Transatlantic multicenter study on the use of a modified preloaded delivery system for fenestrated endovascular aortic repair.

OBJECTIVE: Analyze the outcomes of endovascular complex abdominal and thoracoabdominal aortic aneurysm repair using the Cook fenestrated device with the modified preloaded delivery system (MPDS) with a biport handle and preloaded catheters. METHODS: A multicenter retrospective single arm cohort study was performed, including all consecutive patients with complex abdominal aortic aneurysm repair and thoracoabdominal aortic aneurysms treated with the MPDS fenestrated device (Cook Medical). Patient clinical characteristics, anatomy, and indications for device use were collected. Outcomes, classified according to the Society for Vascular Surgery reporting standards, were collected at discharge, 30 days, 6 months, and annually thereafter. RESULTS: Overall, 712 patients (median age, 73 years; interquartile range [IQR], 68-78 years; 83% male) from 16 centers in Europe and the United States treated electively were included: 35.4% (n = 252) presented with thoracoabdominal aortic aneurysms and 64.6% (n = 460) with complex abdominal aortic aneurysm repair. Overall, 2755 target vessels were included (mean ,3.9 per patient). Of these, 1628 were incorporated via ipsilateral preloads using the MPDS (1440 accessed from the biport handle and 188 from above). The mean size of the contralateral femoral sheath during target vessel catheterization was 15F ± 4, and in 41 patients (6.7%) the sheath size was ≤8F. Technical success was 96.1%. Median procedural time was 209 minutes (IQR, 161-270 minutes), contrast volume was 100 mL (IQR, 70-150mL), fluoroscopy time was 63.9 minutes (IQR, 49.7-80.4 minutes) and median cumulative air kerma radiation dose was 2630 mGy (IQR, 838-5251 mGy). Thirty-day mortality was 4.8% (n = 34). Access complications occurred in 6.8% (n = 48) and 30-day reintervention in 7% (n = 50; 18 branch related). Follow-up of >30 days was available for 628 patients (88%), with a median follow-up of 19 months (IQR, 8-39 months). Branch-related endoleaks (type Ic/IIIc) were observed in 15 patients (2.6%) and aneurysm growth of >5 mm was observed in 54 (9.5%). Freedom from reintervention at 12 and 24 months was 87.1% (standard error [SE],1.5%) and 79.2% (SE, 2.0%), respectively. Overall target vessel patency at 12 and 24 months was 98.6% (SE, 0.3%) and 96.8% (SE, 0.4%), respectively, and was 97.9% (SE, 0.4%) and 95.3% (SE, 0.8%) for arteries stented from below using the MPDS, respectively. CONCLUSIONS: The MPDS is safe and effective. Overall benefits include a decrease in contralateral sheath size in the treatment of complex anatomies with favorable results.

One Year Outcomes of an International Multicentre Prospective Cohort Study on the Gore Excluder Iliac Branch Endoprosthesis for Aorto-Iliac Aneurysms.

