Physician-Modified Endovascular Gore Excluder Graft (Handmade Modified) for Complex Abdominal Aortic Aneurysm: A Step-by-Step Approach.

Endovascular repair has become the gold standard for the treatment of infrarenal abdominal aortic aneurysmal disease. Branched and fenestrated commercially custom-made devices have been developed as a treatment option for short necks or juxtarenal aneurysms. However, the lack of availability in some countries and centers, manufacturing time (6-8 weeks requirements), urgent setting in ruptured abdominal aortic aneurysms, and elevated costs make them not a widespread option. Hereby, we expose our step-by-step technique of physician modified Gore Excluder  to treat complex aneurysms. Physician-modified endovascular graft (PMEG) has emerged as an alternative to open repair for the treatment of complex aortic aneurysms. The ultimate goal of fenestrations is to increase the proximal sealing zone length. The Gore C3 delivery system allows repositioning of the graft by constraining the proximal part after a back-table physician modification; the PMEG technique with the Gore Excluder C3 delivery system can be used for complex aortic aneurysms repair as an alternative treatment option.

Complex Aortic, Visceral and Renal Arteries Reconstruction with a Four-Branch Dacron Graft for Middle Aortic Syndrome Secondary to Takayasu's Arteritis.

The middle aortic syndrome (MAS) is an uncommon clinical expression as a result of isolated stenosis or complete occlusion of the descending thoracic and/or abdominal aorta; Takayasu's arteritis (TA) is a rare vasculitis and a recognized etiology of MAS. We herein present the case of a 52-year-old woman with refractory renovascular hypertension and progressive bilateral lower extremity claudication; she had known history of TA. A computed tomography angiography demonstrated an aortic occlusive lesion compromising the origin of the celiac trunk, superior mesenteric, and bilateral renal arteries. The patient underwent a complex aortic reconstruction with visceral and renal vessels revascularization utilizing a back-table hand-crafted 4-branch Dacron graft through a left thoracoabdominal approach. The patient recovered uneventfully and was discharged on postoperative day 5, and at 36 months from her surgery, she remains symptoms-free and without antihypertensive agents.

Comparison of axillary-atrial and axillary-iliac arteriovenous grafts for hemodialysis access creation.

OBJECTIVE: The aim of this study was to compare two complex vascular access techniques that utilize the axillary artery as inflow and accesses were created with early cannulation grafts: the axillary-atrial arteriovenous graft versus axillary-iliac arteriovenous graft. METHODS: This is a retrospective study of end-stage renal disease patients with occluded intrathoracic central veins that underwent complex hemodialysis access creation in our institution after failed endovascular recanalization attempts. Patients' demographics, comorbidities, number and types of previous accesses, intraoperative variables, and clinical outcomes were collected and compared. RESULTS: Four patients underwent axillary-atrial arteriovenous graft creation with Flixene™ (Atrium™, Hudson, NH, USA) grafts, through a midline sternotomy to expose the right atrium; all were successfully implanted and used for hemodialysis within the first 72 h; one patient developed a pseudoaneurysm in the mid-graft portion, requiring surgical repair, and it is currently functional. Eight axillary-iliac arteriovenous grafts were created; all grafts were patent and were utilized within 96 h after placement. At 6 months of follow-up period, five (62 %) of our patients underwent graft thrombectomy, one (12 %) balloon angioplasty at the vein anastomosis secondary to stenosis, and two (25 %) grafts were removed due to infectious complications. Axillary-atrial arteriovenous graft and axillary-iliac arteriovenous graft primary patency rates at 6 months were 75% and 48%, respectively; 6-month secondary patency of the axillary-atrial arteriovenous graft compares favorably against that of axillary-iliac arteriovenous graft (100% vs 75%, respectively). CONCLUSION: Despite the invasiveness, direct atrial outflow procedures remain a valid alternative in carefully selected patients with adequate cardiopulmonary reserve.

Successful Treatment of a Superficial Femoral Artery Pseudoaneurysm with Balloon Tamponade.

The development of post-catheterization arterial pseudoaneurysms is one of the most common vascular access complications following angiographies and endovascular interventions. Different therapeutic options to treat these lesions have been used. We herein report the case of a 79-year-old woman who was referred to our service for evaluation with a post-catheterization superficial femoral artery pseudoaneurysm measuring 4 cm. Owing to the anatomical location of the arterial pseudoaneurysm and the patient's refusal to undergo open surgery, we treated the lesion using an endovascular approach with a balloon tamponade. The procedure was successful, and the patient recovered well and was discharged from the hospital without complications. At 6-month follow-up she remained symptom-free and without recurrence.

