06 versus CLTI 1.01±0.06, p=0.038). The serum levels of hemoglobin, albumin and triglycerides were also lower in CLTI patients (IC 14,40±1.63g/dL versus CLTI 13.3±1.89g/dL, p=0.048; IC 4.6±0.81g/dL versus CLTI 4.3± 0.67g/dL, p=0.007; IC 212±95.60mg/Dl versus CLTI 111±41.53 mg/dL, p=0.001). No relation was found between the anthropometric measures at admission and the cardiovascular events or mortality at five years. CONCLUSION: CLTI patients had lower anthropometric measures of obesity, when compared to IC patients. These results could be explained by the fact that CLTI patients with severe atherosclerotic disease are in a state of chronic inflammation, with consequent cardiometabolic demands and catabolism.

Overview of evidence on risk factors and early management of acute carotid stent thrombosis during the last two decades.

OBJECTIVE: Acute carotid stent thrombosis (ACST) occurring in the first hours after the procedure is an exceedingly rare complication of carotid artery stenting, but it is potentially devastating. This review aimed to evaluate current literature, identifying all reported cases during the last two decades, with the final purpose of reporting predictive factors and early management. METHODS: A systematic review and meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: A total of 464 potentially relevant articles were selected. After review of records at title and abstract level, 29 articles with 60 patients were included. Twelve studies reported on ACST incidence rate in their cohorts, ranging from 0.36% to as high as 33%. In considering etiology, antiplatelet noncompliance or resistance is the most frequently reported risk factor. Emergency procedures seemed to be associated with greater risk for ACST, reaching 5.6% to 33% incidence. Dual-layer stents were also associated with greater risk (45% vs 3.7%; P = .0001; odds ratio, 21.3). Use of an overlapping stent as a bailout procedure because of dissection, malposition, or long lesions was correlated with increased risk (7.3% vs 0.002%), as were long stenotic lesions (22.9 ± 6.83 mm vs 14.2 ± 6.42 mm; P = .0034) and stent length (3.8 ± 0.4 cm vs 2.8 ± 0.86 cm; P = .0055). ACST was associated with neurologic status deterioration in 56.7% of cases. Time to symptoms or ACST diagnosis had a median of 1.5 hours, with 30% occurring intraprocedurally. In asymptomatic ACST, conservative management was unanimous. Endovascular treatment was the most common approach to intraprocedural ACST. Surgical options included carotid endarterectomy with stent explantation (n = 9), which was also a bailout after failed endovascular treatment in two cases. CONCLUSIONS: ACST incidence is higher in emergent, neurologically unstable patients. Antiplatelet noncompliance, antiplatelet resistance, long stenotic lesions, use of more than one stent, and dual-layer stents are also associated with increased risk. The decision as to the best approach depends on whether ACST occurs intraprocedurally or afterward, the development of neurologic status deterioration, and the center's experience. However, additional studies must be undertaken to better define optimal management.

Impact of Post-EVAR Graft Limb Kinking in EVAR Limb Occlusion: Aetiology, Early Diagnosis, and Management.

OBJECTIVE/BACKGROUND: Endograft limb occlusion is a potential complication of endovascular aneurysm repair (EVAR), being one of the major causes of secondary interventions and rehospitalisation. The aim of this review is to report on the impact of endograft kinking in endograft limb occlusion, as well as on risk factors, prevention, early diagnosis, and management. METHODS: A systematic review and meta-analysis was conducted according to the recommendations of the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. RESULTS: After a MEDLINE and Scopus search, 55 articles (27,509 patients) were included in the qualitative analysis and eight in the quantitative analysis. In this meta-analysis, 179 at risk limbs were treated by pre-emptive stenting, which significantly reduced the risk of limb occlusion: not pre-emptively stenting limbs at risk had a negative impact on graft limb patency (odds ratio 4.30, 95% confidence interval 1.45-12.78). Post-operatively, a kink was identified in 422 patients (1.5%), contributing to 42.8% of all limb occlusions. Relevant data support that completion angiography is an inadequate means of diagnosing high risk limbs, proposing cone beam computed tomography and intravascular ultrasound as adjuncts. The post-operative limb occlusion rate ranged from 0% to 10.6%, affecting 984 patients. Several risk factors for limb occlusion have been identified. Regarding treatment, most patients were submitted to femorofemoral bypass (52.3%) or to deployment of a bare metal stent, either alone or associated with catheter directed thrombolysis or mechanical thrombectomy (26.4%). Complications and outcome after re-intervention for limb occlusion are described infrequently in the literature, but single studies have reported on re-occlusion, major amputation, and limb occlusion related mortality rates. CONCLUSION: Pre-EVAR planning should focus on identification of risk factors for kinking. Adjunctive stenting is an effective prophylaxis for selected high risk limbs, yet intra-operative identification remains problematic. Also, it is noteworthy that most limb occlusions occur in the first year after EVAR, emphasising the importance of careful early follow up of high risk patients.

