Outcomes of Elective and Non-elective Fenestrated-branched Endovascular Aortic Repair for Treatment of Thoracoabdominal Aortic Aneurysms.

OBJECTIVE: To describe outcomes after elective and non-elective fenestrated-branched endovascular aortic repair (FB-EVAR) for thoracoabdominal aortic aneurysms (TAAAs). BACKGROUND: FB-EVAR has been increasingly utilized to treat TAAAs; however, outcomes after non-elective versus elective repair are not well described. METHODS: Clinical data of consecutive patients undergoing FB-EVAR for TAAAs at 24 centers (2006-2021) were reviewed. Endpoints including early mortality and major adverse events (MAEs), all-cause mortality, and aortic-related mortality (ARM), were analyzed and compared in patients who had non-elective versus elective repair. RESULTS: A total of 2603 patients (69% males; mean age 72±10 year old) underwent FB-EVAR for TAAAs. Elective repair was performed in 2187 patients (84%) and non-elective repair in 416 patients [16%; 268 (64%) symptomatic, 148 (36%) ruptured]. Non-elective FB-EVAR was associated with higher early mortality (17% vs 5%, P <0.001) and rates of MAEs (34% vs 20%, P <0.001). Median follow-up was 15 months (interquartile range, 7-37 months). Survival and cumulative incidence of ARM at 3 years were both lower for non-elective versus elective patients (50±4% vs 70±1% and 21±3% vs 7±1%, P <0.001). On multivariable analysis, non-elective repair was associated with increased risk of all-cause mortality (hazard ratio, 1.92; 95% CI] 1.50-2.44; P <0.001) and ARM (hazard ratio, 2.43; 95% CI, 1.63-3.62; P <0.001). CONCLUSIONS: Non-elective FB-EVAR of symptomatic or ruptured TAAAs is feasible, but carries higher incidence of early MAEs and increased all-cause mortality and ARM than elective repair. Long-term follow-up is warranted to justify the treatment.

Comparison of single- and multistage strategies during fenestrated-branched endovascular aortic repair of thoracoabdominal aortic aneurysms.

OBJECTIVE: The aim of this study was to compare outcomes of single or multistage approach during fenestrated-branched endovascular aortic repair (FB-EVAR) of extensive thoracoabdominal aortic aneurysms (TAAAs). METHODS: We reviewed the clinical data of consecutive patients treated by FB-EVAR for extent I to III TAAAs in 24 centers (2006-2021). All patients received a single brand manufactured patient-specific or off-the-shelf fenestrated-branched stent grafts. Staging strategies included proximal thoracic aortic repair, minimally invasive segmental artery coil embolization, temporary aneurysm sac perfusion and combinations of these techniques. Endpoints were analyzed for elective repair in patients who had a single- or multistage approach before and after propensity score adjustment for baseline differences, including the composite 30-day/in-hospital mortality and/or permanent paraplegia, major adverse event, patient survival, and freedom from aortic-related mortality. RESULTS: A total of 1947 patients (65% male; mean age, 71 ± 8 years) underwent FB-EVAR of 155 extent I (10%), 729 extent II (46%), and 713 extent III TAAAs (44%). A single-stage approach was used in 939 patients (48%) and a multistage approach in 1008 patients (52%). A multistage approach was more frequently used in patients undergoing elective compared with non-elective repair (55% vs 35%; P < .001). Staging strategies were proximal thoracic aortic repair in 743 patients (74%), temporary aneurysm sac perfusion in 128 (13%), minimally invasive segmental artery coil embolization in 10 (1%), and combinations in 127 (12%). Among patients undergoing elective repair (n = 1597), the composite endpoint of 30-day/in-hospital mortality and/or permanent paraplegia rate occurred in 14% of single-stage and 6% of multistage approach patients (P < .001). After adjustment with a propensity score, multistage approach was associated with lower rates of 30-day/in-hospital mortality and/or permanent paraplegia (odds ratio, 0.466; 95% confidence interval, 0.271-0.801; P = .006) and higher patient survival at 1 year (86.9±1.3% vs 79.6±1.7%) and 3 years (72.7±2.1% vs 64.2±2.3%; adjusted hazard ratio, 0.714; 95% confidence interval, 0.528-0.966; P = .029), compared with a single stage approach. CONCLUSIONS: Staging elective FB-EVAR of extent I to III TAAAs was associated with decreased risk of mortality and/or permanent paraplegia at 30 days or within hospital stay, and with higher patient survival at 1 and 3 years.

