Surgical Outcomes of Infective Native Aortoiliac Aneurysms in a Chilean Academic Center.

BACKGROUND: Infective native aortic aneurysms (INAAs), formerly called mycotic aneurysms, remain an uncommon disease with significant heterogeneity among cases; hence, there is lack of solid evidence to opt for the best treatment strategy. The present study aims to describe a 20-year experience at a single institution treating this uncommon condition. METHODS: Retrospective study of all patients treated for INAA at a single academic hospital in Santiago, Chile, between 2002 and 2022. Clinical characteristics are described, as well as operative outcomes per type of treatment. Nonparametric Mann-Whitney U-test or Kruskal-Wallis tests were performed when appropriate, and results were reported as median and ranges. Survival at given timeframes was determined by a Kaplan-Meier curve, with analysis performed through a Cox regression model. RESULTS: During the study period, 1,798 patients underwent aortic procedures at our center, of which 35 (1.9%) were treated for INAA. Of them, 25 (71.4%) were male. One patient had 2 INAAs. Median age was 69.5 years (range: 34-89 years). Of the 36 INAAs, the most frequent location was the abdominal and thoracic aorta in 20 (55.5%) and 11 (30.5%) cases, respectively, followed by the iliac arteries in 4 (11.1%) cases. One (2.7%) patient presented a thoracoabdominal INAA. Overall, endovascular treatment associated with long-term antibiotics was used in 20 (57.1%) patients: 4 of them underwent hybrid treatment. Fifteen (42.8%) patients underwent direct aortic debridement followed by in situ or extra anatomic revascularization. There was a significant difference in age between both treatment strategies (a median of 76.5 years for endovascular versus a median of 57 years for open, P = 0.011). The median hospital stay was 15 days (range: 2-70 days). The early complications rate (<30 postoperative days) was 20% (n = 7). Early mortality rate (inhospital or before postoperative 30 days) was 14.2% (n = 5). Median follow-up was 33 months (range: 6-216 months). The overall survival rates at 1, 3, and 5 years were 69.9% (standard error [SE] 8.0), 61.7% (SE 9.8), and 50.9% (SE 11.8), respectively. Five-year survival rate of patients undergoing endovascular treatment compared with open approach was 45.9% (SE 15.1) versus 80.0% (SE 17.8), respectively (P = 0.431). There were no significant differences in survival between open and endovascular treatment, hazard ratio 3.58 (confidence interval 95%: 0.185-1.968, SE ± 0.45 P = 0.454). CONCLUSIONS: Patients treated by endovascular approach were older than patients treated by open approach. Even though, the open group had a higher 5-year survival rate than the endovascular group, not statically significance differences were found between treatments.

Management of Spontaneous Isolated Celiac Artery Dissection.

BACKGROUND: Spontaneous isolated celiac artery dissection (SICAD) is uncommon, with very few series reported in the literature. The present study aims to describe the clinical characteristics and treatment outcomes of patients with SICAD treated at a single Chilean institution over 20 years. METHODS: A retrospective review of all patients from a single academic hospital with SICAD diagnosed between January 2003 and March 2023 was performed. Conservative treatment included antiplatelets, anticoagulation, or both. The normal size of a celiac artery in our population was 7.9 ± 0.79 mm in females and 8.3 ± 1.08 mm in males. We defined a celiac artery with a diameter equal to or more than 12.5 mm as an aneurysmal celiac artery. RESULTS: The cohort included 27 patients; 77.8% (n = 21) were males. The median age was 51.0 years (range: 38-84 years). Fourteen (51.8%) patients presented with aneurysmal dilatation. Fourteen (51.8%) patients were treated with antiplatelets, 6 (22.2%) patients with anticoagulation, and 7 (25.9%) with anticoagulation and antiplatelets. One patient was treated with endovascular therapy due to a pseudoaneurysm of the celiac artery detected 10 days after conservative treatment with antiplatelets. The median length of hospital stay was 5 days (range: 2-14 days). Complete remodeling was seen in 6 (22.2%) patients, partial remodeling in 10 (37.0%) patients, and no change was seen in 8 (26.9%) patients. Three (11.5%) patients were lost to follow-up. There were no significant differences between treatments and remodeling outcomes (P = 0.729). The median celiac artery diameter of patients with aneurysmal dilatation was 13.5 mm (range: 12.5-20.5 mm). Systemic arterial hypertension was found more commonly in patients who presented with aneurysmal dilatation than in patients without (87.5% vs. 12.5%, respectively, P = 0.016). Mean follow-up was 41.5 months and median follow-up was 16 months (range: 6-204 months). CONCLUSIONS: Most patients with SICAD can be treated conservatively with excellent outcomes. Hypertension was more commonly found in patients with SICAD and aneurysmal dilatation.

