RESUMO
BACKGROUND: Endovascular aneurysm repair (EVAR) using a bifurcated stent graft may involve technical challenges when aortic disease (aneurysm or dissection) consists of a length <70 mm between the inferior renal artery and aortic bifurcation or narrow aortic bifurcation that is common in asymmetric distal abdominal aortic aneurysms (AAAs) or iliac artery aneurysms (IAAs). We use EVAR with the double D technique (DDT-EVAR) for such cases, which involves straight type of stent grafts with same diameter in left and right that are deployed parallel to an aortic cuff that has been previously placed. In addition, DDT-EVAR can preserve the inferior mesenteric artery (IMA) for IAA. METHODS: DDT-EVAR was performed for 21 of 910 (2%) cases from April 2007 to April 2019 at our institution. The median patient age was 74 years (range, 52-85). Nineteen patients (90%) were men. Six patients (all saccular; 1 rupture) had AAAs, 12 had IAAs, and 3 had chronic type B aortic dissociation (TBAD) for re-entry closure. AAA and IAA had diameters of 45 mm (range, 34-71) and 34 mm (range, 25-58), respectively. An aortic cuff was used for 19 (90%) cases. Endurant II (Medtronic, Santa Rosa, CA) was used for 12 cases. The Excluder (W.L. Gore & Associates, Inc, Flagstaff, AZ) was used for 7 cases. Endurant II was used for 20 cases, and the VBX (W.L. Gore & Associates, Inc) was used for 1 case as stent-graft limbs. RESULTS: The procedural success rate was 100%. The median operative time was 146 min (range, 88-324). IMA planned for preservation was successful for all 12 cases. Type I and type III endoleaks were not observed. With TBAD, flow to the false lumen decreased or disappeared, and no complications during the hospital stay were associated with the procedure. For 2 patients whose procedure involved Endurant II stent-graft limb, limb occlusions were observed postoperatively, and reintervention was required. No other patients required additional treatment at a median follow-up of 18 months (range, 4-50). CONCLUSIONS: DDT-EVAR is a safe and straightforward technique for the treatment of distal AAA, common iliac artery aneurysm, and TBAD. It may help preserve the IMA and internal iliac artery, even when it is impossible to preserve them with a bifurcated stent graft.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Dissecção Aórtica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Aneurisma Ilíaco/cirurgia , Stents , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico por imagem , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/terapia , Retratamento , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Mycotic aortoiliac aneurysms in neonates are rare. Surgical treatment has traditionally been the standard of care, but recent case reports have suggested that endovascular management of mycotic iliac aneurysms may also be safe and effective. In this case, we describe successful management of a mycotic aortoiliac aneurysm in a neonate with exploratory laparotomy and ligation of the left common iliac artery. METHODS: A full-term infant boy of uncomplicated delivery was transferred to our institution on day 2 of life after a barium enema concerning for small left colon syndrome. An umbilical artery catheter had been placed for monitoring but was removed before transfer. During his hospital course, he developed left leg edema and fever. He was found to have a mycotic aneurysm of the left common and internal iliac arteries, causing common iliac venous compression. A repeat ultrasound revealed the aneurysm measured a maximum of 12 mm in diameter and 26 mm in length. RESULTS: Treatment was delayed until the patient was clinically stable. He was monitored with serial ultrasounds, which showed no significant increase in aneurysmal size. A review of the literature supported the perception the aneurysm posed an impending risk to the patient. On day 16 of life, the neonate underwent ligation and excision of the left common iliac artery aneurysm. CONCLUSION: Our experience found ligation of the common iliac artery to be safe and effective, establishing that surgical reconstruction is not required.
Assuntos
Aneurisma Infectado/cirurgia , Aneurisma Ilíaco/cirurgia , Aneurisma Infectado/diagnóstico por imagem , Aneurisma Infectado/microbiologia , Angiografia por Tomografia Computadorizada , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Aneurisma Ilíaco/microbiologia , Recém-Nascido , Ligadura , Masculino , Resultado do Tratamento , Ultrassonografia Doppler em CoresRESUMO
A total of 576 patients underwent endovascular aneurysm repair using main body devices for treatment of abdominal aortic aneurysms or iliac artery aneurysms. During follow-up, type IIIb endoleaks caused by fabric tear occurred in six patients (1.0% [6/576]). The device used was Zenith (Cook Medical, Bloomington, Ind) in five cases and Talent (Medtronic, Santa Rosa, Calif) in one case. All endoleaks were close to the flow divider of the main body devices. The distance between the lower renal artery and the top end of the contralateral leg was 53 ± 14 mm. Bell-bottom-shaped Excluder (W. L. Gore & Associates, Flagstaff, Ariz) legs were placed parallel from the top of the main body device through both legs to treat these endoleaks. In two patients, coil embolization was required to treat gutter endoleaks. Postoperative computed tomography showed the obliteration of type IIIb endoleaks in all patients. Our technique may be an acceptable method for treatment of type IIIb endoleaks, especially when they occur near the flow divider.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Aneurisma Ilíaco/cirurgia , Falha de Prótese , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Ecocardiografia Doppler em Cores , Embolização Terapêutica , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Masculino , Desenho de Prótese , Resultado do TratamentoRESUMO
Use of endovascular means is gaining ever greater acceptance in the treatment of aorto-iliac aneurysms. Especially, the treatment of patients with common iliac aneurysms (CIAs) may be very challenging due to the complexity of the underlying disease with often involvement of the hypogastric artery. Additionally, the variety of endovascular therapeutic options such as the use of iliac branch devices, parallel grafts, the bell-bottom technique or coil embolization of the hypogastric artery and overstenting of the origin represents significant limitation regarding the presentation of a clear and robust endovascular therapeutic algorithm. Aim of the present article was the demonstration of the institutional experience with the endovascular management of CIAs in order to provide a clinical recommendation and algorithm.