Surgical and endovascular treatment of late postcoarctation repair aortic aneurysms: Results from an international multicenter study.

OBJECTIVE: The formation of postaortic coarctation aneurysms (pCoAA) is well-described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair, depending on the clinical presentation, risk assessment, and anatomy. The aim of this study was to report the early and midterm results of open surgical and endovascular repair of pCoAA. METHODS: This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The preoperative, intraoperative, and postoperative data were recorded and analyzed. RESULTS: A total of 74 patients (46 male; median age, 44 years; interquartile range [IQR], 35-53 years) underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation at a median age of 11 years for the index procedure (IQR, 7-17 years). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. The median pCoAA diameter was 54 mm (IQR, 44-63 mm). The median time from the aortic coarctation repair to the pCoAA diagnosis was 33 years (IQR, 25-40 years). A total of 33 patients had symptoms at presentation, including thoracic or back pain in 8 patients. Open surgical repair was performed in 28 patients, including four frozen elephant trunk procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one frozen elephant trunk and one endovascular). After a median follow-up of 50 months (IQR, 14-127 months), there were a total of seven reinterventions. CONCLUSIONS: This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Because the median time between the coarctation repair and the aneurysm formation was more than 30 years, life-long surveillance of these patients is warranted.

Results of endovascular aortic arch repair using the Relay Branch system.

OBJECTIVES: Our goal was to evaluate results of endovascular aortic arch repair using the Relay Branch system. METHODS: Forty-three patients with thoracic aortic pathology involving the aortic arch have been treated with the Relay Branch system (Terumo Aortic, Sunrise, FL, USA) in 10 centres. We assessed in-hospital mortality, neurological injury, treatment success according to current reporting standards and the need for secondary interventions. In addition, outcome was analysed according to the underlying pathology: non-dissective disease versus residual aortic dissection (RAD) (defined as remaining dissection after previous type A repair, chronic type B aortic dissections). RESULTS: In-hospital mortality was 9% (0% in patients with RAD). Disabling stroke occurred in 7% (0% in patients with RAD); non-disabling stroke occurred in 19% (7% in patients with RAD). Early type IA and B endoleak formation occurred in 4%. Median follow-up was 16 ± 18 months. During the follow-up period, 23% of the patients died. Aortic-related deaths were low (3% in patients with RAD). CONCLUSIONS: The results of endovascular aortic arch repair using the Relay Branch system in a selected patient population with regard to technical success are good. In-hospital mortality is acceptable, the number of disabling strokes is low and technical success is high. Non-disabling stroke is a major concern, and every effort has to be taken to reduce this to a minimum. The best outcome is seen in patients with underlying RAD. Finally, more data are needed.

Lessons Learned from the Impact of the COVID-19 Pandemic in a Vascular Surgery Department and Preparation for Future Outbreaks.

