Analysis of Aortic Arch Hemodynamics With Simulated Bird's Beak Effects.

OBJECTIVE: The objective of this study was to investigate the flow effects in different degrees of thoracic aortic stent graft protrusion extension by creating bird beak effect simulations using accurate 3D geometry and a realistic, nonlinear, elastic biomechanical model using computer-aided software SolidWorks. METHODS: Segmentation in 3D of an aortic arch from a computed tomography (CT) scan of a real-life patient was performed using SolidWorks. A parametric analysis of three models was performed: (A) Aortic arch with no stent, (B) 3 mm bird-beak configuration, and (C) 6.5 mm bird-beak configuration. Flow velocity, pressure, vorticity, wall shear stress (WSS), and time average WSS were assessed. RESULTS: The flow velocity in Model A remained relatively constant and low in the area of the ostium of the brachiocephalic artery and doubled in the left subclavian artery. On the contrary, Models B and C showed a decrease in velocity of 52.3 % in the left subclavian artery. Furthermore, Model B showed a drop in velocity of 82.7% below the bird-beak area, whereas Model C showed a decline of 80.9% in this area. The pressure inside the supra-aortic branches was higher in Model B and C compared with Model A. In Model A, vorticity only appeared at the level of the descending aorta, with low to non-vorticity in the aortic arch. In contrast, Models B and C had an average vorticity of 241.4 Hz within the bird beak area. Regarding WSS, Model A, and Model B shared similar WSS in the peak systolic phase, in the aortic arch, and the bird beak area, whereas Model C had an increased WSS by 5 Pa on average at these zones. CONCLUSION: In the present simulations' lower velocities, higher pressures, vortices, and WSS were observed around the bird beak zone, the aortic arch, and the supra-aortic vessels.

Stereolithographic (SLA) 3D Printing for Preprocedural Planning in Endovascular Aortic Repair of a Thoracic Aneurysm.

BACKGROUND: When treating aortic aneurysm patients with complex anatomical features, preprocedural planning aided by 3D-printed models offers valuable insights for endovascular intervention. This study highlights the use of stereolithographic (SLA) 3D printing to fabricate a phantom of a challenging aortic arch aneurysm with a complex neck anatomy. CLINICAL CASE: A 75-year-old female presented with a 58 mm descending thoracic aortic aneurysm (TAA) extending to the distal arch, involving the left subclavian artery (LSA) and the left common carotid artery (LCCA). The computed tomography (CT) scans underwent scrutiny by radiology and vascular teams. Nevertheless, the precise spatial relationships of the ostial origins proved to be challenging to ascertain. To address this, a patient-specific phantom of the aortic arch was fabricated utilizing an SLA printer and a biomedical resin. The thoracic endovascular aortic repair (TEVAR) procedure was simulated using fluoroscopy on the phantom to enhance procedural preparedness. Subsequently, the patient underwent a right carotid-left carotid bypass and a right carotid-left subclavian bypass. After a 24-hour interval, the patient underwent the TEVAR procedure, during which a 37 mm × 150 mm stent graft (CTAG, WL Gore and Associates, Flagstaff, AZ, USA) and a 40 mm × 200 mm stent graft (CTAG, WL Gore and Associates, Flagstaff, AZ, USA) were deployed, effectively covering the LSA and LCCA. Notably, the aneurysm exhibited complete sealing, with no indications of endoleaks or graft infoldings. At the 12-month follow-up, the patient remains in good health, with no evidence of endoleaks or any other surgery-related complication. CONCLUSION: This report showcases the successful use of a 3D-printed endovascular phantom in guiding the decision-making process during the preparation for a TEVAR procedure. The simulation played a pivotal role in selecting the appropriate stent graft, ensuring an intervention protocol optimized based on the patient-specific anatomy.

Latin America Research Output Within the Top 5 Vascular Surgery Journals.

