The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair.

OBJECTIVE: Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs). METHODS: Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation. RESULTS: We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients. CONCLUSIONS: Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

Ascending aortic rupture incidentally revealed at the cath lab: surprising, rare, and life-threatening.

An 80-year-old woman who was an active smoker with neglected long-term hypertension, but no known previous aortic or connective tissue disorders, presented to the emergency department complaining of sudden chest pain associated with cardiogenic shock.

Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm.

OBJECTIVE: Limited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock. METHODS: We performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality. RESULTS: Detailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality. CONCLUSIONS: Hypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.

Rupture of sinus of Valsalva aneurysm to the right atrium resolved with interventionism.

We present a case of a ruptured right sinus of Valsalva aneurysm to the right atrium that developed global heart failure over the course of three months, and which was completely resolved through cardiac catheterism, placing an occlusive device at the site of the fistula. Its ethology is discussed, as well as the guidelines for clinical diagnosis and treatment.

Se presenta un caso de aneurisma del seno de Valsalva derecho roto a la aurícula derecha, que en el transcurso de tres meses desarrolló insuficiencia cardiaca global y fue resuelto del todo por medio de intervencionismo, colocando un dispositivo oclusor en el sitio de la fístula. Se discute su etología, así como las pautas para el diagnóstico clínico y el tratamiento.

Characterization of multiple organ failure after ruptured abdominal aortic aneurysm repair.

BACKGROUND: Multiple organ failure (MOF) is associated with poor outcomes and increased mortality in sepsis and trauma. There are limited data regarding MOF in patients after ruptured abdominal aortic aneurysm (rAAA) repair. We aimed to identify the contemporary prevalence and characteristics of patients with rAAA with MOF. METHODS: We retrospectively reviewed patients with rAAA who underwent repair (2010-2020) at our multihospital institution. Patients who died within the first 2 days after repair were excluded. MOF was quantified by modified (excluding hepatic system) Denver, Sequential Organ Failure Assessment (SOFA) score, and Multiple Organ Dysfunction Score (MODS) for postoperative days 3 to 5 to determine the prevalence of MOF. MOF was defined as a Denver score of >3, dysfunction in two or more organ systems by SOFA score, or a MODS score of >8. Kaplan-Meier curves and log-rank testing were used to evaluate differences in 30-day mortality between multiple organ failure and patients without MOF. Logistic regression was used to assess predictors of MOF. RESULTS: Of 370 patients with rAAA, 288 survived past two days (mean age, 73±10.1 years; 76.7% male; 44.1% open repair), and 143 had data for MOF calculation recorded. From postoperative days 3 to 5, 41 (14.24%) had MOF by Denver, 26 (9.03%) by SOFA, and 39 (13.54%) by MODS criteria. Among these scoring systems, pulmonary and neurological systems were impacted most commonly. Among patients with MOF, pulmonary derangement occurred in 65.9% (Denver), 57.7% (SOFA), and 56.4% (MODS). Similarly, neurological derangement occurred in 92.3% (SOFA) and 89.7% (MODS), but renal derangement occurred in 26.8% (Denver), 23.1% (SOFA), and 10.3% (MODS). MOF by all three scoring systems was associated with increased 30-day mortality (Denver: 11.3% vs 41.5% [P < .01]; DOFA: 12.6% vs 46.2% [P < .01]; MODS: 12.5% vs 35.9% [P < .01]), as was MOF by any criteria (10.8% vs 35.7 %; P < .01). Patients with MOF were more likely to have a higher body mass index (55.9±26.6 vs 49.0±15.0; P = .011) and to have had a preoperative stroke (17.9% vs 6.0%; P = .016). Patients with MOF were less likely to have undergone endovascular repair (30.4% vs 62.1%; P < .001). Endovascular repair was protective against MOF (any criteria) on multivariate analysis (odds ratio, 0.23; 95% confidence interval, 0.08-0.64; P = .019) after adjusting for age, gender, and presenting systolic blood pressure. CONCLUSIONS: MOF occurred in only 9% to 14% of patients after rAAA repair, but was associated with a three-fold increase in mortality. Endovascular repair was associated with a reduced MOF incidence.

