Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair.

PURPOSE: The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC. METHODS: This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes. RESULTS: Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU. CONCLUSIONS: In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.

Isquemia mesentérica no oclusiva tras revascularización escalonada de troncos viscerales y miembros inferiores / Non-occlusive mesenteric ischemia after staged revascularization of visceral trunks and lower extremities

Introducción:la isquemia mesentérica crónica (IMC) es una patología con alta morbimortalidad. La revascularización puede plantearse de forma escalonada con el fin de mejorar el estado nutricional del paciente. La isquemia no oclusiva es un tipo de isquemia mesentérica aguda que con frecuencia se manifiesta en el posoperatorio de una cirugía mayor o como complicación en un paciente crítico.Caso clínico:presentamos el caso de una paciente con IMC e isquemia crítica de miembros inferiores por enfermedad obstructiva aortoiliaca en el que se planteó una revascularización en dos tiempos. La paciente tuvo un posoperatorio tórpido como consecuencia de una isquemia mesentérica no oclusiva con desenlace fatal.Discusión:la isquemia mesentérica no oclusiva es un tipo de isquemia mesentérica aguda que puede manifestarse con dos tipos de patrones: bien en el contexto de una hipoperfusión sistémica, o bien en el de una hipoperfusión intestinal tras un evento precipitante como una intervención quirúrgica. El diagnóstico y tratamiento precoces son imprescindibles para intentar reducir unas tasas de mortalidad que alcanza el 70-90 % de los casos. El tratamiento endovascular es con frecuencia la primera elección aunque la cirugía abierta todavía juega un rol importante en casos de enfermedad extensa.(AU)

Introduction:chronic mesenteric ischemia (CMI) is a pathology with high morbidity and mortality rates since it’s usually associated with severe systemic arteriosclerosis. Revascularization of visceral trunks can be staggered in order to improve the nutritional status of the patient. Non-occlusive mesenteric ischemia is a type of acute mesenteric ischemia that frequently occurs in the postoperative period of major surgery or as a complication in critical patients.Case report:we present the case of a female patient with chronic mesenteric ischemia and critical ischemia of the lower limbs due to aortoiliac disease in which two-staged revascularization was performed. The patient had a torpid postoperative period as a result of a non-occlusive mesenteric ischemia which led to a fatal outcome.Discussion:non-occlusive mesenteric ischemia is a type of acute mesenteric ischemia that can occur in two contexts: either in a systemic hypoperfusion, or in the context of intestinal hypoperfusion after a precipitating event such as a surgical intervention. Diagnosis and early treatment are essential to trying to reduce mortality rates that reach 70-90 % of the cases. Endovascular treatment is often the first choice although bypass surgery still plays an important role in cases of extensive disease.(AU)

Actualización y algoritmos de toma de decisión en el manejo del aneurisma aórtico abdominal roto / Update and decision making algorithms on the management of ruptured abdominal aortic aneurysms

La rotura de un aneurisma aórtico abdominal (AAA) es un evento altamente letal que continúa asociada a una alta mortalidad, a pesar de su disminución en las últimas dos décadas, asociada a la adopción de la cirugía endovascular como primera línea de tratamiento y a avances en el manejo anestésico y perioperatorio. La actuación frente a un AAA roto (AAAr) puede dividirse en cuatro etapas: diagnóstico, manejo perioperatorio, cirugía y posoperatorio. En el marco de las guías americana y europea sobre manejo de AAAr y de la Guía NICE, se expone una actualización de los puntos críticos en cada etapa: desde el papel diagnóstico clave del angio-TAC hasta el manejo de complicaciones posoperatorias, como el síndrome compartimental abdominal. La creación de protocolos y algoritmos basada en la evidencia ayuda en la toma de decisiones y disminuye el tiempo desde el diagnóstico hasta el control hemorrágico, esencial para la supervivencia

A ruptured abdominal aortic aneurysm (rAAA) is a highly lethal event remaining associated with a high overall mortality, in spite of the reduction in the mortality from rAAA over the last two decades linked with the adoption of an endovascular aneurysm repair (EVAR) as the forefront strategy, as well as the advances in perioperative critical care practices. Management of a rAAA can be divided into four stages: diagnosis, perioperative management, surgical repair and postoperative period. Within the framework of American and European clinical practice guidelines on the management of abdominal aortic aneurysms and NICE guideline, all of them recently published, updated critical issues for each stage are shown. From the key role of CT angiogram for the diagnosis to the postoperative complications, such as abdominal compartment syndrome The creation of evidence-based protocols and algorithms for rapid diagnosis and treatment aids to make decisions and at the same time it will reduce the time since diagnosis to control of hemorrhage, which is essential for survival

Successful Management of a Type B Gutter Related Endoleak after Chimney EVAR by Coil Assisted Onyx Embolisation.