Proactive measurements in the search of aortic aneurysms have an impact in the prevalence.

An abdominal aortic aneurysm is defined as a focal dilation greater than 50% of the normal diameter of the vessel. The prevalence in individuals older than 65 years is estimated between the 2 and 8% with a risk of rupture when the diameter >5.5 cm in men and 5 cm in women. The risk increases exponentially with the expansion of this aneurysmal sac, and if the rupture occurs, its mortality can achieve 80%. The pathogenesis and factors associated to the development and progression of this disease remain not fully understood and isolating the aneurysm from the circulation is the main therapeutic goal to eliminate the risk of rupture. Over the last decades, ultrasonographic screening programs have been implemented for its detection. In this article, we review the epidemiology, natural history of aneurysms and the relevance of ultrasonographic screening programs.

Un aneurisma aórtico abdominal se define como una dilatación focal mayor del 50% del diámetro normal del vaso. La prevalencia en los adultos mayores de 65 años se estima entre el 2 y el 8%, con un riesgo de rotura elevado cuando su diámetro es mayor de 5.5 cm en el sexo masculino y de 5 cm en el femenino. Este riesgo aumenta linealmente con el crecimiento del aneurisma, y de manifestarse la rotura, la mortalidad puede alcanzar hasta el 80%. La patogénesis y otros factores asociados al crecimiento y la progresión de esta enfermedad no se conocen con certeza, por lo que aislar el aneurisma de la circulación mediante cirugía abierta o endovascular es el objetivo terapéutico para el eliminar el riesgo de rotura. En las últimas décadas se han implementado programas de escrutinio ultrasonográfico para la detección. En el presente artículo hacemos una revisión de la literatura sobre la epidemiología, la evolución natural de los aneurismas y la relevancia de estos programas de escrutinio ultrasonográfico.

Revisión sistemática de procedimientos quirúrgicos usados para tratar patología aórtica en México.

INTRODUCTION: In Mexico, there are no appropriate statistical data on aortic disease, which can be treated with medical management or open or endovascular surgical approach. OBJECTIVE: To carry out a systematic search and review of the literature in electronic databases with regard to invasive management of aortic pathology in Mexico. METHOD: A systematic search and narrative review of available literature was carried out using different electronic databases: PubMed, Imbiomed, Clinical Key, Bibliat, Scielo, Sage Journals and Sciencedirect, as well as with the Google Scholar search engine. RESULTS: Ninety articles were found, out of which only 53 met the inclusion criteria. Observational studies and case reports were selected, emphasizing on patient demographics, clinical results, and 30-day postoperative survival. CONCLUSION: An elevated rate of complications is reported for aortic pathologies due to underdiagnosis, which results in management being more complicated and prognosis unfavorable. The creation of a national aortic disease registry is crucial to standardization in the approach and optimization of results.

INTRODUCCIÓN: En México no se cuentan con estadísticas adecuadas acerca de la enfermedad aórtica, que puede ser tratada mediante manejo médico o cirugía abierta o endovascular. OBJETIVO: Identificar la literatura en bases de datos electrónicas relativa al manejo invasivo de la patología aórtica en México. MÉTODO: Se realizó búsqueda sistemática y revisión narrativa de la literatura disponible en diferentes bases de datos electrónicas: PubMed, Imbiomed, Clinical Key, Bibliat, Scielo, Sage Journals, Sciencedirect y con el motor de búsqueda de Google Académico. RESULTADOS: Se encontraron 90 artículos, de los cuales 50 reunían los criterios de inclusión. Fueron seleccionados estudios observacionales y reportes de casos, con énfasis en los datos demográficos de los pacientes, resultados clínicos y la supervivencia posoperatoria a 30 días. CONCLUSIÓN: Se reporta elevada tasa de complicaciones de las enfermedades aórticas debido al infradiagnóstico de estas, que deriva en manejo más complejo y pronóstico desfavorable. La creación de un registro nacional de patología aórtica es crucial para la estandarización en el abordaje y la optimación de los resultados.

