Efforts for detection of aortic aneurysms and human resources training for the optimization of their treatment.

OBJECTIVE: To review admissions, interventions and in-hospital mortality associated to Abdominal Aortic Aneurysms (AAA), and to analyze the impact of the introduction of a training program and imaging screening at our institution. METHODS: Retrospective study where hospitalizations, procedures and mortality secondary to AAA were recorded. The national databases (ND) from the Secretariat of Health were utilized from 2010 to 2020. In-hospital lethality was calculated and compared with the experience at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ). The statistical analysis was completed with the STATA version 17. RESULTS: According to the ND, 899 (91%) hospital admissions secondary to AAA occurred, while in the INCMNSZ 85 (9%). Most of them belonged to the male gender (68%); 811 (82%) patients underwent open surgical repair, and 173 (18%) to an endovascular exclusion (EVAR), the latter approach was significantly more frequently performed at our institution (p = 0.007). The 30-day hospital mortality was 22.5%; in the ND was 23.9 vs. a 16.4% in the INCMNSZ without significant difference (p = 0.1). CONCLUSIONS: AAA remain unrecognized in our country. The introduction of University programs and imaging screening might impact in the early detection, and to reduce the morbidity and mortality associated to emergency procedures.

OBJETIVO: Revisar los ingresos, procedimientos y defunciones intrahospitalarias asociadas a aneurismas aórticos abdominales (AAA) y analizar el impacto de la introducción de programas de formación de recursos humanos y tamizaje ultrasonográfico. MÉTODOS: Estudio retrospectivo, se analizaron las bases de datos nacionales obtenidas del portal datos abiertos de la Dirección General de Información en Salud (DGIS) del año 2010 al 2020. Se calculó la letalidad intrahospitalaria anual y comparamos la experiencia del Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ). El análisis estadístico se realizó en el programa STATA versión 17. RESULTADOS: De acuerdo con la base nacional (BN), se registraron 899 (91%) ingresos, mientras que en el INCMNSZ 85 (9%). La mayoría pertenecía al sexo masculino (68%), un total de 811 (82%) pacientes fueron sometidos a cirugía abierta, mientras que 173 (18%) a terapia endovascular (EVAR), siendo este abordaje más frecuente en nuestra institución (p = 0.007). La mortalidad intrahospitalaria fue del 22.5%, en la BN fue del 23.9%, mientras que en el INCMNSZ fue del 16.4%, sin que encontráramos diferencia significativa (p = 0.1). CONCLUSIONES: Los AAA continúan siendo poco reconocidos en nuestro país. La introducción de programas universitarios de especialidad y el tamizaje podría impactar en la reducción de la morbimortalidad.

Aneurisma poplíteo izquierdo / Left popliteal aneurysm

El aneurisma de la arteria poplítea es el principal aneurisma periférico y el segundo en frecuencia después del aneurisma de la aorta abdominal. Su incidencia se desconoce. Posee un patrón característico de presentación que corresponde a personas del sexo masculinos, mayores de 65 años, con múltiples comorbilidades, donde la hipertensión arterial representa la más frecuente. La definición de aneurisma corresponde a una dilatación del 50 por ciento del diámetro del vaso, en el caso de la arteria poplítea, mayor de 1,5 cm. El 50 por ciento de los aneurismas poplíteos resulta asintomático, el resto presenta síntomas isquémicos (trombosis, embolismos periféricos), compresivos y la ruptura. El tratamiento es quirúrgico: convencional (vías medial-posterior) y endovascular. El objetivo del artículo fue presentar este caso por la infrecuencia del aneurisma de la arteria poplítea unilateral. Se trata de un paciente masculino de 62 años, con aumento de volumen localizado a nivel de la fosa poplítea izquierda con latido y expansión a la palpación, diámetro transversal aproximado de 3 cm y longitudinal de 4 cm, presencia de soplo sistólico a la auscultación con diagnóstico ecográfico y arteriográfico de aneurisma de la arteria poplítea izquierda. La evolución del paciente fue satisfactoria y se mantiene bajo seguimiento médico para evaluar la permeabilidad del injerto sintético(AU)