Assuntos
Algoritmos , Implante de Prótese Vascular , Procedimentos Clínicos , Procedimentos Endovasculares , Aneurisma Ilíaco/cirurgia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Desenho de Prótese , Fatores de Risco , Stents , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the influence of endovascular therapy of ruptured abdominal or iliac aneurysms on total mortality. MATERIALS AND METHODS: We analyzed the mortality of 40 patients from 2005 to 2009, when only surgical treatment was available. These results were compared with the period 2010 to 2013, when endovascular aneurysm repair (EVAR) was assessed as the first option in selected patients. RESULTS: During 2005 to 2009, the mortality was 37.5%. From 2010 to 2013, 45 patients were treated with mortality 28.9%. Open repair was performed in 35 (77.8%) patients and EVAR in 10 (22.2%) patients. The 30-day and 1-year mortality rates of the EVAR group were 0% and 20%, respectively, and the total mortality rate was 30% during follow-up (median 11 months, range 1-42 months). The 30-day mortality in the surgical group remained unchanged, at 37.1%, and 1-year and total mortality rates were 45.7% and 51.4%, respectively. CONCLUSION: Following integration in the treatment algorithm, EVAR decreased total mortality in our center by 8.6%.
Assuntos
Algoritmos , Aneurisma Roto/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Prestação Integrada de Cuidados de Saúde , Procedimentos Endovasculares , Hospitais Universitários , Aneurisma Ilíaco/cirurgia , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/diagnóstico , Aneurisma Roto/mortalidade , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/mortalidade , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Procedimentos Clínicos , República Tcheca , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Estudos de Viabilidade , Feminino , Humanos , Aneurisma Ilíaco/diagnóstico , Aneurisma Ilíaco/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Stents , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
We performed an endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) and a ruptured common iliac artery aneurysm (rCIAA) in a patient complicated by severe liver dysfunction due to obstructive jaundice resulting from hepatocellular carcinoma (HCC). A 68-year-old male presented with acute lower abdominal pain. Abdominal computed tomography (CT) showed a 4.5-cm infrarenal AAA, a 6.0-cm left rCIAA with retroperitoneal hematoma and a 13-cm mass in the liver, which was suspected to be HCC. His laboratory data showed severe liver dysfunction. An emergency EVAR was done under local anesthesia because of his liver dysfunction. He was transferred to another hospital without any complications.
Assuntos
Aneurisma Roto/etiologia , Aneurisma Roto/cirurgia , Aneurisma da Aorta Abdominal/etiologia , Aneurisma da Aorta Abdominal/cirurgia , Carcinoma Hepatocelular/complicações , Procedimentos Endovasculares/métodos , Aneurisma Ilíaco/etiologia , Aneurisma Ilíaco/cirurgia , Neoplasias Hepáticas/complicações , Idoso , Anestesia Local , Emergências , Humanos , Icterícia Obstrutiva/etiologia , Hepatopatias/etiologia , Masculino , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
An 84-year-old woman with heaviness of the right lower extremity had an iliocaval fistula related to a right internal iliac aneurysm. Immediately after deployment of an endovascular device, cardiac arrest occurred because of severely decreased sympathetic activity. After surgery, the patient recovered well and has been followed up with exclusion of the arteriovenous fistula and resolution of the type II endoleak. Endovascular treatment for large arteriovenous fistulas induces rapid closure of the fistula together with restoration of blood supply to the lower extremity. Markedly deactivated sympathetic nerve traffic could result in a critical hemodynamic status in association with endograft deployment.
