The Enzen Trial: Analysis of EVAR Endoprosthesis Zenith and Endurant for Infrarenal Aortoiliac Aneurysms Regarding Outcomes, Endoleaks, and Reinterventions.

OBJECTIVE: The main objective of this paper is to analyze the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. METHODS: This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR between January 2019 and December 2022. Two groups of patients were evaluated: Group Endurant (patients submitted to EVAR with the use of Endurant II) and Group Zenith (patients submitted to EVAR with the use of Zenith Flex). RESULTS: A total of 156 patients were evaluated. Group Zenith (67 patients, 42.9%) and Group Endurant (89 patients, 57.1%). The perioperative mortality was 5.1%, eight patients (six patients Group Zenith, and two patients Group Endurant, p=0.054). There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (expansion or rupture), with no differences among the groups. There were 36 cases (23.1%) of later endoleak, with a higher incidence in Zenith group (23 patients, 34.3%) than Endurant group (13 patients, 14.6%, p=0.002), most of them Type II endoleak (21 patients, 13.4%). There were 12 cases of Type I endoleak, also with a higher prevalence in Zenith group (13.4%) than Endurant group (3.4%, p=0.002). Moreover, regarding limb graft occlusion (LGO), there were nine patients (5.8%), with a higher prevalence in Zenith group (9%) than Endurant group (3.4%, p=0.045). The overall survival in a Kaplan-Meier at 720 days was 82.3% in the Zenith group and 89.1% in the Endurant group, with no statistical significance among the groups (p=0.09). The freedom from reintervention rates in a Kaplan-Meier at 720 days was 82.8% in the Zenith group and 93.2% in the Endurant group (p=0.001). CONCLUSION: In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, LGO and reinterventions than patients submitted to Endurant II endografts. The linear regression analysis showed that the presence of endoleaks, type of endograft device (Zenith graft) and limb graft occlusion were related to higher reintervention rates. CLINICAL IMPACT: In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, limb graft occlusions and reinterventions than patients submitted to Endurant II endografts. The main impact and the innovation that this article provides is an opportunity to evaluate and choose the best endograft suitable for the patient with AAA during EVAR.

Pharmacomechanical thrombectomy with Angiojet in acute arterial occlusions: A prospective study among the results and outcomes.

OBJECTIVE: The main objective of this present paper was to evaluate the results and outcomes of patients with acute limb ischemia (ALI) submitted to pharmacomechanical thrombectomy (PMT) endovascular surgery with Angiojet, regarding the number of cycles/pumps. METHODS: Prospective, consecutive cohort study of ALI patients submitted to PMT endovascular intervention subdivided into two groups according to the number of cycles in the Angiojet technique: Group 1 higher than 150 cycles/second and Group 2 lesser than 150 cycles/second (cycles/s). RESULTS: Overall, 92 patients with ALI submitted to PMT were evaluated. Two groups of patients were identified: Group 1 higher than 150 cycles/s with 60 patients and Group 2 lesser than 150 cycles/s with 32 patients. The overall mortality rate (OMR) was 15.1% (13 patients) in total cohort within the first 30 days. Group 1 had a higher OMR than Group 2 (16.1% vs 9.3%, p = 0.007). There were 4 cases of hematuria (4.3%), all of them in Group 1. We have performed a Kaplan-Meier regarding limb salvage rates: Group 1 had 85% and Group 2 had 95.7% at 1057 days. P = 0.081. Among the factors evaluated, the following were related to overall mortality rate: PMT with higher >150 cycles/s (HR = 7.17, p = 0.007, CI: 1.38-8.89), COVID-19 infection (HR = 2.75, p = 0.010, CI = 1.73-5.97), and post-operative acute kidney injury (HR = 2.97, p < 0.001, CI = 1.32-8.13). Among the factors evaluated, the following was related to limb loss: post-operative acute kidney injury (HR = 4.41, p = 0.036, CI: 1.771-7.132), probably because patients experiencing limb loss have a higher incidence of acute renal insufficiency due to higher circulating myoglobin higher hemolysis from the increased Angiojet cycles inducing rhabdomyolysis. CONCLUSION: PMT with Angiojet is a safe and effective therapy in patients with ALI. However, patients receiving greater than 150 cycles/s were noted to have higher rates of acute kidney injury and mortality. This is likely reflective of increased thrombus burden and higher rates of hemolysis. Acute kidney injury, greater than 150 cycles/s, and COVID-19 infection were the variables with the strongest association to perioperative mortality.

Unruptured Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis of Mortality and Morbidity in Aruba-Eligible Studies.

