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OBJECTIVE: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS: The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS: A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION: The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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BACKGROUND: Although it is evident that a prior history of tunneled dialysis catheter (TDC) affects arteriovenous fistula (AVF) function, it is unclear whether its location (contralateral versus ipsilateral to AVF) has any effect on AVF maturation and failure rates. We aimed to document this possible effect. METHODS: This systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing outcomes between patients with contralateral TDC (CONTRA group) and those with ipsilateral one (IPSI group) were examined for inclusion. A random effects model meta-analysis of the odds ratio (OR) was conducted. Primary outcomes were AVF functional maturation, assisted maturation, and failure rates. RESULTS: Four eligible studies comprising 763 patients were included in the meta-analysis. There were no significant differences in terms of AVF functional maturation (OR: 1.49; 95% confidence interval [CI]: 0.64-3.47; I2 = 83.4%), assisted maturation (OR: 0.59; 95% CI: 0.29-1.19; I2 = 61.4%), and failure rates (OR: 0.67; 95% CI: 0.29-1.58; I2 = 83.3%) between the 2 study groups. CONCLUSIONS: TDC laterality seems not to affect fistula maturation rate in patients requiring TDC placement and concurrent AVF creation, but rather, vein- and patient-related characteristics might play a more important role in choosing TDC access site. Further studies are needed to validate these results.
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Derivação Arteriovenosa Cirúrgica , Diálise Renal , Humanos , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Fatores de Risco , Resultado do Tratamento , Feminino , Pessoa de Meia-Idade , Masculino , Cateteres de Demora , Cateteres Venosos Centrais , Idoso , Grau de Desobstrução Vascular , Cateterismo Venoso Central/instrumentação , Cateterismo Venoso Central/efeitos adversos , Fatores de Tempo , Razão de Chances , Falha de Tratamento , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Distribuição de Qui-QuadradoRESUMO
PURPOSE: To measure the long-term proximal aortic neck dilatation (AND) after elective endovascular aortic aneurysm repair (EVAR) with a variety of contemporary, third-generation, endograft devices. MATERIALS AND METHODS: This is a noninterventional prospective cohort study of 157 patients that underwent standard EVAR with self-expanding abdominal endografts. Patients' recruitment lasted from 2013 to 2017, and postoperative follow-up was up to 5 years. A computed tomography angiography (CTA) was performed at the first month and then at 1, 2, and 5 years. Proximal aortic neck's (PAN) basic morphological characteristics (diameter, length, angulation) were measured based on the analysis of CTA in a standardized fashion. Neck-related adverse events, such as migration, endoleak or rupture, and reinterventions were recorded. RESULTS: Significant straightening of the PAN was evident even in the first-month CTA with concurrent neck shortening that became significant at 5 years. Both the suprarenal aorta and the PAN significantly dilated overtime, with PAN dilating more progressively. Mean neck dilatation at the juxtarenal level was 0.8±0.4 mm at 1 year, 1.8±0.8 mm at 2 years, and 3.9±1.7 mm at 5 years, with a mean neck dilatation rate of 0.07 mm/month overall. The incidence of AND ≥2.5 mm was 37.2% at 2 years and 58.1% at 5 years after EVAR and was considered important (≥5 mm) in 11.5% of patients at 2 years and 30.6% of patients at 5 years. A multivariate analysis performed showed that the endograft oversizing, the preoperative neck diameter, and the preoperative abdominal aortic aneurysm sac diameter served as independent predictors of AND at 5 years. At the 5-year follow-up, 8 late type Ia endoleaks (6.5%) and 7 caudal migrations (5.6%) were identified, while no late ruptures were reported. In total, 11 late endovascular reinterventions (8.9%) were performed. Overall, proximal neck-related adverse outcomes (5/7 migrations and 5/8 endoleaks) and reinterventions (7/11) were significantly associated with the presence of important late AND. CONCLUSION: Proximal AND after EVAR is common. It can influence the long-term durability of proximal endograft fixation and is significantly associated with adverse outcomes, often leading to reinterventions. A systemic and extended surveillance protocol is needed for maintenance of good long-term results. CLINICAL IMPACT: This is a thorough and systematic analysis of the long-term geometric remodeling of the proximal aortic neck after EVAR, that highlights the importance of a strict, and extended surveillance protocol for maintenance of good long-term results of EVAR.
