Strategies to prevent TEVAR-related spinal cord ischemia.

Spinal cord ischemia remains the Achilles' heel of thoracic and thoracoabdominal diseases management. Great improvements in morbidity and mortality have been obtained with the endovascular approach TEVAR (Thoracic Endovascular Aortic Repair) but this devastating complication continues to severely affect the quality of life, even if the primary success of the procedure - dissection/aneurysm exclusion - has been achieved. Several strategies to deal with this complication have been published in the literature over the time. Knowledge and technology have been evolving from identification of the risk factors associated with spinal cord ischemia, including lessons learned from open surgery, and from developments in the collateral network concept for spinal cord perfusion. In this comprehensive review, the authors cover several topics from the traditional measures comprising haemodynamic control, cerebrospinal drainage and neuroprotective drugs, to the staged-procedures approach, the emerging MISACE (minimally invasive selective segmental artery coil-embolization) and innovative neurologic monitoring such as NIRS (near-infrared spectroscopy) of the collateral network.

Emergency Nightmares - Rupture of Type III Thoracoabdominal Aneurysm.

Introduction The rupture of thoracoabdominal aneurysms (rTAA) represents one of the major challenges to the vascular surgeon. Recent developments in the endovascular armamentarium and the high mortality from open surgery make endovascular treatment an attractive option. Devices to be used in an emergency environment should be "off-the-shelf" and include, among others, EVAR snorkel/chimney and branched endoprosthesis (T-branch, Cook®). METHODS: We describe the case of a 70-year-old patient who was admitted to the emergency room due continuous low back pain with 3 days of evolution. RESULTS: The tomographic computer angiography showed a type III thoracoabdominal aneurysm, with a transverse maximum diameter of 75x81mm in the infrarenal aorta and an exuberant hematoma in the left retroperitoneum, but no active extravasation of the contrast was observed (Figure 1). There was still marked tortuosity and moderate iliac calcification. It was decided to place a branched endoprosthesis (34 mm diameter at the top and 18 mm at the bottom). The branched endoprosthesis was extra-corporeally oriented, and introduced through a right femoral approach. The final position was verified with the digital subtraction angiography in anteroposterior incidence, ensuring that the distal border of each branch was 1.5 to 2 cm above the target vessel and that the stent marks presented the desired position. After the endoprosthesis was opened, the branches are catheterized by the left axillary access, however, it was verified that the endoprosthesis had an antero-posteriorly inverted implantation. It was possible to catheterize the superior mesenteric artery and the left renal artery (celiac trunk occlusion was documented intraoperatively); occlusion of the remaining endoprosthesis branches was performed with an Amplatzer. The patient evolved with multiorgan dysfunction and died at 24 hours post-operatively. CONCLUSION: Implantation of an off-the-shelf branched endoprosthesis requires specific anatomical criteria such as aortic diameter> 25mm to allow catheterization of the vessels, the possibility of incorporating each target vessel at a 90o angle in relation to each branch and visceral arteries with a diameter between 4 and 8 mm. Anatomy review is important to understand the lengths and positions of the branches. It should be borne in mind that it is possible that the device might have to be rotated during implantation to better align the marks and that both incidences (anteroposterior and profile) may be useful in confirming the position, something that should be thoroughly pursued to safeguard a correct implantation regardless of the initial stent position in your delivery system.

[TEVAR: a strategy for the diversity of thoracic aorta disease. Series of cases and national prospect]. / Tevar: uma solução para a diversidade de patologias da aorta torácica: revisão institucional e panorama nacional.

OBJECTIVE: To assess endovascular treatment of thoracic aorta diseases in a national centre of angiology and vascular surgery. To quantify the national registry of TEVAR's. MATERIAL AND METHODS: This unicentric and retrospective study included patients submitted to TEVAR until the end of 2012. Twenty-seven patients were considered high-risk for conventional surgery: 14 degenerative thoracic aorta aneurysms or pseudoaneurysms (10 assymptomatic), 1 ruptured thoracoabdominal aneurysm, 5 aortabronchial/aortoesophageal fistulas, 3 complicated dissections, 2 penetrating atherosclerotic ulcer/intramural hematoma, 1 traumatic laceration and 1 embolization from aortic plaque. Eighteen (67%) were emergent/urgent procedures. RESULTS: At the institutional level, immediate technical success was achieved in all cases; average follow up was 24 months (0-97). Thirty days and 24 months global mortality was, respectively, 4% (6% for emergent/urgent procedures and 0% for elective procedures) and 13%. Aortic-related mortality was similar. One case of paraplegia and 2 of case of stoke were registered. Endoleak was present in 4 patients. Survival free from aneurysmal sac expansion (aneurysm, pseudoaneurysm or dissection, n=16) was 88% at 30 days. Survival free from aortic reintervention was 93% at 30 days and 81% at 24 months. Nationally, TEVAR registries triplicated from 2007 top 2010. CONCLUSION: These results favour the actual tendency to consider TEVAR as a first-line solution for several thoracic aortic diseases.