Infected Thrombosed Popliteal Artery Aneurysm With Cutaneous Fistula.

Introduction: Popliteal artery aneurysms (PAAs) pose some challenges in their surgical management and are often treated by exclusion and bypass procedures. However, post-operative complications, such as endoleaks and sac growth, can occur, potentially leading to serious consequences. Endoleaks, characterised by persistent flow within the aneurysm sac after repair, can cause sac expansion, increasing the risk of adverse outcomes, including the formation of cutaneous fistulae, a rare but potentially severe complication. Report: A 75 year old male with a history of previous bilateral PAA exclusion with a left femoropopliteal bypass using reversed great saphenous vein (GSV) graft in 2012 and a right femoropopliteal bypass using a PTFE prosthesis in 2017, both through medial approach, presented with pain and ulceration in the left popliteal region. Previous angiography had shown residual arterial flow through collateral vessels, requiring thrombin injection. Bilateral bypass thrombosis had also occurred after discontinuing anticoagulation. Computed tomography angiography confirmed a complicated excluded left popliteal aneurysm with superinfection. The patient underwent elective surgery, involving partial aneurysmectomy, endoaneurysmorrhaphy, and fistulectomy through a posterior approach. Post-operatively, the patient experienced resolution of symptoms and inflammatory signs. Discussion: The optimal approach for treating PAAs remains a subject of debate, with some experts advocating the posterior approach to prevent sac growth. However, others support the medial approach, reporting satisfactory results. In this case, the medial approach resulted in incomplete exclusion, leading to sac expansion and a cutaneous fistula. Timely re-intervention through the posterior approach successfully resolved the complication. This report highlights a rare but serious complication of incomplete PAA exclusion. Vigilant post-operative surveillance and intervention are crucial to manage such cases effectively. Further research is warranted to determine the optimal approach for PAA repair and prevent associated complications.

Thoracic aortic aneurysms, a single center's 10-years experience and analysis of outcomes.

INTRODUCTION: Thoracic aortic aneurysms (TAAs) are an increasingly prevalent pathology with significant associated morbidity and mortality. Thoracic endovascular aortic repair (TEVAR) is the primary line of treatment. The purpose of this study was to analyse a single center's experience in the treatment of TAAs and identify possible risk factors for worse outcomes. METHODS: A retrospective review of our institutional database was done to identify all patients treated for TAAs in a 10-year period, from 1 January 2012 to 31 December 2022. Data were extracted from patients' medical records. Primary outcome was all-cause mortality and secondary outcomes were procedure related morbidity (vascular access complications, medullary ischaemia, stroke, endoleaks, migration, aneurysm sac enlargement >5 mm) and need for reintervention at 1-, 6- and 12-month follow-up. A descriptive and inferential analysis of the data was performed. Statistical analyses were conducted using the IBM Statistical Package for Social Sciences (SPSS) software. RESULTS: We identified 34 patients treated for TAAs in this period. Mean age was 68 years [47-87] and 79.4% of patients were male. Mean aneurysm diameter was 63 mm [35-100], 55.9% fusiform and 44.1% saccular. The majority (91.2%) were located at the descending thoracic aorta and 3 (8.8%) of them extended to the aortic arch. The most common aetiology was degenerative in 22 patients (64.7%), followed by aortic dissection in 8 patients (23.5%). Elective surgery was performed in 19 (61.3%) patients and 12 (38.7%) had urgent repair. TEVAR was the treatment of choice in 24 (77.4%) patients, and the remaining 7 (22.6%) were treated with hybrid surgery. Mean length of hospital stay was 10 days [2-80] (6 days for elective repair versus 16 days for urgent repair, p = .016). Follow-up period ranged from 1 month to 10 years. At 1 year follow-up, all-cause mortality was 15%, morbidity was 30% (with 6 (22%) patients having a type Ia endoleak) and need for reintervention was 22%. Aneurysm diameter was a significant risk factor for procedure related morbidity (median diameter of 73.5 mm versus 56.0 mm in patients with no morbidity; p = .027). The presence of type Ia endoleak was significantly associated with higher reintervention rates (p = .001), but not with higher mortality rates (p = .515). Age, female sex, aetiology and urgent repair weren't associated with any significant differences in the outcomes. CONCLUSIONS: TEVAR proved to be effective in the treatment of TAAs, with good outcomes at short and mid-term follow-up. TAAs should be diagnosed earlier and be promptly treated when meeting criteria to prevent worse outcomes.

