Symptomatic Aortic Arch Floating Thrombus In A Patient With "Bovine Arch".

Bovine arch is an aortic arch variant in which the left common carotid artery and the brachiocephalic trunk share the same origin. Several vascular pathologies, as aneurysm, dissection or strokes have an increased prevalence in patients with this anatomic variant. We describe the first reported case of a young patient with a symptomatic aortic arch floating thrombus in association with a bovine arch.

Acute arterial ischemia in COVID-19.

Since the coronavirus pandemic set in in Spain in March 2020, a noteworthy increase in the incidence of acute limb ischemia (ALI) has been observed. It has been recently discovered that SARS-CoV 2 may lead to ALI secondary to arterial thrombosis. Elevation of D-dimer (DD) in patients with coronavirus infection (COVID-19) indicates that a hypercoagulable state causes acute arterial thrombosis. A remarkably high DD elevation has been reported to be a poor prognosis factor in COVID-19. The ways in which SARS-CoV 2 results in arterial thrombosis may be multiple. On the other hand, surgical revascularization for ALI is associated with poor outcomes in COVID-19 patients, probably in relation to hypercoagulability. Here, we describe two ALI cases in patients who required urgent surgical treatment for limb salvage and were positive for the novel coronavirus infection (COVID 19).

Desde que a pandemia pelo novo coronavírus se estabeleceu na Espanha, em março de 2020, um aumento notável da incidência de isquemia aguda de membros foi observado. Recentemente, descobriu-se que o coronavírus 2 causador da síndrome respiratória aguda grave (SARS-CoV-2) pode ocasionar isquemia aguda de membros secundária à trombose arterial. A elevação do D-dímero em pacientes acometidos pela doença do novo coronavírus (COVID-19) indica o estado de hipercoagulabilidade como causa da trombose arterial aguda. Vale destacar que a alta elevação do D-dímero foi relatada como um fator de prognóstico reservado na COVID-19. Há diversas maneiras pelas quais o SARS-CoV-2 pode resultar em trombose arterial. Em pacientes com COVID-19, a revascularização cirúrgica para isquemia aguda de membros está associada a desfechos desfavoráveis, provavelmente relacionados a hipercoagulabilidade. Descrevemos dois casos de isquemia aguda de membros de pacientes que necessitaram de tratamento cirúrgico de urgência para salvamento de membro e que haviam testado positivo para COVID-19.

Acute arterial ischemia in COVID-19 / Isquemia arterial aguda em pacientes com COVID-19

Abstract Since the coronavirus pandemic set in in Spain in March 2020, a noteworthy increase in the incidence of acute limb ischemia (ALI) has been observed. It has been recently discovered that SARS-CoV 2 may lead to ALI secondary to arterial thrombosis. Elevation of D-dimer (DD) in patients with coronavirus infection (COVID-19) indicates that a hypercoagulable state causes acute arterial thrombosis. A remarkably high DD elevation has been reported to be a poor prognosis factor in COVID-19. The ways in which SARS-CoV 2 results in arterial thrombosis may be multiple. On the other hand, surgical revascularization for ALI is associated with poor outcomes in COVID-19 patients, probably in relation to hypercoagulability. Here, we describe two ALI cases in patients who required urgent surgical treatment for limb salvage and were positive for the novel coronavirus infection (COVID 19).

Resumo Desde que a pandemia pelo novo coronavírus se estabeleceu na Espanha, em março de 2020, um aumento notável da incidência de isquemia aguda de membros foi observado. Recentemente, descobriu-se que o coronavírus 2 causador da síndrome respiratória aguda grave (SARS-CoV-2) pode ocasionar isquemia aguda de membros secundária à trombose arterial. A elevação do D-dímero em pacientes acometidos pela doença do novo coronavírus (COVID-19) indica o estado de hipercoagulabilidade como causa da trombose arterial aguda. Vale destacar que a alta elevação do D-dímero foi relatada como um fator de prognóstico reservado na COVID-19. Há diversas maneiras pelas quais o SARS-CoV-2 pode resultar em trombose arterial. Em pacientes com COVID-19, a revascularização cirúrgica para isquemia aguda de membros está associada a desfechos desfavoráveis, provavelmente relacionados a hipercoagulabilidade. Descrevemos dois casos de isquemia aguda de membros de pacientes que necessitaram de tratamento cirúrgico de urgência para salvamento de membro e que haviam testado positivo para COVID-19.

Successful Management of a Type B Gutter Related Endoleak after Chimney EVAR by Coil Assisted Onyx Embolisation.

INTRODUCTION: The aim was to describe possible management of a persistent gutter related type Ia endoleak after treatment of a symptomatic pararenal aortic aneurysm with the chimney endovascular technique. REPORT: A 77 year old man with a symptomatic 6 cm pararenal aortic aneurysm was referred. Computed tomography angiography (CTA) showed a pararenal aortic aneurysm with involvement of both renal arteries and extension up to the superior mesenteric artery. The patient underwent treatment by placement of triple chimney grafts and an abdominal stent graft. Completion angiography showed a gutter related type Ia endoleak. As the type Ia endoleak persisted at the three month CTA follow up and according to the PERICLES registry classification of endoleaks, a type B causative mechanism was detected. Embolization of the gutters was performed with coils and onyx, leading to complete resolution of the gutters on completion angiography. The 10 month post-operative magnetic resonance angiogram showed no further evidence of any endoleak and complete exclusion of the aneurysm. CONCLUSION: Treatment of persistent type B gutter related endoleaks after triple chimney endovascular aneurysm repair can be performed with the placement of coils and adjunctive use of fluid agents.