Assuntos
Fístula Arteriovenosa/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Parada Cardíaca/etiologia , Aneurisma Ilíaco/cirurgia , Artéria Ilíaca/cirurgia , Veia Cava Inferior/cirurgia , Idoso de 80 Anos ou mais , Aortografia , Fístula Arteriovenosa/diagnóstico , Fístula Arteriovenosa/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Estimulação Cardíaca Artificial , Eletrocardiografia , Endoleak/etiologia , Procedimentos Endovasculares/instrumentação , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/terapia , Massagem Cardíaca , Hemodinâmica , Humanos , Aneurisma Ilíaco/diagnóstico , Aneurisma Ilíaco/fisiopatologia , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Stents , Sistema Nervoso Simpático/fisiopatologia , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/fisiopatologiaRESUMO
Introduction: Spontaneous dissection of the iliac artery (SDIA) is an extremely rare clinical manifestation, associated to different etiologies, and it usually shows an ischemia of the involved lower extremity. Clinical case: We report a case of a 48-year-old man, with past medical history of chronicle consumption of ergotamine, which presented left lower limb ischemia, while practicing physical exercise. An emergent contrast-enhanced computed tomography scan showed a spontaneous dissection of the common and the external left iliac artery. An endovascular therapy of the lesion was performed with self-expanding stents, achieving the reconstruction of the lesion, the recovery of the blood flow and of the lower limb ischemia. Conclusions: There are no previous descriptions of the association between ergotamine consumption, sport and this very rare pathology. Endovascular treatment represents a less invasive and, such as in our case report, successful management of the SDIA, and it should be considered among the alternative therapies.
Introducción: La disección espontánea de la arteria ilíaca es un cuadro muy poco frecuente asociado a diferentes etiologías que habitualmente se presenta como isquemia de la extremidad comprometida. Caso clínico: Se reporta el caso de un paciente masculino de 48 años con antecedente de consumo crónico de ergotamina, quien mientras practicaba deporte presenta cuadro de isquemia aguda de la extremidad inferior izquierda. Angio tomografía computada demostró disección espontánea de la arteria ilíaca común y externa izquierda. Se realizó terapia endovascular de la lesión con stents auto expandibles, logrando la reparación de la lesión, el restablecimiento del flujo y la recuperación de la isquemia de la extremidad. Discusión y conclusiones: No existen reportes previos de esta patología poco frecuente, en que se asocie en forma conjunta la práctica de deporte y el uso de ergotamina. Dentro de las alternativas terapéuticas, la reparación endovascular representa una opción menos invasiva y, como en este caso, con óptimos resultados.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Dissecção Aórtica/cirurgia , Aneurisma Ilíaco/cirurgia , Exercício Físico , Ergotamina/efeitos adversos , Dissecção Aórtica/etiologia , Aneurisma Ilíaco/etiologia , Procedimentos Endovasculares/métodos , Stents , Resultado do TratamentoRESUMO
We report the case of a 76-year-old man of the Jehovah's Witness faith who had a giant abdominal aortoiliac aneurysm that was successfully operated on using an aortoiliac Y-graft bypass technique, without the use of stored allogenic blood. Cell saver technique and recombinant human erythropoietin (epoetin beta) were used during the perioperative period. The patient had good postoperative care with a multidisciplinary approach.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue Autóloga , Implante de Prótese Vascular , Aneurisma Ilíaco/cirurgia , Testemunhas de Jeová , Religião e Medicina , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Transfusão de Sangue Autóloga/instrumentação , Epoetina alfa , Eritropoetina/uso terapêutico , Hematínicos/uso terapêutico , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Masculino , Proteínas Recombinantes , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
INTRODUCTION: acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles' tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations. METHODS: twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation. RESULTS: median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n=3), or retroperitoneal access (n=2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascularre-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair. DISCUSSION: our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome.
Assuntos
Anestesia Local , Aneurisma Roto/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Aneurisma Ilíaco/cirurgia , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/diagnóstico por imagem , Angiografia , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Feminino , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Modification of endografts are required to simplify and improve the safety of the endovascular management of abdominal aortic aneurysms (AAA). OBJECTIVES: The aim of this study is to evaluate the efficacy of a new custom-made, tubular and bifurcated device. MATERIALS AND METHODS: The graft consisted of a continuous, self-expanding, stainless steel, Z-stent structure, covered with a thin wall PTFE tube. Bifurcated grafts were constructed in vivo from three PTFE tubes with a continuous Z-stent structure. Twenty-seven high risk patients with a mean age of 74 (62-86) years and AAA, mean diameter 5.9 cm, were treated in the last 26 months. Tube grafts were deployed in 13 aortic and one iliac cases, bifurcated grafts in nine cases and aorto-uni-iliac grafts with femorofemoral bypass in four cases. Grafts were deployed percutaneously under local anaesthesia. Patients were followed with contrast CT periodically. RESULTS: All grafts were deployed. There were no open conversions or other major complications. There were nine proximal and one distal postoperative endoleak. Four sealed spontaneously, three were treated successfully with endovascular techniques and three are under surveillance. In the 7 (2-23) months follow-up, one patient died due to heart failure 3 months post-procedure. CONCLUSIONS: Local anaesthesia and percutaneous graft introduction simplify and improve the efficacy of the procedure. Continuous aortic graft support provides stability and reduces the risk of migration. PTFE is a flexible, low-profile material for use in endovascular stent-grafts. The bifurcation concept used offers a simple technique for bifurcated grafts.