Percutaneous Closure of Ruptured Sinus of Valsalva Aneurysm in a Child Using a Patent Ductus Arteriosus Device.

Ruptured sinus of Valsalva aneurysm is rare, although if left untreated, potentially fatal disease. Surgical approach has been the main treatment in most series; nevertheless, percutaneous closure has been described in selected cases. We report a 5-year-old boy presenting with rapid clinical deterioration who underwent percutaneous closure using a patent ductus arteriosus device, with the resolution of symptoms. Descriptions of this technique being utilized in children are infrequent in the literature.

Tratamiento endovascular con técnica de chimenea para patologías del arco aórtico / Endovascular management with chimney technique for pathologies ofthe aortic arch

Introducción. La patología del arco aórtico se ha tratado principalmente con cirugía por vía abierta, pero con una alta morbimortalidad. Las técnicas endovasculares híbridas y las reconstrucciones en "chimenea" son una técnica válida y segura para disminuir el riesgo y la mortalidad. Métodos. Se presentan dos pacientes con patología del arco aórtico y contraindicación de manejo quirúrgico abierto, atendidos en el Servicio de Cirugía Vascular, Hospital Universitario Clínica de San Rafael, Bogotá, D.C., Colombia. Resultados. Se realizaron dos procedimientos endovasculares del arco aórtico para tratar un aneurisma torácico roto y una úlcera aórtica sintomática, con cubrimiento de los troncos supra aórticos con una endoprótesis y canalización de los vasos supra aórticos con prótesis cubiertas y uso de la "técnica de chimenea", de manera exitosa. Discusión. La patología del arco aórtico es de alta complejidad y se asocia con una morbimortalidad elevada por lo que, en los últimos 20 años se han desarrollado diferentes técnicas utilizando procedimientos percutáneos. Conclusión. La "técnica de chimenea" se puede realizar de una manera mínimamente invasiva en pacientes con patología del arco aórtico, no candidatos para cirugía abierta, con resultados exitosos.

Introduction. Aortic arch pathology has been treated mainly by open surgery, but with high morbidity and mortality. Hybrid endovascular techniques and "chimney" reconstructions are a valid and safe techniques to reduce risk and mortality. Method. Two patients with pathology of the aortic arch and contraindication for open surgical management, treated at the Vascular Surgery Service, Hospital Universitario Clínica de San Rafael, Bogotá, Colombia, are presented. Results. Two endovascular aortic procedures were performed successfully to treat a ruptured thoracic aneurysm and a symptomatic aortic ulcer, with coverage of the supra-aortic trunks with an endoprosthesis and cannulation of the supra-aortic vessels with covered prostheses and use of the "chimney technique". Discussion. The pathology of the aortic arch is highly complex and is associated with high morbidity and mortality, being the reason that during the last 20 years, different techniques have been developed using percutaneous procedures. Conclusions. The "chimney technique" can be performed with successful results in a minimally invasive manner in patients with pathology of the aortic arch, who are not candidates for open surgery

Aneurisma de seno de valsalva fistulizado a auricula derecha / Fístula of sinus of valsalva aneurysm to the right atrium

Resumen: Los aneurismas de seno de Valsalva son una malformación rara de observar en la práctica clínica. Se presentan a cualquier edad y pueden ser de origen congénito o adquirido. La importancia de su estudio radica en que potencialmente pueden complicarse con rotura y fistulización a otra estructura cardíaca o extracardíaca, con una alta mortalidad asociada. El diagnóstico muchas veces puede ser complejo, pero existen algunos elementos clínicos inespecíficos que pueden orientarnos en su detección y rápido manejo, lo que puede marcar una diferencia en el pronóstico del paciente. Se presenta el caso de un paciente de 49 años con un aneurisma de seno de Valsalva complicado y a continuación una breve revisión del tema.