BACKGROUND: Dedicated studies on patient outcomes are crucial to the development of effective policies aimed at prevention and management of vascular diseases. This study aims to determine the scientific productivity of Latin American countries through a bibliometric analysis of top 5 vascular journals. METHODS: The 5 dedicated vascular journals indexed in the "surgery" category were selected for analysis. These were the European Journal of Vascular and Endovascular Surgery (EJVES), the Journal of Vascular Surgery (JVS), the Journal of Endovascular Therapy (JEVT), the Journal of Vascular Surgery: Venous and Lymphatic Disorders (JVS-VL) and the Annals of Vascular Surgery (AVS). Databases were queried with the combination of each journal's name + each of the 21 Latin American countries. All possible combinations were searched. Inclusion criteria were articles affiliated with a university, medical center, or hospital from any Latin American country. RESULTS: A total of 501 articles were retrieved, 104 (20.7%) were published between 2000 and 2011, and 397 (79.2%) between 2012 and 2022. The journal with the most publications was AVS with 221 (43.9%), followed by JVS with 135 (26.9%), EJVES with 60 (11.9%), JEVT with 49 (9.9%), and JVS-VL with 36 (7.1%). Brazil had the highest volume of publications at 346 (69.0%), followed by Argentina at 54 (10.7%), Chile at 35 (6.9%), and Mexico at 32 (6.3%). JVS had a higher median citation when compared with AVS, JVS-VL, and JEVT, 18 vs. 5, 5.5, and 7, respectively (P = <0.001). Furthermore, JVS had a greater median citation than EJVES, at 18 vs. 12.5, respectively (P = 0.005). Median citation per year from 2000 to 2011 was 1.59 (range: 0-45), and 1.50 (range: 0-114.5) from 2012 to 2022 (P = 0.02). CONCLUSIONS: Latin America's research output within the vascular surgery field has increased over the years. Efforts must be made to increase research output in this region and translate findings into effective interventions for these populations.

Readmission After COVID-19 for Late Acute Venous Thrombosis; CASE SERIES and Systematic Review of the Literature.

OBJECTIVE: Assess heterogeneity within patients with resolved COVID-19 to broaden the vision about post-discharge thrombotic cases and postulate possible related mechanisms in search of better anticoagulation guidelines. This study details patients' characteristics, medical history, treatment, and outcomes of readmitted patients with late acute thrombosis through a systematic review of the literature and patients from our academic center database. METHODS: We extracted the records of patients readmitted for venous thrombosis complications after discharge from the database of the first 2000 patients admitted with COVID-19 in our academic center; we also performed a systematic review of the literature using the Medical Subject Headings terms "late thrombosis," "COVID-19," + "venous thrombosis" in PubMed and Google Scholar according to PRISMA guideline. RESULTS: The literature review found 20 patients suitable for review matching the inclusion criteria. These patients were added to those in our database, summing up a total of 26 patients. The median age was 50 years old, 76.9% were male, and most were overweight or had grade 1 obesity (n = 11, 42.3%). None had a previous thrombotic history, but 50% had an underlying comorbidity. Thrombotic events presented on a median of 20 days (range: 4-150 days) from discharge. Pulmonary embolisms occurred in 23 patients (88.46%), deep vein thrombosis in 4, mesenteric thrombosis, and cerebral venous thrombosis in 1, respectively. CONCLUSION: This study found that most patients readmitted for thrombotic events after COVID-19 discharge were middle-aged men with Venous Thrombo Embolism events.

Biomechanical Profiling in Real-Life Abdominal Aortic Aneurysms in Different Clinical Scenarios.