Prediction of Survival after 48 Hours of Intensive Unit Care following Repair of Ruptured Abdominal Aortic Aneurysm-Multicentric Study for External Validation of a New Prediction Score for 30-Day Mortality.

BACKGROUND: Ruptured abdominal aortic aneurysm (rAAA) remains a critical life-threatening condition. We aimed to evaluate rAAA management in our center focusing on predictors of mortality at 48 hr of intensive care unit (ICU) and to develop a new mortality prediction score considering data at 48 hr postprocedure. External validation of the modified score with patient data from independent vascular surgery centers was subsequently pursued. METHODS: Clinical data of all patients admitted in our center from January 2010 to December 2017 with the diagnosis of rAAA were retrospectively reviewed for the development of the mortality prediction score. Subsequently, clinical data from patients admitted at independent centers from January 2010 to December 2017 were reviewed for external validation of the score. Statistical analysis was performed with SPSS Version 25. RESULTS: A total of 78 patients were included in the first part of the study: 21 endovascular aneurysm repairs (EVARs), 56 open repairs (ORs), and 1 case of conservative management. Intraoperative mortality in EVAR and OR groups was 0% vs. 24.6%, respectively (P = 0.012). Thirty-day mortality reached 50% and 33% in the OR and EVAR groups. For patients alive at 48 hr, 30-day mortality diminished to 27.6%. Several preoperative predictors of outcome were identified: smoking (P = 0.004), hemodynamic instability(P = 0.004), and elevated international normalized ratio (P < 0.0001). Dutch Aneurysm Score and Vascular Study Group of New England Score (VSGNE) were also significant predictors of outcome (area under the receiver operating characteristic curve [ROC AUC] 0.89 and 0.79, respectively; P < 0.0001). At 48 hr of ICU stay, high lactate level, high Sequential Organ Failure Assessment score, need for hemodyalitic technique, and hemodynamic instability were significant risk predictors for 30-day mortality (P < 0.05). VSGNE score was modified with the inclusion of 2 variables: hemodynamic instability and lactate level at 48 hr and a new score was attained-Postoperative Aneurysm Score (PAS). Comparing AUC for VSGNE and PAS for patients alive at 48 hr, the latter was significantly better (AUC 0.775 vs. 0.852, P = 0.039). The PAS was applied and validated in 3 independent vascular surgery centers (AUC VSGNE 0.782 vs. AUC PAS 0.820, P = 0.027). CONCLUSIONS: Despite recent evidence on preoperative predictors of survival in an era when both EVAR and OR are available, emergent decision to withhold life-saving treatment will always be extremely difficult. Therefore, the policy in our department is to try surgical repair in all cases. It remains important, however, to identify whether late deaths can be predicted, so that unnecessary prolonged treatment can be avoided. A PAS was delineated predicting 30-day mortality significantly better in patients alive at 48 hr. The score was externally applied and validated in independent centers, corroborating the score's usefulness.

Which Aneurysm Characteristics Predict EVAR Non-Success?