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BACKGROUND: The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair. METHODS: PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model. RESULTS: Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I2=62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001). CONCLUSIONS: Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up. CLINICAL IMPACT: Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures.
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BACKGROUND: Matrix metalloproteinases (MMPs) play a significant role in the development and progression of atherosclerotic vascular disease. The purpose of this study was to measure and document the profile of plasma-circulating MMPs in patients with peripheral arterial disease (PAD) undergoing endovascular revascularization. METHODS: This was a single-center prospective observational study with 80 patients with PAD enrolled. They underwent percutaneous balloon angioplasty and/or angioplasty with stent. Exclusion criteria were acute limb ischemia, active inflammation, wet gangrene, liver disease, end-stage renal failure, and cancer. Patients that underwent open or hybrid (open and endovascular) approach were also excluded from the study. Venous blood samples were taken preoperatively, 24 hr, and 6 months postoperatively. The values of MMP-2, MMP-3, MMP-7, MMP-9, and their inhibitors (tissue inhibitor of metalloproteinases [TIMP]), TIMP-1 and TIMP-2 were measured. RESULTS: The mean age was 67.1 years, and 66 of them (82.5%) were male. During the clinical follow-up (mean 35.8% months), 12 patients died (16.4%), 15 (20.5%) of them had a major adverse limb event (MALE), and 14 (19.2%) of them had a major adverse cardiovascular event (MACE). There was a statistically significant rise in the values of MMP-2, MMP-3, and MMP-7 at 6 months postoperatively, when compared to the preoperative and 24 hr postoperative values. There was no correlation of MMP and TIMP values with mortality, MALE, and MACE events. CONCLUSIONS: The present single-center prospective study documented increased circulating levels of MMPs postoperatively in PAD patients undergoing endovascular treatment. Vascular trauma caused by angioplasty could trigger the expression of MMPs and TIMPs, but the absence of any association with clinical complications requires further investigation.
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Metaloproteinase 3 da Matriz , Doença Arterial Periférica , Humanos , Masculino , Idoso , Feminino , Metaloproteinase 2 da Matriz , Metaloproteinase 7 da Matriz , Estudos Prospectivos , Resultado do Tratamento , Inibidor Tecidual de Metaloproteinase-1 , Inibidores Teciduais de Metaloproteinases , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgiaRESUMO
BACKGROUND: Osteoprotegerin (OPG) and osteopontin (OPN) are vascular calcification inhibitors with a known role in the atherosclerotic and inflammatory process. We investigated their relationship with adverse outcomes (restenosis/adverse cardiovascular events) after endovascular revascularisation of patients with peripheral arterial disease (PAD). METHODS: 203 consecutive patients were enrolled in the PAD group (PADG) and 78 age and sex-matched subjects with less than two cardiovascular risk factors served as control group (COG). PADG underwent standard medical assessment at baseline and 12 months after the procedure. During follow up major adverse cardiovascular events (MACEs) including arterial restenosis with need for reintervention were documented and the PADG was divided accordingly into two subgroups. RESULTS: During 12-month follow-up, 82 MACE were recorded (MACE subgroup). The rest of 124 PAD patients remained free of MACE (non-MACE subgroup). At baseline, OPG (9.89 ± 2.85 ng/ml vs 3.47 ± 1.95 ng/ml, p < 0.001) and OPN (79.99 ± 38.29 ng/ml vs 35.21 ± 14.84 ng/ml, p < 0.001) levels were significantly higher in PADG compared to COG, as well as in MACE subgroup compared to non-MACE subgroup (13.29 ± 3.23 ng/ml vs 10.86 ± 3 ng/ml and 96.45 ± 40.12 ng/ml vs 78.1 ± 38.29 ng/ml, respectively). An independent association of PAD with OPG and OPN was found in the whole patient cohort. Although OPG and OPN were significantly related to MACE incidence in the univariate analysis, multiple logistic regression analysis failed to detect any independent predictor of MACE within the PADG. CONCLUSION: Baseline high OPG and OPN levels were independently associated with PAD presence. Even higher levels of those biomarkers were detected among PAD patients with MACE, however, their prognostic role should be further clarified.