Extrinsic venous compression secondary to spine osteophytes.

OBJECTIVE: This study aims to report two cases of symptomatic extrinsic compression of the inferior vena cava and left iliac vein caused by vertebral osteophytes. METHODS: We present two case reports of extrinsic venous compression by vertebral osteophytes. Both cases were endovascularly treated, with a successful outcome. A review of the literature of this unusual condition is also presented. RESULTS: The first patient is an 80-year-old woman who presented to the vascular surgery clinic with bilateral lower extremity edema and pain. A computed-tomography angiography (CTA) revealed extrinsic compression of the inferior vena cava from enlarged osteophytes. Venography and intravascular ultrasound were performed, confirming the diagnosis. A self-expanding venous stent was successfully deployed in the inferior vena cava relieving the extrinsic compression. The edema resolved the following day and was discharged without complications. The second patient is a 61-year-old male that presented to the emergency department with a left iliofemoral deep venous thrombosis. CTA showed left iliac vein compression by a lumbar osteophyte. Percutaneous thrombectomy was successfully achieved and an expanding stent was deployed covering the entire lesion. One month after the procedure the patient died from COVID-19-associated respiratory failure. CONCLUSION: Osteophytes must be considered when dealing with extrinsic venous compression, especially in elderly people.

Thirty-three vascular residency programs among 13 countries joining forces to improve surgical education in times of COVID-19: A survey-based assessment.

BACKGROUND: Academic interaction with mentors has almost become minimal due to the current pandemic of COVID-19. The objective of this study is to introduce how a group of vascular surgery residencies joined forces to improve surgical education in times of COVID-19. METHODS: On May 2020, a group of Hispanic American vascular residency programs created webinar sessions of arterial and venous clinical cases among vascular residents across Latin America and Europe. Participants were surveyed via email. Questions were about the perceived quality and utility of the webinars; answers were stratified into negative (disagree), neutral, and positive (agree). RESULTS: There have been 60 sessions and 118 clinical cases presented. The survey was answered by 106 participants, 82 males (78.8%) and 24 women (23.0%). Fifty-four (51.9%) were board-certified vascular surgeons, 49 (47.1%) vascular surgery residents, and 2 (1.9%) general surgery residents. Mean age of the participants was 41.5 years (range: 25-74 years). Mean years of vascular surgery practice or experience were 11.2 years (range: 0-45 years). The residency programs involved in this project were from 13 different countries. Most answers received were positive for both perceived quality and utility of the webinars. CONCLUSION: Globalization and technology provide an opportunity for international education, with the goal of building well-rounded and academic vascular surgeons. This group is just the beginning of a large collaborative group among Hispanic American countries, hoping that more residency programs will join, with the aim of breaking borders in the education of vascular surgery.

[Concentrating ruptured abdominal aortic aneurysm surgery in specialized centers]. / Concentración de la cirugía de aneurisma de aorta abdominal roto en centros especializados calificados.

