Outcomes after ruptured abdominal aortic aneurysm repair in the era of centralized care.

OBJECTIVE: Little is known about the relationship between case volume and patient outcomes of those treated for ruptured abdominal aortic aneurysm (rAAA) after either endovascular aneurysm repair (EVAR) or open aneurysm repair (OAR). This study evaluated the impact of hospital case volume on outcomes after rAAA. METHODS: Patients with rAAA were identified in the Society for Vascular Surgery Vascular Quality Initiative database from 2003 to 2017, excluding patients from years in which a limited number of hospitals were included (2003-2009, 2017). Patients were stratified according to type of aneurysm repair and further stratified according to aortic surgical volume of the treating facility. Univariate and multivariable analyses were performed. RESULTS: Between 2010 and 2016, of 2895 patients who presented emergently with rAAA, 1246 underwent ruptured OAR (rOAR) and 1649 underwent ruptured EVAR (rEVAR). Before adjustment for demographics, comorbidities, and clinical characteristics, there were no differences in 1-year patient survival based on hospital OAR or EVAR volumes among patients undergoing rOAR or rEVAR. After adjustment for confounding variables, patients treated with rOAR at the highest volume OAR hospitals had a 33% lower hazard of mortality at 1 year relative to patients treated with rOAR at the lowest volume OAR hospitals. Preoperative interfacility transfer was associated with a 27% lower hazard of mortality after rOAR. There was no significant difference in hazard of mortality among patients undergoing rEVAR when they were stratified according to hospital EVAR volumes after adjustment for all other covariates. CONCLUSIONS: Outcomes after rAAA repair are associated with hospital volume among patients undergoing rOAR but not among patients undergoing rEVAR. Thus, centralization of care may have an important impact on outcomes when OAR is indicated, suggesting a benefit for preoperative interfacility transfer of care when it is feasible.

Safety and Efficacy of Surgical Treatment of Intracranial Aneurysms: The Experience of a Single Brazilian Center.

BACKGROUND: The use of microsurgery for aneurysm clipping has decreased considerably in recent years. This study was conducted to demonstrate the safety and effectiveness of surgical treatment of intracranial aneurysms even in less-developed countries. METHODS: This study was a retrospective review of the medical records of 320 patients with 416 aneurysms treated with microsurgical clipping at a single neurosurgical center in Brazil between 2008 and 2016. We evaluated postoperative outcomes using the modified Rankin Scale (mRS) at the time of hospital discharge, treatment efficacy by digital subtraction angiography (DSA) performed postoperatively, and mortality. RESULTS: The 320 patients with aneurysms included 228 patients with ruptured aneurysms and 92 with unruptured aneurysms. Overall, 81 (26.3%) had a poor outcome (mRS score >2), and the other 227 (73.4%) had a good outcome. The presence of a ruptured aneurysm was a statistically significant factor for poor outcome (P < 0.001) and mortality (P < 0.015). Giant and large aneurysms were also associated with poor outcome (P = 0.004). When analyzed separately, unruptured aneurysms with poor outcome were only associated with aneurysm size. Among the patients with ruptured aneurysms, those with Hunt and Hess (HH) grade >2 on hospital admission had unfavorable outcomes (P < 0.0001). Among the patients who underwent postoperative DSA, 207 (89.8%) had complete aneurysm occlusion and 24 (10.2%) had residual aneurysms, with reoperation required in 8 cases. CONCLUSIONS: Microsurgical treatment of intracranial aneurysms is an effective and safe method.

Transoceanic Management and Treatment of Aneurysmal Subarachnoid Hemorrhage: A 10-Year Experience.