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Doença Arterial Periférica , Calcificação Vascular , Biomarcadores , Humanos , Osteopontina , Osteoprotegerina , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/terapia , Fatores de RiscoRESUMO
INTRODUCTION: Electrophysiology (EP) procedures are nowadays the gold-standard method for tachyarrhythmia treatment with impressive success rates, but also with a considerable risk of complications, mainly vascular. A systematic review and meta-analysis was performed to evaluate the safety of ultrasound (US)-guided femoral vein access in EP procedures compared to the traditional anatomic landmark-guided method. METHODS: We searched Pubmed (MEDLINE), Embase, Web of Science, and Cochrane electronic databases for relevant entries, dated from January 1st, 2000 to June 30th, 2021. Only observational studies and randomized controlled trials were included in this analysis. Data extraction included study details, patient characteristics, procedure details, and all types of vascular complications. Complications were classified as major if any intervention, prolongation of hospitalization, or readmission was required. RESULTS: 9 studies (1 randomized controlled trial and 8 observational), with 7858 participants (3743 in the US-guided group, 4115 in the control group), were included in the meta-analysis. Overall vascular complication rates were significantly decreased in the US-guided group compared to the control group (1.2 versus 3.2%, RR = 0.38, 95% CI, 0.27-0.53), in all EP procedures. Sub-group analysis of AF ablation procedures yielded similar results (RR 0.41, 95% CI, 0.29-0.58, p < 0.00001). The event reduction effect was significant for both major and minor vascular complications. CONCLUSION: US-guided vascular access in EP procedures is associated with significantly reduced vascular complications, compared to the standard anatomic landmark-guided approach, regardless of procedure complexity.
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BACKGROUND: RBP4 is an adipokine with an established role in atherosclerosis, while adiponectin has unique anti-inflammatory properties. We investigated the association of RBP4 and adiponectin with the presence of symptomatic peripheral artery disease (PAD) and their possible prognostic role in major adverse cardiovascular events (MACE). METHODS: We enrolled 168 consecutive patients with symptomatic, established PAD, requiring revascularization by endovascular means of any or both of their lower limbs. 88 age- and sex-matched subjects with less than 2 classical cardiovascular risk factors served as controls. Clinical parameters, glycemic and lipid profile, RBP4 and adiponectin levels were assayed. The occurrence of MACE was recorded during the 6-month follow-up and patients were assigned to MACE and non-MACE subgroups. RESULTS: The presence of symptomatic PAD was significantly correlated with age, diabetes, hsCRP, RBP4 and low adiponectin levels (p < 0.05). After adjustment for age, RBP4 (ß = 0.498, p < 0.001), and adiponectin (ß = -0.288, p < 0.001) levels remained as independent predictors of PAD presence in the whole study cohort. At baseline, MACE subgroup appeared with higher RBP-4 and hsCRP serum levels than non-MACE subgroup (p < 0.001), but no differences were detected for adiponectin (p = 0.758). Serum RBP4 levels remained independent predictor of MACE (ß = 0.455, p < 0.001) after adjustment for traditional cardiovascular risk factors. CONCLUSIONS: High RBP4 and low adiponectin serum levels are independently associated with PAD presence. In addition, RBP4 is an independent predictor of MACE incidence in symptomatic PAD patients.
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Adiponectina/sangue , Angioplastia com Balão , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Proteínas Plasmáticas de Ligação ao Retinol/análise , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/instrumentação , Biomarcadores/sangue , Proteína C-Reativa/análise , Estudos de Casos e Controles , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Stents , Resultado do TratamentoRESUMO
BACKGROUND: An aberrant right subclavian artery is the most common congenital anomaly of the aortic arch and may cause symptoms due to aneurysmal dilatation, stenosis or occlusion. We present a case of subclavian-steal syndrome due to post-traumatic dissection of an aberrant right subclavian artery. METHODS AND RESULTS: A 50 year-old man presented with dizziness and fainting episodes after exercising his right arm and a systolic blood pressure gradient of 40 mm Hg between the 2 arms. Suspecting a subclavian steal syndrome, a computed tomography angiography was requested which revealed an aberrant right subclavian artery with a severe stenosis proximal to the ostium of the vertebral artery. Transfemoral digital subtraction angiography showed a local dissection of the aberrant right subclavian artery with late retrograde filling of the ipsilateral vertebral artery. The lesion was successfully treated with primary stent implantation (9 mm x 40 mm, LIFESTAR, BARD). On interrogation, the patient recalled an injury to the right arm after falling off a ladder 10 years earlier, as a possible post-traumatic cause for the dissection. He had an uneventful outcome and is symptom-free 12 months down the line. CONCLUSIONS: The combination of post-traumatic dissection of an aberrant right subclavian artery resulting to subclavian steal syndrome is an extremely rare scenario. Endovascular management is a safe, minimally invasive alternative to open surgery.