BACKGROUND: The aim of this study was to demonstrate the biomechanical properties in different abdominal aortic aneurysm (AAA) presentations of real-life patients. We used the actual 3D geometry of the AAAs under analysis and a realistic, nonlinearly elastic biomechanical model. MATERIALS AND METHODS: Three patients with different clinical scenarios (R: rupture, S: symptomatic, and A: asymptomatic) with infrarenal aortic aneurysms were studied. Factors affecting aneurysm behavior such as morphology, wall shear stress (WSS), pressure, and velocities were studied and analyzed using steady state computer fluid dynamics using SolidWorks (Dassault Systems SolidWorksCorp., Waltham, Massachusetts). RESULTS: When analyzing the WSS, Patient R and Patient A had a decrease in the pressure in the bottom-back region compared with the body of the aneurysm. In contrast, WSS values appeared to be the most uniform across the entire aneurysm in Patient S. Furthermore, Patient A had focal small surface regions with high WSS values. The overall WSS in the unruptured aneurysms (Patient S and Patient A) were a lot higher than in the ruptured 1 (Patient R). All 3 patients showed a pressure gradient, being high at the top and low at the bottom. All patients had pressure values 20 times smaller in the iliac arteries compared with the neck of the aneurysm. The overall maximum pressure was similar between Patient R and Patient A, higher than the maximum pressure of Patient S. CONCLUSIONS: Computed fluid dynamics was implemented in anatomically accurate models of AAAs in different clinical scenarios for obtaining a broader understanding of the biomechanical properties that determine the behavior of AAA. Further analysis and the inclusion of new metrics and technological tools are needed to accurately determine the key factors that will compromise the integrity of the patient's aneurysms anatomy.

High Altitude Carotid Body Tumors Growth During active Surveillance.

BACKGROUND: The gold standard for patients with carotid body tumors (CBT) is surgical resection; nevertheless, some patients are unfit for surgery or, for other reasons, could not be operated on. Active surveillance has been known to be a reasonable strategy for these cases. This study aimed to evaluate tumor growth in unoperated patients with CBTs. METHODS: A retrospective review of all unoperated patients with CBT from a single academic hospital diagnosed between 2014 and 2021 was performed. Results of nonparametric testing were presented using the median and ranges for Mann-Whitney-U or Kruskal-Wallis. Significance was defined as a 2-tailed P < .05. RESULTS: The cohort included a total of 31 patients, with a median age of 60 years (range: 37-80 years), of which 27 (87.1%) were females. The patients live at a median altitude of 2800 meters (range: 2756-2980 meters) above sea level. Twenty (64.5%) patients had Shamblin I tumors, eight (25.8%) patients had Shamblin II tumors, and three (9.7%) patients had Shamblin III tumors. Median CBT volume at diagnosis was 14.1 cm3 (range: .9 - 213.3 cm3). Median volume at diagnosis of symptomatic tumors was substantially larger than asymptomatic tumors, 49.2 cm3 vs 7.9 cm3, respectively (P = .03). Median growth of the tumors during a median 15-month follow-up (range: 3-43 months) was 3.3 cm3 (range: 0-199.9 cm3). Overall, 77% (n = 24) of the CBTs grew at least 1 cm3. CONCLUSION: Most patients in the present study had tumor growth by at least 1 cm3, with a median tumor growth of 3.3 cm.3 In the present study tumor growth was shown to be greater than other low altitude CBT active surveillance studies; therefore, surgical resection should be recommended in patients with CBT living at high altitudes.

An analysis from the CAPACITY database of outcomes of preoperative embolization before carotid body tumor surgery compared with resection alone.

OBJECTIVE: There is no definitive consensus on the impact of preoperative embolization on carotid body tumor (CBT) treatment. The objective of this study was to compare surgical outcomes of patients who underwent preoperative embolization before CBT resection vs patients who underwent resection alone. METHODS: The CAPACITY registry included 1432 patients with CBT from 11 medical centers in four different countries. The group of patients undergoing CBT resection with preoperative embolization was matched in a 1:6 ratio from a pool of patients from the CAPACITY database, using a generated propensity score with patients who did not underwent preoperative embolization. RESULTS: A total of 553 patients were included for analysis. Mean patient age was 56.23 ± 12.22 years. Patients were mostly female (n = 469; 84.8%). Bilateral CBT was registered in 60 patients (10.8%). Seventy-nine patients (14.3%) underwent preoperative embolization. Embolized patients had larger CBT sizes than non-embolized patients (33.8 mm vs 18.4 mm; P = .0001). Operative blood loss was lower in the embolized group compared with the non-embolized group (200 mL vs 250 mL; P = .031). Hematomas were more frequent in the non-embolized group (0% vs 2.7%; P = .044). Operative time, rates of stroke, cranial nerve injuries, and death were not statistically significant between groups. CONCLUSIONS: Embolization before CBT resection was associated with significantly lower blood loss and lower neck hematomas than patients who underwent resection alone. Operative time, stroke, cranial nerve injuries, and death were similar between groups.