BACKGROUND: Treating unruptured brain arteriovenous malformations (bAVMs) represent significant challenges, with numerous uncertainties still in debate. The ARUBA trial induced further investigation into optimal management strategies for these lesions. Here, we present a systematic-review and meta-analysis focusing on ARUBA-eligible studies, aiming to correlate patient data with outcomes and discuss key aspects of these studies. METHODS: Following PRISMA guidelines, we conducted a systematic-review. Variables analyzed included bAVM Spetzler-Martin (SM) grade, treatment modalities, and outcomes such as mortality and neurological deficits. We compared studies with a minimum of 50% cases classified as SM 1-2 lesions and those with less than 50% in this category. Similarly, a comparison between studies with at least 50% microsurgery-cases and those with less than 50% was performed. We examined correlations between mortality incidence, SM distribution, and treatment modalities. RESULTS: Our analysis included 16 studies with 2.417 patients. The frequency of bAVMs SM-grade 1-2 ranged from 44% to 76%, SM-grade 3 from 19% to 48%, and SM 4-5 from 5 to 23%. Notably, studies with more than 50% cases presenting lesions SM-grade 1-2 presented significantly lower mortality rates than those with less than 50% cases of SM 1-2 lesions (P < 0.001). No significant difference in mortality rates or neurological deficits was identified between studies with more than 50% of microsurgery-cases and those with less than 50%. CONCLUSIONS: The analysis revealed that studies with a higher proportion of bAVMs presenting SM 1-2 lesions were associated with lower mortality rates. Mortality did not show a significant association with treatment modalities.

One-step Endovascular Aortic Aneurysm Repair With CO2 contrast and Robotic Partial Nephrectomy for Renal Cell Carcinoma: Case Report.

INTRODUCTION: Although rare, as the population ages, abdominal aortic aneurysm synchronous to abdominal malignancies, as renal cell carcinoma, is expected to become more prevalent. There are only two case reports of minimally invasive surgeries to treat these synchronous diseases, with endovascular aortic repair and laparoscopic nephrectomy, but they were performed in two stages, with iodinated contrast and without robotic assistance. CASE REPORT: We herein present a case of a 71-year-old patient with chronic kidney disease, a 6.4 cm infra-renal abdominal aortic aneurysm associated and a suspicious 6 cm solid-cystic expansile lesion in the right kidney, successfully treated at one stage with endovascular aortic repair using carbon dioxide as a contrast medium and with robotic right partial nephrectomy, aiming to preserve the renal function as much as possible. The patient's postoperative course was free of complications with hospital discharge on the fifth postoperative day, with a serum creatinine of 0.84 mg/dL. CONCLUSION: single-stage minimally invasive surgical treatment of AAA and RCC can be a safe and feasible approach. Combining a robot-assisted laparoscopic partial nephrectomy with an EVAR using carbon dioxide as a contrast medium was safe and successfully preserved renal function.

Peripheral artery disease: a comparison of urgent open and endovascular revascularizations on the public health system in Brazil, from 2010 to 2020.

Background: Peripheral artery disease (PAD) has high prevalence and is associated with high risk of cardiovascular events. Surgical or endovascular intervention is necessary in chronic limb-threatening ischemia. Objectives: To evaluate the distribution of open and endovascular revascularizations in different regions of Brazil, analyzing the health system costs and mortality related to these procedures. Methods: A descriptive, cross-sectional, observational, epidemiological study was carried out to evaluate open and endovascular surgeries performed on the SUS public healthcare system in Brazil, from 2010 to 2020. Data were collected from the SUS Department of Informatics (Datasus). Results: Over the period analyzed, 83,218 admissions for open and endovascular surgeries were registered, with a total cost of R$ 333,989,523.17. There were more hospital admissions for percutaneous procedures (56,132) than for conventional surgery (27,086). Most of the procedures (83%) were performed in the country's Southeast and South regions, while the North region had the lowest number of procedures. Over the period evaluated, there was a decreasing trend for open procedures and an increasing trend for endovascular procedures. The average hospital stay was shorter for endovascular procedures (5.3 days) than for open surgery (10.2 days). The analysis of mortality related to these procedures revealed a higher rate of in-hospital mortality associated with open revascularization than with endovascular (5.24% vs. 1.56%). Conclusions: Endovascular techniques constituted the primary approach for revascularization treatment in critical limb-threatening ischemia, with a lower in-hospital mortality rate and shorter hospital stay when compared to open surgeries.