OBJECTIVES: This study aims to report the changes and adaptations of a vascular tertiary center during a global pandemic and the impact on its activity and patients. METHODS: We conducted a retrospective cohort study within the Vascular Surgery ward in Centro Hospitalar Universitário Lisboa Norte, Portugal. All data from surgical, inpatient and outpatient activity were collected from February to June 2020 and compared to the same 5-month period in 2018 and 2019. We ran a descriptive analysis of all data and performed statistical tests for the variation of procedures and admissions between February and June 2018 and the same time period in 2020. RESULTS: During the outbreak, our staff had to be readapted. Six nurses were transferred to COVID-19 units (out of a total of 33 nurses) while 1 of the 7 residents was transferred to an intensive care unit and 1 senior surgeon was put on prophylactic leave. In the outpatient clinic, there was an increase in the number of telemedicine consultations with a greater focus on first-time referrals and urgent cases. There was a significant increase in the total number of elective admissions whereas there were significantly less admissions from an emergency setting (+57% and -54%, respectively, P < 0.001). The vascular surgery team performed a total number of 584 procedures between February and June 2020 (-17.8% compared to 2018 and 2019), with a significant increase in the number of endovascular procedures (P < 0.001) and in the use of local and regional anesthesia (P < 0.001), especially in the Angio Suite (+600%, P < 0.001). Comparing with 2018 and 2019, the surgical team performed less outpatient procedures in early 2020. We reported a significant increase in the total number of procedures for patients with a chronic limb-threatening ischemia (CLTI) diagnosis (+21%, P < 0.001). We did not report significant changes in the proportion of other vascular conditions. Regarding mortality, we observed a 16% decrease in the intraoperative mortality (P 0.67). CONCLUSIONS: In this study, we assessed the impact of the COVID-19 outbreak in daily activity during the contingency period. During the outbreak, there was an overall decline in outpatient clinics and inpatient admissions. Nevertheless, and despite the restrictions imposed by the pandemic and health authorities, we managed to maintain most procedures for most vascular diseases, particularly for CLTI urgent cases, without a significant increase in the mortality rate. Stringent protective measures for patient and staff or higher use of endovascular techniques and local anesthesia are some of the successful changes implemented in the department. These learned lessons are to be pursued as the pandemic evolves with future outbreaks of COVID-19, such as the current second outbreak currently spreading through Europe.

Clinical aspects and present challenges of the seat belt aorta.

OBJECTIVE: Seat belt aorta is rare and difficult to manage. The lack of data and follow-up increases the complexity of treating such patients. We aimed to create a decision algorithm by reviewing our current experience and analyzing the presentation and management of our patients. METHODS: We performed a descriptive case series based on retrospective analysis of all consecutive patients admitted with the diagnosis of seat belt aorta from 2008 to 2018. Seat belt aorta was defined as any blunt abdominal aortic lesion resulting from a seat belt compression mechanism after a car accident. RESULTS: Nine consecutive patients were admitted with the diagnosis of seat belt aorta, all of whom developed lesions in the infrarenal aorta. Eight patients were assessed in the acute phase and one patient presented with late-onset symptoms. Associated injuries were present in all acute patients, and seat belt sign and small bowel injury were present in 88%. One patient presented with a small intimal tear and was treated conservatively. All other patients diagnosed with large intimal flaps (seven patients) and pseudoaneurysm (one patient) underwent open repair in five cases and endovascular repair in three cases. In-hospital mortality for the acute cases was 38%, with no mortality seen during follow-up. Two patients submitted to endovascular repair required reinterventions. CONCLUSIONS: Seat belt aorta is a deadly condition, frequently associated with blunt thoracoabdominal trauma with concomitant injuries; the presence of a seat belt sign or lower limb ischemia must lead to a high diagnostic suspicion. Management must take into account the other concomitant injuries. Follow-up is crucial as most patients are young; they may develop complications and subsequently require further intervention.

Clinical outcomes of aortic arch hybrid repair in a real-world single-center experience.

