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1.
Vascular ; : 1708538120922098, 2020 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-32356684

RESUMO

OBJECTIVES: Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. METHODS: From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. RESULTS: Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found (P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group (P < 0.001 and P = 0.0001, respectively). CONCLUSIONS: Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.

3.
Rev Port Cir Cardiotorac Vasc ; 27(1): 23-31, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32239822

RESUMO

Peripheral Arterial Disease (PAD) is a prevalent condition that predisposes the patients to major cardiovascular events. The majority of patients are asymptomatic, however PAD has a great impact in the patients' lifestyle due to its chronic nature. The Peripheral Arterial Questionnaire (PAQ) is a validated tool to quantify the patients' subjective experience of the disease. The aim of this work is to validate the Portuguese version of PAQ. A retrospective study of 59 patients with aortoiliac disease Trans-Atlantic Inter Society Consensus (TASC) type D from two centers in Portugal was conducted. Only 36 patients were able to answer the PAQ and two Portuguese validated questionnaires - a disease-specific (Walk Impairment Questionnaire - WIQ) and a generic one (EuroQol 5 dimensions - 5 level EQ5D-5L). Con- vergent validity of the PAQ was evaluated by correlating the extracted PAQ subscales and Summary score with the WIQ subscales and summary score, as with EQ5D-5L Summary score and EQ5D-5L index by calculating the covariance. The Portuguese version of the peripheral artery questionnaire presented a Cronbach's α for the Summary scale of 0.913. Mean inter-item correlation for the Physical Function domain was 0.471, 0.551 for the Perceived Disability, and 0.464 for Treat- ment Satisfaction. In summary, the Portuguese version of PAQ demonstrated a good level of discrimination between patients with or without symptomatic PAD and its severity and was sensitive to the presence of risk-factors relevant for PAD.

4.
Vasc Endovascular Surg ; 54(2): 102-110, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31746273

RESUMO

OBJECTIVE: Compare technical, clinical, and economic outcomes between endovascular and open approaches in patients with type D aortoiliac occlusive disease according to the TransAtlantic Inter-Society Consensus. METHODS: Patients undergoing revascularization for type D aortoiliac lesions, either endovascular or open surgery approach, from 2 Portuguese institutions between January 2011 and October 2017 were included. The surgical technique was left to the surgeon discretion. Patients with common femoral artery affection, both obstructive and aneurysmatic, were excluded. RESULTS: Twenty-seven patients underwent aortobifemoral bypass and 32 patients were submitted to endovascular repair. The patients undergoing endovascular procedure were more likely to present with chronic heart failure (P = .001) and chronic kidney disease (P = .022) and less likely to have a history of smoking (P = .05). The mean follow-up period was 67.84 (95% confidence interval = 61.85-73.83) months. The open surgery approach resulted in a higher technical success (P = .001); however, limb salvage and patency rates were not different between groups. Endovascular approach was associated with a shorter length-of-stay, both inpatient (6 vs 9 days; P = .041) and patients admitted in the intensive care unit (0 vs 3.81 days; P = .001) as well as lower hospital expenses (US$9281 vs US$23 038; P = .001) with a similar procedure cost (US$2316 vs US$1173; P = .6). No differences were found in the postsurgical quality of life. CONCLUSION: Endovascular approach is, at least, clinically equivalent to open surgery approach and is more cost-efficient. The "endovascular-first" approach should be considered for type D occlusive aortoiliac lesions.