Doença arterial obstrutiva periférica: um estudo comparativo entre revascularizações abertas e endovasculares realizadas em caráter de urgência no sistema público de saúde do Brasil entre 2010 e 2020 / Peripheral artery disease: a comparison of urgent open and endovascular revascularizations on the public health system in Brazil, from 2010 to 2020

RESUMO Contexto A doença arterial obstrutiva periférica apresenta alta prevalência, sendo associada a elevado risco de eventos cardiovasculares. A intervenção cirúrgica ou endovascular faz-se necessária na isquemia crítica do membro. Objetivos Avaliar a distribuição de realização de revascularizações abertas e endovasculares nas diferentes regiões do Brasil, analisando os custos para o sistema de saúde e a mortalidade relacionada a esses procedimentos. Métodos Foi realizado um estudo epidemiológico observacional transversal descritivo para avaliar as cirurgias abertas e endovasculares realizadas no sistema público de saúde do Brasil entre 2010 e 2020. Os dados foram coletados através do Departamento de Informática do SUS (Datasus). Resultados No período analisado, foram registradas 83.218 internações para realização de cirurgias abertas e endovasculares, com um custo total de R$ 333.989.523,17. Houve predominância das internações para os procedimentos percutâneos (56.132) em relação aos cirúrgicos convencionais (27.086). As Regiões Sudeste e Sul concentraram a maior parte do total de procedimentos realizados no país (83%), enquanto a Região Norte foi a que apresentou a menor taxa de internação. Observou-se uma tendência decrescente para os procedimentos abertos, e uma tendência crescente para os endovasculares. A média de permanência hospitalar foi menor nos procedimentos endovasculares (5,3 dias) em relação aos abertos (10,2 dias). Além disso, notou-se uma maior taxa de mortalidade hospitalar relacionada à revascularização aberta em relação à endovascular (5,24% versus 1,56%). Conclusões As técnicas endovasculares consistiram em uma abordagem dominante no tratamento cirúrgico da isquemia crítica, apresentando menor taxa de mortalidade hospitalar e menor tempo de internação quando comparada às cirurgias abertas.

ABSTRACT Background Peripheral artery disease (PAD) has high prevalence and is associated with high risk of cardiovascular events. Surgical or endovascular intervention is necessary in chronic limb-threatening ischemia. Objectives To evaluate the distribution of open and endovascular revascularizations in different regions of Brazil, analyzing the health system costs and mortality related to these procedures. Methods A descriptive, cross-sectional, observational, epidemiological study was carried out to evaluate open and endovascular surgeries performed on the SUS public healthcare system in Brazil, from 2010 to 2020. Data were collected from the SUS Department of Informatics (Datasus). Results Over the period analyzed, 83,218 admissions for open and endovascular surgeries were registered, with a total cost of R$ 333,989,523.17. There were more hospital admissions for percutaneous procedures (56,132) than for conventional surgery (27,086). Most of the procedures (83%) were performed in the country's Southeast and South regions, while the North region had the lowest number of procedures. Over the period evaluated, there was a decreasing trend for open procedures and an increasing trend for endovascular procedures. The average hospital stay was shorter for endovascular procedures (5.3 days) than for open surgery (10.2 days). The analysis of mortality related to these procedures revealed a higher rate of in-hospital mortality associated with open revascularization than with endovascular (5.24% vs. 1.56%). Conclusions Endovascular techniques constituted the primary approach for revascularization treatment in critical limb-threatening ischemia, with a lower in-hospital mortality rate and shorter hospital stay when compared to open surgeries.

Endovascular management of a complex high-flow lower limb arteriovenous malformation: Case report and literature review.

INTRODUCTION: Lower limb high-flow arteriovenous malformations (AVM) are a rare pathology with a chronic and progressive evolution. Development in imaging and treatment has helped to improve outcome. OBJECTIVE: We report a case treated with multi-session endovascular embolization therapy with favorable results. CASE REPORT: A 44-year-old man referred with a complex high-flow lower limb AVM, previously treated with covered stents and a bypass. Six endovascular interventions were performed, combining different embolization methods. CONCLUSION: Endovascular treatment is a safe and effective option for high-flow AVMs. Embolization should be done carefully to prevent complications that could threaten the patient's limb or life.

INTRODUCCIÓN: Las malformaciones arteriovenosas (MAV) son una patología con un curso crónico y una evolución progresiva. OBJETIVO: Reportar el caso de una MAV tratada con embolización endovascular en múltiples sesiones con resultados favorables. REPORTE DE CASO: Masculino de 44 años referido con una MAV de alto flujo del miembro pélvico derecho, tratado previamente con un stent recubierto y un bypass. Se realizaron seis sesiones endovasculares combinando diferentes métodos de embolización. CONCLUSIÓN: El manejo endovascular de las MAV de alto flujo es seguro y efectivo, debe de realizarse cuidadosamente evitando poner en riesgo la extremidad del paciente e incluso la vida.

Emergency endovascular repair of aortoiliac aneurysms in COVID-19 times.