Popliteal artery aneurysm is the main peripheral aneurysm and the second in frequency after abdominal aortic aneurysm. Its incidence is unknown. It has a characteristic presentation pattern that corresponds to male people, over 65 years of age, with multiple comorbidities, where arterial hypertension represents the most frequent. The definition of aneurysm corresponds to a dilation of 50 percent of the diameter of the vessel, in the case of the popliteal artery, greater than 1.5 cm. 50 percent of popliteal aneurysms are asymptomatic, the rest have ischemic symptoms (thrombosis, peripheral embolisms), compression and rupture. Treatment is surgical: conventional (medial-posterior pathways) and endovascular. The objective of the article was to present this case due to the infrequency of the unilateral popliteal artery aneurysm. This is a 62-year-old male patient, with localized volume increase at the level of the left popliteal fossa with heartbeat and expansion on palpation, approximate transverse diameter of 3 cm and longitudinal diameter of 4 cm, presence of systolic murmur at auscultation with ultrasound and arteriographic diagnosis of aneurysm of the left popliteal artery. The patient's evolution was satisfactory and he remains under medical follow-up to evaluate the permeability of the synthetic graft(AU)

Aneurisma infeccioso primário da aorta: série de casos e revisão da literatura / Primary infectious aortic aneurysm: a case series and review of the literature

Resumo Aneurismas infecciosos, anteriormente chamados de aneurismas micóticos, são raros; acometem com maior frequência a aorta de pacientes jovens e apresentam maior tendência à rotura do que aneurismas de outras etiologias. O formato sacular é o mais característico, e os agentes etiológicos mais comuns são Staphylococcus sp e Salmonella sp. A literatura fornece informações limitadas e imprecisas sobre a correta nomenclatura, diagnóstico e tratamento da doença. Os autores reuniram três casos cujos procedimentos diagnósticos e terapêuticos foram documentados. Além de relatar essa série de casos, realiza-se uma revisão sobre o tema, a fim de estabelecer estratégias diagnósticas e terapêuticas pertinentes.

Abstract Infectious aneurysms, formerly known as mycotic aneurysms, are rare, most often involve the aorta in young patients, and have a greater tendency to rupture than aneurysms of other etiologies. The most characteristic shape is saccular and the most common etiologic agents are Staphylococcus sp. and Salmonella sp. There is scant and imprecise information in the literature about correct nomenclature, diagnosis, and treatment. The authors present three cases in which diagnostic and therapeutic procedures were documented. In addition to reporting this case series, the authors also present a review of the subject, outlining pertinent diagnostic and therapeutic strategies.

Aneurisma de la aorta abdominal asociado a íctero / Aneurysm of the abdominal aorta associated with icterus

El aneurisma de la aorta abdominal como causa de íctero obstructivo es una situación de excepción en la clínica. El objetivo de esta presentación fue exponer la coexistencia del aneurisma de la aorta abdominal y el íctero. Una asociación muy poco frecuente y de difícil diagnóstico, que coloca al cirujano vascular en la toma de una especial conducta terapéutica. La cuidadosa revisión de los antecedentes patológicos y el análisis del comportamiento clínico del paciente permitieron la solución terapéutica adecuada. Se logró demostrar que el íctero obedecía a una lesión maligna de vías biliares conocida como colangiocarcinoma, que concomitó con la existencia de un aneurisma del V segmento aórtico y no fue el resultado de una compresión extrínseca de la dilatación de la aorta, sobre las vías biliares. La conducta quirúrgica, encaminada a erradicar el íctero y evitar la ruptura aneurismática con resección del aneurisma y colocación de prótesis, no resultó posible por lo avanzado de la lesión tumoral y el grado de metástasis ya establecidos. Solo se realizó resección de la vesícula biliar y seguimiento posterior por oncología(AU)

Abdominal aortic aneurysm as a cause of obstructive icterus is an exceptional situation in the clinic. The aim of this presentation was to expose the coexistence of abdominal aortic aneurysm and icterus. A very rare and difficult to diagnose association, which places the vascular surgeon in a special therapeutic approach. The careful review of the pathological history and the analysis of the patient's clinical behavior allowed the appropriate therapeutic solution. It was possible to demonstrate that the icterus was due to a malignant lesion of the biliary tract known as cholangiocarcinoma, which concomitated with the existence of an aneurysm of the V aortic segment and was not the result of extrinsic compression of the dilatation of the aorta on the biliary tract. The surgical procedure, aimed at eradicating the icterus and avoiding aneurysmal rupture with aneurysm resection and prosthesis placement, was not possible due to the advanced tumor lesion and the degree of metastasis already established. Only gallbladder resection was performed and subsequent follow-up by oncology(AU)

Complicaciones posquirúrgicas en pacientes con aneurisma de la aorta abdominal operados electivamente / Post-surgical complications in patients with electively operated abdominal aortic aneurysm