Assuntos
Doenças da Aorta/cirurgia , Arteriopatias Oclusivas/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Femoral/cirurgia , Artéria Ilíaca/cirurgia , Idoso , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/economia , Doenças da Aorta/fisiopatologia , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/economia , Arteriopatias Oclusivas/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Implante de Prótese Vascular/instrumentação , Redução de Custos , Análise Custo-Benefício , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Custos de Cuidados de Saúde , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Portugal , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Stents , Fatores de Tempo , Resultado do Tratamento
6.
Int J Surg ; 71: 66-71, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31542388

RESUMO

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) occurs in 15% of patients undergoing carotid endarterectomy (CEA) with general anesthesia. Short and long-term risk of myocardial infarction (MI) and stroke have been strongly associated with the presence of MINS, with an associated mortality rate superior to 10% in the first year. Due to the absence of studies concerning CEA with regional anesthesia (RA), the present study aimed to evaluate the incidence of MINS in patients with RA and its prognostic value on cardiovascular events or death. MATERIALS AND METHODS: From January 2009 to January 2018, 156 patients from a Portuguese tertiary care medical center who underwent CEA under RA were retrieved from a prospectively gathered database. Troponin I or high-sensitive troponin I values were systematically measured in the postoperative period and studied as a binary outcome in a logistic regression model. Survival analysis was used to study the impact of MINS in time-dependent clinical outcomes such as stroke and MI. RESULTS: The incidence of MINS after CEA was 15.3%. Multivariate analysis confirmed that chronic heart failure was strongly associated with MINS (OR: 4.458, 95% CI: 1689-11.708, P < 0.001). A previously diagnosed MINS was associated with the long-term risk of MI and major adverse cardiovascular events (MACE) with hazard ratios (HR) of 3.318 (95% CI: 0.97-13.928, Breslow: P = 0.025) and 1.955 (95% CI: 1.01-4.132, Breslow: P = 0.046), respectively. CONCLUSIONS: MINS is a long-term predictor of MI and MACE. Troponin assessment after CEA should be routinely monitored in patients with a cardiovascular risk superior to 5%. Further studies concerning prophylaxis and management of MINS should be carried on, focusing on the effect of anesthetic procedure in postoperative troponin elevation.


Assuntos
Anestesia por Condução/efeitos adversos , Endarterectomia das Carótidas/efeitos adversos , Infarto do Miocárdio/mortalidade , Complicações Pós-Operatórias/mortalidade , Troponina/sangue , Idoso , Anestesia Geral/efeitos adversos , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Endarterectomia das Carótidas/métodos , Feminino , Insuficiência Cardíaca/complicações , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
7.
Rev Port Cir Cardiotorac Vasc ; 26(2): 131-137, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31476814

RESUMO

BACKGROUND: Type B aortic dissection (TBAD) is associated with high morbidity and mortality. The DISSECT classification aims to reunite clinical and anatomical characteristics of interest to clinicians involved in its management. This paper aims to characterize a cohort of patients admitted for type B aortic dissection in a tertiary institution. METHODS: This is a retrospective study that included all patients admitted to the hospital due to TBAD from 2006 to 2016. The computerized tomographic angiography that enabled the TBAD diagnosis were reevaluated using DISSECT classification. RESULTS: Thirty-two patients were included in this case series. As to DISSECT classification, 79.3% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental Extent), 28% presented with Complications, and 28% had partial Thrombosis of false lumen. Six patients underwent intervention during the follow-up period. At 12 months, overall survival was 75.4%±8.3% and survival free of aorta-related mortality was 87.0±6.1%. Survival free of aortic dilatation was 82.6±9.5%. In univariate analysis, the presence of complications and chronic kidney disease associated with increased overall and aorta-related mortality rates. Hypertension was associated with aortic dilatation. CONCLUSIONS: The outcomes after TBAD in a Portuguese center are reported. All interventions in TBAD were performed due to complications. The presence of complications and chronic kidney disease was associated with overall mortality and aorta-related mortality and hypertension with aortic dilatation. DISSECT classification was possible to apply in all patients.