Backgroud: Primary focal hyperhidrosis affects between 1 to 4% of the general population, with a higher prevalence in teenagers and young adults. The condition is characterized by excessive sweating in 1 or more body part, most often the palms, face, armpits and soles. This condition causes a significant negative impact on patient's quality of life. The pathophysiology of focal hyperhidrosis is believed to be due to excessive sympathetic stimulation, and videothoracoscopic sympathectomy is a recognized form of treatment. The aim of this study is to evaluate the post-operative quality of life of patients who underwent thoracoscopic sympathectomy. MATERIALS AND METHODS: This is a retrospective study of fifty-four patients with primary focal hyperhidrosis submitted to bilateral thoracoscopic thoracic sympathectomy at the Center of Cardiothoracic Surgery of Casa de Saúde da Boavista, between January 2011 and December 2014. The Quality of Life questionnaire and the Hyperhidrosis Severity Scale questionnaire were used to evaluate the quality of life in the pre-operative period and 3 months after surgery. Further to this, data was collected regarding medium-term follow-up by telephone. All patients underwent general anesthesia and had bilateral video-assisted thoracoscopic resection of the sympathetic chain. RESULTS: The majority of patients are females 59.3% (32). The mean age is 30.8 ± 7.70 (between 16 and 49 years). Prior to surgery, 85% of the patients had severe hyperhidrosis. 79.6% of respondents stated that general discomfort was promoted by the condition, with the Funcional-Social domain being the most affected aspect of their life (61.1%). The rates of peri-operative complications and major post-operative complications were null, and minor complications were 5.5%. After 3 months, improvement in patient's quality of life and satisfaction level were of 100% and 96.3% respectively, however compensatory hyperhidrosis was observed in 53.7% of patients. 57.3% of the patients reported significant improvements in the Funcional-Social domain. Medium-term follow-up (mean=6 years) allowed for the evaluation of 31 patients (57.4% of the population), of whom 77.4% maintained compensatory hyperhidrosis. 93.5% reported to be highly satisfied with the surgical results and claimed to have improved their quality of life by 93.5%. 94% and 94.4% respectively of the patients evaluated in the medium term follow-up and after 3 months and in the medium term follow-up, recommend the surgery. CONCLUSION: Sympathectomy by video-assisted thoracoscopic surgery (VATS) is an effective and viable therapeutic option for primary focal hyperhidrosis patients. Despite compensatory hyperhidrosis being observed at time, this procedure produces very satisfactory results particularly in regard to the patient's post-operative quality of life.

Arterial Vascular Complications in Peripheral Venoarterial Extracorporeal Membrane Oxygenation Support.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function. The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO. Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). METHODS: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017). The primary outcome of this study was to investigate the prevalence of cannulation-related complications on VA ECMO and to determine its effect on patient morbimortality. RESULTS: Eighty-two patients underwent ECMO during the period of study, 56,1% were male with a mean age of 55,8 years. The VA mode was used in 61 patients, 56 with peripheral cannulation. Femoral arterial access was established in 52 patients (73% percutaneously). Vascular complications were observed in 28,6% of the VA femoral ECMOs: 12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed limb ischemia. For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal: 8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction. There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation. CONCLUSIONS: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%). PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation.

Ilio-Iliac Arteriovenous Fistulae-An Unusual Diagnosis with an Even More Unusual Clinical Presentation.

BACKGROUND: Major pelvic ilio-iliac arteriovenous fistula (AVF) is an exceedingly rare diagnosis with only a few described cases in the literature, most of them related to congenital defects or trauma. In this case report, we aim to present a case of an ilio-iliac AVF with an atypical clinical presentation. METHODS: Relevant medical data were collected from hospital database. RESULTS: The patient is a 77-year-old woman, with a relevant medical history of a temporally remote hysterectomy. She developed an exuberant unilateral right leg edema and was diagnosed with a femoro-iliac deep vein thrombosis (DVT) and started on anticoagulation and daily use of elastic compression stockings. No improvement in leg edema was evident, and she reported painful complaints refractory to medication. She also progressively developed right foot numbness and foot drop. A computed tomography angiography (CTA) was performed to exclude any compressive or paraneoplastic syndrome, with no remarkable findings other than common iliac vein (CIV) occlusion. As the patient's symptoms continued to worsen, a new CTA was performed 5 months later, which revealed an ilio-iliac AVF that was confirmed by angiography. After 2 ineffective attempts to embolize AVF afferents, we chose to completely embolize the arterial component of the AVF with Helix EV3 coils and Onyx glue (Covidien, Irvine, CA, USA). CIV recanalization and deployment of a Venovo stent (Bard Inc, Tempe, AZ, USA) was also performed. The final angiograms showed exclusion of the AVF and rapid venous flow through the stent. There was progressive improvement of edema and pain but little improvement of foot drop. CONCLUSION: AVF etiology and mechanism of neurologic deficits are controversial, with multiple possible explanations. Endovascular treatment modalities are promising a safer and more efficient approach when compared with open surgery. Our experience in this case was encouraging, but long-term results are currently lacking.