In this paper, we describe a case series of four patients who were admitted with emergencies related to aortic aneurysms over a 3-day period and were treated with endovascular repair. The first patient was an 81-year-old female with a history of abdominal pain and a ruptured aortic aneurysm diagnosed by AngioCT-scan. The second patient was a 63-year-old male with a history of oral digestive bleeding and an AngioCT-scan showing an aortoenteric fistula. The third patient was a 77-year-old female with sudden-onset abdominal pain and ruptured right common iliac aneurysm. The fourth patient presented with abdominal pain and an AngioCT-scan showed aortic rupture. All four patients were discharged with no major complications or surgical mortality. These case series show that despite the Covid-19 pandemic situation, since elective surgeries decreased, vascular emergencies have increased.

Relatamos uma série de casos de quatro pacientes consecutivos, admitidos com emergências relacionadas a aneurismas aortoilíacos em um período de 3 dias e submetidos a tratamento endovascular. A primeira paciente, do sexo feminino, com 81 anos e com histórico de aneurisma da aorta, apresentou dor abdominal iniciada nos últimos 12 dias. O segundo paciente era do sexo masculino, com 63 anos e foi admitido com hematêmese 3 dias antes da admissão, com angiotomografia demonstrando fistula aortoentérica. A terceira paciente, do sexo feminino e com 77 anos, foi admitida com quadro de ruptura de aneurisma da artéria ilíaca comum direita. O quarto paciente consecutivo apresentou dor abdominal iniciada 2 semanas antes da internação e aneurisma roto da aorta. Todos os quatro pacientes apresentaram emergências aortoilíacas e receberam alta sem complicações maiores ou mortalidade cirúrgica. O relato desta série de casos demonstra que, apesar da situação pandêmica da COVID-19, uma vez que as cirurgias eletivas diminuíram, as urgências vasculares aumentaram.

Three-dimensional virtual and printed models for planning adult cardiovascular surgery.

BACKGROUND: The objective of this study was to explore the usefulness of virtual models and three-dimensional (3D) printing technologies for planning complex non-congenital cardiovascular surgery. METHODS: Between July 2018 and December 2019, adult patients with different cardiovascular structural diseases were included in a clinical protocol to explore the usefulness of Standard Tessellation Language (STL)-based virtual models and 3D printing for prospectively planning surgery. A qualitative descriptive analysis from the surgeon's viewpoint was done based on the characteristics, advantages and usefulness of 3D models for guiding, planning and simulating the surgical procedures. RESULTS: A total of 14 custom 3D-printed heart and great vessel replicas with their corresponding 3D virtual models were created for preoperative surgical planning. Six of 14 models helped to redefine the surgical approach, 3 were useful to verify device delivery, while the rest did not change the surgical decision. In all open surgery cases, cardiac and vascular anatomy accuracy of virtual and physical 3D replicas was validated by direct visualisation of the organs during surgery. Printing was achieved through an external provider associated with the Hospital, who printed the final prototype in 5-7 days. Printed production cost was between 100 and 500 USD per model. CONCLUSIONS: In the current study, the selected 3D printed models presented different advantages (visual, tactile, and instrumental) over the traditional flat anatomical images when simulating and planning some complex types of surgery. Notwithstanding 3D printing advantages, STL-based virtual models were pre-printing useful tools when instrumentation on a physical replica was not required.

Emergency endovascular repair of aortoiliac aneurysms in COVID-19 times / Tratamento endovascular das emergências dos aneurismas aortoilíacos em tempos de COVID-19

Abstract In this paper, we describe a case series of four patients who were admitted with emergencies related to aortic aneurysms over a 3-day period and were treated with endovascular repair. The first patient was an 81-year-old female with a history of abdominal pain and a ruptured aortic aneurysm diagnosed by AngioCT-scan. The second patient was a 63-year-old male with a history of oral digestive bleeding and an AngioCT-scan showing an aortoenteric fistula. The third patient was a 77-year-old female with sudden-onset abdominal pain and ruptured right common iliac aneurysm. The fourth patient presented with abdominal pain and an AngioCT-scan showed aortic rupture. All four patients were discharged with no major complications or surgical mortality. These case series show that despite the Covid-19 pandemic situation, since elective surgeries decreased, vascular emergencies have increased.

Resumo Relatamos uma série de casos de quatro pacientes consecutivos, admitidos com emergências relacionadas a aneurismas aortoilíacos em um período de 3 dias e submetidos a tratamento endovascular. A primeira paciente, do sexo feminino, com 81 anos e com histórico de aneurisma da aorta, apresentou dor abdominal iniciada nos últimos 12 dias. O segundo paciente era do sexo masculino, com 63 anos e foi admitido com hematêmese 3 dias antes da admissão, com angiotomografia demonstrando fistula aortoentérica. A terceira paciente, do sexo feminino e com 77 anos, foi admitida com quadro de ruptura de aneurisma da artéria ilíaca comum direita. O quarto paciente consecutivo apresentou dor abdominal iniciada 2 semanas antes da internação e aneurisma roto da aorta. Todos os quatro pacientes apresentaram emergências aortoilíacas e receberam alta sem complicações maiores ou mortalidade cirúrgica. O relato desta série de casos demonstra que, apesar da situação pandêmica da COVID-19, uma vez que as cirurgias eletivas diminuíram, as urgências vasculares aumentaram.

COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes.

A 67-year-old male diabetic patient with systemic arterial hypertension was admitted to the emergency department with a necrotic ulcer in the left external malleolus and no palpable popliteal or pedal pulses. Arterial Duplex ultrasound identified femoropopliteal occlusion, with popliteal refilling below the knee and a patent peroneal artery. An endovascular procedure was performed, requiring retrograde access to the popliteal artery to re-establish blood flow and deploy a popliteal stent. Technical success was achieved and the patient underwent debridement of the wound. Two days later, about 48 hours after the operation, the patient began to exhibit respiratory symptoms, with coughing and dyspnea. He immediately underwent a chest CT that identified ground glass opacities, the crazy-paving pattern, and bilateral air bronchogram in the lungs. A reverse transcription - polymerase chain reaction (RT-PCR) test was positive for SARS-Cov-2. The patient was moved to an intensive care unit and put on mechanical ventilation. Both hydroxychloroquine and azithromycin were administered. Despite appropriate treatment, the patient died 4 days after he was diagnosed with COVID-19.

Paciente do sexo masculino, 67 anos, diabético, hipertenso, foi admitido no pronto-socorro com histórico de úlcera necrótica no maléolo externo esquerdo, sem pulsos poplíteos e distais palpáveis. A ultrassonografia Doppler arterial identificou oclusão femoropoplítea, com reenchimento da artéria poplítea infragenicular e perviedade da artéria fibular. Foi realizado procedimento endovascular, com necessidade de acesso retrógrado na artéria poplítea para restabelecer o fluxo sanguíneo e realizar implante de stent poplíteo. O sucesso técnico foi alcançado e, em seguida, o paciente foi submetido ao desbridamento da ferida. No segundo dia, cerca de 48 horas de pós-operatório, o paciente apresentou quadro respiratório com tosse e dispneia. Foi submetido a uma tomografia computadorizada do tórax, que identificou opacidades em vidro fosco e broncograma aéreo bilateralmente nos pulmões, com teste de reverse transcription ­ polymerase chain reaction (RT-PCR) positivo para SARS-Cov-2. O paciente foi transferido para uma unidade de terapia intensiva, necessitando de ventilação mecânica. Recebeu hidroxicloroquina e azitromicina. Apesar do tratamento em suporte intensivo, o paciente morreu 4 dias após o diagnóstico de COVID-19.

The outcomes of internal iliac artery preservation during endovascular or open surgery treatment for aortoiliac aneurysms.

BACKGROUND: Internal iliac artery (IIA) preservation continues to be a challenge during open surgery or endovascular repair of abdominal aortoiliac aneurysm (AAIA). OBJECTIVES: To determine the results in terms of survival and clinical outcomes in patients with aortoiliac aneurysms (AAIA) treated with endovascular (EV) or open surgical (OS) repair. METHODS: This was a retrospective consecutive cohort study of patients with AAIA who underwent EV or OS repair. RESULTS: Post-procedure hospitalization time and intensive care unit stay were both longer in the OS group than in the EV group (7.08 ± 3.5 days vs. 3.32 ± 2.3 days; p = 0.03; 3.35 ± 2.2 days vs. 1.2 ± 0.8 days; p = 0.02, respectively). There were two cases of bowel ischemia (4.7%; OS 8.3% and EV 3.2%; p = 0.48), two cases of buttock claudication (4.7%; OS 8.3% and EV 3.2%; p = 0.48), and one case of sexual dysfunction (2.3% OS), all of them in patients with bilateral occlusion of the internal iliac artery (five patients, 11.6%; p = 0.035). Overall survival at 720 days was 80.6% in the EV group and 66.7% in the OS group (p = 0.58). CONCLUSIONS: In the present study, OS and EV repair of aortoiliac aneurysms had similar overall survival and outcomes. Preservation of at least one internal iliac artery is associated with good results and no further complications.