Endovascular repair versus open surgery in patients in the treatment of the ruptured of aneurysms abdominal. / Reparación endovascular versus cirugía abierta en el tratamiento de la rotura de aneurisma abdominal.

INTRODUCTION: Rupture of abdominal aortic aneurysm is still a difficult challenge for the vascular surgeon due to the high perioperative mortality. The aim of our study is to describe the characteristics of the population as well as to compare morbidity and mortality in patients undergoing open surgery or endovascular repair in our center. METHODS: Database with 82 rAAA between January 2002-December 2014, studying two cohorts, open surgery and endovascular repair. Epidemiologic, clinical, surgical techniques, perioperative mortality and complications are analyzed. RESULTS: 82 rAAA cases were operated (men: 80, women: 2). Mean age 72±9.6 years. 76.8% (63 cases) was performed by open surgery. BACKGROUND: smokers 59, 7%, alcoholism 19.5%, DM 10.9%, AHT: 53.6%, dyslipidemia 30.5%. The most frequent clinical presentation was abdominal pain with lumbar irradiation: 50 cases (20.7% associating syncope). Overall hospital mortality was 58.5%. Hemodynamic shock prior to intervention was associated with increased mortality (p <.001). Anemia, leukocytosis, aneurysm size, sex and age did not show a statistically significant difference with respect to mortality (p>.05). The presence of iliac aneurysms was associated with increased mortality (p <.0045). Perioperative mortality in endovascular repair was 42%, and in open surgery was 63.5% (p>.05). Hospital stay was lower in the endovascular group (p=.3859). CONCLUSIONS: Hemodynamic shock and the presence of concomitant iliac aneurysms have a statistically significant association with perioperative mortality in both groups. We found clinically significant differences in mortality, complications and hospital stay when comparing both groups with better results for EVAR, without statistically significant differences.

Repair of bilateral true aneurysms of the dorsalis pedis artery.

Aneurysms of peripheral arteries are infrequent, with an incidence <1%. Dorsalis pedis artery (DPA) aneurysms are extremely rare, and most of them are pseudoaneurysms secondary to trauma or iatrogenic injuries. We report the first case of simultaneous (synchronous) bilateral DPA true aneurysms and how we repaired them. We review the literature on DPA true aneurysms and focus on the surgical management.

[Cerebral hyperperfusion syndrome in carotid revascularisation surgery]. / Síndrome de hiperperfusión cerebral en la cirugía de revascularización carotídea.

INTRODUCTION: Cerebral hyperperfusion syndrome (CHS) is a serious complication of carotid revascularisation surgery associated with both carotid endarterectomy and carotid stenting. AIM: To review the literature published to date on CHS with the aim of updating the data available on its incidence, pathophysiology, clinical features, risk factors, diagnosis, management and treatment. DEVELOPMENT: Carotid revascularisation surgery entails a transient increase in cerebral blood flow, and if this increase is more than 100% of the pre-operative value, then hyperperfusion occurs. Two pathophysiological mechanisms are involved in increasing cerebral blood flow: alteration of the cerebrovascular autoregulation mechanisms and increased post-operative systolic arterial pressure. CHS consists in the clinical triad headache, convulsions and focal neurological deficit, associated with arterial hypertension and the absence of cerebral ischaemia. If left undiagnosed, as it progresses it will lead to brain oedema, brain or subarachnoid haemorrhage and, finally, death. The main risk factors for CHS are: diminished haemodynamic reserve, post-operative arterial hypertension and hyperperfusion, which remains for several hours after the carotid recanalisation. Diagnosis is based on clinical suspicion and complementary tests, such as trans-cranial Doppler ultrasonography or single-photon emission tomography, which confirm the suspected hyperperfusion. The keystone on which treatment is based is prevention by strict control of the arterial pressure with drugs such as labetalol and clonidine. CONCLUSIONS: CHS is a serious, under-diagnosed complication of carotid revascularisation that the specialist must be aware of so that treatment can be established at an early stage, thereby reducing its high morbidity and mortality rate.

[Laparoscopy-assisted aortobifemoral bypass through the transperitoneal retrorenal approach]. / By-pass aortobifemoral con asistencia laparoscópica por vía transperitoneal retrorrenal.

The aim of laparoscopic vascular surgery in the aortoiliac segment is to replicate the excellent outcomes of open aortic surgery while providing the advantages of minimally invasive surgery. We report the case of a 49-year old man with disabling hip claudication and rest pain in his left lower extremity. On examination the patient had reduced right femoral pulse and absent pulses in his left lower extremity. Angiography revealed occlusive disease in the left aortoiliac segment and right common iliac artery stenoses. Laparoscopic aortobifemoral bypass was planned. The surgical technique included 70 degrees -right lateral decubitus position and retrorenal retrocolic dissection from the left common iliac artery to the left renal vein. Minilaparotomy consisted of aortic clamping, arteriotomy, and end-to-side aorto-prosthetic anastomosis with Dacron graft. Time to extubation was 5 hours; peristalsis was recovered 72 hours after surgery. The patient was discharged from hospital after cardiologic assessment 9 days after surgery.