Coral Reef Aorta: Literature Review and Analysis of the Published Cases in the Last 20 Years.

BACKGROUND: Coral reef aorta (CRA) is defined by the presence of heavily calcified exophytic plaques that protrude into the aortic lumen. However, the exact causes and development of this condition are still not fully understood. When the aortic branches are affected, it can result in various symptoms. Despite ongoing research, there is currently no established consensus on the best treatment for CRA. This review aims to examine the latest findings regarding the clinical presentation and approach to treating patients with CRA. METHODS: We conducted a systematic electronic search of the literature using the PubMed and Embase databases. Throughout the search, we adhered to the guidelines outlined in the PRISMA framework. From the identified publications, we extracted information pertaining to patients' characteristics, symptoms, and types of treatment from a total of 124 cases reported over the past 20 years. The primary focus of our analysis was to assess the improvement of signs and symptoms, as well as to evaluate any postoperative complications. To achieve this, we performed both descriptive and inferential analyses on the collected data. Additionally, we conducted subgroup analyses based on treatment types and symptoms observed at presentation, presenting the findings in the form of odds ratios (ORs). RESULTS: After removing duplicate articles, we carefully screened the titles of 67 retrieved articles and excluded those that did not align with the purpose of our study. Subsequently, we thoroughly analyzed the remaining 41 articles along with their references, ultimately including 29 studies that were deemed most relevant for our systematic review. We examined a total of 124 cases of patients diagnosed with CRA, comprising 77 (62.1%) females and 48 (38.7%) males, with a mean age of 59 years (range: 37-84). The predominant signs and symptoms observed were intermittent claudication, reported in 57 (46.0%) patients, followed by refractory hypertension in 45 (36.3%) patients, intestinal angina in 28 (22.6%) patients, and renal insufficiency in 15 (12.1%) patients. Among the treated patients, 110 (88.7%) underwent open surgery repair (OSR), 11 (8.9%) received endovascular treatment, and 3 (2.4%) underwent laparoscopy. Postoperatively, a significant number of patients experienced substantial relief or complete resolution of their symptoms, as well as improved control of hypertension and renal function. In the group of patients treated with OSR, the inhospital stay mortality rate was 10.9%, the morbidity rate was 28.2%, and the reintervention rate was 15.5%. The high mortality rate during hospital stays in this group may be associated with such invasive procedures performed on patients who have substantial cardiovascular burden and multiple comorbidities. Conversely, no postoperative complications were reported in the group of patients treated with endovascular procedures or laparoscopic surgery. CONCLUSIONS: While coral reef aorta (CRA) is considered a rare condition, it is crucial for the medical community to remain vigilant about its diagnosis, particularly in patients presenting with symptoms such as intermittent claudication, refractory hypertension, renal impairment, or intestinal angina. Based on the findings of this review, both OSR and endovascular treatment have shown promise as viable therapeutic options. Although endovascular therapies may not always be feasible or may have reduced durability in these calcified bulky lesions, they should be considered in patients with multiple comorbidities, due to the high postoperative mortality rates associated with more invasive approaches. Additionally, these endoluminal procedures have demonstrated good patency rates during the 18-month follow-up period. It is essential to emphasize that the treatment strategy should be determined on a case-by-case basis, involving a multidisciplinary team to tailor it to the specific needs of each individual patient.

Aneurysmal Degeneration of the Brachial Artery Following Chronic Arteriovenous Fistula Ligation.