Ruptured abdominal aortic aneurysm (RAAA) is an arterial emergency with an overall mortality of 80%-90% secondary to massive hemorrhage. If a patient with RAAA presents in a primary hospital without resolution capacity, survival will depend on early transfer to a center with adequately trained specialists. This article reviews the evidence supporting the centralization of AAAR treatment in qualified centers, specifying the criteria used for the selection of referral centers and the role of a coordinating unit. Our current referral system, which is based primarily on costs, is also described. Patients with AAAR who consult in non-resolving centers should be rapidly transferred to a qualified referral center, following a transfer protocol, and guided by a coordinating unit acting according to technical and established criteria based on results, quality, and costs. Qualified referral centers should have an accredited vascular surgeon and a high institutional aortic surgery volume, adequate infrastructure, endovascular resolution capacity, support services (intensive care, hemodialysis, etc.) and specialized personnel permanently available.

Endovascular treatment of a right pulmonary sequestration supplied by an aneurysmal aberrant artery originating from the abdominal aorta.

Endovascular embolization of arteries feeding pulmonary sequestrations is a growing therapeutic option. A 51-year-old woman with chest pain and hemoptysis was admitted. During hospitalization she presented 150 mL hemoptysis, hypotension, and hematocrit fell to 23.3%. Contrast-enhanced computed tomography confirmed a pulmonary sequestration irrigated by an aneurysmal artery from the abdominal aorta. The patient underwent endovascular coil embolization of the artery feeding the aneurysm and an Amplatzer device was deployed in the proximal third of the sequestration artery. Subsequent contrast-enhanced computed tomography confirmed complete thrombosis of the aberrant artery feeding the aneurysm and absence of irrigation of the pulmonary sequestration. At 56 months follow-up the patient remains asymptomatic, tomography showed involution of the sequestration and complete thrombosis of the aberrant artery. The challenges presented by the different treatment alternatives are discussed.

A embolização endovascular das artérias que alimentam os sequestros pulmonares é uma opção terapêutica em crescimento. Uma mulher de 51 anos com dor torácica e hemoptise foi internada. Durante a internação, ela apresentou hemoptise de 150 mL, hipotensão e queda do hematócrito para 23,3%. A tomografia computadorizada com contraste confirmou um sequestro pulmonar irrigado por uma artéria aneurismática originária da aorta abdominal. A paciente foi submetida a embolização endovascular da artéria que alimentava o aneurisma com uso de coils e dispositivo Amplatzer no terço proximal da artéria sequestrante. A tomografia subsequente confirmou a trombose completa da artéria aberrante que alimentava o aneurisma e a ausência de irrigação dentro do sequestro pulmonar. No seguimento de 56 meses, a paciente permanecia assintomática, e a tomografia mostrou involução do sequestro e trombose completa da artéria aberrante. Os desafios apresentados pelas diferentes alternativas de tratamento são discutidos neste artigo.

[Rupture of abdominal aortic aneurysm into the duodenum: uncommon cause of massive gastrointestinal bleeding]. / Aneurisma de aorta abdominal roto al duodeno: causa infrecuente de hemorragia digestiva masiva.

Primary aortoenteric fistula is the spontaneous communication between the lumen of the aorta and a portion of the digestive tract. The most common cause is the erosion of an abdominal aortic aneurysm into the 3rd or 4th portion of the duodenum. It manifests clinically as gastrointestinal bleeding, with or without abdominal pain and a pulsatile abdominal mass on physical exam. Gastrointestinal bleeding is initially recurrent and self-limiting and progresses to fatal exsanguinating hemorrhage. Endoscopic examination diagnoses only 25% of aortoenteric fistulas because these are usually located in the distal duodenum. Contrast computed tomography of the abdomen and pelvis is diagnostic in only 60% of cases. We report three cases with this condition. A 67-year-old male presenting with an upper gastrointestinal bleeding. He was operated and a communication between an aortic aneurysm and the duodenum was found and surgically repaired. The patient is well. A 67-year-old male with an abdominal aortic aneurysm presenting with abdominal pain. He was operated and anticoagulated. In the postoperative period he had a massive gastrointestinal bleeding and a new CAT scan revealed an aorto enteric fistula that was surgically repaired. The patient is well. An 82-year-old male with an abdominal aortic aneurysm presenting with hematochezia. A CAT scan revealed a communication between the aneurysm and the third portion of the duodenum, that was surgically repaired. The patient died in the eighth postoperative day.