Revisión sistemática de procedimientos quirúrgicos usados para tratar patología aórtica en México / Systematic review of surgical procedures used to treat aortic pathology in Mexico

Resumen Introducción: En México no se cuentan con estadísticas adecuadas acerca de la enfermedad aórtica, que puede ser tratada mediante manejo médico o cirugía abierta o endovascular. Objetivo: Identificar la literatura en bases de datos electrónicas relativa al manejo invasivo de la patología aórtica en México. Método: Se realizó búsqueda sistemática y revisión narrativa de la literatura disponible en diferentes bases de datos electrónicas: PubMed, Imbiomed, Clinical Key, Bibliat, Scielo, Sage Journals, Sciencedirect y con el motor de búsqueda de Google Académico. Resultados: Se encontraron 90 artículos, de los cuales 50 reunían los criterios de inclusión. Fueron seleccionados estudios observacionales y reportes de casos, con énfasis en los datos demográficos de los pacientes, resultados clínicos y la supervivencia posoperatoria a 30 días. Conclusión: Se reporta elevada tasa de complicaciones de las enfermedades aórticas debido al infradiagnóstico de estas, que deriva en manejo más complejo y pronóstico desfavorable. La creación de un registro nacional de patología aórtica es crucial para la estandarización en el abordaje y la optimación de los resultados.

Abstract Introduction: In Mexico, there are no appropriate statistical data on aortic disease, which can be treated with medical management or open or endovascular surgical approach. Objective: To carry out a systematic search and review of the literature in electronic databases with regard to invasive management of aortic pathology in Mexico. Method: A systematic search and narrative review of available literature was carried out using different electronic databases: PubMed, Imbiomed, Clinical Key, Bibliat, Scielo, Sage Journals and Sciencedirect, as well as with the Google Scholar search engine. Results: Ninety articles were found, out of which only 53 met the inclusion criteria. Observational studies and case reports were selected, emphasizing on patient demographics, clinical results, and 30-day postoperative survival. Conclusion: An elevated rate of complications is reported for aortic pathologies due to underdiagnosis, which results in management being more complicated and prognosis unfavorable. The creation of a national aortic disease registry is crucial to standardization in the approach and optimization of results.

Factors that impact kidney function during open and endovascular reconstruction of aortic aneurysms.

BACKGROUND: To analyze the factors that influence the deterioration of postoperative renal function in patients undergoing open or endovascular aortic reconstruction, and the impact on survival. METHOD: Retrospective review of patients who underwent invasive treatment was conducted. Demographics, laboratory data, clinical, intraoperative and postoperative variables were recorded; renal function was determined, Fisher's exact test was used to find associations and Kaplan Meier analysis to estimate survival. RESULTS: From 2007 to 2017, 80 patients (mean age: 70 years) were studied. Fifty-eight (73%) were male, none of these patients had known diagnosis of chronic kidney insufficiency. Twelve (15%) patients had elevated creatinine in the postoperative period; variables such as intraoperative bleeding greater than 1500 ml were associated with acute renal failure (p = 0.005). During the follow-up period of 60 months, 8 (10%) patients progressed to chronic renal failure, 2 (2.5%) requiring hemodialysis, 18 (22%). Age, gender, comorbidities and anatomic characteristics of the aneurysm, type of intervention or level of aortic cross-clamping did not impact the postoperative renal function. CONCLUSIONS: The repair of complex aortic aneurysms continues to be a challenge. Intraoperative bleeding greater than 1500 ml and the need of blood transfusion was associated with deterioration of postoperative renal function, affecting the 5-year survival of patients.

OBJETIVO: Analizar qué factores influyen en el deterioro de la función renal en pacientes sometidos a reconstrucción aórtica abierta o endovascular, y su impacto en la supervivencia. MÉTODO: Estudio retrospectivo. Se analizaron variables demográficas, de laboratorio, transoperatorias y posoperatorias. Se determinó la función renal y se utilizó la prueba exacta de Fisher en la búsqueda de asociaciones, y el análisis de Kaplan-Meier para estimar la supervivencia. RESULTADOS: De 2007 a 2017, 80 pacientes (media de edad: 70 años) fueron sometidos a procedimientos de reconstrucción aórtica. Cincuenta y ocho (73%) eran de sexo masculino. Doce (15%) tuvieron elevación de creatinina en el posoperatorio y sangrado mayor de 1500 ml con necesidad de transfusión que se asoció a insuficiencia renal aguda (p = 0.005). Durante el periodo de seguimiento de 60 meses, 8 (10%) pacientes desarrollaron insuficiencia renal crónica, 2 (2.5%) requirieron hemodiálisis y 18 (22%) fallecieron. La edad, el sexo, la comorbilidad y las características anatómicas del aneurisma, así como el tipo de intervención o el nivel de pinzamiento aórtico, no impactaron la función renal posoperatoria. CONCLUSIONES: La reparación de los aneurismas aórticos complejos continúa siendo un reto. Un sangrado superior a 1500 ml, con necesidad de transfusión, se asoció a deterioro de la función renal posoperatoria e impactó en la supervivencia a 5 años.