Introduction: Arteriovenous fistulas (AVF) are currently considered to be the best vascular access option for patients with end stage chronic kidney disease requiring haemodialysis. In rare cases of patients with chronic AVF, thrombosis or ligation of the access can lead to the development of brachial artery aneurysms. Despite being uncommon, reports of this phenomenon have arisen in recent decades due to an increase in the number of patients undergoing dialysis worldwide. This case presented with a brachial aneurysm that developed after AVF ligation. Case report: A 62 year old male presented to the emergency department with swelling of the medial aspect of his left arm associated with pain, inflammatory signs, and finger paraesthesia. Swelling had started two months previously but had worsened within the last week. He had history of kidney transplant 20 years ago and a chronic functioning radiocephalic fistula that had not been used since, and which had been ligated in the past year due to the development of venous aneurysms. Physical examination revealed a pulsatile mass in his left arm and absent radial and ulnar pulses, without signs of hand ischaemia. There was significant venous collateralisation of the arm and chest and numbness of the left fingers, suggesting venous and neurological compression. Computed tomography angiography showed a large left brachial artery aneurysm (108 x 87 x 180 mm). The patient underwent aneurysm sac emptying and collateral ligation followed by great saphenous vein interposition, with clinical improvement. Conclusion: The presence of a chronic AVF can lead to progressive changes in the arterial wall. Sudden ligation or thrombosis of a functioning AVF causes increased blood pressure within the artery, which may further contribute to its aneurysmal degeneration. In addition, immunosuppressive therapy following kidney transplant has been described as a synergistic risk factor leading to aneurysm formation. Despite being a rare complication, patients with a chronic AVF should be monitored closely after vascular access ligation.

Giant Sac Growth: A Hybrid Approach to Treat a Misdiagnosed Late Type IIIb Endoleak.

Introduction: Endoleaks are a common complication following endovascular aneurysm repair, yet type IIIb are rare, especially with newer devices, and associated with high morbidity due to repressurisation of the sac. As endografts are used in patients with longer life expectancy, late type IIIb endoleaks are to be expected. This is a report of a giant common iliac aneurysm resulting from a misdiagnosed type IIIb endoleak. Report: An 85 year old man with history of right common iliac artery aneurysm, treated in 2003 with an EXCLUDER AAA Endoprosthesis (WL Gore, Flagstaff, AZ, USA) with iliac limb extension into the external iliac artery, presented at the emergency department with abdominal pain, hypotension, and syncope. He had a known endoleak, unsuccessfully treated by relining the right iliac stent graft overlap zones for a suspected type IIIa endoleak (2009), coil embolisation, and computed tomography (CT) guided thrombin injection of the aneurysmatic sac for a type II (2010), none of which managed to treat the cause with continuous aneurysm growth. The patient refused further treatments, but agreed to maintain surveillance. At admission, CT angiography showed common iliac aneurysm (185 × 134 mm) sac rupture without a visible endoleak. Resuscitative endovascular balloon occlusion of the aorta (REBOA) technique was performed to obtain haemodynamic control, then the aneurysm was approached through a midline incision. A type IIIb endoleak was identified due to a fabric tear on the right iliac limb extension. Suture was attempted without success, then relining of the lesion with an Endurant II Limb (Medtronic, Minneapolis, MN, USA) was performed, which managed to repair the endoleak. Discussion: Type IIIb endoleaks are uncommon and underdiagnosed due to fabric defects being too small or leaking intermittently. They can mimic other types of endoleaks and may cause aneurysm growth and rupture. One should consider this type of endoleak if previous treatments for other types were unsuccessful.

Abdominal Aortic Aneurysms and Q Fever: An Odd Connection to Keep in Mind.

Abdominal aortic aneurysms (AAAs) secondary to Coxiella burnetii infections are rare but carry important implications. The diagnosis is difficult due to unspecific symptoms. To the authors' knowledge, this is the first AAA caused by chronic Q fever treated with an endoprosthesis.

