Un caso complejo de isquemia mesentérica crónica: Reporte de caso y revisión de la literatura / A complex case of chronic mesenteric ischemia: Case report and literature review

Introducción. La isquemia mesentérica crónica es una entidad infrecuente, con una prevalencia de 0,03 %, donde más del 90 % son debidas a enfermedad arterioesclerótica que compromete principalmente la arteria mesentérica superior. Sus síntomas son dolor abdominal crónico y pérdida de peso, asociado a alteraciones imagenológicas que hacen el diagnóstico. El tratamiento depende de las condiciones clínicas del paciente y el número de vasos comprometidos. Es claro que la enfermedad multivaso sintomática requiere revascularización. Caso clínico. Mujer de 67 años, fumadora activa con antecedentes de hipertensión arterial y dislipidemia, con cuadro de crisis hipertensiva tipo urgencia que requirió manejo en Unidad de Cuidados Intensivos. Se hizo diagnóstico de aneurisma toracoabdominal Crawford IV, oclusión aorto-ilíaca (TASC D) y oclusión crónica del tronco celíaco y la arteria mesentérica superior. Por los síntomas de isquemia mesentérica crónica fue llevada a tratamiento quirúrgico con baipás aorto-bifemoral más baipás retrógrado a la arteria mesentérica superior por vía abierta. Resultado. La paciente tuvo mejoría de la sintomatología y aumentó 13 % del peso al seguimiento a los 3 meses. Conclusión. La isquemia mesentérica crónica es una condición subdiagnosticada, marcador de riesgo cardiovascular, con alta carga de morbilidad y mortalidad, en la cual, con una identificación temprana se puede ofrecer una terapia de revascularización, sea por vía endovascular o abierta, con el fin de mejorar la calidad de vida y la ganancia de peso, y evitar la necrosis intestinal.

Introduction. Chronic mesenteric ischemia is a rare entity, with a prevalence of 0.03%, where more than 90% are due to arteriosclerotic disease that mainly affects the superior mesenteric artery. Its symptoms are chronic abdominal pain and weight loss, associated with imaging alterations that make the diagnosis. Treatment depends on the patient's clinical conditions and the number of vessels involved. It is clear that symptomatic multivessel disease requires revascularization. Clinical case. A 67-year-old woman, an active smoker with a history of high blood pressure and dyslipidemia, presented with an emergency-type hypertensive crisis that required management in the Intensive Care Unit. A diagnosis of Crawford IV thoracoabdominal aneurysm, aorto-iliac occlusion (TASC D), and chronic occlusion of the celiac trunk and superior mesenteric artery was made. Due to the symptoms of chronic mesenteric ischemia, she underwent surgical treatment with aorto-bifemoral bypass plus retrograde bypass to the superior mesenteric artery via an open approach. Result. The patient had improvement in symptoms and gained 13% weight at 3-month follow-up. Conclusion. Chronic mesenteric ischemia is an underdiagnosed condition, a marker of cardiovascular risk, with a high burden of morbidity and mortality, in which, with early identification, revascularization therapy can be offered, either endovascularly or open, in order to improve quality of life and weight gain, and avoiding intestinal necrosis.

Surgical repair of abdominal aortic aneurysms on the public health system in the largest city in Brazil: a descriptive analysis of in-hospital data on 2693 procedures over 10 years / Correção cirúrgica do aneurisma de aorta abdominal em 2. 693 procedimentos ao longo de 10 anos no sistema público de saúde: uma análise descritiva na maior cidade brasileira

Abstract Background From 1990 to 2015, mortality from aortic aneurysms increased 16.8% in Brazil. São Paulo is the largest city in Brazil and about 5 million people depend on the public health system there. Objectives To conduct an epidemiological analysis of abdominal aortic aneurysm surgeries in the city of São Paulo. Methods Infra-renal aortic aneurysm procedures performed over a decade (from 2008 to 2017) were studied using publicly-available platforms from the Unified Health System and DATASUS. Results 2693 procedures were analyzed; 66.73% were endovascular; 78.7% of patients were male; 70.7% were aged 65 years or more; 64.02% were elective hospital admissions. There were 288 in-hospital deaths (mortality: 10.69%). In-hospital mortality was lower for endovascular surgery than for open surgery; both for elective (4.13% versus 14.42%) and urgent (9.73% versus 27.94%) (p = 0.019) admissions. The highest volume hospital (n = 635) had the lowest in-hospital mortality (3.31%). USD 24,835,604.84 was paid; an average of $ 2,318.63 for elective open, $ 3,420.10 for emergency open, $ 12,157.35 for elective endovascular and $ 12,969.12 for urgent endovascular procedures. Endovascular procedure costs were statistically higher than the values paid for open surgeries (p <0.001). Conclusions Endovascular surgeries were performed twice as often as open surgeries; they had shorter hospital stays and lower mortality.