Assuntos
Aneurisma Dissecante , Aneurisma da Aorta Torácica , Aneurisma Dissecante/classificação , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/terapia , Aneurisma da Aorta Torácica/classificação , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/terapia , Angiografia por Tomografia Computadorizada , Humanos , Estudos Retrospectivos , Resultado do Tratamento
8.
Ann Vasc Surg ; 61: 193-202, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31382007

RESUMO

BACKGROUND: A number of awake patients undergoing carotid endarterectomy (CEA) present from test clamp neurological deficits (NDs) during the procedure. Current guidelines advocate tighter Doppler ultrasound (DUS) surveillance in these patients because of probable higher likelihood of hemodynamic stroke (class 1 grade C), although evidence is lacking regarding benefit. The aim for the study is the assumption that patients who present ND have a higher risk of developing a complete stroke if the ipsilateral carotid artery becomes occluded, and for this reason, surveillance over restenosis of endarterectomy in this group is justifiable; hence, the authors would like to contribute to this matter presenting their experience on restenosis in this specific group of patients. METHODS: Data were prospectively collected between 2009 and 2018 for patients of a university tertiary referral center who underwent CEA under regional anesthesia and developed alterations in the neurologic monitoring during internal carotid artery (ICA) test clamping. Control patients were consecutively selected as the next patient submitted to the same procedure but who did not develop neurologic alterations. Patients who did not present to the first postoperative evaluation were excluded (4-6 weeks). Primary outcome was any restenosis (>30%; >50%; >70%) detected by DUS evaluations between 16 and 30 months of follow-up. Clinical adverse events such as stroke, myocardial infarction, acute heart failure, and all-cause death were assessed 30 days after the procedure and in the subsequent long-term surveillance period. A multivariate analysis of factors with significant associations to restenosis identified in a univariate analysis was performed by binary logistic regression. Kaplan-Meier analysis and life tables were used to evaluate time-dependent variables. RESULTS: Ninety patients with ND and 94 controls were included. Those with ND had a higher prevalence of obesity, mean age, and scores of American Society of Anesthesiologist physical status, as well as a lower mean degree of ipsilateral stenosis (82.3% vs. 85.8%, P = 0.032) and a higher mean degree of contralateral stenosis (67.8% vs. 61.1%, P = 0.030). The incidence of restenosis after 2 years did not differ significantly between groups. The univariate analysis yielded two significant associations to restenosis >50%, which remained significant after adjustment: ipsilateral stenosis (1.927 + -0.656, P = 0.02) and peripheral arterial disease (3.006 + -1.101, P = 0.048). NDs were not found to be associated to restenosis (P = 0.856). After a median follow-up period of 52 months, patients with NDs did not have a higher incidence of stroke (90.6%, standard deviation [SD]: 3.5%; ND: 91.1%, SD: 3.6%, P = 0.869), major adverse cardiovascular events (ND: 69.2%, SD: 5.5%; control, 73.6%, SD: 5.2%, P = 0.377), or all-cause death (ND: 90.6%, SD: 3.5%; control: 91.1, SD: 3.6%, P = 0.981) than controls. The presence of any restenosis was not associated with later stroke rate (ND: 89.5%, SD: 3.2%; control: 100%, P = 0.515). CONCLUSIONS: Cost-effective DUS surveillance after CEA requires the definition of evidence-based factors associated with restenosis and late stroke. The present study does not support the assumption that patients who presented NDs during the ICA test clamping present a higher risk of developing late stroke. This group of patients also did not present a higher incidence of restenosis. For these reasons, tighter DUS surveillance in this group seems not justifiable. Results from other groups are required to support this position.