Which Aneurysm Characteristics Predict EVAR Nonsuccess.

INTRODUCTION: Hostile anatomic characteristics in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) may lead to technical nonsuccess of the procedure, late complications, reintervention or death. The authors analyzed anatomical abdominal aortic aneurysm specific considerations so as technical endoprosthesis implantation and correlate them with endoleak development and postoperative survival. METHODS: Authors retrospectively reviewed all consecutive, elective, EVAR's that occurred between 2010 and 2016, with available data, at one institution for abdominal, infra renal, aortic aneurysms. The patients comorbidities were registered and preoperative CT scan was analyzed considering the proximal zone (diameter, length, presence of thrombus or calcification), the distal zone (length and diameter), aortic aneurysm (maximum diameter, angulation, axis deviation, mural thrombus and patency of the inferior mesenteric artery and the lumbar arteries) and concomitant iliac aneurysm or peripheral occlusive disease. Outcomes were endoleak development and death. RESULTS: We analyzed 56 patients, 54 (96%) male with a medium age of 78 (min 61, max 89) years. During a medium 3,4 years of follow up, 12 (21%) patients developed endoleak (10 type II and 2 type I) and 18 (32%) died. The adjusted analysis showed a statistically significant association between aneurysm angulation (p=0,046), patency of the inferior mesenteric artery and the lumbar arteries (p=0,044) and aneurysm diameter (p=0,009) with endoleak development. Notice that 40% of the aneurysms that impaired a significant axis deviation developed endoleak. All except one endoleak were diagnosed within the first year after EVAR. None of the deaths that occurred during the follow up period were correlated to post intervention aneurysm enlargement or rupture. However we found a statistically significant association between patency of the inferior mesenteric artery and the lumbar arteries (p=0,042) and early death during the first year after EVAR. CONCLUSION: Even though many aneurysm are suitable for EVAR, unfavorable aneurysm morphologic characteristics and predictable complicated endograft placement should be taken into consideration. For such clinical cases, a surgical approach should be considered. We believe that current recommendations for follow up with angioCT only at 1 and 12 months during the first year following EVAR is a good practice conduction since most of endoleaks developed during these period. If neither endoleak nor aneurysm enlargement is documented during first year after EVAR, colour duplex ultrasonography is a good alternative for annual postoperative surveillance.

Arterial Vascular Complications in Peripheral Venoarterial Extracorporeal Membrane Oxygenation Support.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has been evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function.The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO.Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). In patients with severe peripheral arterial disease (PAD) these risks are even higher and its presence may be considered a relative contraindication for femoral artery cannulation. METHODS: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017).The primary outcome of this study was to investigate the prevalence of cannulation- -related complications on VA ECMO and to determine its effect on patient morbimortality.We evaluated demographics and co-morbidities data.Patients were divided into two groups (complications present VS not present) and statistic analysis was performed to determine the impact of different variables such as co-morbidities,cannulation strategy and time on ECMO in each group.Operative reports were reviewed to analyze the surgical procedures implied for treating vascular complications. RESULTS: Eighty-two patients underwent ECMO therapy during the period of study, 56,1% were male with a mean age of 55,8 years.The median time on the ECMO device was 5,5 days.The VA mode was used in 61 patients, 56 with peripheral cannulation.Femoral arterial access was established in 52 patients (73% percutaneously).Vascular complications were observed in 28,6% of the VA femoral ECMOs:12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed subsequent limb ischemia.For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal:8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction.There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation.VA femoral ECMO mortality was 69,2% (n=36).Vascular complications after ECMO support are not associated with higher mortality rates (p>0,05). CONCLUSION: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%).PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation.Physical examination and the assessment of ankle-brachial índex before ECMO implantation is therefore recommended.Improved efforts at preventing these complications need to be developed to avoid additional morbidity in an already critical patient population.

Carotid Stenosis in Cardiac Surgery Patients.