Abstract: Aneurysms of the sinus of Valsalva are. They occur at any age, either as a congenital or an acquired malformation. They may rupture and form a fístula to other cardiac structures, with a high mortality rate. The clinical case of a 49 year-old patient with a ruptured sinus of Valsalva an a fístula to the right atrium is presented. A brief review of the subject is included.

Percutaneous closure of a ruptured right coronary sinus of Valsalva aneurysm that mimics severe aortic regurgitation.

A 34-year-old male was admitted with presumed acute, severe aortic regurgitation. Multimodal imaging was performed and showed a ruptured right coronary sinus of Valsalva aneurysm into the right atrium. He underwent a percutaneous closure of the ruptured sinus of Valsalva aneurysm. The patient had major clinical improvement.

Concentración de la cirugía de aneurisma de aorta abdominal roto en centros especializados calificados / Concentrating ruptured abdominal aortic aneurysm surgery in specialized centers

Ruptured abdominal aortic aneurysm (RAAA) is an arterial emergency with an overall mortality of 80%-90% secondary to massive hemorrhage. If a patient with RAAA presents in a primary hospital without resolution capacity, survival will depend on early transfer to a center with adequately trained specialists. This article reviews the evidence supporting the centralization of AAAR treatment in qualified centers, specifying the criteria used for the selection of referral centers and the role of a coordinating unit. Our current referral system, which is based primarily on costs, is also described. Patients with AAAR who consult in non-resolving centers should be rapidly transferred to a qualified referral center, following a transfer protocol, and guided by a coordinating unit acting according to technical and established criteria based on results, quality, and costs. Qualified referral centers should have an accredited vascular surgeon and a high institutional aortic surgery volume, adequate infrastructure, endovascular resolution capacity, support services (intensive care, hemodialysis, etc.) and specialized personnel permanently available.

Surgical Repair of a Ruptured Giant Abdominal Aortic Aneurysm in a 16-Year-Old with Takayasu's Arteritis: Case Report and Etiological Review

Abstract Takayasu's arteritis is a type of primary systemic vasculitis that affects medium and large arteries, including the aorta and its main branches, as well as the pulmonary and coronary arteries. Although rare in children, it is the third most common vasculitis in the pediatric population, often with delayed diagnosis due to the nonspecific presentation of clinical symptoms in its initial phase. This is a case of a 16-year-old girl with a giant ruptured abdominal aortic aneurysm, who needed surgery on an emergency basis. The etiological aspects involved in aneurysms in young patients are also addressed.

Um cirurgião sob o olhar de Deus

Objetivo A síndrome de Terson (ST), também conhecida como hemorragia vítrea, é relatada em pacientes com hemorragia subaracnóide causada por um aneurisma rompido. Este estudo tem como objetivo avaliar a presença de hemorragia ocular nesses pacientes, buscando identificar aqueles que poderiam se beneficiar do tratamento específico para a recuperação do déficit visual. Métodos Estudo prospectivo de 53 pacientes com hemorragia subaracnóide espontânea (SSAH) por aneurisma rompido. Os pacientes foram avaliados quanto à hemorragia vítrea por fundoscopia indireta com 6 a 12 meses de seguimento. Resultados A idade dos pacientes variou de 17 a 79 anos (média de 45,9 ± 11,7); 39 pacientes eram do sexo feminino (73%) e 14 do sexo masculino (27%). Seis pacientes (11%) apresentaram ST e 83,3% apresentaram perda transitória de consciência durante a ictus. Conclusões Uma avaliação oftalmológica deve ser realizada rotineiramente em pacientes com hemorragia subaracnóide, especialmente naqueles com pior grau neurológico. Além disso, o prognóstico foi ruim em pacientes com ST.

Epidemiology of Abdominal Aortic Aneurysm Repair in Brazil from 2008 to 2019 and Comprehensive Review of Nationwide Statistics Across the World.