OBJECTIVE: Aortic arch aneurysmal disease remains a therapeutic challenge. For patients unsuitable for standard open surgery, hybrid repair with debranching of the supra-aortic arteries followed by thoracic endovascular grafting has been shown to be an effective solution. The aim of this study was to report the clinical outcomes of a single-institution experience using hybrid aortic arch repair. METHODS: The cases of all consecutive patients submitted to hybrid aortic arch repair between January 2010 and June 2018 were prospectively collected and retrospectively analyzed. The outcomes of the study were 30-day mortality, perioperative complications, 2-year survival, endoleak, and reintervention rates. RESULTS: A total of 35 patients with a median age of 71 years (interquartile range, 62-77 years) were submitted to hybrid aortic arch repair, with a median follow-up of 26.9 months (interquartile range, 2.4-63.6 months). Ten procedures (28.6%) were performed urgently for contained rupture. The most common etiology was degenerative (n = 14 [40.0%]). The proximal landing zones according to the Ishimaru classification were zone 2 in 20 patients (57.1%), zone 1 in 12 patients (34.3%), and zone 0 in 3 patients (8.6%). Early endoleaks were observed in six patients (17.1%), equally distributed between type I and type II. Late endoleaks were identified in 4 of 24 patients (16.7%; type I, n = 2 [8.3%]; type II, n = 1 [4.2%]; and type III, n = 1 [4.2%]). Thirty-day mortality rate was 14.3% (n = 5) with an early death rate of 8.7% (2/23) in elective cases and 30.0% (3/10) in urgent cases (odds ratio [OR], 4.93; confidence interval [CI], 0.68-35.67; P = .128). Except in one patient, 30-day mortality was associated with landing zone 0 or zone 1 (26.7% vs 5.0%; OR, 6.91; CI, 0.68-69.86; P = .141). Three patients (8.6%) suffered a postoperative stroke, and no episodes of spinal cord ischemia were observed. Two-year survival rate was 67.8% (CI, 49.4%-80.8%). Survival rates were significantly lower with increasing age (hazard ratio [HR], 1.10; CI, 1.03-1.18; P = .004), urgent procedure (HR, 4.80; CI, 1.56-14.80; P = .003), zone 0 or zone 1 (HR, 6.34; CI, 1.73-23.18; P = .001), presence of arrhythmia (HR, 3.76; CI, 1.22-11.62; P = .013), and cerebrovascular disease (HR, 4.12; CI, 1.38-12.35; P = .006). A multivariate analysis identified age (HR, 1.11; P = .047) and zone 0 or zone 1 (HR, 4.93; P = .033) as the only predictors for overall mortality. CONCLUSIONS: Hybrid aortic arch repair seems to be an alternative for higher risk patients not suitable for open repair, but selection of patients is crucial and may benefit from further refinement. In this study, worse outcomes were seen in older patients and those who required more proximal landing zones.

A single-center experience in the eversion femoral endarterectomy.

OBJECTIVES: Endarterectomy is the treatment of choice for arterial occlusive disease of the femoral bifurcation. Longitudinal arteriotomy and prosthetic patch angioplasty is the standard technique but, due to the increasing concerns with prosthetic-related infections and multidrug-resistant pathogens our group adopted an alternative approach. We present our experience with eversion femoral endarterectomy. METHODS: All patients submitted to eversion femoral endarterectomy in a single institution during 2016-2019 were retrospectively analyzed. Patient demographics, surgical data, and complications were captured from medical records. RESULTS: Nineteen patients, 84.2% male and a median age of 67 years (IQR 62-78) were submitted to eversion femoral endarterectomy with a median follow-up of 180 days (IQR 71-395). Seventeen (89.4%) patients were treated for chronic limb ischemia and the other two were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Most of the patients had smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). Only 3 patients (15.8%) were submitted exclusively to endarterectomy, 13 (68.4%) were submitted to endarterectomy as an adjuvant for peripheral endovascular treatment, 2 (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm, and 1 (5.3%) was complemented with thrombectomy of the femoro-popliteal sector. Primary patency rates were 100% and 87.5% (CI (38.7-98.1)) at 6 and 12 months, respectively. Primary-assisted and secondary patency rates were 100%. The 30-day mortality rate was 5.3% (n = 1) and complication rate 10.5% (n = 2). One patient complicated with acute renal disease related to rhabdomyolysis. Another patient developed a wound-related hematoma treated with surgical drainage, but died three days after consequent to ischemia-reperfusion injury. CONCLUSIONS: Eversion femoral endarterectomy is a safe and feasible technique, with good patency results and respecting the concept of leaving nothing behind. A careful control of the proximal and distal endpoints is essential for the success of the technique.

Surgical Treatment of Post-Carotid Endarterectomy Carotid Pseudoaneurysm.