Resumo Contexto No Brasil, a mortalidade por aneurisma de aorta aumentou 16,8% de 1990 a 2015. São Paulo é a maior cidade do Brasil, e cerca de 5 milhões de pessoas dependem do sistema público de saúde. Objetivos Análise epidemiológica das cirurgias do aneurisma de aorta abdominal na cidade de São Paulo. Métodos As cirurgias para correção do aneurisma de aorta infrarrenal realizadas no período de uma década (de 2008 a 2017) foram estudadas utilizando-se plataformas publicamente disponíveis do Sistema Único de Saúde e do Departamento de Informática do Sistema Único de Saúde. Resultados Foram analisados ​​2.693 procedimentos, entre os quais 66,73% eram endovasculares. Entre os pacientes, houve predominância do sexo masculino (78,7%) e daqueles com 65 anos ou mais (70,7%). Um total de 64,02% eram admissões hospitalares eletivas. Ocorreram 288 óbitos hospitalares (mortalidade: 10,69%). A mortalidade durante a internação foi menor para cirurgia endovascular do que para cirurgia aberta tanto no contexto eletivo (4,13% versus 14,42%) quanto urgente (9,73% versus 27,94%) (p = 0,019). O maior volume (n = 635) apresentou menor mortalidade intra-hospitalar (3,31%). Foi pago um total de $24.835.604,84, sendo uma média de $2.318,63 para cirurgia abertura eletiva, $3.420,10 para cirurgia abertura de emergência, $12.157,35 para cirurgia endovascular eletiva e $12.969,12 para cirurgia endovascular na urgência. Os custos dos procedimentos endovasculares foram estatisticamente superiores aos valores pagos para as cirurgias abertas (p < 0,001). Conclusões Foram realizadas duas vezes mais cirurgias endovasculares do que abertas, as quais apresentaram menor tempo de internação e menor mortalidade.

Increased blood pressure variability predicts poor outcomes from endovascular treatment for aneurysmal subarachnoid hemorrhage / Aumento da variabilidade da pressão arterial prediz resultados ruins de tratamento endovascular para hemorragia subaracnóide aneurismática

ABSTRACT Background: Predictors of outcomes following endovascular treatment (ET) for aneurysmal subarachnoid hemorrhage (aSAH) are not well-defined. Identifying them would be beneficial in determining which patients might benefit from ET. Objective: To identify the predictive factors for poor outcomes following ET for aSAH. Methods: 120 patients with ruptured cerebral aneurysms underwent endovascular embolization between January 2017 and December 2018. Blood pressure variability was examined using the standard deviation of the 24-hour systolic blood pressure (24hSSD) and 24-hour diastolic blood pressure (24hDSD). Predictors were identified through univariate and multivariate regression analysis. All patients were followed up for three months. Results: At follow-up, 86 patients (71.7%) had good outcomes and 34 (28.3%) had poor outcomes. Patients with poor outcomes had significantly higher 24hSSD than those with good outcomes (19.3 ± 5.5 vs 14.1 ± 4.8 mmHg; P < 0.001). The 24hDSD did not differ significantly between patients with good outcomes and those with poor outcomes (9.5 ± 2.3 vs 9.9 ± 3.5 mmHg; P = 0.464). The following were significant risk factors for poor outcomes after endovascular embolization: age ≥ 65 years (odds ratio [OR] = 23.0; 95% confidence interval [CI]: 3.0-175.9; P = 0.002); Hunt-Hess grade 3-4 (OR = 6.8; 95% CI: 1.1-33.7; P = 0.039); Fisher grade 3-4 (OR = 47.1; 95% CI: 3.8-586.5; P = 0.003); postoperative complications (OR = 6.1; 95% CI: 1.1-34.8; P = 0.042); and 24hSSD ≥ 15 mmHg (OR = 14.9; 95% CI: 4.0-55.2; P < 0.001). Conclusion: Elevated 24hSSD is a possibly treatable predictive factor for poor outcomes after ET for aSAH.