INTRODUCTION: Ischemic stroke is a potential perioperative complication after an open heart surgery (OHS). Whether a carotid stenosis or occlusion is associated with an increased risk of perioperative stroke in patients or just a risk factor has been a concern of intense debate in the literature. METHODS: We retrospectively analyzed patients submitted to OHS between January and December2016 with known asymptomatic carotid disease. The data from 85 consecutive patients undergoing coronary artery bypass grafting, valve replacement, or both was collected. The final events registered were stroke, acute myocardial infarct or death. Our aim was to assess whether the presence of carotid stenosis precluded a higher rate of stroke after cardiac surgery. RESULTS: 70 male and 15 female patients, with a medium age of 74(min 45,max84) years were analyzed. 45(53%) patients were submitted to bypass grafting, 21(25%) to valve replacement and 19(22%) to both. Of these patients,42(49%) had unilateral significant carotid stenosis equal or greater than 50%, 12(14%) had bilateral significant stenosis and 20(24%) had a stenosis equal or greater than70%. 2(2%) patients had a previous history of neurologic event. In the peri-operative period, 3 patients (3,5%) developed transient ischemic attack (TIA) or stroke, 3(3,5%) a cardiac event and 6(7%) patients died (3 due to a cardiac event and 2 due to a neurologic event). Two (67%) of the neurologic events occurred in the corresponding side of an hemodynamic carotid stenosis although both this patients had also significant aortic arch calcification and atrial fibrillation. None of the patients that developed post-operative TIA or stroke had previously a neurologic event. CONCLUSION: Some studies reported an average stroke incidence around 1.9%following OHS. Despite carotid stenosis, other risk factors should be taken into consideration before considering OHS such as advanced age, prior stroke/TIA, unstable angina, predicted prolonged time for cardiopulmonary bypass, severe aortic arch disease and atrial fibrillation. In our studied population two of the post-operative neurologic events occurred in patients with significant bilateral stenosis, one side between50-69% and the other side 70-99%. According to the new guidelines "Management of Atherosclerotic Carotid and Vertebral Artery Disease:2017 Clinical Practice Guidelines of the European Society for Vascular Surgery" staged or synchronous carotid intervention may be considered for OHS patients with bilateral asymptomatic 70-99% carotid stenosis, or a 70-99% stenosis with contralateral occlusion. Our results may suggest that a sub-group of patients with bilateral significant (>50%) carotid stenosis may benefit from staged or synchronous carotid intervention.

Acute Mesenteric Ischemia: Epidemiology, Risk Ractors and Determinants of Mortality.

INTRODUCTION: Acute mesenteric ischemia (AMI) is a condition with a difficult diagnosis and a high mortality rate. Despite the fact that AMI is a rather common condition in the elderly, review of the literature evidences lack of data concerning perioperative assessment of risk of death. The purpose of this study was to evaluate clinical, laboratory and imagiologic findings at admission and identify variables associated with adverse outcome with the final purpose of supporting treatment decision. METHODS: The clinical data of all patients admitted to Centro Hospitalar de Vila Nova de Gaia e Espinho with the diagnosis of AMI from January 2010 to December 2014 were retrospectively reviewed. RESULTS: A total of 64 patients (40 females and 24 males) with a mean age of 78±9.7 years were included. The most common aetiology was arterial embolization (36% of cases) followed by arterial thrombosis (34%), non-occlusive mesenteric ischemia in 22% and venous thrombosis in 8%. Global mortality rate reached 62.3%, with higher rates amongst patients submitted to revascularization and bowel resection (80%). Several clinical and laboratory findings were evaluated. Univariate analysis showed that leucocytosis, lactate level >2 mmol/L, age >80 years and colon involvement were associated with higher mortality (p<0.05). CONCLUSION: Contemporary management of AMI requires a high index of suspicion and rapid surgical intervention, if the time frame for intervention has not already elapsed. A better definition of determinants of mortality seems vital for treatment decision. More studies are needed to support clinical decision making in AMI.