Two Cases of Popliteal Cystic Adventitial Disease Treated with Primary Stenting: Long-Term Results.

The cystic adventitial disease of the popliteal artery is an uncommon cause of intermittent claudication in young patients. Several treatment options are available, oriented to either drainage of the cyst and/or arterial reconstruction. Endovascular techniques have been exceptionally used to treat this condition, with mixed results. We report 2 young claudicants treated with primary stenting with continuous 4- and 10-year symptomatic relief and arterial patency.

Higher Prevalence of Bovine Aortic Arch Configuration in Patients Undergoing Blunt Isthmic Aortic Trauma Repair.

BACKGROUND: The prevalence of a bovine aortic arch configuration is higher in patients treated for thoracic aortic aneurysms and type B dissection; its prevalence in aortic isthmic trauma has not been described. METHODS: A case control study was performed comparing consecutive patients treated at our institution for acute isthmic aortic transection after blunt trauma between 2002 and 2019 and a control group of consecutive sex-matched individuals undergoing imaging for nonaortic disease. Imaging and clinical findings were reviewed. Subjects were divided into bovine and nonbovine groups and prevalence was compared. The length of the aortic segment between the left subclavian artery (LSA) and the next proximal great vessel was measured in the control population and a comparison was performed between bovine and nonbovine aortic arch subjects. RESULTS: Thirty-three consecutive (30 male) patients were reviewed, 66 individuals (60 male) were included in the control group. A higher incidence of bovine arch in trauma patients was found: 57.6% vs. 34.8% (P = 0.007). The median (range, mm) and mean (SD) distance between the bovine trunk and the LSA were 13 mm (2-27) and 12.4 mm (5.9), respectively, compared with 5 mm (1-27) and 7.8 mm (6.1) between the left common carotid and LSA in nonbovine aortic arches (P < 0.005). CONCLUSION: A higher incidence of bovine arch in patients reaching out for surgical treatment for traumatic isthmic aortic transection was found in our population. Clinical interpretation of this finding can lead to several alternatives. Confirmation with larger series and data on prevalence of this anatomic variation in nonsurvivors is needed to provide a better understanding of this finding.

Endovascular Repair of Bilateral Internal Mammary Artery Aneurysms in a Patient with Marfan Syndrome.

BACKGROUND: True internal mammary artery aneurysms are rare but rupture has been described. CASE REPORT: A 39-year-old male patient with Marfan syndrome was diagnosed with large asymptomatic bilateral internal mammary artery aneurysms (IMAAs) on contrast-enhanced CT scan, without other arterial lesions. Both aneurysms were coil embolized, a stent graft was deployed in the left subclavian artery to cover a wide neck that precluded complete and safe embolization of the left IMAA. Reintervention on the right side was performed 5 years later due to recanalization. Eight years after the initial procedure, the patient presented with a type A aortic dissection that was successfully repaired. CONCLUSIONS: Although extremely rare, endovascular treatment should be considered to prevent rupture of internal mammary artery aneurysms.

Open Surgery for Ruptured Abdominal Aortic Aneurysm - 38 Years Experience at an Academic Center in Chile.