Risk Factors for Stroke After Carotid Paraganglioma Surgery.

BACKGROUND: The Carotid Paraganglioma Cooperative International Registry (CAPACITY) is an international registry composed of 1,432 patients with carotid body tumors (CBT) from 11 centers from 4 countries. The aim of this study was to identify risk factors for patients who presented stroke after carotid paraganglioma resection. METHODS: Clinical characteristics and demographics of patients who presented transoperatively and postoperatively stroke from the CAPACITY database were retrospectively gathered. Regression analysis was performed using single logistic regression with Omnibus' test for possible factors that might contribute to present stroke. RESULTS: Out of 1,432 patients, 8 (0.5%) female patients presented stroke. Median age was 53 years (range: 41-70 years). Six strokes occurred transoperatively, diagnosed clinically in the immediate postoperative period. Of them, none of the patients received any further treatment. Three of them died on postoperative day 2, 3, and 4. Two patients developed stroke during the first 24 postoperative hours, patients showed dysarthria, and aphasia. One of them was reintervened with thrombectomy due to thrombosis of the common carotid artery the other patient was treated conservatively. Median follow-up was 16 months (range: 2-72 months). Single logistic regression analysis revealed a history of diabetes mellitus (odds ratio (OR) 7.62), carotid artery disease (OR 17.51), and vascular lesion (OR 2.37) to have significantly increased odds of stroke during CBT surgery. CONCLUSIONS: In the present study history of diabetes mellitus, carotid artery disease, and vascular lesion had increased odds of stroke during CBT surgery. Findings are limited by low event rate and even larger cohorts are needed to fully define preventive preoperative strategies for preventing stroke.

Current trends in carotid body tumors: Comprehensive review.

BACKGROUND: Carotid body tumor (CBT) is a rare neoplasm that has been increasingly studied during the last decades; nevertheless, it continues to be a topic of controversy. This review aims to provide an update on the general features of CBT and particularly review different treatment strategies and primary outcomes. METHODS: Data for this literature review were identified by PubMed, Scopus, and Medline. 93 articles from the initial search were included, as well as 28 relevant studies utilizing the snowballing method; totaling 121 articles about CBT. RESULTS: Main features such as anatomy, embryology, genetics, clinical presentation, and diagnosis of CBT are presented, followed by evidence of different treatment strategies such as radiotherapy, preoperative embolization, vascular resection, and vascular reconstruction. Main complications are also discussed. CONCLUSION: This review summarizes the most critical aspects regarding CBT. Future studies should compare different treatments to attain the best surgical results with lower morbidity rates.

Clinical Characteristics and Surgical Outcomes of Carotid Body Tumors: Data from the Carotid Paraganglioma Cooperative International Registry (CAPACITY) Group.

BACKGROUND: This study's objective was to conduct a multinational registry of patients with carotid body tumors (CBTs) and to analyze patients' clinical characteristics, treatments, and outcomes. METHODS: Retrospective study from the Carotid Paraganglioma Cooperative International Registry involving eleven medical centers in Bolivia, Ecuador, Mexico, and Spain, of all patients with a CBT who underwent resection between 2009 and 2019. RESULTS: A total of 1432 patients with a CBT surgically treated were included. Median patient age was 54 years (range: 45-63 years), and 82.9% (1184) of the study cohort were female. While at low altitude, the proportion of female-to-male cases was 2:1, at high altitude, this proportion increased to 8:1, with statistically significant differences (p = .022). Median operative time was 139 min (range: 110-180 min), while median operative blood loss was 250 ml (range: 100-500 ml), with statistically significant difference in increased blood loss (p = .001) and operative time (p = .001) with a higher Shamblin classification. Eight (0.6%) patients suffered stroke. Univariate analysis analyzing for possible factors associated with increased odds of stroke revealed intraoperative vascular lesion to present an OR of 2.37 [CI 95%; 1.19-4.75] (p = 0.001). In 245 (17.1%), a cranial nerve injury was reported. Seven (0.5%) deaths were recorded. CONCLUSION: The most common CBT type on this cohort was hyperplasic, which might be partially explained by the high altitudes where these patients lived. Increased blood loss and operative time were associated with a higher Shamblin classification, and the risk of stroke was associated with patients presenting transoperative vascular lesions.