Introdução: A isquemia mesentérica aguda é uma entidade clínica com um diagnóstico complexo fruto do quadro clínico inespecífico e com uma elevada taxa de mortalidade associada. Apesar de se tratar de um diagnóstico relativamente comum em idosos, uma revisão da literatura revela dados escassos relativos à avaliação de risco peri-operatório. Neste estudo pretendeu-se a avaliação de achados clínicos, laboratoriais e imagiológicos à admissão e identificar variáveis associadas com mau prognóstico. Métodos: Selecionaram-se retrospetivamente de todos os pacientes admitidos no Centro Hospitalar de Vila Nova de Gaia e Espinho com o diagnóstico de IMA de janeiro de 2010 a dezembro de 2014. Resultados: Um total de 64 doentes (40 do sexo feminino e 24 do sexo masculino), com idade média de 78±9,7 anos foram identificados. A etiologia mais comum foi a embolização arterial (36% dos casos), seguido de trombose arterial (34%), isquemia mesentérica não oclusiva (22%) e por último trombose venosa (8%). A taxa de mortalidade global foi de 62,3%, com taxas mais elevadas em doentes submetidos a revascularização e ressecção intestinal (80%). Foram avaliados vários achados clínicos e laboratoriais. A análise univariada mostrou que leucocitose, níveis de lactatos superiores a 2 mmol/L, idade superior a 80 anos e envolvimento do cólon (imagiológico ou intra-operatório) foram associados a maior mortalidade (p <0,05). Conclusão: O tratamento de IMA requer um elevado índice de suspeição e intervenção cirúrgica emergente, assumindo que a viabilidade do intestino já não foi ultrapassada. Uma melhor definição dos determinantes da mortalidade parece vital para suportar a decisão terapêutica.

Endoleak type II post-EVAR - predictive factors and therapeutic intervention - single centre experience in 100 EVAR procedures.

INTRODUCTION: Endovascular aortic repair (EVAR) has significantly altered the therapeutic strategy for abdominal aortic aneurysm (AAA), due to less invasiveness and lower perioperative morbi-mortality. However, specific complications such as persistent type 2 endoleak (pT2E, present > 6 months after EVAR) have been associated with adverse outcomes. However conflicting results from heterogeneous studies, failed to support an optimal threshold for intervention. The purpose of this study was to identify predictive factors associated with pT2E. METHODS: The clinical data of the last 100 patients admitted for EVAR in our hospital until April 2016 were retrospec- tively reviewed. Statistical analysis was performed using SPSS V.22. RESULTS: We analyzed 100 cases of EVAR, performed with a branched stentgraft for AAA or aorto-iliac aneurysms. Most cases (n=83) were performed electively but 17 were performed for ruptured AAA. No pre-operative inferior mesen- teric artery (IMA) coil embolization was performed. A pT2E was observed by Computed Tomography Angiography (CTA) in 21 cases (21%). Univariate analysis of risk factors for pT2E revealed that the number of patent lumbar arteries, patent IMA, platelet antiaggregants, absence of thoracic aortic aneurysm, and ruptured AAA were risk factors for pT2E (p<0.05). Binary logistic regression concluded platelet antiaggregants and increasing number of patent lumbars were independent risk factors for pT2E (p<0.05). DISCUSSION: Recently, pT2E that persists over a long period of time following EVAR has been reported to be involved in aneurysm sac growth, open conversion and rupture. Identification of pT2E predictive factors is crucial to prevent compli- cations and to consider measures such as pre-operative IMA coil embolization. We identified the number of patent lumbar arteries, the presence of patent IMA, platelet antiaggregants, absence of thoracic aortic aneurysm and ruptured AAA as sta- tistically significant risk factors for pT2E (p<0.05).