BACKGROUND: Few series of ruptured abdominal aortic aneurysm (RAAA) from Latin America have been published. OBJECTIVES: To report the outcomes of RAAA treated with open surgical repair (OSR) in a University Hospital in Chile. Secondary objectives are the identification of prognostic factors and survival rates. METHODS: Retrospective review of consecutive RAAA patients treated with OSR between September 1979 and December 2017. Medical records, diagnostic images, and follow-up details were obtained. Statistical methods include multiple logistic regression analysis. RESULTS: One hundred and sixteen patients underwent OSR for RAAA. The average age was 72.3 years (54-95), 62.9% ≥ 70 years, and 81.9% male. Preoperative systolic pressure <90 mm Hg was present in 74 patients (63.8%), and 10 (8.6%) experienced cardiac arrest before surgery. Only 30.2% were known to have an AAA before rupture. The mean aortic diameter was 7.9 cm. Sixteen patients had juxtarenal aneurysms (13.8%). The rupture was intra or retroperitoneal in 111 cases (95.7%), there were 4 fistulas to neighboring veins and one into the duodenum. Reconstruction included tubular graft in 39.7% and bifurcated in 58.6%. The estimated mean blood loss was 3,456 ± 2,768 mL (median 3,000). Mean mechanical ventilation was 7.4 ± 12.0 days and hemodialysis requirement in 21.8%. Six patients died during surgery and other 24 during the first postoperative month or in hospital, for an overall mortality rate of 25.9%. Age ≥70 years (P < 0.01), blood pressure less than 90 mm Hg (P = 0.03) and dialysis (P < 0.01) were associated with higher 30-day mortality rates. The survival rate was 68.0, 65.3, 44.3, and 25.2% at 1, 2, 5, and 10 years, respectively. CONCLUSIONS: EVAR for RAAA is not affordable in every country. Outcomes of open RAAA repair at our institution are similar to results reported recently for OSR by the USA and European Medical centers.

Juxtarenal Abdominal Aortic Aneurysm: Results of Open Surgery in an Academic Center.

BACKGROUND: The objective of the study is to report our experience with conventional surgery for juxtarenal abdominal aortic aneurysms (JRAs) by evaluating incidence of acute renal failure and perioperative mortality. Secondary objectives are to evaluate general morbidity and the need for permanent postoperative dialysis and to assess the influence on long-term survival of preoperative risk factors and deterioration of perioperative renal function. METHODS: A retrospective cohort study of 110 patients with JRA electively treated by open surgery between March 1992 and March 2018 was made. Data were obtained from clinical records, describing demographics, perioperative variables, and results. Acute kidney injury (AKI) was defined as 50% decrease in glomerular filtration rate or two-fold increase in serum creatinine. Multivariate analysis was performed by logistic regression to establish risk factors for renal failure. The influence of preoperative risk factors and deterioration of perioperative renal function on long-term survival was studied using Cox regression model. Descriptive and inferential statistics were used in the analysis. RESULTS: 110 consecutive patients were treated with an average age of 71 years, 82.7% male; 81% hypertensive and 41% active smokers. 46.3% had stage III or higher preoperative chronic kidney disease. Median diameter of the aneurysm was 5.7 cm. Interruption of bilateral renal flow was required in 73 patients (66.4%) and unilateral in 37 (33.6%). The average renal clamping time was 34.5 min. AKI occurred in 9 patients (8.2%). Two patients (1.8%) required postoperative dialysis, one of them permanent. Median hospital stay was 7 days. Thirty-three patients (30%) had at least one complication. Postoperative mortality was 2.7% (3 patients), two of them developed AKI. Multivariate analysis established a longer operative time and need for renal revascularization as independent risk factors for AKI. In the survival analysis, age, cerebrovascular disease, chronic obstructive pulmonary disease, and perioperative AKI were identified as risk factors for long-term mortality. CONCLUSIONS: JRA open surgical repair can be performed with low morbidity and mortality. Although transient acute renal dysfunction may be relatively frequent, the need for hemodialysis is low. Our study is a reference point to compare with endovascular repair.

[Endovascular management of chronic limb ischemia. Experience in 48 procedures]. / Manejo endovascular de la isquemia crítica distal: análisis de una serie contemporánea.