Introducción: Los aneurismas aórticos abdominales constituyen un problema de salud por la alta mortalidad que provocan. Su seguimiento y tratamiento son fundamentales para evitar las complicaciones posquirúrgicas. Objetivo: Caracterizar las principales complicaciones posquirúrgicas de los pacientes con aneurisma de la aorta abdominal operados electivamente. Métodos: Se realizó un estudio observacional y descriptivo en 94 pacientes operados de forma electiva en el Instituto Nacional de Angiología y Cirugía Vascular por presentar un diagnóstico de aneurisma de la aorta abdominal. Las variables de estudio fueron: edad, sexo, color de la piel, enfermedades asociadas, diámetro del aneurisma, profilaxis antibiótica, tiempo quirúrgico, tipo de prótesis vascular, tipo de complicación posoperatoria, tiempo de aparición de las complicaciones, estadía hospitalaria posoperatoria y estado al egreso. Se determinaron las frecuencias absolutas y relativas. Resultados: El 56,4 por ciento de los pacientes operados presentó algún tipo de complicación, las cuales fueron más frecuentes en el sexo masculino por encima de los 60 años. Las más predominantes resultaron la bronconeumonía (24,5 por ciento) y las arritmias cardíacas (20,8 por ciento). La proporción de complicaciones se mostró mayor en los pacientes con injertos bifurcados, así como en aquellos sin profilaxis y con un tiempo quirúrgico prolongado. Hubo mayor frecuencia de enfermedades cardiovasculares entre los fallecidos. Conclusiones: En los pacientes operados de forma electiva de aneurisma de la aorta abdominal predominaron las complicaciones respiratorias y cardiovasculares, estas últimas provocaron un aumento en la mortalidad(AU)

Introduction: Abdominal aortic aneurysms are a health problem because of the high mortality they cause. Their follow-up and treatment are essential to avoid post-surgical complications. Objective: Characterize the main post-surgical complications of patients with electively operated abdominal aortic aneurysm. Methods: An observational and descriptive study was conducted in 94 electively operated patients at the National Institute of Angiology and Vascular Surgery after having a diagnosis of abdominal aortic aneurysm. The study variables were: age, sex, skin color, associated diseases, aneurysm diameter, antibiotic prophylaxis, surgical time, type of vascular prosthesis, type of postoperative complication, time of onset of complications, postoperative hospital stay, and state at discharge moment. Absolute and relative frequencies were determined. Results: 56.4 percent of operated patients had some form of complication, which were more common in the males over 60 years. The most predominant complications were bronchopneumonie (24.5 percent) and cardiac arrhythmias (20.8 percent). The proportion of complications was shown to be higher in patients with forked grafts, as well as in those without prophylaxis and with prolonged surgical time. There was a higher frequency of cardiovascular diseases among the deceased patients. Conclusions: In patients electively operated of abdominal aortic aneurysm, there was a predominance of respiratory and cardiovascular complications, and the latter caused an increase in mortality(AU)

Aneurisma idiopático de aorta abdominal en una paciente de 4 años de edad / Idiopathic aneurysm of abdominal aorta in a 4 years patient

Se describe el caso clínico de una paciente de 4 años de edad, quien ingresó en el Servicio de Terapia Intensiva del Hospital Infantil Docente Sur Dr. Antonio María Béguez César de Santiago de Cuba por presentar dolor abdominal intenso, vómitos sanguinolentos, distención abdominal, tumoración palpable en el epigastrio, palidez cutáneo - mucosa, polipnea, taquicardia, hipotensión y trastornos de perfusión periférica, con evolución rápida y progresiva hacia un cuadro de insuficiencia multiorgánica y estado de choque. Los estudios clínicos e imagenológicos confirmaron el diagnóstico de aneurisma de aorta abdominal. A pesar de la atención médica intensiva, la evolución fue desfavorable.

The case report of a 4 years patient is described. She was admitted to the Intensive Therapy Service of Dr. Antonio María Béguez César Southern Teaching Pediatric Hospital in Santiago de Cuba due to an intense abdominal pain, bloody vomits, abdominal strain, palpable tumor in the epigastrium, cutaneous - mucous paleness, polipnea, tachycardia, hypotension and perypheral perfusion disorders, with quick and progressive clinical course toward a picture of multiorganic failure and state of shock. The clinical and imaging studies confirmed the diagnosis of abdominal aorta aneurysm. In spite of the intensive medical care, there was an unfavorable clinical course.