RESUMO Antecedentes: Fatores preditores de resultados após tratamento endovascular (TE) para hemorragia subaracnóide aneurismática (HSA) não estão bem definidos. Identificá-los seria útil para determinar quais pacientes podem se beneficiar de TE. Objetivo: Identificar os fatores preditivos de resultados ruins após TE para HSA. Métodos: 120 pacientes com aneurismas cerebrais rompidos foram submetidos à embolização endovascular entre janeiro de 2017 e dezembro de 2018. A variabilidade da pressão arterial foi examinada usando-se o desvio padrão da PA sistólica de 24 horas (DPPAS- 24h) e da PA diastólica de 24 horas (DPPAD-24h). Os fatores preditores foram identificados por meio de análises de regressão univariada e multivariada. Todos os pacientes foram acompanhados por três meses. Resultados: No acompanhamento, 86 pacientes (71,7%) tiveram bons resultados e 34 (28,3%) tiveram resultados ruins. Pacientes com resultados ruins apresentaram DPPAS-24h significativamente maior do que aqueles com bons resultados (19,3 ± 5,5 vs 14,1 ± 4,8 mmHg; P <0,001). O DPPAD-24h não diferiu significativamente entre os pacientes com bons resultados e aqueles com resultados ruins (9,5 ± 2,3 vs 9,9 ± 3,5 mmHg; P = 0,464). Os fatores de risco significativos para resultados ruins após embolização endovascular foram os seguintes: idade ≥ 65 anos (razão de probabilidade [OR] = 23,0; intervalo de confiança de 95% [IC]: 3,0-175,9; P = 0,002); escala de Hunt-Hess 3-4 (OR = 6,8; IC 95%: 1,1-33,7; P = 0,039); escala de Fisher 3-4 (OR = 47,1; IC 95%: 3,8-586,5; P = 0,003); complicações pós-operatórias (OR = 6,1; IC 95%: 1,1-34,8; P = 0,042); e DPPAS 24h ≥ 15 mmHg (OR = 14,9; IC 95%: 4,0-55,2; P <0,001). Conclusão: O DPPAS 24h elevado é um fator preditivo possivelmente tratável para resultados ruins após TE para HSA.

Reparación endovascular de la aorta torácica, resultados a largo plazo / Endovascular repair of the thoracic aorta, long-term results

Resumen Introducción: Las diversas patologías de la aorta torácica descendente, representan una implícita amenaza para la vida, y son potencialmente tratables mediante reparación endovascular. Objetivo: Evaluar los resultados de la reparación endovascular de la aorta torácia descendente (TEVAR). Material y Método: Estudio observacional, retrospectivo y descriptivo, donde se analiza TEVAR, en un período de 10 años (2009 al 2019), en el Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Se realizó TEVAR en 31 pacientes, sexo masculino 74,2%, femenino 25,8%, edad promedio 67,8 años (rango 53-85), patologías asociadas: hipertensión arterial sistémica (77,4%), tabaquismo (67,7%) y dislipidemia (38,7%), las indicaciones para TEVAR fueron: el aneurisma de la aorta descendente (51,61%), la disección tipo B crónica complicada (29,03%), y la disección tipo B aguda complicada (19,35%), relacionado al procedimiento se evidenció: morbilidad cardiovascular (12,9%) y morbilidad neurológica (6,45%), complicaciones relacionadas a la endoprótesis (29,03%), incidencia de endofugas (19,35%), estancia hospitalaria promedio de 5,2 días (rango 3 a 17), seguimiento promedio de 47,3 meses (9-108), éxito técnico primario (100%), tasa de reintervención: 3,22%, tasa de supervivencia a 1, 3, 5 años del 96,77%, 93,54 y 90,32% respectivamente, no hubo mortalidad menor a 30 días. Discusión: La evidencia demuestra que TEVAR puede realizarse en forma segura y efectiva, cumpliendo estrictos criterios clínicos y condiciones anatómicas, representando la modalidad de elección para la reparación de las lesiones de la aorta descendente. Conclusión: Los resultados demuestran que TEVAR, representa una excelente estrategia terapeutica, menos invasiva, con baja morbilidad y mortalidad asociada.

Introduction: The pathological injuries of the descending thoracic aorta, represent an implicit threat to life, and are potentially treatable by endovascular repair. Aim: To evaluate the results of endovascular repair of the descending thoracic aorta (TEVAR) in the medium and long term. Material and Method: Observational, retrospective and descriptive study, where TEVAR is analyzed, over a period of 10 years (2009 to 2019), at the Dr. Eduardo Pereira Hospital in Valparaíso, Chile. Results: TEVAR was performed in 31 patients, male sex 74.2%, average age 67.8 years (range 53-85), symptomatic 64.5%, associated pathologies: systemic arterial hypertension (77.4%), smoking (67.7%) and dyslipidemia (38.7%), indications for endovascular repair were descending aortic aneurysm (51.61%), complicated Stanford type B chronic aortic dissection (29.03%), and complicated Stanford type B acute aortic dissection (19.35%), neurological morbidity (6.45%), cardiovascular morbidity (12.9%), complications related to the stent (29.03%), where endoleaks predominate (19.35%), average hospital stay of 5.2 days (range 3 to 17), average followup of 47.3 months (9-108), primary technical success (100%), survival rate at 1, 3, 5 years of 96.77%, 93.54 and 90.32% respectively, there was no mortality less than 30 days or reoperation. Discussion: the evidence shows that TEVAR can be performed safely and effectively, meeting strict clinical criteria and anatomical conditions, which represents the modality of choice for the repair of lesions in the descending aorta. Conclusion: The results show that TEVAR represents an excellent therapeutic strategy, less invasive, with low associated morbidity and mortality.