BACKGROUND: Chronic limb ischemia can lead to high rates of limb loss and mortality. Open surgery is the gold standard for treatment of distal disease. Endovascular surgery should have less complications with similar outcomes. AIM: To report a cohort of patients with distal arterial disease treated with endovascular surgery at our institution. MATERIAL AND METHODS: Review of angioplasty records of patients undergoing distal lower extremity endovascular procedures between 2016 and 2019. Demographics, comorbidities, form of presentation, type of intervention, perioperative complications, and length of stay were analyzed. The primary outcomes were wound healing, reinterventions and freedom from major amputation. Secondary outcomes were overall survival and amputation-free survival. RESULTS: Forty-eight limbs of 41 patients with a mean age 75 years (78% males) were treated. Ninety-three percent had hypertension, 88% diabetes, 30% chronic kidney disease. 73% presented with major wounds. Plain balloon and drug coated balloon angioplasties were carried out in 65 and 31% of procedures respectively, with no difference in results. In 46% of the cases, only chronic total occlusions were treated. Wound healing was achieved in 85% of procedures and 90% of patients were free from amputation at one year of follow up. Complications were observed in 18% of procedures, perioperative mortality was 2% and one-year survival was 76%. CONCLUSIONS: Endovascular therapy achieves high rates of wound healing and freedom from amputation with low perioperative mortality and moderate complication rates.

[Mechanical and pharmacomechanical trombolysis in deep venous thrombosis with no clinical response to conventional treatment]. / Trombolisis mecánica y fármaco-mecánica en el tratamiento de trombosis venosa profunda sin respuesta clínica con tratamiento médico convencional.

BACKGROUND: Conventional treatment of deep vein thrombosis (DVT) is anticoagulation, bed rest and limb elevation. Proximal DVT patients with persisting edema, pain and cyanosis of extremities despite of conventional therapy may develop ischemia. Direct treatment of thrombosis becomes necessary. AIM: To report our experience with mechanical trombolysis of proximal lower extremity DVT. MATERIAL AND METHODS: Retrospective review of medical records of proximal DVT patients treated with thrombolysis between March 2012 and August 2015. Thirteen patients, 14 limbs, median age 34 years (22-85), 8 women, were admitted with pain and swelling of recent onset; one patient with venous gangrene. All patients initially received heparin in therapeutic doses without clinical improvement. RESULTS: In all 13 cases, mechanical thrombolysis was performed using AngioJet®, and associated with single dose thrombolytic agent in 9. Additional angioplasty for residual stenosis was performed in 12 (7 stents) and IVCF were implanted in 8. All patients were subsequently anticoagulated. Early outcomes with disappearance of pain and decrease of edema, with no mortality or bleeding complications. The patient with foot gangrene required amputation. CONCLUSIONS: Mechanical thrombolysis with a single dose of a thrombolytic agent is safe and effective in patients with proximal DVT with an unfavorable evolution.

Management of Carotid Bifurcation Tumors: 30-Year Experience.

BACKGROUND: The carotid bifurcation can host a variety of tumors requiring complex surgical management. Treatment requires resection and, in some cases, vascular reconstruction that may compromise the cerebral circulation. The most frequent lesion at this location is the carotid body tumor (CBT). CBT are classified according to Shamblin in 3 types depending on the degree of carotid vessels encasement. Our main objective was to report our clinical experience managing carotid bifurcation tumors throughout the last 30 years. METHODS: Between 1984 and 2014, we treated 30 patients with 32 carotid bifurcation tumors. There were 21 women and 9 men (2.3:1), with a mean age of 45.5 years (18-75). The most frequent presentation was an asymptomatic neck swelling or palpable mass localized at the carotid triangle (86.7%). RESULTS: Thirty of 32 tumors were resected. Since 1994, computed tomography scan has been the most frequently used diagnostic imaging tool (80%), followed by magnetic resonance imaging. Angiography was used mainly during the first 10 years of the study period. Mean size of the tumor was 44.6 mm (20-73 mm). Nineteen (63%) were classified as Shamblin II and 6 (20%) as Shamblin's III. All specimens were analyzed by a pathologist; 28 tumors (93%) were confirmed as paragangliomas, 2 (7%) were diagnosed as schwannomas. Two patients underwent preoperative embolization of the CBT; 5 patients (17%) required simultaneous carotid revascularization, all of them Shamblin III. Mean hospitalization time was 4.5 days (1-35 days). Transient extracranial nerve deficit was observed in 7 patients (23.3%). Three patients (Shamblin III) required red blood cells transfusion. One patient (Shamblin III) underwent a planned en bloc excision of the vagus nerve. There was no perioperative mortality or procedure-related stroke. No malignancy or tumor recurrence were observed during follow-up. CONCLUSIONS: CBTs can be diagnosed on clinical grounds requiring vascular imaging confirmation. These infrequent lesions are generally benign. Early surgical removal by surgeons with vascular expertise avoids permanent neurologic and or vascular complications.