BACKGROUND AND PURPOSE: Because of the small number of yearly cases of ruptured cerebral aneurysms, endovascular treatment is not performed in Martinique. Therefore, patients from Martinique are sent 7000 km to Paris on commercial flights as soon as possible, where treatment is performed. Nontransportable patients are treated locally with either surgery or symptomatic care. The objective of our study was to assess patient outcomes and safety of this treatment strategy. METHODS: We retrospectively examined all cases of aneurysmal subarachnoid hemorrhage in Martinique diagnosed during 2004 to 2013. Medical case records were searched for the type and location of treatment, clinical status, and transfer duration. RESULTS: A total of 119 patients had an aneurysmal subarachnoid hemorrhage during the 10-year period. Of these, 91 were transferred to Paris, 12 were surgically treated locally, and 16 received symptomatic treatment. None of the transferred patients experienced any hemorrhagic recurrence, and none suffered a significant complication related to the air transportation. The median time between aneurysmal subarachnoid hemorrhage diagnosis and arrival at the referral center was 32 hours. The 30-day case fatality rate for treated cases was 14.6% (8.8% for those treated in Paris and 58.3% for those treated locally). CONCLUSIONS: Our treatment strategy for aneurysmal subarachnoid hemorrhage resulted in a 30-day case fatality rate similar to those observed elsewhere, despite an 8-hour flight and a median treatment delay of 32 hours. This strategy therefore seems to be safe and reliable for isolated regions with small populations.

Vitreous Hemorrhage after Aneurismal Rupture: Terson Syndrome

Introduction Terson syndrome is described as an intraocular hemorrhage consequent to a spontaneous subarachnoid hemorrhage (SSAH). In the present article, we describe cases of patients who underwent neurosurgical treatment of ruptured cerebral aneurysmat our institution over a period of one year, and who were diagnosed with Terson syndrome. Methods The present study included patients with a diagnosis of SSAH by rupture of a cerebral aneurysm who underwent treatment in our neurosurgical service from December 2009 to December 2010. The patients were followed-up for a minimum of 20 months.We have also performed a literature review and compared the data with those available in the current literature. Results The present study included 34 patients, 18 (53%) of which underwent endovascular treatment, and 16 (47%) who underwent microsurgical clipping. In the sample, the mortality was 14.7% (5 patients), the same percentage of patients who were diagnosed with Terson Syndrome, which is an incidence of 14.7%. Regarding the ophthalmologic evaluation, all patients had vitreous hemorrhage detected by an ultrasound examination, which was unilateral in only two patients. Visual acuity improved in all patients, being incomplete in only one of them. Conclusion Terson syndrome is relatively common and is associated with higher mortality. With the existence of an effective treatment, it should be investigated in all patients with SSAH.

Contemporary outcomes of intact and ruptured visceral artery aneurysms.

OBJECTIVE: The treatment outcomes of ruptured visceral artery aneurysms (rVAAs) have been sparsely characterized, with no clear comparison between different treatment modalities. The purpose of this paper was to review the perioperative and long-term outcomes of open and endovascular interventions for intact visceral artery aneurysms (iVAAs) and rVAAs. METHODS: This was a retrospective review of all treated VAAs at one institution from 2003 to 2013. Patient demographics, aneurysm characteristics, management, and subsequent outcomes (technical success, mortality, reintervention) and complications were recorded. RESULTS: The study identified 261 patients; 181 patients were repaired (77 ruptured, 104 intact). Pseudoaneurysms were more common in rVAAs (81.8% vs 35.3% for iVAAs; P < .001). The rVAAs were smaller than the iVAAs (20.7 mm vs 27.5 mm; P = .018), and their most common presentation was abdominal pain; 29.7% were hemodynamically unstable. Endovascular intervention was the initial treatment modality for 67.4% (75.3% for rVAAs, 61.5% for iVAAs). The perioperative complication rate was higher for rVAAs (13.7% vs 1% for iVAAs; P = .003), as was mortality at 30 days (13% vs 0% for iVAAs; P = .001), 1 year (32.5% for rVAAs vs 4.1% for iVAAs; P < .001), and 3 years (36.4% for rVAAs vs 8.3% for iVAAs; P < .001). Lower 30-day mortality was noted with endovascular repair for rVAAs (7.4% vs 28.6% open; P = .025). Predictors of mortality for rVAAs included age (odds ratio, 1.04; P = .002), whereas endovascular repair was protective (odds ratio, 0.43; P = .037). Mean follow-up was 26.2 months, and Kaplan-Meier estimates of survival were higher for iVAAs at 3 years (88% vs 62% for rVAAs; P = .045). The 30-day reintervention rate was higher for rVAAs (7.7% vs 19.5% for iVAAs; P = .019) but was similar between open and endovascular repair (8.2% vs 15%; P = NS). CONCLUSIONS: rVAAs have significant mortality. Open and endovascular interventions are equally durable for elective repair of VAAs, but endovascular interventions for rVAAs result in lower morbidity and mortality. Aggressive treatment of pseudoaneurysms is electively recommended at diagnosis regardless of size.