Surgical Management of Bilateral Carotid Body Tumors.

BACKGROUND: Carotid body tumors (CBTs) are rare neoplasms located in the carotid bifurcation. The majority of these tumors are unilateral; bilateral CBTs represent approximately 5% of all affected patients, and the recommended treatment is to surgically remove them in staged-planned surgeries. We describe the experience, outcomes, and the surgical management of bilateral CBTs in our institution. METHODS: A retrospective review of CBTs patients was completed; patient demographics, comorbidities, lesion location, anatomic characteristics, surgical techniques, complications, reinterventions, and other factors that may influence outcomes were evaluated. RESULTS: A total of 109 patients with CBTs were treated surgically; of these, 8 had bilateral CBTs (7%); the mean age was 56 years, and 7 (87%) were females. Thirteen surgical resections were performed, and in 2 of the cases, the pathology report was malignant (15%). Five were classified as Shamblin I (31%), 5 as Shamblin II (31%), and remaining 6 as Shamblin III (38%). The mean time between the first and second procedure was of 10.7 months. Complications included one case of neck hematoma requiring evacuation and postoperative neurologic complications occurred in three patients (one patient with facial and two with vocal cord palsies). None of the studied individuals had a family history of CBT, and all of them lived in altitude areas higher than 2000 meters above mean sea level (mamsl). The mean tumor size was 3.55 cm and 2.75 cm for right and left CBTs, respectively. CONCLUSIONS: A better understanding of the clinical characteristics of patients with bilateral CBTs may lead to a more standardized and optimal management with fewer complications and a better quality of life afterward.

A case report of a concomitant total thyroidectomy and carotid body tumor resection in a 43 year old female.

INTRODUCTION: Carotid body tumors (CBT) are rare neoplasms with relatively; due to their malignant potential, the indicated treatment is surgical resection. There have been described some associations of carotid body tumors with other neoplasms, however, the concomitant presentation of CBT with multinodular goiter is rarely encountered. PRESENTATION OF CASE: We herein present the case of a 43-year old woman with the aforementioned association. As a part of the diagnostic evaluation, an ultrasound was performed, revealing both conditions simultaneously. The surgery took place with the aim of resecting both lesions during the same intervention. The patient was discharged without complications. DISCUSSION: The concomitant presentation of goiter and carotid body tumor is rarely reported but an extended Kocher incision could be enough to an adequate exposure and same surgical procedure resection. CONCLUSION: This case reinforce the concomitant assessment in two different pathologies. Although there is one case reported before, this case lead to improvement in the treatment of these patients.

Left Common Femoral to Right Common Iliac Venous Bypass Through a Retroperitoneal Exposure.

The endovascular recanalization of the iliocaval system has replaced venous surgical reconstructions as the primary treatment option in severe post-thrombotic syndrome (PTS). We herein present a 51-year-old female with previous deep venous thrombosis, complicated with PTS with a large and complex circumferential calf ulcer measuring 25 cm of length in the left lower extremity. Venogram revealed a complete and extensive occlusion in the left iliofemoral system. A surgical bypass from the left common femoral vein to the right common iliac vein was performed. Patient recovered well and after 12 months postoperation her large wound is healing favorably with a clean and well granulated bed. Iliofemoral venous bypass is a feasible treatment for non-healing ulcer of lower extremity.

Successful Embolization of a Ruptured Ovarian Artery Aneurysm in a Postmenopausal Woman: Case Report and Literature Review of Gonadal Artery Aneurysms.