[Correlation between aPTT and antifactor Xa to determine therapeutic ranges for unfractionated heparin]. / Correlación de valores de TTPa con anti factor Xa para establecer rango terapéutico en tratamiento anticoagulante con heparina sódica.

BACKGROUND: The therapeutic range (TR) of activated partial thromboplastin time (aPTT) for unfractionated heparin (UFH) dosing was established in the 1970 decade. Since then aPTT determination has changed. Current TR may be sub or supra-therapeutic depending on the reagents of the test, and therefore, responsible for complications of therapy. AIM: To establish the TR for UFH dosing in our institution using antifactor Xa analysis as reference standard. MATERIAL AND METHODS: After obtaining an informed consent, 43 blood samples were obtained for aPTT determination and antifactor Xa assay in 23 patients treated with intravenous UFH. Samples were processed at Emergency and Hemostasis Labs. We excluded patients receiving other anticoagulants, with thrombophilia, pregnancy or liver disease. RESULTS: Mean aPTT values in the Hemostasis and Emergency labs ​​were 57.1 ± 18.9 and 56.6 ± 18.3 seconds, respectively (p = 0.77). The squared correlation coefficients between aPTT and antifactor Xa at hemostasis and emergency labs were R2 0.5 and 0.45 respectively, p < 0.001. Using a linear regression analysis, therapeutic aPTT range values ​​in our laboratory were established between 50 and 80 seconds, corresponding to antifactor Xa values of 0.3 to 0.7 IU/mL. CONCLUSIONS: According to current recommendations, validation of aPTT determination with reference techniques should be done in every institution.

Initial experience with the Ventana fenestrated system for endovascular repair of juxtarenal and pararenal aortic aneurysms.

OBJECTIVE: Customized fenestrated endovascular stent grafts have been investigated as an alternative to open surgery for repair of more complex juxtarenal aortic aneurysms (JAAs). The substantial time required to design and manufacture these devices has led to the desire for a standardized fenestrated endovascular system. We report the initial pilot study results of a potential "off-the-shelf" fenestrated device system to assess its initial safety and feasibility for endovascular repair of JAAs and pararenal aortic aneurysms (PAAs). METHODS: Following ethics committee approvals, consenting patients were evaluated for eligibility. Patients with aneurysms abutting or including the renal artery orifices who were not candidates for standard infrarenal endograft placement because of proximal aortic neck morphology were further assessed for anatomic suitability for this "off-the-shelf" device. There were a number of anatomic requirements, the most important being a stable infra-superior mesenteric artery aortic neck length ≥ 15 mm. Patients are assessed in-hospital and in follow-up at 1, 6, and 12 months, and annually thereafter to 5 years for adverse events and using contrast-enhanced computed tomography angiography with Core Laboratory interpretation of renal perfusion, device integrity, migration, endoleak, and aneurysm morphology. RESULTS: Fifteen patients (87% male) with JAAs (93%) or PAAs (6.7%) presented at mean age of 77 years (range, 66-85 years) and with mean sac diameter of 5.9 cm (range, 5.1-7.9 cm). Four Ventana fenestrated stent graft models having aligned fenestrations (three models) or offset fenestrations (one model) and renal stent grafts were successfully implanted among the patients, and all renal and visceral arteries were preserved. Mean endovascular procedure time was 108 minutes (range, 71-212 minutes) with mean contrast usage and fluoroscopy time of 254 mL (range, 67-420 mL) and 55 minutes (range, 27-104 minutes), respectively. Five patients received blood products. Mean time to hospital discharge was 3.3 days (range, 2-9 days). In follow-up to 6 months and 1 year, no rupture, conversion to open repair, migration, type I/III endoleak, or renal loss/infarcts were observed. Two late nonaneurysm-related deaths have occurred. One secondary procedure for iliac limb kinking/occlusion and one secondary procedure for renal artery stenosis have been performed. CONCLUSIONS: Early experience supports procedural and initial postprocedural safety and demonstrates proof of concept for the off-the-shelf Ventana fenestrated system for the endovascular repair of JAAs and PAAs in selected patients. Continued follow-up and expanded multicenter clinical experience is warranted.