Derivação axilo-ilíaco para proteção de rim transplantado durante a correção de aneurisma de aorta abdominal: relato de caso / Axillary-iliac bypass to protect a transplanted kidney during abdominal aortic aneurysm repair: case report

Resumo Os aneurismas de aorta abdominal (AAA) são os mais frequentes, mesmo quando comparados a outros segmentos da aorta. A prevalência e a história natural de aneurismas arteriais em receptores de transplante de órgão abdominal permanecem incertas. Relatamos a abordagem de um caso de aneurisma de aorta abdominal em um paciente transplantado renal e com alergia ao contraste. Foi realizado o tratamento convencional do aneurisma de aorta abdominal com um by-pass aorto bi-ilíaco. Para manutenção do enxerto renal, foi confeccionado um by-pass temporário da artéria axilar direita até a artéria ilíaca comum direita. O paciente foi encaminhado para a unidade de terapia intensiva, onde permaneceu estável hemodinamicamente e recebeu alta no 2º pós-operatório. A cirurgia convencional aberta com derivação extra-anatômica temporária é uma alternativa para o tratamento do AAA em pacientes com transplante renal.

Abstract Abdominal aortic aneurysms (AAA) are the most common type, even when compared to those involving other segments of the aorta. The prevalence and natural history of arterial aneurysms in abdominal organ transplant recipients remain uncertain. We report a case of abdominal aortic aneurysm in a kidney transplant patient with contrast allergy. Conventional abdominal aortic aneurysm repair was performed, constructing a bi-iliac aortic bypass. A temporary bypass was constructed from the right axillary artery to the right common iliac artery to maintain the renal graft. The patient was transferred to the intensive care unit, where he remained hemodynamically stable, and he was discharged on the 2nd postoperative day. Conventional open surgery with temporary extra-anatomic bypass is an alternative option for treatment of AAA in patients with transplanted kidneys.

Podemos adotar a dosagem sérica da Tenascina-C na avaliação prognóstica do aneurisma e dissecção da aorta? / Could we adopt serum Tenascin-C assays to determine prognosis in aortic aneurysms and dissections?

Resumo O aneurisma da aorta abdominal corresponde a uma dilatação anormal, enquanto a dissecção aórtica aguda é uma delaminação da túnica média com formação de um falso lúmen. A Tenascina-C é uma glicoproteína que pode ser encontrada em situações de lesão tecidual. Nesse sentido, este artigo pretendeu avaliar se a Tenascina-C pode auxiliar na avaliação do prognóstico do aneurisma da aorta abdominal e da dissecção aórtica aguda. Realizou-se uma revisão integrativa da literatura em que foram considerados elegíveis quatro artigos, sendo que dois associaram maiores níveis da Tenascina-C a fatores de proteção e menor risco de lesões, enquanto dois correlacionaram com prognóstico pior. Alguns autores acreditam que a Tenascina-C poderia ser um biomarcador elegível, mas esses estudos ainda são inconclusivos no que diz respeito a seu papel no desfecho clínico dos pacientes com aneurismas.

Abstract Abdominal aortic aneurysm is an abnormal dilatation, while acute aortic dissection is a delamination of the tunica media, forming a false lumen. Tenascin-C is a glycoprotein that can be found in situations involving tissue damage. The objective of this article is to evaluate whether Tenascin-C assays could be of use for predicting prognosis in abdominal aortic aneurysms and acute aortic dissection. We conducted an integrative literature review, for which four articles were considered eligible. Two of these studies associated higher Tenascin-C levels with protective factors and lower risk of injury, whereas the other two correlated them with worse prognosis. Some authors believe that Tenascin-C could be a candidate biomarker, but these studies are still inconclusive with regard to its role in the clinical outcomes of patients with aneurysms.

Tratamiento endovascular del aneurisma de la aorta abdominal con endoprótesis percutáneas en pacientes cubanos / Endovascular treatment of abdominal aortic aneurysm with percutaneous endoprosthesis in Cuban patients