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Acidentes por Quedas , Angioplastia , Dissecção Aórtica/terapia , Anormalidades Cardiovasculares/complicações , Artéria Subclávia/anormalidades , Síndrome do Roubo Subclávio/terapia , Lesões do Sistema Vascular/terapia , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/etiologia , Dissecção Aórtica/fisiopatologia , Angioplastia/instrumentação , Anormalidades Cardiovasculares/diagnóstico por imagem , Anormalidades Cardiovasculares/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Stents , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/fisiopatologia , Síndrome do Roubo Subclávio/diagnóstico por imagem , Síndrome do Roubo Subclávio/etiologia , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/fisiopatologiaRESUMO
BACKGROUND: We aimed to investigate whether the transfusion of 2 units of fresh frozen plasma (FFP) immediately post aneurysm exclusion has any effect on the perioperative fibrinogen levels and the outcome of patients undergoing elective endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). METHODS: Consecutive infrarenal AAA patients undergoing elective EVAR with the bifurcated Endurant-II stent-graft (Medtronic) were recruited from 2 vascular units. The first unit has a routine policy of administering 2 units of FFP immediately upon aneurysm exclusion (FFP group), whereas the second unit has no such policy (control group). Serum fibrinogen levels were measured on admission and 24 hr post-EVAR and the perioperative change in fibrinogen (Δfib) was calculated (24-hr postoperative minus preoperative fibrinogen). The 2 groups were compared with regards to the perioperative fibrinogen levels (preoperative, 24-hr postoperative, and Δfib) and the outcome (endoleaks, reinterventions, major adverse cardiovascular events, death) during follow up. RESULTS: A total of 70 patients (41 in the FFP group, 29 controls) were examined. There were 68 men, the mean age was 70 ± 7 years and the maximum AAA diameter was 63.3 ± 13.8 mm. During the follow up (34 ± 19 months), a total of 6 endoleaks were recorded (2 type Ia, 2 type Ib and 1 type II). Mean preoperative fibrinogen, 24-hr postoperative fibrinogen and Δfib was 391.1 ± 92.8 mg/dL, 367.7 ± 97.8 mg/dL and -23.5 ± 51.02 mg/dL, respectively. There was a trend for the fibrinogen to fall 24 hr postprocedure, but this was not statistically significant (P = 0.07). There was a weak negative association between Δfib and endoleaks (P = 0.007, r = -0.29). Compared to controls, the FFP group had a higher 24-hr postoperative fibrinogen (401.8 ± 112.9 mg/dL vs. 319.3 ± 34.9 mg/dL, P < 0.0001) and a lower Δfib (-3.00 ± 56.01 mg/dL vs. -52.48 ± 21.15 mg/dL, P < 0.0001). No significant difference was observed between the 2 groups with regards to endoleaks, reinterventions, major adverse cardiovascular events, or deaths. CONCLUSIONS: Transfusion of 2 units of FFP postaneurysm exclusion prevents a significant drop in plasma fibrinogen 24 hr post-EVAR, but the impact on clinical outcome has yet to be defined.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Fibrinogênio/metabolismo , Troca Plasmática , Plasma , Idoso , Aneurisma da Aorta Abdominal/sangue , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Biomarcadores/sangue , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Grécia , Humanos , Masculino , Pessoa de Meia-Idade , Troca Plasmática/efeitos adversos , Troca Plasmática/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Delayed embolization after filter-protected carotid artery stenting (CAS) may occur because of the protrusion and release of loose atherosclerotic plaque fragments through the stent cells. METHODS AND RESULTS: We describe a technical modification to the standard filter-protected CAS by introducing an extra step, that of washing away the luminal stent surface debris with heparinized saline while the filter is still in place. Aided by the guiding catheter, flushing heparinized saline under manual pressure against the stent will force all loose fragments distally in the internal carotid artery to be captured by the overlying filter. CONCLUSIONS: Stent washout with heparinized saline before filter retrieval during filter-protected CAS may potentially increase debris capture and reduce delayed embolization.