CONTEXTO: A preservação de uma artéria ilíaca interna continua a ser um desafio terapêutico nos pacientes com aneurismas aorto-ilíacos submetidos tanto ao tratamento endovascular quanto a cirurgia aberta. OBJETIVOS: Determinar os resultados da sobrevida e desfechos clínicos em pacientes com aneurismas aorto-ilíacos (AAIA) que recebem reparo endovascular (EV) ou cirúrgico aberto (CA). MÉTODOS: Este foi um estudo de coorte consecutivo e retrospectivo de pacientes com AAIA submetidos a reparo EV ou CA. RESULTADOS: Houve maior tempo de internação pós-procedimento e permanência na unidade de terapia intensiva no grupo CA comparado com o grupo EV (7,08±3,5 dias vs. 3,32±2,3 dias; p = 0,03; 3,35±2,2 dias vs. 1,2±0,8 dias; p = 0,02, respectivamente). Houve dois casos de isquemia intestinal (4,7%; CA 8,3% e EV 3,2%; p = 0,48), dois casos de claudicação das nádegas (4,7%; CA 8,3% e EV 3,2%; p = 0,48) e um caso de disfunção sexual (2,3% CA), todos em pacientes com oclusão bilateral da artéria ilíaca interna (AII) (cinco pacientes, 11,6%; p = 0,035). A sobrevida global aos 720 dias foi de 80,6% no grupo EV e de 66,7% no grupo CA (p = 0,58). CONCLUSÕES: No presente estudo, o EV e o CA para aneurismas aorto-ilíacos apresentaram sobrevida e desfechos clínicos semelhantes. A preservação de pelo menos uma AII está associada a bons resultados e sem complicações adicionais.

COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes / Diagnóstico de COVID-19 em paciente com isquemia crítica do membro: complicações e desfechos clínicos

Abstract A 67-year-old male diabetic patient with systemic arterial hypertension was admitted to the emergency department with a necrotic ulcer in the left external malleolus and no palpable popliteal or pedal pulses. Arterial Duplex ultrasound identified femoropopliteal occlusion, with popliteal refilling below the knee and a patent peroneal artery. An endovascular procedure was performed, requiring retrograde access to the popliteal artery to re-establish blood flow and deploy a popliteal stent. Technical success was achieved and the patient underwent debridement of the wound. Two days later, about 48 hours after the operation, the patient began to exhibit respiratory symptoms, with coughing and dyspnea. He immediately underwent a chest CT that identified ground glass opacities, the crazy-paving pattern, and bilateral air bronchogram in the lungs. A reverse transcription - polymerase chain reaction (RT-PCR) test was positive for SARS-Cov-2. The patient was moved to an intensive care unit and put on mechanical ventilation. Both hydroxychloroquine and azithromycin were administered. Despite appropriate treatment, the patient died 4 days after he was diagnosed with COVID-19.

Resumo Paciente do sexo masculino, 67 anos, diabético, hipertenso, foi admitido no pronto-socorro com histórico de úlcera necrótica no maléolo externo esquerdo, sem pulsos poplíteos e distais palpáveis. A ultrassonografia Doppler arterial identificou oclusão femoropoplítea, com reenchimento da artéria poplítea infragenicular e perviedade da artéria fibular. Foi realizado procedimento endovascular, com necessidade de acesso retrógrado na artéria poplítea para restabelecer o fluxo sanguíneo e realizar implante de stent poplíteo. O sucesso técnico foi alcançado e, em seguida, o paciente foi submetido ao desbridamento da ferida. No segundo dia, cerca de 48 horas de pós-operatório, o paciente apresentou quadro respiratório com tosse e dispneia. Foi submetido a uma tomografia computadorizada do tórax, que identificou opacidades em vidro fosco e broncograma aéreo bilateralmente nos pulmões, com teste de reverse transcription - polymerase chain reaction (RT-PCR) positivo para SARS-Cov-2. O paciente foi transferido para uma unidade de terapia intensiva, necessitando de ventilação mecânica. Recebeu hidroxicloroquina e azitromicina. Apesar do tratamento em suporte intensivo, o paciente morreu 4 dias após o diagnóstico de COVID-19.

The outcomes of internal iliac artery preservation during endovascular or open surgery treatment for aortoiliac aneurysms / Os resultados da preservação da artéria ilíaca interna durante o tratamento endovascular ou em cirurgia aberta para aneurismas aorto-ilíacos

Abstract Background Internal iliac artery (IIA) preservation continues to be a challenge during open surgery or endovascular repair of abdominal aortoiliac aneurysm (AAIA). Objectives To determine the results in terms of survival and clinical outcomes in patients with aortoiliac aneurysms (AAIA) treated with endovascular (EV) or open surgical (OS) repair. Methods This was a retrospective consecutive cohort study of patients with AAIA who underwent EV or OS repair. Results Post-procedure hospitalization time and intensive care unit stay were both longer in the OS group than in the EV group (7.08 ± 3.5 days vs. 3.32 ± 2.3 days; p = 0.03; 3.35 ± 2.2 days vs. 1.2 ± 0.8 days; p = 0.02, respectively). There were two cases of bowel ischemia (4.7%; OS 8.3% and EV 3.2%; p = 0.48), two cases of buttock claudication (4.7%; OS 8.3% and EV 3.2%; p = 0.48), and one case of sexual dysfunction (2.3% OS), all of them in patients with bilateral occlusion of the internal iliac artery (five patients, 11.6%; p = 0.035). Overall survival at 720 days was 80.6% in the EV group and 66.7% in the OS group (p = 0.58). Conclusions In the present study, OS and EV repair of aortoiliac aneurysms had similar overall survival and outcomes. Preservation of at least one internal iliac artery is associated with good results and no further complications.