Introducción: Los aneurismas de aorta abdominal resultan dilataciones arteriales a dicho nivel. Su ruptura constituye uno de los principales riesgos y provoca la muerte del paciente, de ahí la importancia de tratarlos a tiempo. Las opciones actuales de tratamiento son la cirugía abierta y la reparación aneurismática endovascular; esta última representa la primera línea de tratamiento, por constituir una técnica mínimamente invasiva con bajas tasas de morbilidad y mortalidad. Objetivo: Evaluar el tratamiento endovascular del aneurisma de la aorta abdominal con endoprótesis percutáneas en pacientes cubanos. Métodos: Entre enero y abril de 2018 se realizó un estudio prospectivo, descriptivo y cualitativo en 6 pacientes del sexo masculino con aneurisma de aorta abdominal, seleccionados aleatoriamente, que cumplieron los criterios de uso de endoprótesis vasculares y estuvieron de acuerdo con realizar el proceder. Se colocaron 6 dispositivos en una sala de angiografía, y se utilizó en los pacientes anestesia general y guía fluoroscópica. Resultados: De forma satisfactoria fue posible el tratamiento endovascular por vía percutánea de los 6 pacientes seleccionados; solo 1 presentó una complicación menor y fue dado de alta a las 72 horas y el resto fue egresado en menos de 24 horas. Se logró implementar por vez primera en el país el sistema de cierre percutáneo Proglide sin complicaciones. Conclusiones: El tratamiento endovascular por vía percutánea de aneurismas de aorta abdominal con endoprótesis vasculares es una alternativa eficaz para la cirugía convencional en pacientes que cumplen los criterios de uso del dispositivo(AU)

Introduction: Abdominal aortic aneurysms are arterial dilations in that level. Their rupture is one of the main risks and it causes death in patients; that is why the importance of treating them early. Among the current treatment options are open surgery and endovascular aneurismal reparation, being the last one in the first line of treatment since it is a minimal invasive technique with low rates of morbidity and mortality. Objective: To evaluate the endovascular treatment of abdominal aortic aneurysm with percutaneous endoprosthesis in Cuban patients. Methods: It was conducted from January to April 2018 a retrospective, descriptive and qualitative study in 6 male patients with aneurysm of the abdominal aorta, selected randomly and who met the criteria of vascular endoprosthesis use and agreed with the performance of the procedure. Six devices were placed in an angiography room and it was used general anaesthetic and fluoroscopic guidance. Results: It was possible in a satisfactory way the endovascular treatment by percutaneous way in the six patients selected; just one presented a minor complication and he was discharged after 72 hours; and the rest were discharged in less than 24 hours. It was implemented for the first time in the country without complications the system of percutaneous closure called Proglide. Conclusions: Endovascular treatment by percutaneous way of abdominal aortic aneurysms with vascular endoprosthesis is an efficient alternative for conventional surgery in patients that met the criteria of use of the device(AU)

Investigation of an Immunogenetic Profile in Patients with Abdominal Aortic Aneurysms and Possible Applications in Screening and Surveillance.

BACKGROUND: The pathogenesis of atherosclerotic abdominal aortic aneurysms (AAAs) remains not fully understood. Histological analyses confirm chronic adventitial and medial inflammatory cell infiltration, and its pathophysiology involves the upregulation of proteolytic pathways; added to this, genetic factors have been suggested to favor the susceptibility for AAA. The aim of the present study was to analyze the association between genetic polymorphism of the class II human leukocyte antigens (HLAs, HLA-DRB1) with the susceptibility to develop AAA in Mexican patients and to initiate a pilot study of single-nucleotide polymorphisms (SNPs) rs1024611 in the monocyte chemoattractant protein-1 (MCP-1/CCL2) gene to investigate a possible role in the AAA pathogenesis. METHODS: In a cohort of patients with AAA, HLA molecular typing was completed for DRB1 loci with LABType SSO-One Lambda kit in 39 patients (69% men with a mean age of 72 years) and compared with 99 without the disease (60% men, mean age 65 years) (control group). Genotyping of rs1024611 in the MCP-1 gene was performed using TaqMan predesigned SNP genotyping assays in 27 patients with AAA (63% men, mean age of 71). Gene frequencies (gfs) and genotype frequencies (Gfs) were determined; categorical data were analyzed by nonparametric statistic test at significance level (P < 0.05), and odds ratios (ORs) were calculated using the STATA v14 software and StatCalc software Epi Info™ 7.2.2.2. RESULTS: Seventy-eight HLA-DRB1 alleles of patients with AAA and 198 from the control group were studied. We observed that the gf of HLA-DRB1*01 was 0.128 in the AAA group compared with 0.05 in the control group (P = 0.03, OR: 2.6, 95% confidence interval [CI]: 1.04-6.5); the gf of HLA-DRB1*16 was 0.115 in the AAA and 0.025 in control group (P = 0.002, OR: 5, 95% CI: 1.6-16.9). The Gf for SNP rs1024611 were 0.51 in the GA genotype, 0.30 in AA, and 0.19 of GG. Four patients with the proinflammatory homozygous genotype GG (80%) were women and younger than patients with other genotypes, and only one had a history of dyslipidemia. CONCLUSIONS: The dissection and interpretation of an immunogenetic profile in patients with AAA is an active and complex field of research that might assist in a more precise identification of those patients at genetic risk. Our study demonstrated increased frequencies of HLA-DRB1*01 and HLA-DRB1*16 alleles in Mexican patients with AAA compared with an ethnically matched control group.