Angiographic results in intracranial aneurysms treated with inert platinum coils.

This study was designed in an attempt to identify the risk factors that could be significantly associated with angiographic recurrences after selective endovascular treatment of aneurysms with inert platinum coils. A retrospective analysis of all patients with selective endovascular coil occlusion of intracranial aneurysms was prospectively collected from 1999 to 2003. There were 455 aneurysms treated with inert platinum coils and followed by digital subtraction angiography. Angiographic results were classified according Roy and Raymond's classification. Recurrences were subjectively divided into minor and major. The most significant predictors for angiographic recurrences were determined by ANOVAs logistic regression, Cochran-Mantel-Haenszel test, Fisher exact probability. Short-term (4.3 ± 1.4 months) follow-up angiograms were available in 377 aneurysms, middle-term (14.1 ± 4.0 months) in 327 and long-term (37.4 ± 11.5 months) in 180. Recurrences were found in 26.8% of treated aneurysms with a mean of 21 ± 15.7 months of follow-up. Major recurrences needing retreatment were present in 8.8% during a mean period follow-up of 17.9 ± 12.29 months after the initial endovascular treatment. One patient (0.2%) experienced a bleed during the follow-up period. Recurrences after endovascular treatment of aneurysms with inert platinum coils are frequent, but hemorrhages are unusual. Single aneurysm, ruptured aneurysm, neck greater than 4 mm and time of follow-up were risk factors for recurrence after endovascular treatment. The retreatment of recurrent aneurysm decreases the risk of major recurrences 9.8 times. Long-term angiogram monitoring is necessary for the population with significant recurrence predictors.

Endovascular treatment for acute aortic syndrome.

BACKGROUND: The term "acute aortic syndrome" (AAS) includes conditions of high mortality, such as ruptured aneurysm, pseudoaneurysm and, aortic dissection. Open surgery for these cases has demonstrated unsatisfactory results, and endovascular treatment has become an excellent alternative. METHODS: We performed a retrospective review of patients with AAS who underwent endovascular treatment in our emergency department from July 2009 to February 2011. They represent 64% (16 of 25) of all patients with AAS seen during this period. RESULTS: Sixteen patients underwent endovascular treatment: eight ruptured aneurysms, six aortic dissections, one nonruptured painful aneurysm, and one pseudoaneurysm. No intramural hematoma or penetrating atherosclerotic ulcer was found. The mean age was 64.3 years, and arterial hypertension (100%) and smoking (64.7%) were the major comorbidities. Technical success rate was 93%, and overall 30-day mortality was 6.25%. CONCLUSION: Endovascular treatment for AAS was feasible. Technical success, 30-day mortality, hospital stay, and procedure time were similar to those of the other series reported in the literature, and the endovascular approach has became the main technique for AAS in our hospital.

Open abdominal aortic aneurysm repair in the era of endovascular repair / Reparación abierta de la aorta abdominal en la era de la reparación endovascular

OBJECTIVES: The development of minimally invasive techniques for abdominal aortic aneurysm (AAA) repair and the establishment of specialized centres have resulted in improved patient outcomes. This study examines open AAA repair at a non-specialized centre where advanced techniques are not practised. METHODS: We conducted a retrospective analysis on a cohort of 83 patients presenting for AAA repair to a non-specialized hospital, the University Hospital of the West Indies (UHWI). The end points assessed included operative (30-day) mortality, postoperative complications, duration of operation, blood loss, intensive care unit (ICU) stay and overall hospital stay. RESULTS: The overall operative mortality was 9.4% (23% for ruptured aneurysms and 5% for unruptured aneurysms). Mean operating time, blood loss, ICU stay and hospital stay were 326 ± 98 minutes, 2420 ± 1397 mls, 3 ± 5 days and 9 ± 5 days, respectively with no significant differences noted between ruptured and unruptured aneurysms. Mean aneurysm diameter was 6.13 ± 1.59 cm. CONCLUSION: Mortality rates for open aneurysm repair at the UHWI are consistent with findings in the current literature. Open AAA repair remains a safe treatment option in this environment. Continued improvements need to be made with respect to minimizing blood loss and operation duration, particularly in repairs of unruptured aneurysms.