OBJECTIVE: The Gore Excluder Iliac Branch Endoprosthesis (IBE) was developed to preserve perfusion in the hypogastric artery after endovascular repair of aorto-iliac aneurysms. This study reports the 12 month technical and clinical outcomes of treatment with this device. METHODS: This study was a physician initiated international multicentre, prospective cohort study. The primary endpoint was primary patency of the hypogastric branch at 12 months. Secondary endpoints included technical and clinical outcomes. Patients with an indication for elective treatment with the Gore Excluder IBE were enrolled between March 2015 and August 2018. Baseline and procedural characteristics, imaging data, physical examinations and questionnaire data (Walking Impairment Questionnaire [WIQ], EuroQol-5-Dimensions [EQ5D], International Index of Erectile Function 5 [IIEF-5]) were collected through 12 month follow up. RESULTS: One hundred patients were enrolled of which 97% were male, with a median age of 70.0 years (interquartile range [IQR] 64.5 - 75.5 years). An abdominal aortic aneurysm (AAA) above threshold for treatment was found in 42.7% and in the remaining patients the iliac artery diameter was the indication for treatment. The maximum common iliac artery (CIA) diameter on the Gore Excluder IBE treated side was 35.5 mm (IQR 30.8 - 42.0) mm. Twenty-two patients received a bilateral and seven patients had an isolated IBE. Median procedural time was 151 minutes (IQR 117 - 193 minutes) with a median hospital stay of four days (IQR 3 - 5 days). Primary patency of the IBE at 12 month follow up was 91.3%. Primary patency for patients treated inside and outside the instructions for use were 91.8% and 85.7%, respectively (p = .059). Freedom from secondary interventions was 98% and 97% at 30 days and 12 months, respectively. CIA and AAA diameters decreased significantly through 12 months. IIEF-5 and EQ5D scores remained stable through follow up. Patency of the contralateral internal iliac artery led to better IIEF-5 outcomes. WIQ scores decreased at 30 days and returned to baseline values through 12 months. CONCLUSION: Use of the Gore Excluder IBE for the treatment of aorto-iliac aneurysms shows a satisfactory primary patency through 12 months, with significant decrease of diameters, a low re-intervention rate, and favourable clinical outcomes.

National Diagnostic Reference Levels for Endovascular Aneurysm Repair and Optimisation Strategies.

OBJECTIVE: The International Commission on Radiological Protection (ICRP) has highlighted the large number of medical specialties using fluoroscopy outside imaging departments without programmes of radiation protection (RP) for patients and staff. Vascular surgery is one of these specialties and endovascular aneurysm repair (EVAR) is one of the most challenging procedures requiring RP guidance and optimisation actions. The recent European Directive on Basic Safety Standards requires the use and regular update of diagnostic reference levels (DRL) for interventional procedures. The objective of the study was to know the doses of patients undergoing EVAR with mobile Xray systems and with hybrid rooms (fixed Xray systems), to obtain national DRLs and suggest optimisation actions. METHODS: The Spanish Chapter of Endovascular Surgery launched a national survey that involved hospitals for 10 autonomous communities representing the 77% of the Spanish population (46.7 million inhabitants). Patient dose values from mobile Xray systems were available from nine hospitals (sample of 165 EVAR procedures) and data from hybrid rooms, from seven hospitals, with dosimetric data from 123 procedures. The initial national DRLs have been obtained, as the third quartile of the median values from the different centres involved in the survey. RESULTS: The proposed national DRLs are 278 Gy cm2 for hybrid rooms and 87 Gy cm2 for mobile Xray systems, and for cumulative air kerma (cumulative AK) at the patient entrance reference point, 1403 mGy for hybrid rooms, and 292 mGy for mobile systems. CONCLUSION: An audit of patient doses for EVAR procedures to identify optimised imaging protocol strategies is needed. It is also appropriate to evaluate the diagnostic information required for EVAR procedures. The increase by a factor of 3.2 (for kerma area product) and 4.8 (for cumulative AK) in the DRLs needs to be justified when the procedures are performed in the hybrid rooms rather than with mobile Xray systems.

Adventitial cystic disease of radial artery. Apropos of a case and review of literature.

Adventitial cystic disease is an uncommon condition that is characterized by the collection of mucinous material that accumulates in the adventitial layer of the artery. Predominantly, this entity affects the popliteal artery, whereas it is extremely rare in the radial artery. We report a 72-year-old female patient that underwent surgical treatment of an adventitial cyst of the right radial artery. The involved arterial segment was resected, and reconstruction by means of the interposition of a saphenous vein graft was performed. Although the etiology is still debated, the finding of a pedicle through the superficial palmar branch of the radial artery connecting to the adjacent wrist joint reinforces the hypothesis of synovial origin. After 12 months, the patient is asymptomatic, and duplex ultrasound shows no signs of recurrence and patency of the bypass. This rare entity should be suspected when a pulsatile mass is noted in the radial artery because an early diagnosis and appropriate management may prevent further complications.

Fenestrated and chimney endovascular aneurysm repair versus open surgery for complex abdominal aortic aneurysms.