Reemplazo de aorta ascendente con paro circulatorio con hipotermia sistémica moderada y perfusión cerebral retrógrada / Total replacement of the ascending aorta with moderate systemic hypothermic circulatory arrest and retrograde cerebral perfusion

Resumen: Antecedentes: El daño neurológico es una complicación devastadora de la cirugía con paro circulatorio del cayado aórtico y aorta ascendente. La perfusión anterógrada del encéfalo permite disminuir la incidencia de esta complicación, pero es un procedimiento engorroso que interfiere el campo quirúrgico. Para procedimientos más simples que requieran de paro circulatorio de menor duración, la Perfusión Cerebral Retrógrada (PCR) es una alternativa válida. Objetivo: Evaluar nuestros resultados en la cirugía del reemplazo total de la aorta ascendente tubular con paro circulatorio con hipotermia sistémica moderada y PCR. Material y Método: Entre enero de 2015 y enero de 2020 se identificaron los pacientes en la Base de Datos del Servicio de Cirugía Cardiaca de nuestra institución, se revisaron los protocolos operatorios, registros de perfusión y epicrisis, para obtener datos demográficos, clínicos y quirúrgicos pertinentes. La supervivencia alejada se certificó a través del "Servicio Registro Civil e Identificación de Chile". Resultados: En el periodo en estudio, 27 pacientes (21 hombres) tuvieron un reemplazo total de la aorta ascendente tubular con paro circulatorio con hipotermia moderada y PCR. Ocho pacientes tenían una cirugía previa; 7 de estos un reemplazo valvular aórtico. El 75% de los otros 20 pacientes tenía una válvula aórtica bicúspide. El diámetro máximo de la aorta ascendente fue en promedio 53,7 mm (45 a 67), y fue reemplazada en el 52% de los casos con un tubo protésico de 34 mm (promedio:32,4 mm; margen:30 a 34 mm). En 20 pacientes se efectuó un reemplazo valvular aórtico (15 con prótesis biológica). El tiempo promedio de circulación extracorpórea fue 174,6 min (97 a 243) y la temperatura sistémica mínima promedio fue 21ºC (18 a 25). El tiempo promedio de paro circulatorio fue 22,3 min (12 a 40) y de PCR 13 min (6 a 27). No hubo mortalidad operatoria. La morbilidad más frecuente fue la fibrilación auricular (33%). Una paciente presentó un episodio convulsivo aislado y otro fue reoperado por hemorragia postoperatoria. Una paciente falleció a los 48 meses de su operación. Conclusión: El paro circulatorio con hipotermia sistémica moderada y PCR para la cirugía de reemplazo total de la aorta ascendente facilitó la operación, con baja mortalidad y morbilidad en este grupo de pacientes.

Abstract: Background. Neurological damage is a devastating complication of aortic arch and ascending aorta surgery with deep hypothermic circulatory arrest. Antegrade cerebral perfusion significantly decreases the incidence of this complication, but it is a cumbersome procedure that interfere the surgical field. For more simple procedures, requiring a shorter period of circulatory arrest, retrograde cerebral perfusion (RCP) would be a valid alternative. Objective. To evaluate the results of total surgical replacement of the tubular ascending aorta with moderate hypothermic circulatory arrest and retrograde cerebral perfusion (RCP). Methods. Patients operated between January 2015 and January 2020 were included.Demographic, clinical and surgical information was obtained from the operatives notes, perfusion registry and discharge reports. Long-term survival was certified by the "Chilean Civil and Identification Registry". Results. 27 patients (21 men) underwent a total replacement of the tubular ascending aorta with circulatory arrest with moderate hypothermia and RCP. Eight patients had been previously operated on;7 of them had a previous aortic valve replacement. Of the remaining 20 patients, 75% had a bicuspid aortic valve. Average maximum diameter of the ascending aorta was 53.7 mm (45 - 67). Average size of the ascending aorta replacement graft was 32.4 mm (30 -34). In 20 patients a concomitant aortic valve replacement was performed (15 with a biological valve). Mean extracorporeal circulation time was 174.6 min (97 - 243) and mean minimal systemic temperature was 21ºC (18 - 25). Mean circulatory arrest time was 22.3 min (12 - 40) and mean RCP time was 13 min (6 - 27), There was no operative mortality. Atrial fibrillation was the most frequent post-operative morbidity (33%). One patient presented an isolated convulsive episode and another was re-operated due to postoperative hemorrhage. One patient died, 48 months after her operation. Conclusion. Moderate hypothermic circulatory arrest with RCP simplifies total tubular ascending aorta replacement, with low mortality and morbidity.

Enfermedad de Kawasaki: ¿una entidad exclusiva de niños? / Kawasaki disease, is it exclusive of children?