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Anticoagulantes/administração & dosagem , Doenças das Artérias Carótidas/terapia , Dispositivos de Proteção Embólica , Embolia/prevenção & controle , Procedimentos Endovasculares/instrumentação , Heparina/administração & dosagem , Solução Salina/administração & dosagem , Stents , Irrigação Terapêutica , Anticoagulantes/efeitos adversos , Doenças das Artérias Carótidas/diagnóstico por imagem , Embolia/etiologia , Procedimentos Endovasculares/efeitos adversos , Heparina/efeitos adversos , Humanos , Fatores de Risco , Solução Salina/efeitos adversos , Irrigação Terapêutica/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Chronic thrombosis of an abdominal aortic aneurysm (AAA) is a rare entity and the ideal management is debatable. METHODS AND RESULTS: A 74-year-old man presented with an enlarging chronically thrombosed AAA and incapacitating bilateral claudication, worse on the left side. We opted for an endovascular approach. Under local anesthesia and via a left axillary and left femoral cutdown, an aorto-uni-iliac stent graft (Endurant, Medtronic) was implanted down the left common iliac artery. A femorofemoral crossover bypass was not necessary because the right leg circulation was considered adequate on completion of the endovascular procedure. He had an uneventful recovery. His left leg symptoms were completely resolved and he was able to walk with only moderate right leg claudication after 300-400m. CONCLUSIONS: Endovascular treatment of a chronically thrombosed AAA can be performed under local anesthesia and is a safe alternative to open surgery in high-risk patients. The long-term results need further investigation.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Ilíaca/cirurgia , Claudicação Intermitente/cirurgia , Trombose/cirurgia , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Doença Crônica , Procedimentos Endovasculares/instrumentação , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Claudicação Intermitente/diagnóstico por imagem , Claudicação Intermitente/fisiopatologia , Masculino , Recuperação de Função Fisiológica , Stents , Trombose/diagnóstico por imagem , Trombose/fisiopatologia , Resultado do TratamentoRESUMO
A 75-year-old man presented with abdominal and lumbar pain 6 years after previous endovascular repair of an abdominal aortic aneurysm. At the time of the initial operation, the aneurysm measured 6.0 cm in maximum diameter and a bifurcated Anaconda (Vascutek) endograft had been implanted. This time, computed tomography showed a distally migrated endograft which had been folded within the sac and the aneurysm measured 8.4 cm in maximum diameter. We opted to treat this by endovascular means deploying a new bifurcated endograft with suprarenal fixation within the old one. We consider the different management options and discuss the associated technical difficulties.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Migração de Corpo Estranho/cirurgia , Stents , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/etiologia , Humanos , Masculino , Desenho de Prótese , Resultado do TratamentoRESUMO
BACKGROUND: We investigated the potential association between perioperative fibrinogen levels and outcome in patients undergoing elective endovascular abdominal aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). METHODS: Consecutive patients with an intact AAA undergoing elective EVAR with a specific bifurcated endograft (Endurant, Medtronic) were recruited between December 2012 and October 2016. Preoperative and 24-hr postoperative fibrinogen levels were recorded, and potential associations with outcome were tested. Primary outcome measures included endoleaks, lower limb ischemic complications, including endograft limb occlusion, and aneurysm-related reinterventions. RESULTS: Ninety-four patients (91 male, mean age 71.8 ± 8.0 years) with an intact AAA were enrolled in the study. The technical success was 98% (2 failures: 1 type Ia endoleak on completion angiography, 1 lower limb ischemia immediately postoperatively requiring femoral endarterectomy). There