9.
Scand Cardiovasc J ; 53(5): 266-273, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31251084

RESUMO

Objetives. Carotid endarterectomy (CEA) is an established treatment for carotid stenosis (CS). However, this procedure is not risk-free and it is insufficient to control disseminated atherosclerosis. Our aim was to determine long-term cardiovascular morbidity and mortality after CEA and identify associated risk predictors. Design. Consecutive cohorts of CEAs performed between 2010 and 2018 in two Portuguese hospitals were retrospectively analysed. The major end-points were acute myocardial infarction (AMI), stroke, all-cause death and major adverse cardiovascular events (MACE). Results. 248 patients (mean age 69 years; 79% male) were enrolled in the study. 24% had postoperative complications. At 52 months median follow-up, 9 ± 2.0% (mean ± standard error) of patients experienced an acute myocardial infarction (AMI), 12 ± 2.4% a stroke and 26 ± 3.2% a MACE. All-cause mortality rate was 21 ± 3.0%. Multivariate analysis identified coronary artery disease (CAD) as significant predictor of AMI (p < .001; Hazard Ratio (HR):9.628; 95% Confidence Interval (95%CI):2.805-33.046), whereas no statistically significant risk factor of stroke was found. Predictors of death included left sided CS (p = .042; HR:1.886; 95%CI:1.024-3.475), chronic kidney disease (CKD) (p = .007; HR:2.352; 95%CI:1.266-4.372) and anticoagulant medication (p = .015; HR:2.107; 95%CI:1.216-6.026), while statin use was significantly protective (p = .049; HR:0.482; 95%CI:0.233-0.998). Concerning MACE, male gender (p = .040; HR:1.709; 95%CI:1.025-2.849), tobacco use (p = .004; HR:2.181; 95%CI:1.277-3.726), CAD (p = .002; HR:2.235; 95%CI:1.340-3.727) and CKD (p < .001; HR:3.029; 95%CI:1.745-5.258) were risk predictors. Conclusions. Patients continue to have high rates of AMI, MACE and death after CEA. Prior CAD is a risk factor for future AMI, whereas CKD is a significant predictor of MACE and death. Aggressive best medical treatment and risk factors modification should be advised in all patients with systemic atherosclerosis.


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Idoso , Estenose das Carótidas/mortalidade , Causas de Morte , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Portugal , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
10.
Rev Port Cir Cardiotorac Vasc ; 25(1-2): 41-48, 2018.
Artigo em Português | MEDLINE | ID: mdl-30317709

RESUMO

INTRODUCTION: Minimally invasive revascularization of the left anterior descending coronary artery has gained popularity. Recently, the emergence of new surgical instruments and the improvement of the technique, allowed its use by routine. Its use in Heart Team allows excellent results. Our aim is to present the results of patients undergoing this technique in our center. METHODS: Retrospective study of patients submitted to minimally invasive revascularization of the left anterior descending coronary artery at our center. RESULTS: We identified 14 patients. The mean age was 67 years old. In the total of the procedures, 79% were elective and 21% urgent. The ventricular function was preserved in 86% of the patients. In the preoperative catheterization, 64% of the patients showed single disease of the anterior descending coronary artery, 29% had trunk lesions and 3 vessels and 7% had lesion of 2 vessels. The mean Euroscore II was 4.8%. The mean time of surgery was 103 minutes with a mean blood loss of 250mL. The main complications were wound dehiscence and revision of hemostasis. The mean hospitalization rate was 6.2 days. The hospital survival rate was 100%. CONCLUSION: Minimally invasive revascularization allows coronary artery bypass grafting with the best conduit. Revascularization may be total in single disease of the left anterior descending artery, or in case of multivessel disease, achieved with hibrid revascularization, with angioplasty of the remaining vessels. This technique has shown to be promising and safe, being the discussion in Heart Team of the patient candidates essential for achieving the best results.


Assuntos
Angiografia , Continuidade da Assistência ao Paciente/normas , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Atenção Primária à Saúde , Encaminhamento e Consulta , Idoso , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Equipe de Assistência ao Paciente , Estudos Retrospectivos , Resultado do Tratamento
11.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 108, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701341