Venous Thromboembolism in Hospitalized COVID-19 Patients Treated in a Single Academic Center in Mexico: A Case Series Study.

BACKGROUND: The increasing prevalence of venous thromboembolism (VTE) among patients with coronavirus disease 2019 (COVID-19) is a matter of concern as it contributes significantly to patients' morbidity and mortality. Data regarding the optimal anticoagulation regimen for VTE prevention and treatment remain scarce. This study describes the characteristics, treatment, and outcomes of COVID-19 patients with VTE treated in a single academic center in Mexico. METHODS: We conducted a retrospective study of all patients with a positive PCR test for SARS-CoV-2 hospitalized in a single academic center in Monterrey, Mexico, between March 2020 and February 2021, with a radiologically confirmed VTE, including deep venous thrombosis (DVT) and pulmonary embolism (PE). Informed consent was obtained from each patient before reviewing their medical records. RESULTS: Of the 2000 COVID-19 hospitalized patients, 36 (1.8%) developed VTE and were included in the analysis. The median age was 60 years (range 32-88 years), and up to 78% (n = 28) were males. Most patients (n = 34, 94%) had an underlying comorbidity and 47% (n = 17) had a BMI ≥ 30 kg/m2. In most cases (n=28, 78%), VTE presented as a PE, whereas the remaining 22% (n = 8) had a DVT. The median time between hospital admission and VTE was 8 days (range 0-33 days). Regarding the thromboprophylaxis regimen, 35/36 patients received low molecular weight heparin enoxaparin on admission, most commonly at a dose of 60 mg daily (n = 19, 53%). Other complications presented were superinfection (n = 19, 53%), acute kidney injury (n = 11, 31%), and septic shock (n = 5, 14%). A total of 69% of patients (n = 25) required intensive care unit admission, and patients' overall mortality was 55.6%. CONCLUSION: VTE remains a significant cause of increased morbidity and mortality among patients with COVID-19. The strikingly high mortality among patients with VTE highlights the need for further investigation regarding the best preventive, diagnostic, and treatment approaches.

Thirty-three vascular residency programs among 13 countries joining forces to improve surgical education in times of COVID-19: A survey-based assessment.

BACKGROUND: Academic interaction with mentors has almost become minimal due to the current pandemic of COVID-19. The objective of this study is to introduce how a group of vascular surgery residencies joined forces to improve surgical education in times of COVID-19. METHODS: On May 2020, a group of Hispanic American vascular residency programs created webinar sessions of arterial and venous clinical cases among vascular residents across Latin America and Europe. Participants were surveyed via email. Questions were about the perceived quality and utility of the webinars; answers were stratified into negative (disagree), neutral, and positive (agree). RESULTS: There have been 60 sessions and 118 clinical cases presented. The survey was answered by 106 participants, 82 males (78.8%) and 24 women (23.0%). Fifty-four (51.9%) were board-certified vascular surgeons, 49 (47.1%) vascular surgery residents, and 2 (1.9%) general surgery residents. Mean age of the participants was 41.5 years (range: 25-74 years). Mean years of vascular surgery practice or experience were 11.2 years (range: 0-45 years). The residency programs involved in this project were from 13 different countries. Most answers received were positive for both perceived quality and utility of the webinars. CONCLUSION: Globalization and technology provide an opportunity for international education, with the goal of building well-rounded and academic vascular surgeons. This group is just the beginning of a large collaborative group among Hispanic American countries, hoping that more residency programs will join, with the aim of breaking borders in the education of vascular surgery.