OBJETIVOS: El desarrollo de técnicas mínimamente invasivas para la reparación del aneurisma aórtico abdominal (AAA) y el establecimiento de centros especializados para esos fines, han traído consigo el mejoramiento de los resultados clínicos de los pacientes. Este estudio examina reparaciones del tipo AAA en un centro no especializado, en el que no se practican técnicas avanzadas. MÉTODOS: Se llevo a cabo un análisis retrospectivo en una cohorte de 83 pacientes que acudieron para reparación de AAA a un hospital no especializado - el Hospital Universitario de West Indies (UHWI). Los aspectos finales evaluados incluyeron la mortalidad operatoria (30 días), las complicaciones post-operatorias, la duración de la operación, la pérdida de sangre, la estadía en la unidad de cuidados intensivos, y la estadía general en el hospital. RESULTADOS: La mortalidad operatoria general fue 9.4% (23% para los aneurismas rotos y 5% para los aneurismas no rotos). El tiempo promedio de operación, la pérdida de sangre, la estadía en la UCI, y la estadía hospitalaria fueron 326 ± 98 minutos, 2420 ± 1397 mls, 3 ± 5 días y 9 ± 5 días respectivamente, sin que se observen diferencias significativas entere aneurismas rotos y no rotos. El diámetro promedio de los aneurismas fue 6.13 ± 1.59 cm. CONCLUSIÓN: Las tasas de mortalidad para la reparación abierta de aneurismas en el UHWI concuerdan con los hallazgos en la literatura corriente. Se necesita continuar los esfuerzos por lograr mejorías en cuanto a minimizar la pérdida de sangre, y reducir el tiempo de duración de la operación, especialmente en las reparaciones de aneurismas no rotos.

Terson's syndrome as a prognostic factor for mortality of spontaneous subarachnoid haemorrhage.

PURPOSE: To evaluate the prognosis of mortality in patients with spontaneous subarachnoid haemorrhage associated with Terson's syndrome. METHODS: A prospective, consecutive case series study was conducted in patients admitted to the emergency room with a diagnosis of acute subarachnoid haemorrhage. After a complete neurological examination, funduscopic examination using binocular indirect ophthalmoscopy under mydriasis was performed upon admission and at days 3, 7, 30 and 60 after the onset. In all cases, the diagnosis of intracranial bleeding was made by computerized tomography, and the clinical condition was graded according to the Hunt & Hess and Glasgow coma scales. RESULTS: Forty-seven patients with the diagnosis of subarachnoid haemorrhage were enrolled. Forty-four cases were associated with a ruptured aneurysm and three cases with arterio-venous malformation. Fourteen patients (29%) were diagnosed with Terson's syndrome. Seven patients (50%) with Terson's syndrome died, whereas death occurred in three patients (9%) without Terson's syndrome (p = 0.002). Ocular findings in Terson's syndrome were preretinal, intraretinal, sub-retinal and vitreous haemorrhage. Associated ocular findings included third-nerve palsy, papilloedema and subconjunctival haemorrhage. CONCLUSION: The presence of Terson's syndrome was associated with an increased mortality rate (50% versus 9%; p < 0.01). Therefore, patients with the diagnosis of intracranial haemorrhage should be submitted to a funduscopic examination, because the presence of intraocular haemorrhage is an important life-threatening prognostic factor.

Open abdominal aortic aneurysm repair in the era of endovascular repair.

OBJECTIVES: The development of minimally invasive techniques for abdominal aortic aneurysm (AAA) repair and the establishment of specialized centres have resulted in improved patient outcomes. This study examines open AAA repair at a non-specialized centre where advanced techniques are not practised. METHODS: We conducted a retrospective analysis on a cohort of 83 patients presenting for AAA repair to a non-specialized hospital, the University Hospital of the West Indies (UHWI). The end points assessed included operative (30-day) mortality, postoperative complications, duration of operation, blood loss, intensive care unit (ICU) stay and overall hospital stay. RESULTS: The overall operative mortality was 9.4% (23% for ruptured aneurysms and 5% for unruptured aneurysms). Mean operating time, blood loss, ICU stay and hospital stay were 326 +/- 98 minutes, 2420 +/- 1397 mls, 3 +/- 5 days and 9 +/- 5 days, respectively with no significant differences noted between ruptured and unruptured aneurysms. Mean aneurysm diameter was 6.13 +/- 1.59 cm. CONCLUSION: Mortality rates for open aneurysm repair at the UHWI are consistent with findings in the current literature. Open AAA repair remains a safe treatment option in this environment. Continued improvements need to be made with respect to minimizing blood loss and operation duration, particularly in repairs of unruptured aneurysms.