Genetic polymorphism of HLA-DRB1 alleles in Mexican mestizo patients with abdominal aortic aneurysms.

BACKGROUND: Multiple factors are implicated in the etiology and pathogenesis of Abdominal Aortic Aneurysms (AAA). Available literature of genetic studies has previously suggested the possible roles of autoimmunity, genetic predisposition and ethnic susceptibility. Due to the association with autoimmune diseases and proven application in population genetics, we aimed to investigate alleles of the Class II Human Leukocyte Antigens (HLA-DRB1) in the Mexican Mestizo population with aortic aneurysms and determine possible associations with susceptibility. METHODS: We performed a case Control Study; the HLA molecular typing was completed for DRB1 loci by LabType Sequence-Specific Oligonucleotide (SSO) SSO-OneLambda kit (Applied Biosystems; Thermo Fisher Scientific. Inc.) in the studied individuals. Allele frequencies (af) were determined, associations were assessed by chi square or fisher exact tests at significance level (< 0.05), and Odds Ratios (OR) were calculated using the STATA software version 14. RESULTS: The genetic polymorphism of HLA-DRB1 of fifty one patients (70% males with a mean age of 71 years) with atherosclerotic or also known as degenerative AAA were compared with 99 unrelated patients (60% males, mean age 65 years) without the disease [Control group (CG)] from the same ethnic group. We examined a total of 102 Class II HLA-DRB1 alleles of AAA patients and 198 from CG. When comparing af, we observed the HLA-DRB1*01 af of 0.139 in the AAA compared to 0.05 in the CG [p = 0.015, OR 3, 95% confidence interval (CI) 1.29-7.08], the HLA-DRB1*16 af were 0.109 in the AAA and 0.025 in CG (p = 0.006, OR 4.7, 95% CI 1.59-13.98). CONCLUSIONS: Our study confirmed increased frequencies of the alleles HLA-DRB1*01 and HLA-DRB1*16 and their association to the development of AAA in Mexican Mestizo patients. The utility of genetic testing may assist in identifying individuals at genetic risk for the development of this disease in different ethnic groups, who might benefit from earlier ultrasound screening and closer imaging surveillance.

African Americans are less likely to have elective endovascular repair of abdominal aortic aneurysms.

OBJECTIVE: Recently published Society for Vascular Surgery guidelines recommend endovascular aneurysm repair (EVAR) for both elective and emergent treatment of abdominal aortic aneurysm in patients with suitable anatomy. Racial disparities in health care are well known. The aim of this study was to stratify the patients undergoing EVAR on the basis of their racial differences and to determine the differences in preoperative, intraoperative, and postoperative variables among patients of different races. METHODS: The 2013 EVAR targeted American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were used for this retrospective study. Patients were divided into three groups by race: whites for non-Hispanic whites, blacks for non-Hispanic blacks, and Hispanic. Bivariate analysis was performed for the patients' demographics and preoperative risk factors. Multivariable analysis was used to determine associations of independent variables with elective surgery as the primary outcome. RESULTS: A total of 1991 patients (18.7% female, 81.3% male) underwent EVAR in 2013. Among these patients, 1824 (91.6%) were white, 121 (6.1%) were black, and 46 (2.3%) were Hispanic. When all patients undergoing EVAR are stratified on the basis of race, we found the following differences: a larger proportion of Hispanic patients were older than 80 years (43% vs 30% for white patients; P < .01); black patients were more likely to have body mass index <25 kg/m2 (39.8% vs 25.2% for white patients; P < .01); black patients were more likely to undergo nonelective operation (34.7% vs 17.9% for white patients; P < .01); incidence of active smoking was higher among blacks (44.6% vs 30% for white patients); a higher percentage of black patients were functionally dependent (9.9% vs 2.6% for white patients); and black patients were more likely to be on hemodialysis (6.6% vs 0.9% for white patients). CONCLUSIONS: Black patients were less likely to have elective EVAR compared with Hispanic and white patients. The incidence of nonelective EVAR among black patients was higher compared with white patients. Future studies are warranted to investigate whether reduced frequency of elective EVAR among the black population leads to need for nonelective EVAR.