INTRODUCTION: Studying epidemiology of abdominal aortic aneurysms repairs is essential to prevent related deaths. Although outcomes are influenced by socioeconomic factors, there are no nationwide studies on these statistics in low-and-middle income countries. Therefore, we designed this study to evaluate abdominal aortic aneurysms repair rates, trends, costs, and in-hospital mortality in the Brazilian Public Health System, which exclusively insures over 160 million Brazilians. MATERIAL AND METHODS: Retrospective cross-sectional population-based analysis of publicly available data referring to all abdominal aortic aneurysm repairs performed between 2008 and 2019 in Brazilian public hospitals. RESULTS: We observed a total of 13,506 abdominal aortic aneurysm repairs, of which 32% were emergency endovascular repairs, 20% emergency open repairs, 32% elective endovascular repairs and 16% elective open repairs. There has been a downward trend in total abdominal aortic aneurysms repairs and an increasing predominance of endovascular repair. Elective and endovascular repairs were significantly associated with lower in-hospital mortality. For ruptured abdominal aortic aneurysms, we observed mortality rates of 13.8% after endovascular repair and 52.1% after open repair. For intact abdominal aortic aneurysms, we observed mortalities of 3.8% after endovascular repair and 18.6% after open repair. Procedure and mortality rates varied significantly among the Brazilian regions. CONCLUSIONS: We observed a low and decreasing rate of abdominal aortic aneurysm repair. Most repairs were emergency and endovascular and there was an increasing predominance of endovascular repair. Endovascular and elective repairs were associated with lower mortality.

[Concentrating ruptured abdominal aortic aneurysm surgery in specialized centers]. / Concentración de la cirugía de aneurisma de aorta abdominal roto en centros especializados calificados.

Ruptured abdominal aortic aneurysm (RAAA) is an arterial emergency with an overall mortality of 80%-90% secondary to massive hemorrhage. If a patient with RAAA presents in a primary hospital without resolution capacity, survival will depend on early transfer to a center with adequately trained specialists. This article reviews the evidence supporting the centralization of AAAR treatment in qualified centers, specifying the criteria used for the selection of referral centers and the role of a coordinating unit. Our current referral system, which is based primarily on costs, is also described. Patients with AAAR who consult in non-resolving centers should be rapidly transferred to a qualified referral center, following a transfer protocol, and guided by a coordinating unit acting according to technical and established criteria based on results, quality, and costs. Qualified referral centers should have an accredited vascular surgeon and a high institutional aortic surgery volume, adequate infrastructure, endovascular resolution capacity, support services (intensive care, hemodialysis, etc.) and specialized personnel permanently available.

Rare Presentation of Sinus of Valsalva Aneurysm Treated by Aortic Valve Reimplantation Technique.

Sinus of Valsalva aneurysm is a rare cardiac abnormality which can be acquired or of congenital origin. A spontaneous rupture into the right atrium is possible and, if not adequately treated, may result in a progressive heart failure due to the left-to-right intracardiac shunt. If ruptured sinus of Valsalva aneurysm is diagnosed, surgical repair is indicated, and different surgical techniques have been reported. If concomitant aortic regurgitation is present, aortic valve replacement is usually performed. Herein, we describe an uncommon clinical presentation of a ruptured sinus of Valsalva aneurysm which has been corrected by aortic valve reimplantation.

Proximal false lumen thrombosis is associated with low false lumen pressure and fewer complications in type B aortic dissection.