BACKGROUND: Many patients with complex abdominal aortic aneurysms are unfit for open repair. New endovascular technologies and bailout techniques are being used for managing these complex anatomies. The purpose of this study is to compare the results obtained with advanced endovascular aneurysm repair (a-EVAR) techniques (fenestrated and chimney endografts) to those obtained with open repair for the treatment of complex abdominal aortic aneurysms not anatomically suitable for standard endovascular exclusion (infrarenal neck <10 mm, juxtarenal, suprarenal and Crawford's type IV thoracoabdominal aneurysms). METHODS: All patients that underwent open surgery (OS cohort; historical, January 1994-December 2015) or a-EVAR (a-EVAR cohort; prospective, January 2006-December 2015) at our institution for complex abdominal aortic aneurysms that meet the anatomical criteria described above on the preoperatory contrast-enhanced computed tomography scan were included. Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (V-POSSUM) was employed for risk-assessment. RESULTS: A total of 108 patients were included, all of them male: 56 in the OS cohort and 52 in the a-EVAR cohort (mean age: 67.5±6.7 vs. 72.65±6.4 years, respectively; P=0.000). V-POSSUM predicted 4 deaths for the OS cohort and 3 deaths for the a-EVAR cohorts within the postoperative period and morbidity rates of 57% and a 44.4%, respectively. All-cause 30-day mortality rates were 9 patients (16%) for the OS cohort and 2 patients (3.8%) for the a-EVAR cohort (P=0.038). Thirty-day morbidity rates were 59% for the OS cohort and 44% for the a-EVAR cohort (P=0.09). Mean cost of treatment was € 15,707 per patient for the OS cohort (median: € 11,516; inter-quartilic range [IQR]: € 7901; min-max: € 5069-11,0052) and € 33,457 per patient for the a-EVAR cohort (median: € 29,663; IQR: € 5979; min-max: € 13,865-19,3536), P=0.000. CONCLUSIONS: A-EVAR is a feasible alternative to open surgery for complex abdominal aortic aneurysms at our institution, with lower 30-day mortality rates, yet increasing double the amount the total cost of the therapy.

Development of an individualized scoring system to predict mid-term survival after carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is a prophylactic surgery focused in preventing stroke in the mid-long term. The purpose of this study was to analyze mid-term mortality in patients undergoing CEA, identify predictors of 3-year mortality and design a score to estimate individual risk of mortality in this population. METHODS: A retrospective single-center study including consecutive patients undergoing CEA between 1997-2010. Demographic data and comorbidities, postoperative results and patient follow-up data were registered and evaluated. Kaplan Meier analysis was used to analyze survival. After multivariable COX regression analysis, a score based on the calculated Hazards Ratios (HR) was designed. The sum of all points performed the individual score for each patient for estimating 3-years mortality. Population was stratified into four groups according to percentiles of score obtained: Group A (-7 to 4 points), Group B (5-8 points), Group C (9-10 points), Group D (score greater than 11 points). RESULTS: A total of 453 patients with a mean follow-up of 53.4 months were included in the study. Overall 3-year survival was 88.4%. On the univariate analysis the variables associated with significant increasing in 3-year mortality were: female gender (OR 2.32), diabetes mellitus (OR 2.28), COPD (OR 2.98), ischemic heart disease (OR 2.29), critical carotid stenosis >90% (OR 2.16) and antiplatelet therapy as a protective factor (OR 0,23). Factors associated with mortality in multivariate analysis were age (HR 1.14 P=0.001), diabetes mellitus (HR 1.62, P=0.031), COPD (HR 1.88 P=0.022), ischemic heart disease (HR 1.59 P=0.05), critical stenosis >90% (HR 1.70 P=0.015) and antiplatelet therapy as a protective factor (HR 0.23 P=0.027). The scoring system includes the following items: female gender (+2 points), age (50-69 years +7 points, 70-79 years +12 points, >80 years +15 points), diabetes (+4 points), COPD (+5 points), ischemic heart disease (+4 points), carotid stenosis> 90% (+4 points). Antiplatelet (-7 points). The score range from -7 to 26 points. The 3-year mortality range was 5.6% (group A) versus 25.5% (group D). The incidence of stroke at 3-year folllow-up was not correlated with the score (99%, 100%, 97% and 94.5%, respectively groups A-D, P=0.11) CONCLUSIONS: The score developed based on the risk factors of mortality allows individualized risk prediction of 3-year mortality in patients with carotid stenosis. This represents a useful and practical tool for decision-making in the indication of the CEA, allowing surgeons to identify high-risk patients who would benefit from medical treatment due to their limited life expectancy, mainly in asymptomatic patients.