Expression in Whole Blood Samples of miRNA-191 and miRNA-455-3p in Patients with AAA and Their Relationship to Clinical Outcomes after Endovascular Repair.

BACKGROUND: The purpose of this study was to quantify and evaluate the expression response of miRNA-191 and miRNA-455-3p endovascular repair of abdominal aortic aneurysm (AAA) based in whole blood samples. METHODS: This report describes a prospective study of a single center of 30 patients with AAA who underwent endovascular repair. Blood samples were collected preoperatively and 6 months postoperatively. The differential expression of the miRNAs was performed by the real-time polymerase chain reaction method, after extraction of the RNA from the blood samples at the 2 moments. In addition, bioinformatic tools were used to determine pathophysiological pathways related to AAA. RESULTS: The miR-191 and miR-455-3p were overexpressed preoperatively. After 6 months postoperatively, miR-191 (median 0.98, IQR 0.5-2.1, P < 0.0001) and miR-455-3p (median 1.4, IQR 0.6-3.1, P = 0.0003) presented a significant reduction in their expressions. There was no correlation between the diameter of the aneurysm and the expression of the miRNAs studied. In addition, analysis of the influence of the various types of devices used for the endovascular treatment of AAA showed no significant differences in the expression of miR-191 and miR-455-3p. CONCLUSIONS: Exclusion of the aneurysmal sac after endovascular treatment induces a decrease in the expression of the studied miRNAs in whole blood samples, which suggests a possible use of them as biomarkers of therapeutic success.

The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm

BACKGROUND: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity. METHODS: The committee made specific practice recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. Three systematic reviews were conducted to support this guideline. Two focused on evaluating the best modalities and optimal frequency for surveillance after endovascular aneurysm repair (EVAR). A third focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included (1) general approach to the patient, (2) treatment of the patient with an AAA, (3) anesthetic considerations and perioperative management, (4) postoperative and long-term management, and (5) cost and economic considerations. RESULTS: Along with providing guidance regarding the management of patients throughout the continuum of care, we have revised a number of prior recommendations and addressed a number of new areas of significance. New guidelines are provided for the surveillance of patients with an AAA, including recommended surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. We recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. Incorporating knowledge gained through the Vascular Quality Initiative and other regional quality collaboratives, we suggest that the Vascular Quality Initiative mortality risk score be used for mutual decision-making with patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year. We also suggest that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year. To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergent repair, we suggest a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm. We recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion. Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised. Increased utilization of color duplex ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion. CONCLUSIONS: Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices

Tratamento endovascular de aneurisma de aorta abdominal com erosão de vértebra lombar associada à doença de Behçet: relato de caso / Endovascular repair of abdominal aortic aneurysm with lumbar vertebral erosion in Behçet's disease: case report

A doença de Behçet é uma doença sistêmica, multifatorial e autoimune com diversas manifestações clínicas, entre elas o acometimento vascular. Aneurisma de aorta associado a erosão de vértebra lombar é condição rara na literatura, existindo apenas quatro relatos de caso nas bases de dados da PubMed. O presente artigo relata o caso de paciente do sexo feminino com diagnóstico de Doença de Behçet de longa data e aneurisma sacular de aorta abdominal infrarrenal com erosão de vértebra lombar. O caso foi tratado por meio de técnica endovascular com colocação de endoprótese monoilíaca e enxerto fêmoro-femoral cruzado, devido a limitações anatômicas da bifurcação aórtica. O artigo aborda a raridade desse tipo de apresentação da doença e o desfecho do tratamento e apresenta revisão da literatura sobre esse tema

Behçet's disease is an autoimmune, multifactorial, systemic condition with several clinical manifestations, including vascular disorders. An aortic aneurysm with vertebral erosion is rare in association with this pathology and there are only four case reports listed on the PubMed database. This article reports the case of a female patient with a long-standing diagnosis of Behçet's Disease who developed a saccular infrarenal abdominal aortic aneurysm with lumbar vertebral erosion. Her surgical treatment consisted of endovascular repair with a monoiliac endoprosthesis and a femorofemoral crossover bypass, because of limitations imposed by the anatomy of the aortic bifurcation. This paper discusses the rarity of this presentation of the disease and treatment outcomes and offers a brief review of the relevant literature