Resumen La enfermedad de Kawasaki es un síndrome febril agudo y autolimitado, de presunta etiología autoinmune, que característicamente afecta a niños menores de 5 años. Esta enfermedad consiste en una vasculitis aguda de pequeños y medianos vasos que favorece la formación de aneurismas en las arterias coronarias. El diagnóstico en la fase aguda es esencialmente clínico, mientras que en la fase crónica suele hacerse al documentar las secuelas vasculares. La importancia de la identificación apropiada de esta enfermedad radica en que muchos de los infartos fatales y no fatales en personas menores de 40 años tienen hallazgos compatibles con este diagnóstico. Se presenta el caso de un adulto joven con dolor torácico y angiotomografía coronaria con hallazgos compatibles con secuelas de enfermedad de Kawasaki del adulto.

Abstract Kawasaki disease is an acute and self-limited febrile syndrome with a presumed autoimmune etiology that characteristically affects children under 5 years of age. Kawasaki disease is an acute vasculitis of small and medium vessels that facilitates the formation of coronary aneurysms. The diagnosis of the disease during the acute phase is essentially clinical, while the diagnosis of Kawasaki disease during the chronic phase is performed when the vascular complications are detected. The importance of proper identification of Kawasaki disease lies in the fact that many of the fatal and non-fatal infarcts in young adults (<40 years) have findings compatible with this diagnosis. This article describes the case of a young patient with chest pain and coronary angiotomography showing sequelae of Kawasaki disease in the adult.

Colangiopancreatografía retrógrada endoscópica en un paciente con gran aneurisma de la aorta abdominal / Endoscopic retrograde cholangiopancreatography in a patient with a large abdominal aortic aneurysm

Introducción: El aneurisma de la aorta abdominal es una enfermedad que cursa, por lo general, de forma asintomática, asociado a una elevada mortalidad cuando se rompe. Se describen factores de riesgo asociados a la historia natural de esta afección. La realización de procederes terapéuticos endoscópicos, como la colangiopancreatografía retrógrada endoscópica ha sido polémica; aunque no se establece como contraindicación, presupone un alto riesgo. Objetivo: Presentar un paciente con aneurisma de la aorta abdominal, con elevado riesgo quirúrgico para realizar una colangiopancreatografía retrógrada endoscópica. Caso clínico: Se presenta un paciente con un gran aneurisma de la aorta abdominal y sospecha clínica de un ampuloma. Se le realizó terapéutica endoscópica mediante la colangiopancreatografía retrógrada endoscópica, con algunas variaciones en el procedimiento. Se logró el drenaje exitoso de la vía biliar principal, sin complicaciones. Conclusiones: La terapéutica realizada fue una opción, pero con muy alto riesgo(AU)

Introduction: The abdominal aortic aneurysm is a disease that usually occurs asymptomatically, associated with high mortality when it ruptures. Risk factors associated with the natural history of this condition are described. The performance of endoscopic therapeutic procedures, such as endoscopic retrograde cholangiopancreatography, has been controversial; although it is not established as a contraindication, it presupposes a high risk. Objective: To present a patient with an abdominal aortic aneurysm, with high surgical risk to perform an endoscopic retrograde cholangiopancreatography. Clinical case: A patient with a large abdominal aortic aneurysm and clinical suspicion of an ampuloma is presented. Endoscopic therapy was performed using endoscopic retrograde cholangiopancreatography, with some variations in the procedure. Successful drainage of the main bile duct was achieved without complications. Conclusions: The therapy carried out was an option, but with a very high risk(AU)

Retroperitoneal iliac conduits as an alternative access site for endovascular aortic repair: a tertiary care center experience / Condutos ilíacos retroperitoneais como local de acesso alternativo para reparo endovascular de aneurisma: experiência em centro de atenção terciária

Abstract Background Retroperitoneal open iliac conduits (ROIC) are used in patients with hostile iliac anatomy undergoing endovascular aortic repair (EVAR). Objectives We hereby report our experience of ROIC in patients subjected to EVAR. Methods This was a retrospective evaluation of 8 patients out of a total of 75 patients (11%) who underwent EVAR in the last 10 years. Pre-procedure computed tomography angiography was used to assess the dimensions of iliac and femoral arteries. Patients who had small arterial dimensions (i.e. smaller than the recommended access size for the aortic endograft device) were subjected to ROIC. Results The mean age of the 3 males and 5 females studied was 45.7 ± 15.2 years. The indication for ROIC was the small caliber ilio-femoral access site in 7 patients and atherosclerotic disease in 1 patient. All external grafts were anastomosed to the right common iliac artery except one which was anastomosed to the aortic bifurcation site because of a small common iliac artery. The procedural success rate was 100%. Local access site complications included infection (n=1), retroperitoneal hematoma (n=1), and need for blood transfusion (n=3). The median post-intervention hospital stay was 10 days. All patients had favorable long-term outcomes at a median follow-up of 18 months. Conclusions Female patients require ROIC during EVAR more frequently. Adjunctive use of iliac conduit for EVAR was associated with favorable perioperative and short-term outcomes.