Arteriocutaneous Fistula Associated with Bilateral Femoral Pseudoaneurysms Caused by Bacillus Calmette-Guérin. Apropos of a Case and Review of Literature.

Vascular complications of intravesical instillation of bacillus Calmette-Guérin (BCG) are rare. BCG is an attenuated strain of Mycobacterium bovis that was initially developed for vaccination against tuberculosis, but it has also been used as an adjuvant treatment for bladder transitional carcinoma. We report a patient with a history of instillation of BCG 2 years before, who underwent surgical treatment of 2 pseudoaneurysms. The first, located in the left superficial femoral artery (SFA), was resected, and the artery was ligated because he had a history of femoropopliteal occlusion. After 4 weeks, he presented another one associated with hemorrhage by cutaneous fistula, in the right common femoral artery. In this case, revascularization was performed by means a common-to-deep femoral artery bypass with polytetrafluorethylene graft and reimplantation of SFA. Initially, bacterial cultures were negative, but bacilli cultures identified M. bovis after 3 weeks. Antituberculosis therapy was administered. After 13 months, the patient was asymptomatic and duplex ultrasound showed no signs of recurrent infection. This exposure should be considered if presentation of the false aneurysm is spontaneous and there is a history of bladder carcinoma.

Combined non-surgical treatment for Paget-Schröetter syndrome: a case report.

BACKGROUND: Paget-Schröetter syndrome is an uncommon form of venous thrombosis, which is related to thoracic outlet syndrome. Axillary-subclavian vein thrombosis typically presents in healthy young adults. We present this case of particular interest because it indicates that a combined treatment involving thrombolysis, anticoagulation therapy, rehabilitation, and elastic compression sleeves can be a valid non-surgical alternative for some patients with Paget-Schröetter syndrome. CASE PRESENTATION: This report describes a case of a 38-year-old white woman, a swimmer, who presented with a sudden episode of swelling and pain in her right upper extremity. After duplex ultrasound diagnosis of venous thrombosis, computed tomography (CT) showed extrinsic compression of the vessel. Catheter-directed thrombolysis was performed in the first 24 hours, followed by anticoagulant therapy with bemiparin at a dose of 7500 IU/24 hours for the first week, and then reduced to 3500 IU/24 hours for the next 3 months. After treatment there was restoration of her venous flow and she returned to work 2 weeks later. Anticoagulant treatment was continued for 3 months; decompression surgery was not performed. At 6 months she was asymptomatic. CONCLUSION: Combined treatment involving thrombolysis, anticoagulant therapy, rehabilitation, and elastic compression sleeves may be a valid non-surgical alternative for a selected subset of patients with Paget-Schröetter syndrome.

Applicability of Zenith p-branch Standard Fenestrated Endograft in Our Series.