was 1 death during the first 30 days due to myocardial infarction (1%). Another patient died 15 months after the procedure from cardiac causes. During the existing follow-up (mean 14.8 ± 14.3 months), 14 patients (15%) developed an endoleak (4, type Ia endoleak and 10, type II endoleak), 6 patients (6.3%) had lower limb ischemia/endograft limb occlusion, and 10 patients (10.6%) required reintervention. Compared with the preoperative values, no significant change occurred with regard to the fibrinogen levels 24 hr after procedure (mean preoperative fibrinogen 360 ± 101 mg/dl vs 24-hr postoperative fibrinogen 349 ± 105 mg/dl, P = 0.1). Neither preoperative nor 24-hr postoperative fibrinogen levels were significantly associated with the development of endoleaks, lower limb ischemia, or reinterventions. However, the difference in fibrinogen levels (baseline to 24 hr after procedure) was significantly higher in patients with endoleaks (median -65 mg/dl vs. 15 mg/dl, P = 0.04). CONCLUSIONS: Perioperative fibrinogen levels may play a role in predicting midterm outcomes in patients undergoing elective EVAR and appears to be associated, directly or indirectly, with the development of endoleaks. Further studies are needed to investigate these findings and explore future therapeutic implications.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Fibrinogênio/análise , Idoso , Aneurisma da Aorta Abdominal/sangue , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Biomarcadores/sangue , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Stents , Fatores de Tempo , Resultado do TratamentoRESUMO
A pseudoaneurysm located at the subclavian artery ostium is an infrequent but life-threatening pathology that usually requires major thoracic surgery with a high risk of mortality and morbidity. Endovascular therapy applied to the aortic arch branches is a recent alternative technique, which is still in its early stages because dedicated endovascular devices for the aortic arch are lacking. In this article, we present the emergency endovascular management of a symptomatic pseudoaneurysm of the left subclavian artery ostium which was presumably secondary to an atherosclerotic plaque rupture. Endovascular exclusion required a combination of an abdominal aortic stent-graft extension cuff, which was placed via a retroperitoneal iliac access, and a subclavian artery periscope stent graft.
Assuntos
Falso Aneurisma/cirurgia , Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Aterosclerose/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Artéria Subclávia/cirurgia , Idoso , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/complicações , Doenças da Aorta/diagnóstico por imagem , Aortografia/métodos , Aterosclerose/complicações , Aterosclerose/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Emergências , Humanos , Masculino , Desenho de Prótese , Artéria Subclávia/diagnóstico por imagem , Resultado do TratamentoRESUMO
BACKGROUND: We present a unique case scenario of a periaortic liposarcoma masquerading as an impending rupture of an inflammatory abdominal aortic aneurysm (AAA). METHODS AND RESULTS: A 57-year-old man was referred to our unit for an emergency endovascular repair of "an inflammatory AAA with computed tomography (CT) features of impending rupture." He underwent an uneventful endovascular repair with a bifurcated endograft (C3; Gore, Flagstaff, AZ). Seven weeks later, CT showed that the periaortic "mass" grew larger and asymmetric, and a CT-guided needle biopsy suggested the presence of a high-grade malignant mesenchymal tumor. He underwent laparotomy and excision of the retroperitoneal tumor en bloc with the anterior wall of the infrarenal aorta. The endograft acted as an excellent "safety net" providing adequate hemostatic control and obviating the need for aortic cross-clamping and repair of the aortic defect with a patch or tube graft. CONCLUSIONS: The learning point from the present case is that when faced with an inflammatory AAA and/or retroperitoneal fibrosis, the rare possibility of a retroperitoneal neoplasm should be kept in mind.