Resumo Contexto Os condutos ilíacos abertos retroperitoneais são utilizados em pacientes submetidos a reparo endovascular de aneurisma (REVA) com anatomia ilíaca hostil. Objetivos Relatamos a nossa experiência com os condutos ilíacos em pacientes submetidos a REVA. Métodos Trata-se de uma avaliação retrospectiva de oito pacientes, de um total de 75 (11%), os quais foram submetidos a REVA nos últimos 10 anos. Foi realizada angiotomografia computadorizada antes do procedimento para avaliar as dimensões das artérias ilíaca e femoral. Os pacientes com dimensões arteriais menores, abaixo do tamanho de acesso recomendado para o dispositivo de endoprótese aórtica, foram submetidos a condutos ilíacos. Resultados A média de idade dos participantes foi de 45,7±15,2 anos, sendo três do sexo masculino e cinco do sexo feminino. As indicações para condutos ilíacos foram local de acesso ilíaco femoral de pequeno calibre, para sete pacientes, e doença aterosclerótica, para um paciente. Todas as próteses externas foram anastomosadas na artéria ilíaca comum direita, com exceção de uma, que foi anastomosada no local da bifurcação aórtica por apresentar artéria ilíaca comum menor. A taxa de sucesso do procedimento foi de 100%. As complicações no local de acesso incluíram infecção (n = 1), hematoma retroperitoneal (n = 1) e necessidade de transfusão de sangue (n = 3). O tempo mediano de internação hospitalar pós-intervenção foi de 10 dias. Todos os pacientes apresentaram desfechos de longo prazo favoráveis no seguimento mediano de 18 meses. Conclusões As pacientes do sexo feminino necessitaram de condutos ilíacos durante REVA com maior frequência. O uso adjuvante de condutos ilíacos com REVA foi associado a desfechos perioperatórios e de curto prazo favoráveis.

Mycotic aortic aneurysm in a debilitated patient with compromised immunity; beware of Candida! / Aneurisma micótico da aorta em paciente debilitado com imunidade comprometida - um alerta para Cândida

Abstract Candida is a rare cause of infected aortic aneurysms. We report the case of a diabetic patient with end stage kidney disease who underwent repair of a leaking abdominal aortic aneurysm. He was on long-term antibiotic treatment for malignant otitis externa. Candida albicans was isolated from the culture of the excised aneurysm wall. An infected aortic aneurysm due to Candida has not been previously reported in a patient with malignant otitis externa. This case report aims to highlight that Candida should be suspected as a cause of infected aortic aneurysms in patients with debilitation and chronic immunosuppression. Management of such cases can be extremely challenging, especially in resource-poor settings, and we will be touching upon the advantages and disadvantages of various treatment options.

Resumo A cândida é uma causa rara de aneurismas da aorta infecciosos. Relatamos o caso de um paciente diabético com doença renal terminal, que foi submetido a reparo de aneurisma da aorta abdominal com vazamento. Ele estava em tratamento de longo prazo com antibióticos para otite externa maligna. A Candida albicans foi isolada da cultura da parede do aneurisma que sofreu a excisão. Não há relatos prévios de aneurisma da aorta infeccioso causado por cândida em pacientes com otite externa maligna. Este relato de caso visa reforçar que a cândida deve ser uma das suspeitas de causa de aneurisma da aorta infeccioso em pacientes debilitados e com imunossupressão crônica. O manejo desses casos pode ser extremamente desafiador, principalmente em contextos em que os recursos são escassos, e mencionaremos as vantagens e desvantagens das diversas opções de tratamento.

Endovascular correction of isolated descending thoracic aortic disease: a descriptive analysis of 1, 344 procedures over 10 years in the public health system of São Paulo

OBJECTIVES: In Brazil, descending thoracic aorta disease (TAD), including aneurysms and dissection, are preferentially managed by endovascular treatment (TEVAR) due to the feasibility and good results of this technique. In this study, we analyzed endovascular treatment of isolated TAD (ITAD) in the public health system over a 10-year period in São Paulo, a municipality in Brazil in which more than 5 million inhabitants depend on the governmental health system. METHODS: Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The following types of data were analyzed: demographic data, operative technique, elective or urgent status, number of surgeries, in-hospital mortality, length of hospital stay, mean length of stay in the intensive care unit, and reimbursement values paid by the government. Trauma cases and congenital diseases were excluded. RESULTS: A total of 1,344 procedures were analyzed; most patients were male and aged ≥65 years. Most individuals had a residential address registered in the city. Approximately one-third of all surgeries were urgent cases. There were 128 in-hospital deaths (9.52%), and in-hospital mortality was lower for elective than for urgent surgeries (7.29% vs. 14.31%, p=0.031). A total of R$ 24.766.008,61 was paid; an average of R$ 17.222,98 per elective procedure and R$ 18.558,68 per urgent procedure. Urgent procedures were significantly more expensive than elective surgeries (p=0.029). CONCLUSION: Over a 10-year period, the total cost of ITAD interventions was R$ 24.766.008,61, which was paid from the governmental system. Elective procedures were associated with lower mortality and lower investment from the health system when compared to those performed in an urgent scenario.