Novel Combined Approach for Digital Necrosis Secondary to Raynaud's Phenomenon.

The presence of severe Raynaud's Phenomenon (RP), with permanent pain or digital necrosis is a rare condition. Cervical sympathectomy or distal sympathectomy or A botulinum toxin have demonstrated efficacy after medical treatment failure. We report the case of a 38-year-old female patient with an acute onset of severe RP in both hands secondary to systemic sclerosis. Medical treatment failed, so a novel approach by a combination of a modified distal sympathectomy and injection of A botulinum toxin on digital neuromuscular bundles was performed. Remission of the pain occurred immediately after the procedure and 45 days later she had complete healing of the digital wounds and recovered full mobilization of both hands. The patient remained asymptomatic 6 month after the procedure, and a Doppler ultrasound showed tri-phasic flows distal to the surgical site. This novel technique is described, and a brief review of the literature is performed.

3D Modeling of Blood Flow in Simulated Abdominal Aortic Aneurysm.

BACKGROUND: Besides biological factors, abdominal aortic aneurysm rupture is also caused by mechanical parameters, which are constantly affecting the wall's tissue due to their abnormal values. The ability to evaluate these parameters could vastly improve the clinical treatment of patients with abdominal aortic aneurysms. The objective of this study was to develop and demonstrate a methodology to analyze the fluid dynamics that cause the wall stress distribution in abdominal aortic aneurysms, using accurate 3D geometry and a realistic, nonlinear, elastic biomechanical model using a computer-aided software. METHODS: The geometry of the abdominal aortic aneurysm; was constructed on a 3D scale using computer-aided software SolidWorks (Dassault Systems SolidWorksCorp., Waltham MA). Due to the complex nature of the abdominal aortic aneurysm geometry, the physiological forces and constraints acting on the abdominal aortic aneurysm wall were measured by using a simulation setup using boundary conditions and initial conditions for different studies such as finite element analysis or computational fluid dynamics. RESULTS: The flow pattern showed an increase velocity at the angular neck, followed by a stagnated flow inside the aneurysm sack. Furthermore, the wall shear stress analysis showed to focalized points of higher stress, the top and bottom of the aneurysm sack, where the flow collides against the wall. An increase of the viscosity showed no significant velocity changed but results in a slight increase in overall pressure and wall shear stress. CONCLUSIONS: Conducting computational fluid dynamics modeling of the abdominal aortic aneurysm using computer-aided software SolidWorks (Dassault Systems SolidWorksCorp., Waltham MA) proves to be an insightful approach for the clinical setting. The careful consideration of the biomechanics of the abdominal aortic aneurysm may lead to an improved, case-specific prediction of the abdominal aortic aneurysm rupture potential, which could significantly improve the clinical management of these patients.

Bilateral Vein Compression by Popliteal Artery Aneurisms Mimicking Post-Thrombotic Syndrome.

PURPOSE: To report a case of a 79-year-old man who presented a bilateral popliteal artery aneurysm compressing both popliteal veins mimicking signs and symptoms of post-thrombotic syndrome. CASE REPORT: A 79-year-old male patient, was seen in the ambulatory clinic with a 2-year history of bilateral leg swelling, calf pain, chronic ulceration, and hyperpigmentation. Upon physical examination, lower extremities were edematous, with a 3 cm suppurative ulcer on each leg. Image studies showed a popliteal right arterial aneurysm of maximum diameter of 41.7 mm, extrinsically compressing the ipsilateral popliteal vein. Likewise, on the left leg, a popliteal arterial aneurysm of maximum diameter of 47.9 mm was encountered triggering the same phenomenon. Bilateral endovascular treatment deploying stent grafts was auspiciously performed. At 36-months follow up, his symptoms are completely resolved, and his ulcers healed. US follow up showed exclusion of the aneurysms with progressive shrinkage of both residual sacs. CONCLUSION: Popliteal artery aneurysm compressing and constraining flow in the popliteal vein must be included as a differential diagnosis among the causes of chronic venous syndromes. Prompt diagnosis with its appropriate treatment is needed for reducing severe complications caused by PAA, such as the venous disorder our patient had.