RESUMO

INTRODUCTION: The aim of this study is to evaluate the outcome of catheter directed thrombolysis (CDT) in acute lower limb ischaemia depending on the underlying etiology. METHODS: Retrospective single center analysis of electronic clinical data on patients with acute lower limb ischaemia treated with CDT. Between January 2011 and September 2017, 128 procedures in 106 patients were included. The etiology of ischaemia was native artery thrombosis in 39 procedures (30,5%), PTFE graft thrombosis in 56 (43,8%), intra-stent thrombosis in 11 (8,6%), emboly in 9 (7%), popliteal aneurysm thrombosis in 9 (7%), vein graft thrombosis in 2 (1,6%) and popliteal artery entrapment in 2 (1,6%). RESULTS: Median follow-up time was 14 months [range: 6-31], during which 22% needed further intervention. The need for reintervention was 27,6% in native artery thrombosis group, 65,2% in PTFE graft thrombosis group, 18,2% in intra- stent thrombosis group. No reinterventions occurred neither in popliteal aneurysm group or emboly group. Amputation free survival was 83,3% (SE 4,6%) at 27 months and cumulative incidence of death was 10,1% (SE 5,2%) at 32 months, with no differences between the groups. CONCLUSION: Intra-arterial thrombolytic therapy achieves good mid-term clinical outcomes, reducing obviating the need to open surgical treatment in many patients. These results support the choice for CDT as a valid option in acute limb ischaemia of several etiologies.


Assuntos
Isquemia , Terapia Trombolítica , Humanos , Isquemia/tratamento farmacológico , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução Vascular
12.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 112, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701345

RESUMO

Introduction The rupture of thoracoabdominal aneurysms (rTAA) represents one of the major challenges to the vascular surgeon. Recent developments in the endovascular armamentarium and the high mortality from open surgery make endovascular treatment an attractive option. Devices to be used in an emergency environment should be "off-the-shelf" and include, among others, EVAR snorkel/chimney and branched endoprosthesis (T-branch, Cook®). METHODS: We describe the case of a 70-year-old patient who was admitted to the emergency room due continuous low back pain with 3 days of evolution. RESULTS: The tomographic computer angiography showed a type III thoracoabdominal aneurysm, with a transverse maximum diameter of 75x81mm in the infrarenal aorta and an exuberant hematoma in the left retroperitoneum, but no active extravasation of the contrast was observed (Figure 1). There was still marked tortuosity and moderate iliac calcification. It was decided to place a branched endoprosthesis (34 mm diameter at the top and 18 mm at the bottom). The branched endoprosthesis was extra-corporeally oriented, and introduced through a right femoral approach. The final position was verified with the digital subtraction angiography in anteroposterior incidence, ensuring that the distal border of each branch was 1.5 to 2 cm above the target vessel and that the stent marks presented the desired position. After the endoprosthesis was opened, the branches are catheterized by the left axillary access, however, it was verified that the endoprosthesis had an antero-posteriorly inverted implantation. It was possible to catheterize the superior mesenteric artery and the left renal artery (celiac trunk occlusion was documented intraoperatively); occlusion of the remaining endoprosthesis branches was performed with an Amplatzer. The patient evolved with multiorgan dysfunction and died at 24 hours post-operatively. CONCLUSION: Implantation of an off-the-shelf branched endoprosthesis requires specific anatomical criteria such as aortic diameter> 25mm to allow catheterization of the vessels, the possibility of incorporating each target vessel at a 90o angle in relation to each branch and visceral arteries with a diameter between 4 and 8 mm. Anatomy review is important to understand the lengths and positions of the branches. It should be borne in mind that it is possible that the device might have to be rotated during implantation to better align the marks and that both incidences (anteroposterior and profile) may be useful in confirming the position, something that should be thoroughly pursued to safeguard a correct implantation regardless of the initial stent position in your delivery system.


Assuntos
Aneurisma Roto , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aneurisma Roto/complicações , Aneurisma Roto/cirurgia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/cirurgia , Aortografia , Prótese Vascular , Humanos , Desenho de Prótese , Stents , Resultado do Tratamento
13.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 113, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701346