Innominate artery post-traumatic pseudoaneurysm presenting with Horner's syndrome.

Isolated innominate artery trauma after blunt thoracic contusion is rare and occurs mostly at its origin. We report a case of a post-traumatic distal innominate artery pseudoaneurysm presenting with Horner's syndrome treated by conventional surgical approach.

Is There an Impact of COVID-19 on Admission of Patients to the Emergency Department for Vascular Surgery?

BACKGROUND: On March 2020, the World Health Organization declared the coronavirus disease 2019 outbreak a pandemic. During this period, surgical activity and admission to the Emergency Department (ED) decreased globally. The aim of this article is to understand how the admission of a patient to the ED for vascular surgery changed in our center in Portugal and if this situation prevented urgent surgical procedures. METHODS: Through a retrospective study, we compared the volume of patients admitted to the ED during the emergency state (ES) in Portugal with the same period in 2019. In addition, we analyzed the urgent surgical activity during the ES and in the correspondent period of the previous 10 years, regarding limb acute ischemia, acute aortic pathology, and vascular trauma. Two groups of patients were formed-patients operated during the ES and during the non-ES, for control. Statistical analysis was performed using IBM SPSS® Statistics, version 25. RESULTS: In the ES, 115 patients were observed at the ED and 179 in the 2019 corresponding period. During the ES, patients significantly recurred less to the ED directly from home (P < 0.001) and were less referred to the ED by primary care doctors (P < 0.001). Patients observed at the ED were significantly more urgent-required urgent surgery or were admitted to the department-than those in 2019 (40% vs. 24%). However, there were no differences when only considering urgent surgery (14% in ES vs. 10% in 2019). In the ES, 38% of patients observed at the ED were discharged with no follow-up related to vascular surgery against 60% in 2019, although this difference was not significant. Compared with the preceding 10 years, there are not significant differences in the number of patients who underwent urgent surgery in both ES and non-ES periods. In patients with acute limb ischemia, we did not find an increase in the time between onset of symptoms and ED admission, during the ES. CONCLUSIONS: Fewer patients were admitted at the ED during the ES, and those admitted were significantly more urgent. We did not find a decrease in the number of urgent surgeries when compared with the preceding 10 years. Therefore, we cannot assume that coronavirus pandemic precluded urgent surgical procedures.

New Oral Anticoagulants (NOACs) are The Gold Standard Invenous Thromboembolism.

INTRODUCTION: Venous Thromboembolism (VTE) is an important cause of morbidity and mortality. The risk of recur- rence could be very high without thromboprophylaxis. New oral anticoagulants (NOACs or DOACs) represent a new step in anticoagulation. MATERIAL AND METHODS: We searched for papers with trials, systematic reviews and meta-analysis involving NOACs in the treatment and secondary prevention of VTE. We also searched for guidelines of two medical societies (American College of Chest Physicians and International Society of Thrombosis and Haemostasis - ISTH). RESULTS: Six RCT (randomized controlled trial) comparing NOACs with Warfarin shew a non-inferiority in relation with recurrent VTE and major bleeding. Two RCT (SELECT-D and Hokusay cancer) and one meta-analysis shew low recurrence rate of VTE in cancer patients and higher rate of bleeding, mainly in gastrointestinal and genitourinary cancers. There are two RCTs involving NOACs in treatment of patients with Antiphospholipid Syndrome (APS). DISCUSSION: NOACs shew non-inferiority over AVK. Guidelines of CHEST 2016 recommend NOACs for VTE treatment in no cancer patients, and Low Molecular Weight Heparin (LMWH) for cancer patients. ISTH suggest NOACs as the first option in VTE cancer patients with low risk of bleeding. A recent RCT shews no benefit and increased risk of vascular events in APS patients treated with NOACs. NOACs are the gold standard for VTE treatment and secondary prevention in no cancer patients. They could be the first option in cancer patients with low risk of bleeding.