Post-endarterectomy pseudoaneurysms (PEPA) are a rare complication of carotid endarterectomy (CEA), but are associated with high morbidity risk. Therefore, once they are diagnosed, treatment is urgent to prevent possible complications such as rupture, embolisation, thrombosis, or airway and cranial nerve compression. In this video, the surgical procedure is shown in a case of PEPA 10 years after CEA with patch angioplasty, which was successfully managed by surgical excision and interposition of great saphenous vein graft. Follow up duplex examination at six months was normal, with patency of the vein graft. This case reiterates the importance of open surgery as the treatment of choice for this difficult clinical setting.

An Original Bailout Solution for Renal Artery Dissection after Fenestrated/Branched EVAR.

BACKGROUND: Renal artery (RA) dissection may occur during endovascular treatment of thoracoabdominal aneurysms. The aim of this paper is to report the use of kissing coronary stents in the renal bifurcation as a bailout solution for dissection after fenestraded/branched endovascular aortic repair (F/B-EVAR). METHODS/RESULTS: A 73-year-old male with an asymptomatic Crawford type 4 thoracoabdominal aneurysm and a concomitant right common iliac artery aneurysm was proposed for endovascular repair, consisting of thoracic endovascular aortic repair plus custom-made device F/B-EVAR, followed by staged bifurcated EVAR plus right-sided IBD. In the control angiogram of the first procedure, a distal occlusion of the left renal artery was observed and attributed to iatrogenic dissection. The 6F sheath was reintroduced and the two main branches of the RA were catheterized with 0.014 wires. Then, two coronary drug-eluting stents were used for a kissing stenting technique with good angiographic and clinical results. As planned, one week later the patient underwent an uneventful second stage procedure. Follow-up CTA at 1 year showed normal patency of the renal stents as well as aneurysm shrinking and no signs of endoleak. CONCLUSIONS: In the reported case, the use of coronary stents was a safe and long-lasting solution to rescue an iatrogenic renal artery dissection during F/B-EVAR.

Hybrid Surgery in Lower Limb Revascularization: A Real-World Experience from a Single Center.

BACKGROUND: Through the association of endovascular and open procedures, hybrid surgery for lower limb revascularization allows the treatment of multilevel occlusive disease with a lower risk when compared to extensive open interventions. The aim of this study is to evaluate the immediate and midterm clinical outcomes of hybrid techniques for lower limb revascularization in a cohort of patients with multilevel arterial disease. METHODS: Data from elective procedures between 2012 and 2017 were retrospectively collected regarding hybrid lower limb revascularization procedures. The outcomes of the study were categorical clinical improvement, patency rates, major amputation rates, and mortality. RESULTS: A total of 81 patients, 89 limbs, with a median age of 69 years (interquartile range [IQR] 61-73) were submitted to hybrid lower limb revascularization, with a median follow-up of 10.7 months (IQR 2.5-25.1). Treatment indications were chronic limb-threatening ischemia in 80.9% of the cases (rest pain in 18.0% and tissue loss in 62.9%). One-year primary, primary-assisted, and secondary patency rates were 78.28% (95% confidence interval [CI] 65.20-86.92), 85.12% (95% CI 72.96-92.09), and 90.19% (95% CI 79.13-95.54), respectively. Overall categorical clinical improvement was observed in 56.2%. Major amputation and mortality rates were 14.6% and 16.0%, respectively. Multilevel Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) C or D and stage IV Leriche-Fontaine classification were strongly associated with decreased categorical clinical improvement (adjusted odds ratio [aOR] 0.08, P < 0.0001 and aOR 0.25, P = 0.013, respectively). Multilevel TASC C or D was also related to higher amputation rates, contrary to clinical presentation (adjusted hazard ratio [aHR] 11.37, P = 0.002 and aHR 4.70, P = 0.091, respectively). Primary-assisted and secondary patency rates were associated with higher categorical clinical improvement (aOR 4.30, P = 0.036 and aOR 7.36, P = 0.021, respectively) and decreased major amputation rates (aHR 0.11, P = 0.003 and aHR 0.09, P = 0.001, respectively) but were not related to multilevel TASC and Leriche-Fontaine classifications. CONCLUSIONS: The present study reports a real-world experience with a large proportion of patients with chronic limb-threatening ischemia. Hybrid interventions for lower limb revascularization revealed to be a potential approach for patients with complex arterial disease that would beneficiate from less invasive procedures.