Utilidad del eco-Doppler en el screening de la aorta abdominal / Usefulness of Doppler ultrasound for the screeining of the abdominal aorta

An aneurysm is a permanent dilatation of an artery due to a weakness in the arterial wall. The aortic aneurysm is defined as the enlargement of the diameter greater than 50% in his original size compared with a previous segment, or greater than 3 cm. If an abdominal aortic aneurysm is suspected on the basis of either the patient history or a prominent aortic pulse, an abdominal ultrasound examination should be done. The presence of an aneurysm is an indication for complete evaluation for strong consideration of surgical treatment. Rupture of an abdominal aneurysm is associated with sudden, massive blood loss. Many of these patients die before reaching a hospital. The striking difference in mortality rates between patients with ruptured aneurysms and those undergoing elective treatment makes a strong case for advising surgery to prevent deaths due to rupture. For these motives it is imperious to indicate ultrasound studies to provide concrete images of this disease. These considerations are expressed in this paper

Buenos Aires experience with the Neuroform self-expanding stent for the treatment of intracranial aneurysms.

OBJECT: The authors report their experience with the use of the Neuroform Microdelivery System for intravascular reconstruction. They assess the technical feasibility of the system, the efficacy of the combined application of stent and detachable coils, and the follow-up findings. METHODS: Fifty patients found to harbor a complex wide-necked intracranial aneurysm were selected for the study. Different strategies were chosen and the performance and technical success of the device were evaluated. Stent placement was recorded as optimal or suboptimal with respect to the stent position. Clinical and angiographic follow-up examinations were obtained. Forty-six patients with 48 intracranial aneurysms were treated, leading to a technical success rate of 92%. Forty-two lesions were located in the anterior circulation. In every case the dome/neck ratio was less than 2 and the mean aneurysm size in these patients was 8.8 mm. The most frequent clinical presentation was subarachnoid hemorrhage in 48% of cases. Stent placement was optimal in 81.2% of cases and suboptimal in 18.8%. In 31% of cases, the investigators encountered difficulties in placing the Neuroform stent. Clinical follow up was recorded in all patients and angiographic follow up was obtained in 63%. There were no cases of repeated hemorrhage. In a single case in which only the stent was implanted progressive thrombosis was identified during the follow-up period. The procedure-related morbidity and mortality rates were 8.6 and 2.1%, respectively. CONCLUSIONS: On the basis of the results, the authors conclude that the Neuroform self-expanding stent is a flexible and useful device that can be readily and safely maneuvered through tortuous intracranial vessels, enabling the endovascular treatment of complex wide-necked aneurysms. Early in the authors' experience, stent delivery presented difficulties; however, a second generation of devices has resolved this limitation. Although the early results are promising, the long-term benefit of this technique has to be proved by angiographic and clinical follow-up examinations.

Aneurisma toracoabdominal roto: relato de caso com uso de anel rígido sulcado de Delrin intraluminal na anastomose proximal / Thoracoabdominal aneurysm rupture: case report of the use of a intraluminal rigid Delrin sulcate ring in anastomosis of the proximal aorta

A rotura do aneurisma de aorta toracoabdominal possui altas taxas de mortalidade e morbidades graves como paraplegia, falência renal e cardíaca, sendo de difícil resolução cirúrgica. Paciente de 51 anos, sexo masculino, tem aneurisma de aorta toracoabdominal roto,tipo III, no qual foi utilizado anel rígido proximalmente, sendo queuma anastomose única, biselada, incluindo os ramos viscerais, foi realizada distalmente. O uso do anel e a anastomose distal única, com substituição completa da porção aneurismática, permitiram um tempo cirúrgico e de clampeamento reduzidos, além de baixa morbidadeconstatada. A técnica cirúrgica adotada possibilitou boa evolução pós-operatória.(AU)#S#a