Prospective, multicenter experience with the Ventana Fenestrated System for juxtarenal and pararenal aortic aneurysm endovascular repair.

OBJECTIVE: This study assessed preliminary results of the Ventana Fenestrated System (Endologix, Irvine, Calif) as an off-the-shelf integrated device for juxtarenal aortic aneurysm (JAA) or pararenal aortic aneurysm (PAA) endovascular repair. METHODS: From November 2010 to April 2012, seven centers enrolled 31 patients with JAAs or PAAs in an international clinical trial of the Ventana Fenestrated System. Clinical and laboratory evaluations were done predischarge and at 1 month, with continuing follow-up through 5 years. Core laboratory computed tomography imaging assessments were performed at 1 month and at each subsequent follow-up. RESULTS: Patients (mean age, 73 years; 90% male) presented with mean aneurysm sac diameter of 6.0 cm. One patient with a short, reversed tapered infra-superior mesenteric artery (SMA) neck was enrolled under a protocol waiver. Among the 31 patients, one of five Ventana device models was used to preserve main renal arteries, the SMA, and celiac arteries; 20 patients (65%) received the same Ventana device (aligned fenestrations, 28-mm diameter). Median fluoroscopy and procedure times were 49 and 197 minutes, respectively; median hospital length of stay was 3.0 days. The 1-month clinical success rate was 94% (29 of 31), with no perioperative mortality. One intervention on day 26 was done to resolve limb kink/occlusion. A type IA endoleak and renal occlusion secondary to procedural device damage led to a reintervention on day 52 and dialysis at 5 months. During follow-up to 23 months, three non-aneurysm-related deaths occurred. No aneurysm rupture or conversion to open repair has occurred. One late migration with endoleak and covered renal stent fracture/occlusion occurred at 8 months in the patient with a short, reverse tapered infra-SMA neck performed under a protocol waiver, which was managed successfully with bilateral renal bypasses and endovascular repair of the endoleak. Another patient underwent late endovascular interventions to resolve bilateral renal stenosis. CONCLUSIONS: The multicenter experience of the Ventana Fenestrated System supports its safety and early-term to midterm effectiveness for the endovascular repair of JAAs and PAAs. This off-the-shelf integrated system permits endovascular treatment of JAAs or PAAs; however, further expanded clinical experience and longer-term follow-up are needed to more fully assess this device system.

Endovascular treatment of cystic adventitial disease of the popliteal artery.

Cystic adventitial disease of the popliteal artery is an uncommon cause of intermittent claudication in young patients. Several treatment options are available, oriented to either drainage of the cyst and/or arterial reconstruction. Endovascular techniques have been used in exceptional cases to treat this condition, mostly balloon angioplasty and only 2 cases of stenting, with mixed to poor results. We report the case of a 36-year-old female patient with claudication who was treated with primary stenting with long-term symptomatic relief and arterial patency.