Tratamento endovascular de aneurisma de aorta abdominal com fístula aorto-cava utilizando oclusor vascular concomitante a endoprótese bifurcada: relato de caso / Endovascular treatment of an abdominal aortic aneurysm with aortocaval fistula using a vascular occluder and a bifurcated endograft in a single intervention: case report

As fístulas aorto-cava são entidades raras e de etiologia variada, estando frequentemente associadas a significativa morbimortalidade. Acredita-se que o aumento da tensão da parede nos grandes aneurismas resulte em reação inflamatória e aderência à veia adjacente, culminando na erosão das camadas aderidas e na formação da fístula. O tratamento cirúrgico convencional tem altas taxas de mortalidade. Embolia pulmonar paradoxal e o vazamento são complicações temidas do tratamento endovascular. O uso de oclusor vascular associado a endoprótese bifurcada é boa opção no tratamento do aneurisma de aorta abdominal com fístula aorto-cava

Aortocaval fistulae are rare entities with a variety of etiologies and are very often associated with significant morbidity and mortality. It is believed that increased tension in the walls of large aneurysms can cause an inflammatory reaction resulting in adhesion to the adjacent vein and culminating in erosion of the adherent layers and fistula formation. Conventional surgical treatment has high mortality rates. Paradoxical pulmonary embolism and endoleaks are the most concerning complications linked with endovascular treatment. Using a vascular occluder in combination with a bifurcated endograft is a good option for the treatment of an abdominal aortic aneurysm with aortocaval fistula

Retroperitoneal fibrosis: case series of five patients and review of the literature.

Chronic periaortitis (CP) is an umbrella term used to describe a group of nosologically allied conditions that include idiopathic retroperitoneal fibrosis (Ormond's disease), inflammatory abdominal aortic aneurysm, and perianeurysmal retroperitoneal fibrosis. Retroperitoneal fibrosis encompasses a range of diseases characterized by the presence of a fibro-inflammatory tissue, which usually surrounds the abdominal aorta and the iliac arteries and extends into the retroperitoneum to envelop neighboring structures-ureters. Retroperitoneal fibrosis is generally idiopathic, but can also be secondary to the use of certain drugs, malignant diseases, infections, and surgery. Here we describe a 5 years follow-up (2006-2011) of 5 patients admitted to our hospital with symptoms, laboratory, imaging and pathologic finding compatible with retroperitoneal fibrosis. We review our clinical course of our patient with respect to the literature.

Retroperitoneal fibrosis: case series of five patients and review of the literature / Fibrose retroperitoneal: série de cinco casos e revisão da literatura

ABSTRACT Chronic periaortitis (CP) is an umbrella term used to describe a group of nosologically allied conditions that include idiopathic retroperitoneal fibrosis (Ormond's disease), inflammatory abdominal aortic aneurysm, and perianeurysmal retroperitoneal fibrosis. Retroperitoneal fibrosis encompasses a range of diseases characterized by the presence of a fibro-inflammatory tissue, which usually surrounds the abdominal aorta and the iliac arteries and extends into the retroperitoneum to envelop neighboring structures-ureters. Retroperitoneal fibrosis is generally idiopathic, but can also be secondary to the use of certain drugs, malignant diseases, infections, and surgery. Here we describe a 5 years follow up (2006-2011) of 5 patients admitted to our hospital with symptoms, laboratory, imaging and pathologic finding compatible with retroperitoneal fibrosis. We review our clinical course of our patient with respect to the literature.

RESUMO Periaortite crônica (PC) é um termo genérico usado para descrever um grupo de condições nosologicamente ligadas que incluem a fibrose idiopática retroperitoneal (doença de Ormond), o aneurisma da aorta abdominal inflamatório e a fibrose retroperitoneal perianeurismática. O termo fibrose retroperitoneal engloba uma gama de doenças que se caracterizam pela presença de um tecido fibroinflamatório que geralmente envolve a aorta abdominal e as artérias ilíacas, se estende ao retroperitôneo e envolve estruturas ureterais vizinhas. A fibrose retroperitoneal geralmente é idiopática, mas pode também ser secundária ao uso de determinados fármacos, doenças malignas, infecções e cirurgia. Este estudo descreve o seguimento por cinco anos (2006-2011) de cinco pacientes internados em nosso hospital que apresentavam sintomas e achados laboratoriais, de imagem e patológicos compatíveis com a fibrose retroperitoneal. Revisou-se a evolução clínica dos pacientes, que foi comparada com os achados da literatura.