RESUMO

INTRODUCTION: The suitability of the proximal and distal landing zones remains one of the main limitations to thoracic endovascular aortic repair. The advent of custom-made scalloped stent grafts widened the endovascular options in some challenging anatomies. METHODS: The authors present three cases of thoracic aortic aneurysm (TAA), with three different hostile anatomies, successfully treated with custom-made scalloped stent grafts. RESULTS: Case1: Male patient, 47 years old, no relevant medical history. Angio-CT revealed a 54mm post- traumatic TAA, extending distally from the origin of the left subclavian artery. Inadequate sealing in Ishimaru zone 2 was evident. The patient was sequentially treated by means of a carotid-subclavian bypass followed by TEVAR with proximal scallop to the left common carotid artery. Proper proximal sealing was obtained. Case2: Male patient, 76 years old, diagnosed with a 65mm diameter TAA, involving the origin of the left subclavian artery. Presence of a bovine trunk, and inadequate landing zone distally to it, were noted. The patient was sequentially treated by means of a carotid-subclavian bypass followed by TEVAR with proximal scallop to the bovine trunk. Proper sealing in Ishimaru zone 2 was granted. Case3: Male patient, 77 years old, multiple comorbidities. Angio-CT revealed a 59,3mm saccular aneurysm of the distal thoracic descending aorta, extending proximally from the origin of the celiac trunk. Good collateralization was observed after celiac trunk occlusion test. Proper distal seal was obtained by means of selective embolization of the celiac trunk followed by TEVAR with distal scallop to the superior mesenteric artery. All procedures were uneventful, with no reported endoleaks, birdbeaks, migrations or re- interventions. There are no reported complications at 1-year follow-up. CONCLUSION: Custom-made scalloped thoracic stentgrafts are an accessible, reproducible and safe therapeutic option when dealing with hostile descending thoracic anatomies, and should be considered as a minimally-invasive effective solution in selected cases.


Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Animais , Aneurisma da Aorta Torácica/terapia , Aortografia , Prótese Vascular , Bovinos , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Estudos Retrospectivos , Stents , Resultado do Tratamento
14.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 171, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701401

RESUMO

INTRODUCTION: Hepatic artery aneurysms (HAAs) are rare, representing about 0.1-2% of all arterial aneurysms. They are the second most common splanchnic aneurysms, after splenic artery aneurysms. They have the highest rate of rupture among all splanchnic artery aneurysms and frequently become symptomatic. METHODS: To present a case of a hepatic artery aneurysm treated by endovascular technique. RESULTS: A 65-year old man who had a medical history of hypertension, dyslipidemia and smoking, with an incidental finding on a CT imaging of a hepatic artery aneurysm (maximum diameter 75mm) was admitted for selective arteriography and treatment. He was asymptomatic. We proceeded to aneurysm exclusion with a self-expandable covered stent (Viabahn®) 6x100mm. Final angiography revealed permeability of right hepatic artery, splenic artery and gastroduodenal artery, and no visible endoleaks. He was discharged on the 4th postoperative day, asymptomatic and without analytic changes. On a 6 months follow-up, CT-angio confirmed a fully patent stent with no visible endoleaks and complete aneurysm exclusion. CONCLUSION: HAAs should be diagnosed before rupture. Abdominal pain, bleeding or compression may be the first symptoms. Exclusion by endovascular techniques, namely through covered- stent use, may be a good option.


Assuntos
Aneurisma , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Hepática , Idoso , Aneurisma/cirurgia , Artéria Hepática/cirurgia , Humanos , Masculino , Artéria Esplênica , Stents , Resultado do Tratamento
15.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 182, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701411

RESUMO

INTRODUCTION: Brachial artery aneurysms are relatively uncommon and generally due to infectious, post-traumatic or iatrogenic etiology. They seem to affect 4.5% of arteriovenous fistula. The usual manifestation is an accidental finding of a pulsatile, painless, and asymptomatic mass. Complications include sac thrombosis, thromboembolic ischaemic events, and disruption with profuse bleeding. METHODS: The aim of this study is to present a case of true brachial artery aneurysm in end-stage renal disease patient after arteriovenous fistula creation. RESULTS: Sixty-six-year-old men with a past medical history of hypertension, dyslipidemia, smoking and poliquistic renal disease. He started a hemodialysis program in March 2006, using a brachiocephalic fistula on the left upper limb, built in February 2005. Submitted to kidney transplant in June 2010 and subsequent fistula ligation in December 2012. He goes to the emergency service in June 2016 with a pulsatile mass on the medial aspect of the left arm. Pain, redness and heat were present. Radial pulse was palpable. Inflammatory parameters were high and ultrasound revealed a fusiform aneurysm of the brachial artery with partial thrombosis and triphasic flow. An MRI was performed, documenting a brachial artery aneurysm, with 44mm greatest diameter and an extension of 17.5cm. Patient was hospitalized under antibiotic therapy and submitted to a reversed great saphenous vein interposition graft. Discharge from hospital occurred on the 7th postoperative day, with no sensitive or motor deficits and a present radial pulse. CONCLUSION: Arterial aneurysm is a rare, but significant complication long after the creation of a hemodialysis access. High flow, immunosuppression and increased resistance following ligation of the AV fistula may accelerate this process.