Type II Endoleaks After EVAR: A Literature Review of Current Concepts.

Endoleak is the most frequent complication following endovascular aneurysm repair, which is not present in the surgical counterpart. The most frequent type of endoleak corresponds to type II, and its natural history remains poorly understood. Therefore, their treatment continues to be a topic of debate. The vast majority of the studies found in the literature are of a retrospective nature, and there are no prospective studies comparing intervention versus a conservative approach. Future studies should aim to compare not only different approaches to resolve type II endoleak but also when should be the right time to treat them, with the primary purpose of avoiding sac rupture. The objective of this review is to provide the reader with a literature overview about type II endoleaks to help in the decision-making process on this topic.

A Late Post-EVAR Rupture in a 102-Year-Old Patient Related to a Type II Endoleak.

PURPOSE: Endovascular abdominal aortic aneurysm repair (EVAR) is progressively being applied in the elderly population. Type II endoleaks are common and mostly benign, but they are related to more aneurysm sac expansion after EVAR. They may lead to rupture in <1% of cases. We present a case of a centenarian with a post-EVAR rupture, related to type II endoleak, and discuss the use of EVAR on the management of this type of endoleak in an extremely old patient. CASE PRESENTATION: A 102-year-old man with a history of EVAR 12 years earlier, presented to the emergency department with a drop of consciousness. A computed tomography revealed a ruptured abdominal aortic aneurysm. Angiography showed a type II endoleak related to patent lumbar arteries deriving from collateral branches of the right internal iliac artery. Embolization was not successful and subsequently the ostium of the iliolumbar artery was overstented, obliterating the feeding branch. The postoperative course was complicated by a deterioration of chronic obstructive pulmonary disease and patient was discharged home on the seventh postprocedural day; nonetheless, he died on postoperative day sixteenth due to respiratory complications. CONCLUSION: Complications following EVAR are a real threat and emphasize the need for follow-up. The current case report shows that age per se should not be a contraindication for EVAR nor for follow-up. Also, late ruptures due to type II endoleaks could be treated in the very elderly population although larger series are required for robust conclusions.

EVAR Approach for Abdominal Aortic Aneurysm with Horseshoe Kidney: A Multicenter Experience.

BACKGROUND: Horseshoe kidney is a congenital abnormality, with an incidence of 0.25% of the total population. Only 0.12% of patients who undergo an abdominal aortic aneurysm repair might also have a coexisting horseshoe kidney. We present a series of 10 cases auspiciously treated with an endovascular approach along with their respective patient evolutions. A review of the literature is also presented. MATERIALS AND METHODS: A retrospective review of the medical records (January 2004-December 2013) of 10 patients with abdominal aortic aneurysms and horseshoe kidney treated with endovascular repair was done. Patients were treated at 6 different centers in 3 different countries. Demographics, clinical status, medical history, anatomical morphology of the aneurysms and kidneys, as well as surgical outcomes were all analyzed. RESULTS: The median age was 67.5 years (range 47-81), and the median aortic aneurysmal diameter was 57 mm (49-81 mm). A total of 35 arteries provided renal perfusion. There were 13 right renal arteries and 13 left renal arteries, all successfully preserved, with 9 isthmus arteries covered. Median hospital stay consisted of 3.5 days (1-14 days). All aortic aneurysms were successfully excluded with no endoleaks, hematomas, wound infections, or renal failure. During a median follow-up of 7 years, 3 patients died of myocardial infarction 7 years after endovascular aortic repair (EVAR), and the other 7 patients are doing well, with a median aneurysm reduction size sac of 16.5 mm. CONCLUSIONS: Endovascular repair is a safe and efficient endovascular option for the treatment of patients presenting concomitant aortic aneurysm and horseshoe kidney, with excellent short- and medium-term outcomes. To our knowledge, our study represents the largest series of cases with horseshoe kidney successfully treated via EVAR without significant complications.