Técnica de remodelamento com uso de stents em T e molas para tratamento de aneurisma renal complexo / Remodeling technique using T-stenting and coils to treat complex renal aneurysm

Resumo O aneurisma da artéria renal é uma condição rara, que vem sendo cada vez mais diagnosticada devido ao uso mais amplo da angiotomografia. Descrevemos um caso de aneurisma da artéria renal tipo II complexo em uma paciente com hipertensão arterial sistêmica e doença renal crônica não dialítica. O tratamento estabelecido foi o reparo endovascular através da combinação da técnica de remodelamento com stents em T e molas, para a preservação dos ramos arteriais renais. Foram obtidos resultados arteriográficos satisfatórios e boa evolução clínica.

Abstract Renal artery aneurysm is a rare condition that is being diagnosed with increasing frequency because of wider use of angiotomography. We describe a case of complex type II renal artery aneurysm in a patient with systemic arterial hypertension and non-dialysis chronic kidney disease. The treatment performed was endovascular repair using the remodeling technique with T-stenting and coils to preserve the renal arterial branches, obtaining satisfactory arteriographic results and good clinical outcomes.

Comparison between arch zones in modified frozen elephant trunk procedure for complex thoracic aortic diseases

Abstract Introduction: The aim of this study is to compare postoperative outcomes and follow-up of two different modifications facilitating surgical technique of frozen elephant trunk (FET) procedure for complex thoracic aortic diseases - zone 0 (fixation with total arch debranching) and zone 3 (fixation with islet-shape arch repair). Methods: From May 2012 to December 2018, data were collected from 139 patients who had been treated with FET procedure for complex thoracic aortic diseases. According to Ishimaru arch map, patients with proximal anastomotic site of hybrid graft at zone 0 and zone 3 were grouped as Group A (n=58, 41.7%) and Group B (n=81, 58.3%), respectively. Mean age of study population was 54.7±11.4 years, and 111 patients were male (79.9%). Results: In-hospital mortality was observed in 20 (14.4%) patients (n=12, acute type A aortic dissection, and n=4, previous aortic dissection surgery). There was no significant difference between both groups in terms of in-hospital mortality. Four patients from Group A and three patients from Group B had permanent neurological deficit (P=0.32). Three patients from both groups had transient spinal cord ischemia (P=0.334). Although mean total perfusion time was longer in Group A, duration of visceral ischemia, when compared with Group B, was shorter (P<0.001). Five-year survival rate was 82.8% in Group A and 81.5% in Group B (P=0.876). Conclusion: FET procedure is a feasible repair technique in the treatment of complex aortic diseases, providing satisfactory early results. Because of its advantageous aspects, zone 0 fixation with debranching is the preferred technique in our clinic.

Predictive factors of mortality in acute aortic dissection and validity of the euroscore algorithm in a small-sized cardiac surgery institution

Abstract Introduction: Acute aortic dissection (AAD) is a devastating surgical emergency, with high operative mortality. Several scoring algorithms have been used to establish the expected mortality in these patients. Our objective was to define the predictive factors for mortality in our center and to validate the EuroSCORE and Penn classification system. Methods: Patients who underwent surgery for AAD from 2006 to 2016 were retrieved from the institution's database. Preoperative, operative and postoperative variables were collected. Observed and expected mortality was calculated by EuroSCORE. Logistic regression analysis and Cox regression analysis were performed to find predictors of operative mortality and survival, respectively. The receiver operating characteristic (ROC) curves were plotted for logistic EuroSCORE, and the area under the ROC curve (AUC) was calculated. Results: 87 patients (27.6% female) underwent surgery for AAD. The mean age was 58.6±9.7 years. Expected and observed operative mortality was 25.8±15.1% and 20.7%, respectively. Penn Aa, Ab and Abc shared similar observed/expected (O/E) mortality ratio. The only independent predictor of operative mortality (OR: 3.63; 95% CI: 1.19-11.09) and survival (HR: 2.6; 95% CI: 1.5-4.8) was female gender. EuroSCORE showed a very poor prediction capacity, with an AUC=0.566. Conclusion: Female gender was the only independent predictor of operative mortality and survival in our institution. EuroSCORE is a poor scoring algorithm to predict mortality in AAD, but with consistent results for Penn Aa, Ab and Abc.