Complete Disruption of The Iliac Vessels During Spinal Surgery With Delayed Presentation.

INTRODUCTION: The posterior approach to the lumbar spine is most commonly used to treat lumbar spine pathology. Vascular complications, although rare, have a high mortality rate. This is the report of an arterial lesion complicating a L5 hemilaminectomy and its surgical resolution. The need to remain vigilant for this condition, which requires prompt diagnosis and treatment, is emphasised. REPORT: A 31 year old woman was admitted to the neurosurgery department with L5 right-sided sciatica and an associated radiculopathy, and paraesthesia of the first toe of the right foot. She had previously undergone surgical correction of a L4 - L5 lumbar disc herniation, as well as a left oophorectomy and chemotherapy for ovarian neoplasia. A right L5 hemilaminectomy associated with right L5 - S1 foraminotomy and L5 - S1 discectomy was performed with the patient in the ventral position. The procedure was carried out without any apparent complications. In the first three post-operative days the patient complained persistently of orthostatic hypotension and a drop in haemoglobin was observed. Computed tomography angiography revealed what appeared to be a complete transection of the right common iliac artery and vein, with active haemorrhage, and a large pseudoaneurysm. Immediate surgery was carried out with reconstruction consisting of a 9 mm Dacron graft interposed in the right common iliac artery, as well as ligation of the right common iliac vein, which was not amenable to repair. The post-operative period was uneventful. The patient was discharged on day 13 with normal lower limb pulses and mild oedema of the right lower limb, controlled with elastic compression stockings. DISCUSSION: Iatrogenic injuries of the large abdominal vessels during spinal surgery is rare but serious. Close patient surveillance and remaining vigilant for these life threatening vascular lesions are crucial in the peri-operative period of spinal surgery.

Endovascular Repair of Bilateral Carotid Dissection in a Near Hanging Victim.

INTRODUCTION: There is much debate in the literature regarding the management of blunt cervical carotid injuries. This report describes a case of bilateral carotid artery dissection in the very uncommon case of a near hanging victim and the treatment controversies regarding its management. REPORT: A 50 year old male patient was admitted after attempted suicide through hanging, having been swiftly rescued by a bystander. On admission, six hours after the event there was no neurological deficit. There was evidence of soft tissue damage related to the rope position, subcutaneous emphysema, and neck swelling. The CT angiogram showed dissection of both common carotid arteries with significant luminal narrowing as well as fracture of the thyroid cartilage; brain injury was excluded. Heparin infusion was started and an endovascular repair with bilateral covered stent placement, requiring coverage of the external carotid artery on the left side, was performed. The vascular procedure was uneventful. The patient was discharged 36 days after the event, on dual antiplatelet drugs and under regular psychiatric and speech therapy care, and is currently alive and well 22 months after surgery with no neurological damage. DISCUSSION: The choice of treatment was not straightforward as there are no guidelines or consensus around its management. In this case, however, an endovascular repair seemed suitable and the result was optimal, with no neurological damage and a good result after 22 months.

Early Experience with the Use of Inner Branches in Endovascular Repair of Complex Abdominal and Thoraco-abdominal Aortic Aneurysms.