Resumo Contexto A preservação de uma artéria ilíaca interna continua a ser um desafio terapêutico nos pacientes com aneurismas aorto-ilíacos submetidos tanto ao tratamento endovascular quanto a cirurgia aberta. Objetivos Determinar os resultados da sobrevida e desfechos clínicos em pacientes com aneurismas aorto-ilíacos (AAIA) que recebem reparo endovascular (EV) ou cirúrgico aberto (CA). Métodos Este foi um estudo de coorte consecutivo e retrospectivo de pacientes com AAIA submetidos a reparo EV ou CA. Resultados Houve maior tempo de internação pós-procedimento e permanência na unidade de terapia intensiva no grupo CA comparado com o grupo EV (7,08±3,5 dias vs. 3,32±2,3 dias; p = 0,03; 3,35±2,2 dias vs. 1,2±0,8 dias; p = 0,02, respectivamente). Houve dois casos de isquemia intestinal (4,7%; CA 8,3% e EV 3,2%; p = 0,48), dois casos de claudicação das nádegas (4,7%; CA 8,3% e EV 3,2%; p = 0,48) e um caso de disfunção sexual (2,3% CA), todos em pacientes com oclusão bilateral da artéria ilíaca interna (AII) (cinco pacientes, 11,6%; p = 0,035). A sobrevida global aos 720 dias foi de 80,6% no grupo EV e de 66,7% no grupo CA (p = 0,58). Conclusões No presente estudo, o EV e o CA para aneurismas aorto-ilíacos apresentaram sobrevida e desfechos clínicos semelhantes. A preservação de pelo menos uma AII está associada a bons resultados e sem complicações adicionais.

Endovascular Treatment of the Ascending Aorta: is this the Last Frontier in Aortic Surgery?

Regardless the successful treatment of the descending aorta with endovascular prosthesis, for the ascending aorta segment, because of several anatomic and physiologic issues, this technique has been considered an alternative only for high-risk or inoperable patients. Despite restricted indications, hundreds of treatments have been performed worldwide, demonstrating its safety and reproducibility if it is done in high-quality centers. Therefore, understanding patients' selection criteria and technique limitations are critical to its application.

Endovascular treatment of the ascending aorta: is this the last frontier in aortic surgery?

Abstract Regardless the successful treatment of the descending aorta with endovascular prosthesis, for the ascending aorta segment, because of several anatomic and physiologic issues, this technique has been considered an alternative only for high-risk or inoperable patients. Despite restricted indications, hundreds of treatments have been performed worldwide, demonstrating its safety and reproducibility if it is done in high-quality centers. Therefore, understanding patients' selection criteria and technique limitations are critical to its application.

Analysis of the results of endovascular and open surgical treatment of acute limb ischemia.

OBJECTIVE: The objective of this study was to evaluate the long-term estimates of limb salvage and survival in patients with acute limb ischemia (ALI) receiving open surgery or endovascular revascularization. METHODS: This was a retrospective consecutive cohort study of patients with ALI who underwent open surgery or endovascular treatment at the Vascular and Endovascular Surgery Unit, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2010 and July 2016. The overall mortality, limb salvage, and survival rates at 720 days were analyzed in both the open surgery (group 1) and endovascular treatment (group 2) groups. RESULTS: A total of 69 patients were admitted for a limb salvage procedure. The mean follow-up period was 822 ± 480.5 days. All of the analyses were performed at 720 days. Of the 69 patients, 46 (66.6%) were in group 1 and 23 (33.4%) in group 2. The clinical characteristics were similar between the groups, except for higher rates of chronic kidney disease (P = .04) and arrhythmia (P = .01) in group 1. Group 1 had a higher postoperative ankle-brachial index (P = .03). Concerning the Rutherford classification, group 1 had a higher prevalence of Rutherford IIB ALI (P = .003). The preoperative creatine kinase level was higher in group 1 than in group 2 (780 [range, 198-6546] mg/dL and 245 [65-78] mg/dL, respectively). A creatine kinase level >200 mg/dL was seen in 65.2% and 47.8% of patients in group 1 and group 2, respectively (P = .028). The limb salvage and overall survival estimates at 720 days were similar between group 1 and group 2 (79.2% vs 90.6% [P = .27] and 53% vs 60.8% [P = .45], respectively). The overall mortality rate was 10.1% (seven patients) within the first 30 days, and it was higher in group 1 (six patients [13.0%]; P = .03). CONCLUSIONS: Both open surgery and endovascular procedures are safe treatments of patients with ALI, with acceptable limb salvage and survival rates. No previous study has suggested the preferred treatment of ALI. However, based on this study and the overall literature, endovascular treatment may be the preferred treatment of patients with Rutherford I and IIA ALI; open surgery may be the best option for ALI due to arterial embolism and for Rutherford IIB acute arterial thrombosis because of a greater urgency to restore blood flow.