Gonadal artery aneurysms (GADs) are extremely rare; their prevalence and natural history are unknown and their pathogenesis remains poorly understood. Based on the limited literature reports, these might present with rupture (ovarian artery) or pain and acute thrombosis (testicular artery). The present article reports the case of an 80-year-old woman who came to the emergency department (ED) with acute onset of abdominal and left flank pain. A computed tomography angiography (CTA) revealed a large retroperitoneal hematoma associated with the presence of a left ovarian artery aneurysm. The patient was taken to the angiography suite for a selective vessel catheterization and embolization with N-butyl-2-cyanoacrylate (NBCA). Following the procedure, her serial hemoglobin remained stable, her symptoms subsided, and she was discharged home 2 days later. The GADs are unrecognized entities until an acute event such as rupture occurs, and vessel embolization is effective for hemorrhage control. Close communication and collaboration with gynecologists and urologists are crucial to better define the prevalence, natural history, and the appropriate behavior and timing for elective treatment. With this article, the authors additionally present a review of the literature.

Analysis of the MELD Score Impact in the Outcome of Endovascular Portal Vein Reconstruction.

INTRODUCTION: Endovascular therapy represents a less invasive alternative to open surgery for reconstruction of the portal vein (PV) and the spleno-mesenteric venous confluence to treat Portal hypertension. The objective of this study is to determine if the Model for End-Stage Liver Disease (MELD) score is a useful method to evaluate the risk of morbidity and mortality during endovascular approaches. MATERIAL AND METHODS: Patients that underwent endovascular reconstruction of the PV or spleno-mesenteric confluence were identified retrospectively. Data were collected from November 2011 to August 2016. The MELD score was calculated using international normalized ratio, serum billirubin and creatinine. Patients were grouped into moderate (≤ 15) and high (> 15) MELD. Associations of the MELD score on the postprocedural morbidity, mortality and vessels patency were assessed by two-sided Fisher's exact test. RESULTS: Seventeen patients were identified; MELD score distribution was: ≤ 15 in 10 patients (59%) and > 15 in 7 (41%). Even distribution of severe PV thrombosis was treated in both groups, performing predominately jugular access in the high MELD score group (OR 0.10; 95%; CI 0.014-0.89; p = 0.052) in contrast to a percutaneous transhepatic access in the moderate MELD score group. Analysis comparing moderate and high MELD scores was not able to demonstrate differences in mortality, morbidity or patency rates. CONCLUSION: MELD score did not prove to be a useful method to evaluate risk of morbidity and mortality; however a high score should not contraindicate endovascular approaches. In our experience a high technical success, good patency rates and low complication rates were observed.

Surgical Interventions for Organ and Limb Ischemia Associated With Primary and Secondary Antiphospholipid Antibody Syndrome With Arterial Involvement.

OBJECTIVE: The association of antiphospholipid antibody syndrome (APS) and hypercoagulability is well known. Arterial compromise leading to ischemia of organs and/or limbs in patients with APS is uncommon, frequently unrecognized, and rarely described. We evaluated our institutional experience. METHODS: Retrospective review was conducted. From August 2007 to September 2016, 807 patients with diagnosis of APS were managed in our Institution. Patients with primary and secondary APS who required interventions were examined. Demographics, comorbidities, manifestations, procedures, complications, and other factors affecting outcomes were recorded. RESULTS: Fourteen patients (mean age 35 years old, standard deviation ±14) were evaluated and treated by our service. Six (43%) of them had primary APS and 8 (57%) had secondary APS; 11 (79%) were female. Two (14%) experienced distal aorta and iliac arteries involvement, 3 (21%) visceral vessels disease, 2 (14%) in upper and 7 (50%) in the lower extremity vasculatures. Thirteen (93%) patients underwent direct open revascularization and 1 with hand ischemia (Raynaud disease) underwent sympathectomy. During the mean follow-up period of 48 months, reinterventions included a revision of the proximal anastomosis of an aortobifemoral bypass graft, 1 (7%) abdominal exploration for bleeding, 1 (7%) graft thrombectomy, and 4 (29%) amputations (2 below the knee, 1 above the knee, and 1 transmetatarsal). One (7%) death occurred secondary to sepsis in a patient who had acute mesenteric ischemia. Significant differences in clinical manifestations and outcomes were not observed among patients with primary and secondary APS. All patients remained on systemic anticoagulation. CONCLUSION: APS is a prothrombotic disorder that may lead to arterial involvement with less frequency than the venous circulation but has significant morbidity and limb loss rate. Arterial reconstruction seems feasible in an attempt to salvage organs and limbs; however, research is necessary to establish the optimal anticoagulation regime and long-term management following surgical interventions.