BACKGROUND: In the endovascular treatment of abdominal aortic aneurysm (AAA) with short or absent infrarenal neck, the delay in the availability of fenestrated device and its high cost, have led to the manufacture of standardized models. Another option is the endografts with stents in parallel; however, regulated criteria for their use and long-term studies are lacking. The aim of this study was to assessed whether the AAA treated with fenestrated device or stents in parallel in our department, complied with the characteristics for the placement of the new endograft p-branch(®). Furthermore, the differences between the p-branch and the implanted prosthesis were analyzed. METHODS: Single-center and descriptive study of 41 aneurysms treated consecutively from 2008 to 2015. The anatomic characteristics analyzed were: relative distances between the visceral arteries, time position, diameter in the sealing area and number of fenestrations, and its compatibility with the p-branch. RESULTS: The anatomic compatibility rate with the p-branch options was 73.2% (30 cases). Of the 11 incompatible cases, 6 were due to misalignment of the visceral branches, 2 due to the aortic neck diameter being greater, another because the femoral access was inappropriate, and 2 more due to the fenestration configuration. Of the 30 cases in which compatibility existed, in 12 (40%) the configuration used coincided with the p-branch. In 13 cases, the number of fenestrations was higher than those actually used, with 23 fenestrations carried out and 39 hypothetical fenestrations with the new endograft. In the 5 remaining cases, a fenestration for the celiac trunk was necessary to achieve an adequate seal. CONCLUSIONS: The p-branch could meet the needs of three-quarters of the aortic anatomies of our series, with favorable expectations on cost and waiting time. However, in most cases either a higher number of fenestrations are needed for visceral arteries or the proximal seal was shorter than would be ideal.

Rapidly expanding ulnar false aneurysm related to a tablet computer.

Aneurysms of the ulnar artery are rare, usually related to the hypothenar hammer syndrome and caused by repetitive blunt trauma over the hook of the hamate bone. However, rapidly expanding ulnar false aneurysms are extremely rare, and nearly all are caused by a penetrating injury. We report a singular case of rapidly expanding pseudoaneurysm caused by the repetitive use of the hypothenar eminence as the supporting point of a tablet computer. This tablet model has a notch on its posterior side that played an essential role in the pathogenesis. This report illustrate that even low-intensity trauma can be an exceptional cause of injury to the palmar portion of the ulnar artery, and subsequently, can lead to the development of these lesions. The false aneurysm was repaired by means of resection and reconstruction by an end-to-end anastomosis because a rapid diagnosis and surgical treatment can prevent further complications.

The Roadside Technique for Type II Endoleak Embolization 4 Years after Endovascular Aortic Aneurysm Repair.

Endoleaks are the most common cause of reintervention after endovascular aortic aneurysm repair (EVAR). Type II endoleaks have been implicated as a risk factor for expansion and rupture. Several techniques have been described to manage type II endoleaks, being transarterial catheterization the most commonly used. In some cases this technique can be difficult or impossible to achieve. We report the use of a technique that offers a direct access to the aneurysm sac and the possibility of catheterization of the involved vessels or the embolization of the communication between them, even 4 years after EVAR.

Endograft-assisted coil embolization of a celiac trunk aneurysm.

BACKGROUND: Celiac trunk aneurysms are rare but potential life-threatening lesions. Endovascular techniques are more often used for their treatment because of low rates of morbidity and mortality. CASE REPORT: We describe a modification of stent-assisted coil embolization technique more commonly used in the treatment of intracranial aneurysm, to exclude a 50-mm diameter celiac trunk aneurysm. The patient was a 67-year-old man who had a previous exclusion of a symptomatic aortic aneurysm, with occlusion of the inferior mesenteric and both hypogastric arteries. Anatomic features of the celiac trunk aneurysm and its branches do not allow treatment with a straight endograft or maintain direct flow to the hepatic artery. We then performed an endograft-assisted coil embolization of the aneurysm, with a straight flow line to the splenic artery. CONCLUSION: Endograft-assisted coil embolization is a feasible and safe technique to allow selective embolization of the sac and the presence of direct flow to the splenic artery and indirect flow to the hepatic artery.

Predictors of cervical bleeding after carotid endarterectomy.