Assuntos
Aneurisma , Fístula Arteriovenosa , Derivação Arteriovenosa Cirúrgica , Idoso , Aneurisma/etiologia , Aneurisma/cirurgia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Artéria Braquial/patologia , Humanos , Masculino , Diálise Renal , Resultado do Tratamento
16.
Rev Port Cir Cardiotorac Vasc ; 24(3-4): 183, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29701412

RESUMO

INTRODUCTION: Popliteal artery entrapment is an uncommon syndrome, caused by extrinsic compression of the popliteal artery by muscular or tendinous structures. It occurs mainly in young individuals, with no atherosclerostic risk factors, and a mean age of presentation of 20 to 40 years, and has higher prevalence in males (83% of patients). Clinical presentation depends on the degree of arterial lesion, the most common being intermittent claudication, with critical ischemia being frequent. Occasionally, it may present as acute ischaemia. METHODS: A 40-year-old female patient, physical education teacher, presented with a history of left foot paresthesia and left calf muscle pain during jogging for one year. The patient used to previously run 10 kilometers, currently mentioning claudication at 500 meters. No other medical conditions were mentioned. Lower extremity arterial duplex ultrasound revealed left popliteal artery compression and occlusion during active plantar flexion and passive dorsal flexion. The patient was referred to a vascular surgery center. Physical examination revealed palpable bilateral lower extremity pulses, with left asymmetry. Lower limb angiography and magnetic resonance imaging (MRI) were performed which demonstrated left popliteal artery compression and occlusion during a resisted plantar flexion. MRI revealed no anatomic anomalies, pointing to a probable functional entrapment caused by calf muscle hypertrophy (typo VI). RESULTS: Entrapment correction surgery was performed through a posterior approach and exposure. During the procedure, the artery showed no signs of significant fibrosis. Since compression by the medial head of the gastrocnemius muscle was observed, myotomy of its lateral fibers was performed. The patient was discharged on the second day post-surgery. After three months, the patient remained free of symptoms, having taken up sports practice with no limitations. CONCLUSION: Continuous popliteal artery compression leads to its progressive fibrosis, which may cause thrombosis or post-stenotic aneurysmal dilation. Treatment should be performed as soon as possible as to avoid this course and the eventual necessity of interposition or bypass grafting. Futhermore, late intervention worsens the interposition/ bypass grafting prognosis5. In this sense, the possibility of this diagnosis should be considered in a young patient presenting with intermittent claudication. Diagnostic tests are often decisive for differential diagnosis and to establish the disease subtype and intervention strategy. In most patients, a culprit muscular or tendinous anomaly is detected before surgery, however, in some individuals, especially physically active ones, compression results from muscular hypertrophy.