OBJECTIVES: Visceral arteries in fenestrated and branched endovascular repair (F/BEVAR) have been addressed by fenestrations or directional side branches. Inner branches, as used in the arch branched device, could provide an extra option for visceral arteries "unsuitable" for fenestrations or directional side branches. Early experience with the use of inner branches for visceral arteries in F/BEVAR is described. METHODS: All consecutive patients treated by F/BEVAR for complex abdominal aortic aneurysm (AAA) or thoraco-abdominal aneurysm (TAAA) using stent grafts with inner branches were included. Data were collected prospectively. RESULTS: Thirty-two patients (28 male, mean age 71.6 ± 8.3 years) were included. Seven (21.9%) patients had a complex AAA and 25 (78.1%) had a TAAA. A stent graft with inner branches only was used in four (12.5%) patients. The remaining 28 (87.5%) patients received a stent graft with fenestrations and inner branches. In total 52 vessels were targeted with inner branches. Technical success was achieved in all 32 (100%) patients. All 38 inner branch target vessels in grafts including fenestrations and inner branches were instantly catheterised (<1 minute), whereas catheterisation of target vessels in "inner branch only" grafts proved more difficult (<1 minute, n = 3; 1-3 min, n = 4; and >3 min, n = 7). The 30 day operative mortality was 3.1% (1/32). Estimated survival at 1 year was 80.0% ± 8.3%. During follow-up, four renal inner branches occluded in three patients. The estimated inner branch target vessel stent patency at 1 year was 91.9 ± 4.5%. The estimated freedom from re-intervention at 1 year was 78.4% ± 8.9%. CONCLUSIONS: Early data suggest that visceral inner branches might represent a feasible third option to address selected target vessels in F/BEVAR. Stent grafts with inner branch(es) in combination with fenestrations seem to be a better configuration than stent grafts with inner branches alone. Durability of the inner branch design needs further investigation.

Rectus femoris muscle flap based on proximal insertion mobilization to cover a groin infected vascular graft.

The rectus femoris (RF) muscle flap, which is widely used to cover groin infected vascular grafts, is usually harvested through distal tendon division and an extensive muscle elevation and transposition into the groin wound defect. A case of a vascular prosthetic graft infection in the groin was successfully controlled after coverage with an RF flap that was harvested based on proximal portion mobilization instead of the conventional distal one. This case suggests that the RF muscle flap based on proximal insertion mobilization is a feasible, effective, technically simpler, and less invasive alternative to cover infected vascular grafts in the groin.

[A new method of ostial revascularization of digestive and renal arteries in complex obstructive aortic pathology]. / Um novo método de revascularização ostial das artérias digestivas em patologia aórtica obstrutiva complexa.

A new method of revascularization of digestive and renal arteries is reported in this paper, accomplished through the intra-aortic or ostial root, in a 53-year old woman, with the diagnosis of thrombotic occlusion of the terminal aorta associated to a protuberant and calcified lesion of the supraceliac aorta ("coral reef"). The procedure consisted in the implantation of a bifurcated prosthesis from the descending thoracic aorta to both common iliac arteries, through the diaphragm, followed by a longitudinal aortotomy aimed at the removal of the "coral reef" lesion and revascularization of renal, mesenteric and celiac arteries, by means of additional prosthesis placed between the bypass graft and the ostia of these arteries. The left renal artery was reattached to the bypass graft. Visceral ischemic times were short. The post operative course was uneventfull. Two months later, an angio-CT disclosed the complex procedure of revascularization working in excellent condition. The advantages of this new method of revascularization of abdominal visceral arteries in complex obstructive aortic pathology are analysed and discussed.

[Revascularization surgery of an anuric solitary kidney using the left colic artery as a free graft]. / Cirurgia de revascularização de rim único em anúria utilizando a artéria cólica esquerda como enxerto livre.

The thrombotic occlusion of one renal artery may become completely asymptomatic, due to the functionality of the contralateral kidney. However, in rare circumstances, such is the case of individuals with a solitary kidney, a situation of anuria and acute renal failure may constitute the main presentation of the condition. The authors report the clinical case of a 43 year old male patient, with the previous diagnosis of an infrarenal aortic occlusion and a single left kidney, who developed a thrombotic occlusion of the renal artery, with anuria and acute renal failure. The patient underwent an emergency revascularization procedure, consisting in the implantation of a prosthetic bypass graft from the superceliac aorta to the renal artery, with immediate recovery of the diuresis and renal function. Seventeen months later as a consequence of an anastomotic hyperplasia, an occlusion of the bypass graft occurred, again with anuria and acute renal failure. The patient was reoperated on and due to the inadequacy of both saphenous veins to be used as the material of choice for the revascularization procedure, a redundant segment of the left colic artery (Riolan's arcade) was removed and used as an interposition graft, from the middle colic artery to the renal artery, followed by an immediate restoration of diuresis and renal function. The singular and recurrent character of this clinical condition and the utilization of an original, eventually unique and well succeeded revascularization procedure, prompted its presentation and divulgation.