Endovascular treatment of pseudoaneurysms secondary to chronic pancreatitis: reports of two cases.

Pseudoaneurysm secondary to chronic pancreatitis is a rare complication, but one with a high mortality rate. It is etiologically associated with chronic pancreatitis, and most diagnoses are made after rupture, which manifests with clinical signs of acute hemorrhage. Computed tomography plays an important role in diagnosis, but digital subtraction angiography remains the gold-standard method for diagnostic confirmation and for treatment planning. This article describes two cases of pseudoaneurysm in patients with chronic alcoholic pancreatitis; one involving the splenic artery and the other the gastroduodenal artery, complicated by thoracic and abdominal bleeding respectively. Both were successfully treated, using minimally invasive endovascular methods to implant coils and stent-grafts.

O pseudoaneurisma decorrente de pancreatite crônica consiste em complicação rara, porém com alta taxa de mortalidade. Está etiologicamente associado à pancreatite crônica, e seu diagnóstico é feito mais comumente após ruptura, manifestando-se através de sinais clínicos de hemorragia aguda. A tomografia computadorizada desempenha papel importante no diagnóstico; contudo, a angiografia por subtração digital mantém-se como método padrão-ouro para confirmação diagnóstica e direcionamento do tratamento. O presente artigo relata dois casos de pseudoaneurisma em pacientes com pancreatite crônica alcoólica, sendo um da artéria esplênica e outro da artéria gastroduodenal, complicados com sangramento torácico e abdominal respectivamente. Ambos foram submetidos a tratamento endovascular minimamente invasivo com sucesso, através de implante de molas e de stent-grafts.

Endovascular treatment of pseudoaneurysms secondary to chronic pancreatitis: reports of two cases / Tratamento endovascular de pseudoaneurisma decorrente de pancreatite crônica: relato de dois casos

Abstract Pseudoaneurysm secondary to chronic pancreatitis is a rare complication, but one with a high mortality rate. It is etiologically associated with chronic pancreatitis, and most diagnoses are made after rupture, which manifests with clinical signs of acute hemorrhage. Computed tomography plays an important role in diagnosis, but digital subtraction angiography remains the gold-standard method for diagnostic confirmation and for treatment planning. This article describes two cases of pseudoaneurysm in patients with chronic alcoholic pancreatitis; one involving the splenic artery and the other the gastroduodenal artery, complicated by thoracic and abdominal bleeding respectively. Both were successfully treated, using minimally invasive endovascular methods to implant coils and stent-grafts.

Resumo O pseudoaneurisma decorrente de pancreatite crônica consiste em complicação rara, porém com alta taxa de mortalidade. Está etiologicamente associado à pancreatite crônica, e seu diagnóstico é feito mais comumente após ruptura, manifestando-se através de sinais clínicos de hemorragia aguda. A tomografia computadorizada desempenha papel importante no diagnóstico; contudo, a angiografia por subtração digital mantém-se como método padrão-ouro para confirmação diagnóstica e direcionamento do tratamento. O presente artigo relata dois casos de pseudoaneurisma em pacientes com pancreatite crônica alcoólica, sendo um da artéria esplênica e outro da artéria gastroduodenal, complicados com sangramento torácico e abdominal respectivamente. Ambos foram submetidos a tratamento endovascular minimamente invasivo com sucesso, através de implante de molas e de stent-grafts.

Endovascular treatment of acute gastrointestinal bleeding from a large splenic artery pseudoaneurysm: case report and literature review.

Pseudoaneurysm of the splenic artery is a rare entity, with little more than 150 cases described in the literature. Pancreatitis is the most common etiology, followed by trauma. In contrast with true aneurysms, pseudoaneurysms are frequently symptomatic, with a 47% risk of rupture and 90% mortality if left untreated. We describe the case of a 48-year-old female patient who suffered a gastrointestinal hemorrhage associated with acute-on-chronic pancreatitis. During workup, endoscopy revealed signs of recent bleeding and magnetic resonance angiography of the abdomen showed a large pseudoaneurysm of the splenic artery. The patient underwent endovascular treatment with microcoil embolization and no further bleeding episodes occurred. Endovascular treatment is now an effective option with low morbidity and mortality and success rates in the range of 79-100%, making it a viable technique for patients with active abdominal inflammation. We conducted a review of endovascular techniques and embolization agents used to treat this pathology.