Assuntos
Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Lipossarcoma/diagnóstico por imagem , Fibrose Retroperitoneal/diagnóstico por imagem , Neoplasias Retroperitoneais/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Diagnóstico Diferencial , Procedimentos Endovasculares , Humanos , Lipossarcoma/cirurgia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fibrose Retroperitoneal/cirurgia , Neoplasias Retroperitoneais/cirurgiaRESUMO
Rupture of an abdominal aortic aneurysm (AAA) after previous endovascular repair (EVAR) may require endograft explantation and replacement with a prosthetic surgical graft. Recent reports have suggested that total endograft removal during late surgical conversion in the nonruptured setting may not be necessary and that preserving functional parts of the endograft may improve results. Similar techniques may be used for ruptured cases diminishing the magnitude of an already difficult and complex procedure. We describe the successful treatment of a ruptured AAA after previous EVAR with complete endograft preservation by combining transmural endograft fixation with sutures, proximal aortic neck banding, and sac plication.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Stents , Técnicas de Sutura , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/etiologia , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Humanos , Masculino , Resultado do TratamentoRESUMO
Popliteal artery injury is a potentially limb-threatening complication of traumatic knee dislocation. We describe 2 such cases that had been treated in our unit over the last decade. The first one was a 23-year-old woman who injured her right knee during a long jump competition, and the second was a 27-year-old man who had a motorbike accident. Both suffered traumatic knee dislocation along with significant ligament and neurovascular injuries. In the first patient, the popliteal artery was found thrombosed due to intimal rupture and required thrombectomy and vein patch repair, whereas in the second patient, the artery was completely transected and required end-to-end anastomosis. Both limbs were successfully revascularized and required subsequent orthopedic procedures to stabilize the knee joint. Traumatic knee dislocations are rare injuries that may be associated with potentially devastating vascular complications. A prompt diagnosis and timely arterial repair is of paramount importance if limb salvage is to be achieved.
Assuntos
Acidentes de Trânsito , Traumatismos em Atletas/etiologia , Luxação do Joelho/etiologia , Artéria Poplítea/lesões , Trombose/etiologia , Lesões do Sistema Vascular/etiologia , Adulto , Anastomose Cirúrgica , Traumatismos em Atletas/diagnóstico por imagem , Feminino , Humanos , Luxação do Joelho/diagnóstico por imagem , Salvamento de Membro , Angiografia por Ressonância Magnética , Masculino , Artéria Poplítea/diagnóstico por imagem , Veia Safena/transplante , Trombectomia , Trombose/diagnóstico por imagem , Trombose/cirurgia , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Adulto JovemAssuntos
Ecocardiografia Transesofagiana , Átrios do Coração/diagnóstico por imagem , Cardiopatias/diagnóstico por imagem , Trombose/diagnóstico por imagem , Acidentes de Trabalho , Idoso , Átrios do Coração/cirurgia , Cardiopatias/etiologia , Cardiopatias/cirurgia , Humanos , Traumatismos da Perna/complicações , Masculino , Trombose/etiologia , Trombose/cirurgiaRESUMO
BACKGROUND: The aim of this study is to document the outcome following endovascular treatment of subacute type B aortic dissection (AD). METHODS: Between October 2000 and June 2014, 40 patients (33 men, mean age 65 [range 35-87] years) with type B AD underwent thoracic endovascular aortic repair (TEVAR) during the subacute phase (defined as 15-90 days from the onset of symptoms). Indications for intervention were acute aortic enlargement, resistant hypertension, and/or intractable pain. The primary outcome was survival. Secondary outcome measures included reinterventions and aortic remodeling (i.e., the fate of the false lumen [FL] post-TEVAR, which was classified as complete, partial, or no thrombosis of the FL). RESULTS: The intraprocedural technical success was 95% (2 proximal endoleaks). Three patients died within 30 days (7.5%), all 3 from dissection-related causes (retrograde type A AD in 2, ruptured thoracic aorta in 1). Another 11 deaths occurred during follow-up (median 64 months, range 1-167), 3 of which were dissection-related. The 1-, 3-, and 5-year Kaplan-Meier survival probability was 87.5%, 79%, and 71.5%, respectively. With regard to the aortic remodeling, there was complete FL thrombosis in 10 (25%) patients, partial thrombosis in 22 (55%), and patent FL with no thrombosis in 8 (20%) patients. There was no statistically significant association between FL status and survival, or between FL status and initial extent of dissection. However, there was a statistically significant association between FL status and reinterventions, the latter being more frequent in patients with no FL thrombosis. CONCLUSIONS: TEVAR for subacute type B AD appears to be associated with acceptable perioperative and long-term results. In contrast to previous reports, there is still a risk for postoperative retrograde type A AD even when patients are treated in the subacute phase when the aorta is less fragile. Aortic remodeling occurs in the majority of patients, but requires frequent aortic reinterventions, an observation that underlines the need for life-long surveillance.