BACKGROUND: Improved risk stratification is a key priority for type B aortic dissection (TBAD). Partial false lumen thrombus morphology is an emerging predictor of complications. However, partial thrombosis is poorly defined, and its evaluation in clinical studies has been inconsistent. Thus, we aimed to characterize the hemodynamic pressure in TBAD and determine how the pressure relates to the false lumen thrombus morphology and clinical events. METHODS: The retrospective admission computed tomography angiograms of 69 patients with acute TBAD were used to construct three-dimensional computational models for simulation of cyclical blood flow and calculation of pressure. The patients were categorized by the false lumen thrombus morphology as minimal, extensive, proximal or distal thrombosis. Linear regression analysis was used to compare the luminal pressure difference between the true and false lumen for each morphology group. The effect of morphology classification on the incidence of acute complications within 14 days was studied using logistic regression adjusted for clinical parameters. A survival analysis for adverse aortic events at 1 year was also performed using Cox regression. RESULTS: Of the 69 patients, 44 had experienced acute complications and 45 had had an adverse aortic event at 1 year. The mean ± standard deviation age was 62.6 ± 12.6 years, and 75.4% were men. Compared with the patients with minimal thrombosis, those with proximal thrombosis had a reduced false lumen pressure by 10.1 mm Hg (95% confidence interval [CI], 4.3-15.9 mm Hg; P = .001). The patients who had not experienced an acute complication had had a reduced relative false lumen pressure (-6.35 mm Hg vs -0.62 mm Hg; P = .03). Proximal thrombosis was associated with fewer acute complications (odds ratio, 0.17; 95% CI, 0.04-0.60; P = .01) and 1-year adverse aortic events (hazard ratio, 0.36; 95% CI, 0.16-0.80; P = .01). CONCLUSIONS: We found that proximal false lumen thrombosis was a marker of reduced false lumen pressure. This might explain how proximal false lumen thrombosis appears to be protective of acute complications (eg, refractory hypertension or pain, aortic rupture, visceral or limb malperfusion, acute expansion) and adverse aortic events within the first year.

Terson Syndrome: Assessment of 53 Patients with Subarachnoid Hemorrhage by a Ruptured Aneurysm

Objective Terson syndrome (TS), also known as vitreous hemorrhage, is reported in patients with subarachnoid hemorrhage caused by a ruptured aneurysm. This study aims to evaluate the presence of ocular hemorrhage in such patients, trying to identify those who could benefit from the specific treatment for visual deficit recovery. Methods Prospective study of 53 patients with spontaneous subarachnoid hemorrhage (SSAH) due to ruptured aneurysm. The patients were evaluated for vitreous hemorrhage through indirect fundoscopy with 6 to 12 months of follow-up. Results The ages of the patients ranged from 17 to 79 years-old (mean age, 45.9 11.7); 39 patients were female (73%) and 14 were male (27%). Six patients (11%) presented TS, and 83.3% had a transient loss of consciousness during ictus. Conclusions An ophthalmologic evaluation must be routinely performed in subarachnoid hemorrhage patients, especially in those with worse neurological grade. Moreover, prognosis was bad in TS patients.

[Rupture of abdominal aortic aneurysm into the duodenum: uncommon cause of massive gastrointestinal bleeding]. / Aneurisma de aorta abdominal roto al duodeno: causa infrecuente de hemorragia digestiva masiva.

Primary aortoenteric fistula is the spontaneous communication between the lumen of the aorta and a portion of the digestive tract. The most common cause is the erosion of an abdominal aortic aneurysm into the 3rd or 4th portion of the duodenum. It manifests clinically as gastrointestinal bleeding, with or without abdominal pain and a pulsatile abdominal mass on physical exam. Gastrointestinal bleeding is initially recurrent and self-limiting and progresses to fatal exsanguinating hemorrhage. Endoscopic examination diagnoses only 25% of aortoenteric fistulas because these are usually located in the distal duodenum. Contrast computed tomography of the abdomen and pelvis is diagnostic in only 60% of cases. We report three cases with this condition. A 67-year-old male presenting with an upper gastrointestinal bleeding. He was operated and a communication between an aortic aneurysm and the duodenum was found and surgically repaired. The patient is well. A 67-year-old male with an abdominal aortic aneurysm presenting with abdominal pain. He was operated and anticoagulated. In the postoperative period he had a massive gastrointestinal bleeding and a new CAT scan revealed an aorto enteric fistula that was surgically repaired. The patient is well. An 82-year-old male with an abdominal aortic aneurysm presenting with hematochezia. A CAT scan revealed a communication between the aneurysm and the third portion of the duodenum, that was surgically repaired. The patient died in the eighth postoperative day.