INTRODUCTION: The aim was to describe possible management of a persistent gutter related type Ia endoleak after treatment of a symptomatic pararenal aortic aneurysm with the chimney endovascular technique. REPORT: A 77 year old man with a symptomatic 6 cm pararenal aortic aneurysm was referred. Computed tomography angiography (CTA) showed a pararenal aortic aneurysm with involvement of both renal arteries and extension up to the superior mesenteric artery. The patient underwent treatment by placement of triple chimney grafts and an abdominal stent graft. Completion angiography showed a gutter related type Ia endoleak. As the type Ia endoleak persisted at the three month CTA follow up and according to the PERICLES registry classification of endoleaks, a type B causative mechanism was detected. Embolization of the gutters was performed with coils and onyx, leading to complete resolution of the gutters on completion angiography. The 10 month post-operative magnetic resonance angiogram showed no further evidence of any endoleak and complete exclusion of the aneurysm. CONCLUSION: Treatment of persistent type B gutter related endoleaks after triple chimney endovascular aneurysm repair can be performed with the placement of coils and adjunctive use of fluid agents.

Direct health costs and clinical outcomes of open surgery in patients with abdominal aortic aneurysm in Spain. The RECAPTA study.

OBJECTIVE: Abdominal aortic aneurysm (AAA) is a chronic, progressive disease that often requires surgical repair. This study aimed to assess the healthcare costs and clinical outcomes of open AAA repair in Spain. METHOD: Observational, retrospective, multicenter study with a one-year follow-up. Healthcare resource use and costs related to the surgical procedure, hospital stay, and follow-up period were assessed. RESULTS: Ninety patients with asymptomatic AAA who underwent open repair were recruited between 2003 and 2009 at three Spanish hospitals. Four patients (4.44%) died in the first 30 postoperative days. Mean [standard deviation] procedure time was 292.83 [72.10] minutes and mean hospital length of stay was 11.44 days [5.42]. Thirty two patients (35.56%) presented in-hospital complications and three patients (3.45%) underwent re-intervention during follow-up. The mean overall cost per patient during the study period was €21,622.59, of which 42.40% (€9,168.19), 52.08% (€11,261.74), and 5.52% (€1,192.66) corresponded to the surgical procedure, the inpatient stay, and the study follow-up period, respectively. CONCLUSIONS: Given the economic burden imposed by the treatment of patients admitted with AAA on the Spanish health system, additional efforts comparing the cost of open repair with endovascular treatments are needed to ensure greater efficiency.

Sequential intravenous allogeneic mesenchymal stromal cells as a potential treatment for thromboangiitis obliterans (Buerger's disease).

Thromboangiitis obliterans (TAO), also known as Buerger's Disease, is an occlusive vasculitis linked with high morbidity and amputation risk. To date, TAO is deemed incurable due to the lack of a definitive treatment. The immune system and inflammation are proposed to play a central role in TAO pathogenesis. Due to their immunomodulatory effects, mesenchymal stromal cells (MSCs) are the subject of intense research for the treatment of a wide range of immune-mediated diseases. Thus far, local intramuscular injections of autologous or allogeneic MSCs have shown promising results in TAO. However, sequential intravenous allogeneic MSC administration has not yet been explored, which we hypothesized could exert a systemic anti-inflammatory effect in the vasculature and modulate the immune response. Here, we report the first case of a TAO patient at amputation risk treated with four sequential intravenous infusions of bone marrow-derived allogeneic MSCs from a healthy donor. Following administration, there was significant regression of foot skin ulcers and improvements in rest pain, Walking Impairment Questionnaire scores, and quality of life. Sixteen months after the infusion, the patient had not required any further amputations. This report highlights the potential of sequential allogeneic MSC infusions as an effective treatment for TAO, warranting further studies to compare this approach with the more conventionally used intramuscular MSC administration and other cell-based therapies.

Isquemia aguda en extremidad superior secundaria a un mixoma / Acute ischemia in upper limb secondary to myxoma

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Angiosomas y cirugía vascular / Angiosomes and vascular surgery

La palabra ‘angiosoma’comienza a incluirse en las publicaciones que se refieren a la revascularización de laisquemia crítica de miembros inferiores. Es un concepto utilizado en cirugía plástica desde hace décadas y recientementeadquirido por cirujanos vasculares, que merece su revisión y actualización(AU)

The word ‘angiosome’ is starting to be used in the literature that deals with the revascularisation of criticallower-limb ischaemia. It is a concept that has been used in plastic surgery for decades and has recently been taken upby vascular surgeons, and as a result deserves a review and update(AU)

La cirugía vascular del siglo XXI. Reflexiones desde la ética / Vascular surgery in the 21st century. Reflections from an ethical point of view

La cirugía vascular del siglo XXI, cada vez más dependiente de la tecnología, incluye muchos desafíos éticos.Nuestra obligación es mantener una continua reflexión y debate para no alejarnos de los principios de la ética y del humanismo,con el paciente como centro y fin último de nuestra actividad profesional(U)

The vascular surgery of the 21st century, with its increasing dependence on technology, entails many ethicalchallenges. Our obligation is to sustain ongoing reflection and debate in order to ensure that we do not drift away fromthe principles of ethics and humanism, where the patient is the focus point and ultimate aim of our professional activity(AU)