Assuntos
Arteriopatias Oclusivas , Artéria Poplítea , Trombose , Adulto , Angiografia , Arteriopatias Oclusivas/cirurgia , Feminino , Humanos , Isquemia , Masculino , Artéria Poplítea/patologia , Artéria Poplítea/cirurgia , Fatores de Risco
17.
Rev Port Cir Cardiotorac Vasc ; 22(1): 47-51, 2015.
Artigo em Português | MEDLINE | ID: mdl-27912233

RESUMO

OBJECTIVE: Presentation of a clinical case of an aorto-esophageal fistula secondary to thoracic aorta pseudoaneurysm, complicated by early type Ia endoleak after endovascular repair. CLINICAL CASE: A 64 years old male patient, with a history of arterial hypertension, smoking, alcohol abuse and ischemic heart disease with previous coronary revascularization was observed because of chest pain and abundant hematemesis, with Angio-CT revealing a 77mm pseudoaneurysm of the descending thoracic aorta, close to the left subclavian artery, with mass effect on the esophagus and trachea and signs of fistulization. He was proposed to endovascular repair with sealing in zone 2 of the aortic arch after building a left carotid-subclavian bypass. In the first 24 hours there were two episodes of massive hematemesis, with new Angio-CT revealing a early distal migration of the prosthesis, conditioning a type Ia endoleak. A carotid-carotid right-left bypass with left carotid ligation was performed and a new endoprosthesis was implanted in the origin of the brachycephalic trunk (zone 1). The final angiography showed aneurysm exclusion with permeability of the supra-aortic trunks. Later contrasted esophageal examination and endoscopy revealed an ulcer of the posterior left lateral wall with clot suggestive of fistula, and an esophageal prosthesis was successfully implanted. It held seven days of antibiotic therapy with ceftriaxone and metronidazole with no evidence of mediastinal infection and with aneurysm exclusion in the CT follow-up. CONCLUSION: The recognized biomechanical and anatomical complexity of the aneurysmatic thoracic aorta represents a considerable challenge to the endovascular treatment of aorto-esophageal fistulas, especially in aneurysmatic sealing of the aortic arch, with significant rates of type Ia and III endoleaks.

18.
Rev Port Cir Cardiotorac Vasc ; 21(3): 179-181, 2014.
Artigo em Português | MEDLINE | ID: mdl-27866403

RESUMO

The vast majority of renovascular hypertension is treated nowadays resorting to endovascular procedures (angioplasty/stenting). We report a case of malignant hypertension derived from bilateral ostial renal artery occlusion with unfit anatomy for endovascular correction. The patient maintained assymptomatic with controlled arterial tension at the thirteenth yeah of follow-up, due to a splenorenal bypass. A review of the literature and this surgery indications is discussed.

19.
Rev Port Cir Cardiotorac Vasc ; 21(4): 233-236, 2014.
Artigo em Português | MEDLINE | ID: mdl-27911508

RESUMO

Traumatic lesions of the axillary artery are rare in fractures of the proximal humerus. Clinical manifestations are sparse, generally presenting in the acute form, although in some cases the clinical signs only emerge later after the traumatic event. The early diagnosis might prevent serious complications. The authors present a case of a traumatic lesion of the axillary artery, with a delayed presentation, resulting from a traumatic fracture of the proximal third of the humerus that required emergent surgical management.

20.
Rev Port Cir Cardiotorac Vasc ; 21(2): 115-9, 2014.
Artigo em Português | MEDLINE | ID: mdl-26182455

RESUMO

There is a gap in international guidelines for acceptable wait times for cardiovascular surgery. Most patients benefit from surgery as fast as possible after the establishment of an indication. However due to extrinsic factors a continuous and cost-effective response is not feasible to all of them. Priority criteria for surgery after the indication is heterogeneous. The physician/surgeon is responsible for the surgical prioritization upon experience-based criteria. The prioritization is accepted by the hospitals most of the times, but incorrections are verified in excess and defect. There is a press in need for evidence-based prioritization criteria in cardiac and vascular surgery that maintains an adequate waiting time with maximum benefit. Surgical waiting times superior to what is clinically reasonable affects not only the patient but also the health system by indirect costs (morbidity, absence from work). The objective is to establish recommendations in extra-carotid disease, abdominal aortic disease, peripheral artery disease and vascular access construction. A review from the data is made to define an appropriate balance between the surgical scheduling and the prevention of pre an perioperatory adverse events.


Assuntos
Procedimentos Cirúrgicos Vasculares/normas , Artérias/cirurgia , Humanos
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