Cirugía de los aneurismas de aorta abdominal: resultados de los últimos 10 años en el Hospital de Clínicas / Surgery of abdominal aortic aneurysms: results of the last 10 years at the Hospital de Clinicas

Con el objetivo de conocer la frecuencia y los resultados de la cirugía de los aneurismas de aorta abdominal (AAA) en el Hospital de Clínicas de Montevideo, se recabaron los datos de los pacientes intervenidos entre enero de 1988 y julio de 1998. Se operaron 63 enfermos, 35 de coordinacion y 28 de urgencia, entre estos últimos 21 aneurismas rotos. La mortalidad hospitalaria de la cirugía de coordinacion fue de 8,5 por ciento y la de los aneurismas con rotura de 81 por ciento. El 27 por ciento de los pacientes tuvieron complicaciones intraoperatorias y el 34 por ciento desarrollaron complicaciones postoperatorias graves. Se analizan la presentación clínica, estudios realizados y resultados del tratamiento quirúrgico. La morbimortalidad de esta cirugía fue mayor que la publicada recientemente por los centros de referencia en cirugía vascular; se discuten los factores que pueden haber influido en estos resultados. (AU)

[The results of surgical treatment in 100 patients operated on for intracranial aneurysms of the anterior circulation]. / Resultados del tratamiento quirúrgico en 100 pacientes operados de aneurismas intracraneales de la circulación anterior.

INTRODUCTION: Rupture of intracranial aneurysms causes nearly 80% of all spontaneous subarachnoid haemorrhages. OBJECTIVE: To determine the variables with prognostic value in view of the results of patients operated on for intracranial aneurysms. Patients and methods. The sample was made up of 100 patients from whose clinical histories useful data was obtained. This data was then fed into a database using DBASE111 and discriminant analysis made to determine the variables of predictive value regarding mortality. RESULTS: The average age was 45 years, with a predominance of women. Arterial hypertension was observed in 52.9% of the patients. The patients with the best pre operative evaluation on the WFNS scale obtained the best results. Correct evaluation of 97% of the cases was done on discriminant analysis of certain variables studied. Excellent results were obtained by 75% of the patients, 10% had a slight degree of disability, four patients had severe disability and 11 patients died, five of them of non neurological conditions. CONCLUSIONS: The application of discriminant analysis made it possible to determine amongst over 50 variables studied, a group which by themselves lead to the definite classification of our patients regarding survival. These were: the state of the brain during operation, number of post operative complications, difficulty in dissecting the sac of the aneurysm, early rupture of the aneurysm, pre operative neurological state and action on the aneurysm.

Mortalidade materna no município de Ribeiräo Preto: fatores determinantes e coadjuvantes / Maternal mortality in Ribeiro Preto City: elements determinants and coadjuvants

O propósito deste estudo foi identificar os fatores determinantes e coadjuvantes da mortalidade materna no município de Ribeiräo Preto - SP, nos anos de 1994 a 1996. A populaçäo constou de 14 mulheres que residiam e morreram por causas maternas, no período e no município do estudo. Tratou-se de um estudo descritivo e retrospectivo, com fatores coadjuvantes que levaram as mulheres à morte. A coleta de dados inclui informaçöes fornecidas pelo Comitê de Mortalidade Materna do município, dados dos prontuários médicos do hospital onde ocorreram os óbitos e informaçöes através de questionário aplicado ao familiar da mulher falecida, durante visita domiciliar. As causas das 14 mortes, foram hemorragia, infecçäo, doença hipertensiva específica da gestaçäo, rotura de aneurisma, cardiopatia e distúrbio hidroeletrolítico e metabólico. No que concerne ao local dos óbitos, 13 ocorreram em hospitais e um no domicílio. As complicaçöes do ciclo-gravídico-puerperal foram relativas ao aborto, descolamento prematuro da placenta, óbito fetal, síndrome hipertensivas da gestaçäo, nefropatia, cardiopatia, acidente vascular cerebral hemorrágico, infecçöes urinárias e complicaçöes no parto. Considera-se que na maioria dos casos, as principais causas destas mortes estavam associadas a fatores sociais e a problemas de assintência durante a gestaçäo, parto e puerpério, quer por causas advindas do sistema de saúde quer pela falta de informaçäo por parte da gestante