ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique): A New Technical Option for Recanalization of Complete Superior Mesenteric Artery Occlusion in Chronic Mesenteric Ischemia.

OBJECTIVE: To report our experience with a new technique for recanalization of the superior mesenteric artery (SMA)/celiac trunk (CT) with complete occlusion at the origin. TECHNIQUE: We describe our ABS-SMART (Aortic Balloon Supporting for Superior Mesenteric Artery Recanalization Technique) for recanalization of the CT and SMA in cases of complete occlusion of these arteries with a short or inexistent stump, which usually corresponds to chronic lesions with important calcification of the ostium. CONCLUSION: The ABS-SMART is an alternative for the recanalization of visceral arteries in cases where other conventional techniques have failed. It is particularly useful in scenarios characterized by a short occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin. CLINICAL IMPACT: Catheterization and recanalization of visceral stenoses may pose a challenge in some cases, as for example in the presence of a very narrow angle between the root or origin of the vessel and the aorta, as well as in the case of long and calcified stenoses, or when arteriography is unable to visualize the origin of the vessel. The present study describes our experience with the endovascular revascularization of visceral vessels using an aortic balloon-supported recanalization technique not previously described in the literature, that may be an effective alternative for the treatment of lesions of difficult access, such as total occlusion at the origin of the target vessel, with no entry stump or severe calcification at the origin of the SMA and CT, by improving the chances for technical success.

A multicenter study of emergency endovascular repair of the thoracic aorta: Indications and outcomes.

OBJECTIVE: Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE: A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA: 1) Ruptured descending thoracic aortic aneurysms (RTAA); 2) Blunt traumatic thoracic aortic injury (TAI); and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES: Patient mortality, survival and reoperation rate. SECONDARY VARIABLES: Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS: A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ±â€¯16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the RTAA group (27.9%). The mean actuarial survival rate was 67 ±â€¯6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS: Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.

A multicenter study of emergency endovascular repair of the thoracic aorta: indications and outcomes. / Estudio multicéntrico de la reparación endovascular urgente de la aorta torácica: indicaciones y resultados.

OBJECTIVE: Endovascular techniques have become an essential tool for the treatment of descending thoracic aortic disease (thoracic endovascular aneurysm repair [TEVAR]). The aim is to analyze the indications and outcomes of emergency TEVAR at national level in relation to elective surgery. STUDY DESIGN AND SCOPE: A retrospective multicenter registry of patients with descending thoracic aortic disease treated on an emergency basis using endovascular techniques between 2012-2016, in 11 clinical units. PATIENTS, INCLUSION CRITERIA: 1) Ruptured descending thoracic aortic aneurysms; 2) Blunt traumatic thoracic aortic injury; and 3) Complicated acute type B aortic dissections (TBADc). PRIMARY VARIABLES: Patient mortality, survival and reoperation rate. SECONDARY VARIABLES: Demographic data, cardiovascular risk factors, specific data by indication, technical resources and postoperative complications. RESULTS: A total of 135 urgent TEVARs were included (111 men, mean age 60.4 ± 16.3 years): 43 ruptured thoracic aortic aneurysms (31.9%), 54 type B dissections (40%) and 32 traumatic aortic injuries (23.7%), and other etiologies 4.4%. The overall mortality rate at 30 days was 18.5%, and proved higher in the ruptured descending thoracic aortic aneurysms group (27.9%). The mean actuarial survival rate was 67± 6% at 5 years. The postoperative stroke rate was 5.2%, and the paraplegia rate was 5.9%. Aortic reoperations proved necessary in 12 patients (9%). CONCLUSIONS: Emergency descending thoracic aortic diseases can be treated by endovascular techniques with optimal results and low morbidity and mortality - though the figures are slightly higher than in elective cases. This registry provides, for the first time, real information on the daily clinical practice of emergency TEVAR in Spain.

Acute lower limb ischemia in a patient with aortic thrombus and essential thrombocytosis.

Aortic thrombus is rare in patients with essential thrombocytosis (ET), so the optimal treatment remains undefined. A 45-year-old man with history of ET, under chronic treatment with aspirin, presented to the emergency department complaining of acute onset in both the legs and abdominal pain. Physical examination revealed that both dorsalis pedis pulses were not palpable with cold and pale feet. His abdomen was soft and nondistended. The platelet count was 436 x 10(9)/L. The thoraco-abdominal computerized tomographic scanning revealed normal aortic diameter with supraceliac and infrarenal nonoccluding thrombus and infarction areas in spleen and left kidney. At the emergency department he presented with recurrent symptoms, losing bilateral posterior tibial pulses. A decision was made to perform a thoracoretroperitoneal incision. A longitudinal sequential aortotomy was performed in the distal thoracic and infrarenal aorta, and the thrombus was easily removed. Following this, he underwent bilateral crural thrombectomy and local intra-arterial thrombolytic therapy. The postoperative course was uneventful. The left toes were amputated because of necrosis. He was discharged and put on antiaggregants, anticoagulants and hydroxyurea. Aortic thrombus in patients with ET is unusual, but potentially lethal. There is complete relief from symptoms in recurrent cases following surgery. An appropriate medical treatment after intervention must be supported.

Surgical treatment of distal renal artery expansive pseudoaneurysm after blunt trauma.

Renal artery pseudoaneurysms are rare after blunt abdominal trauma. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or car accidents. Patients may be asymptomatic for months or years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. We report a case of distal renal artery pseudoaneurysm in a 51-year-old male patient, who had had a previous trauma while playing tennis 16 months ago. It was diagnosed by consecutive computed tomography-scans demonstrating a thrombosed pseudoaneurysm of the distal right renal artery, with progressive enlargement and involving persistent pain. Angiography showed right lower polar artery aneurysm and a small renal infarction due to a distal branch thrombosis. Open surgery was performed revealing a hole in a segmentary artery ostium, that was sutured with single stitches. The patient was discharged a few days late with normal renal function. Despite the development of endovascular techniques, sometimes surgical treatment is the only therapeutic alternative.

Surgery for aortoiliac aneurysm after kidney transplant.

OBJECTIVE: Although aortoiliac aneurysm in kidney transplant patients is uncommon, aortic clamping during the surgical repair of an aneurysm could pose a risk to the grafted kidney and might also increase the risk of vascular prosthesis infection due to immunosuppression. Herein, we present our results related to the treatment of the aortoiliac aneurysm subsequent to kidney transplant. MATERIAL AND METHODS: Four male kidney transplant recipients underwent surgery for aortoiliac aneurysm repair. RESULTS: In the first patient, we protected the kidney graft by perfusion with cold physiological saline. No such protective measures were taken in the remaining three patients other than reducing warm ischemia to a minimum. In one patient with occlusive disease and impaired graft function, renal function improved after surgery. In the other three patients renal function was unaffected by surgery. Despite immunosuppression, no infection of the prostheses was observed. CONCLUSIONS: Surgery for aortoiliac aneurysm can be safely performed in kidney transplant patients. No ischemic damage is incurred by the graft and perioperative infection can be easily avoided. The need to protect the graft during the surgical procedure should be evaluated in each individual case according to predicted times of ischemia and vascular reconstruction and preoperative graft function.