BACKGROUND: The aim of this study is to determine the incidence of severe cervical bleeding requiring reintervention after carotid endarterectomy (CEA), to identify its predictive parameters, and to find out the influence of these on major complications. METHODS: This was a retrospective review of 502 CEAs carried out in 455 consecutive patients between 1995-2011 in our institution. The end points were: postoperative cervical bleeding that required reoperation and major postoperative complications (i.e., stroke, myocardial infarction, and death). Patients' demographics, antiplatelet and anticoagulant treatment, anaesthetic technique, surgical details, and perioperative management were registered. The end point predictors were univariate and multivariate analyzed. RESULTS: Neck bleeding after CEA occurred in 42 cases (8.4%), requiring reoperation in 28 cases (5.6%). In the univariate analysis, chronic anticoagulation and anticoagulation 24 hours before surgery were associated with reoperation for bleeding (16.6% vs. 4.8% [P = 0.02] and 17.8% vs. 4.7% [P = 0.014], respectively). The agent used for antiplatelet treatment before surgery was related to reoperation in the univariate analysis and was the only factor with statistical significance in the multivariate analysis: acetylsalicylic acid (ASA) 100 mg (2.4%), ASA 300 mg (1.5%), clopidogrel 75 mg (7.8%), ASA 100 mg associated with clopidogrel (3.3%), triflusal (5.5%), and ticlopidine (2.2%); there was a higher incidence of reoperation only in the group of patients who had taken clopidogrel 24 hours before CEA (4.7% vs. 1.05% [P = 0.06], respectively) but without statistical significance (odds ratio: 2; 95% confidence interval: 0.95-4.84). No reoperations were registered using vein patch compared to prosthetic patch (0% vs. 6.1% [P = 0.028]). Conversion to general anesthesia (22.2% vs. 4.9% [P = 0.014]) and noncontrollable postoperative hypertension (6.9% vs. 2.5% [P = 0.028]) were associated with a higher rate of reoperation. There were no statistically significant differences in the reoperation rates related to bleeding for anesthetic technique (local versus general), surgical procedure (classic endarterectomy versus eversion technique), type of prosthetic patch (Dacron/politetrafluoroethylene), use of shunt, intraoperative dose of heparin, protamine reversal, activated clotting time monitoring, or surgeon qualification level. The combined rate of stroke mortality was 2.6%. Reoperation for bleeding was not associated with an increased rate of thrombosis, stroke, death, or injury of cranial nerves. CONCLUSIONS: Postoperative severe bleeding after carotid surgery in our institution is not an uncommon complication. Its incidence is within the range reported in the literature, but it is not associated with major complications or mortality. Antiplatelet treatment with clopidogrel is the main risk factor associated with reintervention. Other factors, such as coagulation control, postoperative hypertension management, and the use of an autologous patch, could help reduce its incidence.

[Natural history of moderate-degree carotid stenosis in patients with peripheral artery disease]. / Historia natural de la estenosis carotídea de grado moderado en pacientes con enfermedad arterial periférica.

BACKGROUND AND OBJECTIVE: To understand the evolution of moderate asymptomatic carotid stenosis, the factors that influence its progression and the related morbimortality. PATIENTS AND METHODS: Retrospective observational study of 133 patients with asymptomatic carotid stenosis between 50-69% in one or both carotids between 2002 and 2009. Included patients were subjected to screening for peripheral arterial disease (PAD), aneurysmal disease or carotid bruit. The monitoring was carried out using an annual duplex scan. The rate of progression, the variables related to this, the appearance of neurological events, and global and cardiovascular mortality were evaluated. Descriptive studies, univariate analysis (chi-squared test and Student's t-test), multivariate analysis (logistic regression), and survival curves (Log-Rank test) were carried out. RESULTS: With an average time of monitoring: 30.8 ± 1.7 months, stenosis progression was observed in 33% of the patients, with an average progression time of 31.3 ± 2.7 months. Greater progression was observed in the subgroup of patients with PAD and ischemic heart disease (odds ratio [OR] 2.84, confidence interval [CI] 95% 1.14-7.03). In the multivariate analysis only the PAD was identified as a risk factor for progression (P=.043). The group of patients with progression showed greater rates of neurological events: 15 vs. 1.6% (P=.01), greater global mortality: 15 vs. 3% (P=.04), and greater cardiovascular mortality: 12.1 vs. 1.5% (P=.03). CONCLUSIONS: The progression of asymptomatic carotid stenosis between 50-69% is common in patients subjected to screening, especially in those with a history of ischaemic heart disease and/or PAD. This progression is associated with an increased rate of cardiovascular complications. For this reason, we recommend clinical and echographic follow-up of these patients.