Introdução: A reparação endovascular de aneurisma da aorta abdominal (EVAR) alterou progressivamente a estratégia terapêutica devido à menor morbi-mortalidade peri-operatória associada. No entanto existem complicações específicas associa- das, como o endoleak tipo 2 persistente (pT2E, presente> 6 meses após EVAR). O principal objetivo deste estudo foi a identifi- cação de fatores preditivos associados a pT2E. Métodos: Os dados clínicos dos últimos 100 doentes admitidos para EVAR no nosso centro até abril de 2016 foram retrospetivamente analisados. O estudo estatístico foi realizado utilizando o SPSS V.22. Resultados: Foram analisados 100 casos de EVAR, realizados com endoprótese ramificada para aneurisma da aorta abdominal (AAA) ou aneurismas aorto-ilíacos. A maioria dos casos (n=83) foram realizados eletivamente, mas 17 foram reali- zados por rotura de AAA. Não houve nenhum caso de embolização pré-operatória da artéria mesentérica inferior (AMI). pT2E foi diagnosticado por Angio-Tomografia Computadorizada (AngioTC) em 21 casos (21%). A análise univariada dos fatores de risco para pT2E revelou que o número de artérias lombares (AL) permeáveis, permeabilidade da AMI, antiagregação plaquetária, ausência de aneurisma aórtico torácico e rotura de AAA são fatores de risco para pT2E (p<0,05). Uma regressão logística binária foi realizada e permitiu concluir que a antiagregação plaquetária e o número crescente de AL permeáveis são fatores de risco independentes para pT2E (p<0,05). Discussão: Atualmente, o pT2E tem sido cada vez mais associado a outcomes adversos como o crescimento do saco aneurismático, re-intervenção endovascular, conversão aberta e rotura. No entanto, a discrepância de dados na literatura condu- zem à ausência de um limiar consensual para tratamento. A identificação dos fatores preditivos de pT2E é crucial para prevenir complicações e considerar medidas como a embolização pré-operatória da AMI. Identificamos o número de AL permeáveis, AMI permeável, antiagregação plaquetária, ausência de aneurisma aórtico torácico e rotura de AAA como fatores de risco estatistica- mente significativos para pT2E (p<0,05).

Treatment Strategies And Outcomes Of Thoracic Aortic Blunt Injuries In Adults: A Systematic Review.

INTRODUCTION: Blunt thoracic aortic injuries (BTAI) once had mortality rates up to 32%, but the advent of thoracic endovascular aortic repair (TEVAR) has significantly improved outcomes. However, concerns persist regarding long-term devicerelated complications, device integrity in aging aortas, and the criteria for selecting patients for endovascular repair. We aimed to assess BTAI treatment strategies based on injury grade and their associated outcomes. METHODS: A systematic search of MedLine and Scopus databases was conducted to identify original articles published after 2013, which provided information on injury characteristics, outcomes, secondary effects, and reinterventions following BTAI. We classified aortic injuries following the SVS Clinical Practice Guidelines. RESULTS: We included 28 studies involving 1888 BTAI patients, including 5 prospective studies. Most patients were under 45 years old (86.4%), and grade III injuries were the most common (901 patients), followed by grades I and II (307 and 291 patients, respectively). TEVAR was performed in 1458 patients, mainly with grade III and IV injuries (1040 patients). Approximately half of the grade I injuries (153 of 307) were treated with TEVAR. Thirty-day mortality rate was 11.2%, primarily due to associated injuries. Aortic-related deaths were reported in 21 studies, with an overall rate of 2.2%, but none occurred beyond the first 30 days. Partial or complete coverage of the left subclavian artery was performed in 522 patients, with 27.9% requiring immediate or delayed revascularization. Aortic reintervention rates were relatively low (3.9%). CONCLUSION: TEVAR effectively treats BTAI grades III and IV, with potential benefit for some grade II injuries with more aggressive early intervention. Despite SVS guidelines suggesting conservative management for grade I injuries, there is a substantial rate of intervention with positive outcomes and low mortality. Long-term follow-up data, extending up to almost 20 years, reveal the durability of grafts, aortic remodeling, and minimal reintervention and complications.

[Unruptured symptomatic abdominal aortic aneurysms]. / Aneurismas da aorta abdominal sintomáticos não rotos.

OBJECTIVES: The authors aim to present a case series of patients with unruptured symptomatic abdominal aortic aneurysms with atypical presentation or clinical manifestations. METHODS: A retrospective analysis from 2010 to 2013 of unruptured symptomatic abdominal aortic aneurysms was made in a Vascular Surgery department. RESULTS: 4 clinical cases were selected, all male, mean age of 72.2 years, with a history of smoking (75 %), hypertension (50 %), dyslipidemia (25 %) , DM (25 %) and CRI (25 %). Abdominal aortic aneurysms were diagnosed with unusual forms of presentation, from those associated to local events (venous or spinal compression), to infectious processes "in situ", complete thrombosis of the aneurysmal sac, to those with remotely manifestations (peripheral embolization). Medical and surgical treatments are described in this paper, taking into account the particularities of each patient. CONCLUSION: Rupture is the most common manifestation of abdominal aortic aneurysms. Although more rare, symptomatic unruptured AAA require a higher degree of suspicion, with some specific features to be considered, as we intend to demonstrate.