Endovascular repair of an iliac arteriovenous fistula secondary to perforation from a common iliac aneurysm in a patient with Ehler-Danlos syndrome.

BACKGROUND: Type IV Ehler-Danlos syndrome (EDS) patients are prone to life-threatening vascular complications. Surgical management of those complications is challenging owing to vessel wall fragility, which may result in hemorrhagic events and high mortality rates. Here we report a case of left common iliac aneurysm perforation of the ipsilateral iliac vein repaired using endovascular technique in a patient with EDS. METHOD AND RESULTS: A 54-year-old patient presented with heart failure symptoms that evolved over 1 week in association with left leg edema and steal syndrome due to a perforation of the left iliac vein caused by a left common iliac aneurysm. A thrombosed right common iliac aneurysm and several other visceral and peripheral aneurysms were discovered on computed tomographic scan at admission. An aortouniiliac stent graft was used to seal the fistula. After 18 months of follow-up, the patient remained asymptomatic. CONCLUSIONS: We suggest that endovascular therapy is useful to manage vascular complications in patients with EDS.

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm.

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.

Popliteal artery aneurysm in patient with Klippel--Trénaunay--Weber syndrome.

BACKGROUND: The association of Klippel-Trénaunay-Weber syndrome (KTWS) with artery aneurysms is very rare. METHODS AND RESULTS: A 61-year-old man, diagnosed with left lower limb KTWS, presented with a venous ulcer and a popliteal aneurysm measuring 3.5 cm in diameter in the same limb. Endovascular treatment with covered stent was applied with good morphological and clinical results. CONCLUSION: We report a singular case of the association of a popliteal aneurysm with KTWS and its endovascular treatment. This treatment enabled exclusion of the popliteal artery aneurysm with safety and effectiveness and reduced the number of arteriovenous fistulas.

Endovascular treatment of a ruptured iliac aneurysm previously excluded.

We report a case of an isolated ruptured iliac artery aneurysm that had previously been treated, 25 months before, with iliac endovascular exclusion. Urgent computed tomographic (CT) scan showed the retroperitoneal hematoma and a type IA endoleak. On an emergency basis, at the operating room, an aortouni-iliac graft and femorofemoral crossover bypass were performed, successfully. This is a very rare but serious complication and requires careful indication and close follow-up with CT. In isolated common iliac artery aneurysms, the common iliac artery and distal aorta may tend to enlarge with failure of the endograft proximal attachment site and migration, thus leading to a late aneurysm rupture. A safe length and width, especially of the proximal sealing zone, should be accurately defined and closely followed up, or otherwise complete exclusion of the aortoiliac arteries should be considered.

[Value of the Doppler-ultrasonography for the diagnosis of temporal arteritis]. / Valor de la ecografía Doppler en el diagnóstico de la arteritis de la temporal.

BACKGROUND AND OBJECTIVE: The aim of this study was to investigate the accuracy of color Doppler-ultrasonography (CDU) compared with biopsy for the diagnosis of temporal arteritis (TA). PATIENTS AND METHOD: Twenty-three patients with suspected TA on the basis of clinical criteria were evaluated with CDU prior to temporal artery biopsy. The presence of a hypoechoic halo, suggesting edema of the inflamed vessel, and inflammatory stenoses were registered. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and eficiency or global test value (GTV) were evaluated. RESULTS: All patients completed a bilateral CDU examination of temporal arteries, and in 72% of patients the biopsy was negative for TA. When the presence of an halo in CDU examination was regarded as determinant for disease, sensitivity, specificity, PPV, NPV and GTV compared with TA histologic confirmation were 80%, 92%, 80%, 92% and 88%, respectively. When the criteria used was presence of the halo sign with or without inflammatory stenosis, the values were 100%, 77%, 62.5%, 100% and 83% respectively. CONCLUSIONS: Because of the high sensitivity and NPV, we consider CDU as a good screening test for the diagnosis of TA.