Comparison of femoral and axillary artery cannulation in acute type a aortic dissection surgery

Abstract Introduction: One of the most important points of the acute type A aortic dissection surgery is how to perform cannulation regarding cerebral protection concerns and the conditions of arterial structures as a pathophysiological consequence of the disease. Objective: In this study, femoral and axillary cannulation methods were compared in acute type A aortic dissection operations. Methods: The study retrospectively evaluated 52 patients who underwent emergency surgery for acute type A aortic dissection. Patients without malperfusion according to Penn Aa classification were chosen for preoperative standardization of the study groups. The femoral arterial cannulation group was group 1 (n=22) and the axillary arterial cannulation group was group 2 (n=30). The groups were compared in terms of perioperative and postoperative results. Results: There was no statistically significant difference in terms of preoperative data. In terms of postoperative parameters, especially early mortality and new-onset cerebrovascular event, there was no statistically significant difference. Mortality rates in group 1 and group 2 were 13.6% (n=3) and 10% (n=3), respectively (P=0.685). Postoperative new-onset cerebral events ratio was found in 5 (22.7%) in the femoral cannulation group and 6 (20%) in the axillary cannulation group (P=0.812). Conclusion: Both femoral and axillary arterial cannulation methods can be safely performed in patients with acute type A aortic dissection, provided that cerebral protection strategies should be considered in the first place. The method to be performed may vary depending on the patient's current medical condition or the surgeon's preference.

Chagas disease in Virgem da Lapa, Minas Gerais, Brazil: left ventricle aneurysm and the risk of death in the 24-year interval

BACKGROUND Left ventricular aneurysm (LVA) is indicator of high morbidity in Chagas' disease. A cross-sectional study performed identified LVA in 18.8% of the chronic chagasic patients (CCP). OBJECTIVE Determine the risk of death of patients with chronic chagasic cardiopathy (CCC) and LVA in 24-year interval. MATERIAL AND METHODS In 1995 a cohort of 298 CCP was evaluated by anamnesis, physical examination, EKG and ECHO and classified in groups: G0 = 86 without cardiopathy; G1 = 156 with cardiopathy without LVA and G2 = 56 with cardiopathy and LVA. 38 patients of G0 and G1 used benznidazole. Information about the deaths was obtained in the notary, death certificates, hospital records and family members. FINDINGS Were registered 113 deaths (37.9%): 107 (35.9%) attributed to cardiopathy and 6 (2.0%) to other causes (p < 0.05). Amongst these 107 deaths, 10 (11.6%) occurred in G0; 49 (31.4%) occurred in G1 and 48 (85.7%) occurred in G2 (p < 0.05). The risk of death was 2.7 and 7.4 times significantly higher in G2, than in G1 and G0, respectively. CONCLUSION Chronic chagasic patients with LVA and ejection fraction < 45% have a higher risk of death than those without.

"Overtime Hours Effect" on emergency surgery of acute type A aortic dissection

Abstract Objective: Treatment of acute diseases of the aorta is still associated with high mortality and morbidity. It is believed that interventions for these diseases on overtime hours (night shifts or weekend shifts) may increase mortality. In this study, we investigated the effect of performing acute type A aortic dissection surgery on overtime hours in terms of postoperative outcomes. Methods: 206 patients who underwent emergency surgery for acute type A aortic dissection were retrospectively evaluated. Two groups were constituted: patients operated on daytime working hours (n=61), and patients operated on overtime hours (n=145), respectively. Results: Chronic obstructive pulmonary disease and repeat surgery were higher in group 1. There was no statistically significant difference between the two groups in terms of operative and postoperative results. Mortality rates and postoperative neurological complications in group 1 were 9.8% and 13.1%, respectively. In group 2, these rates were 13.8% and 12.4%, respectively (P=0.485 - P=0.890). Multivariate analysis identified that cross-clamp time, amount of postoperative drainage, preoperative loss of consciousness and postoperative neurological complications are the independent predictors of mortality. Conclusions: As the surgical experience of the clinics improves, treatment of acute type A aortic dissections can be successfully performed both overtime and daytime working hours.

Association of platelet to lymphocyte and neutrophil to lymphocyte ratios with in-hospital mortality in patients with type A acute aortic dissection

Abstract Objective: To evaluate the relationship between neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) with in-hospital mortality in type A acute aortic dissection (AAD). Methods: A total of 96 patients who presented to the emergency department between January 2013 and June 2018 with a diagnosis of type A AAD were enrolled in this study. White blood cell count subtypes such as NLR and PLR were calculated at the time of admission. The end point was in-hospital mortality. Results: Of the 96 type A AAD patients included in this analysis, 17 patients (17.7%) died during hospitalization. NLR and PLR were significantly elevated in patients with type A AAD (P<0.001 and <0.001, respectively). Based on the receiver operating characteristic curve, the best NLR cut-off value to predict in-hospital mortality was 9.74, with 70.6% sensitivity and 76.8% specificity, whereas the best PLR cut-off value was 195.8, with 76.5% sensitivity and 78.1% specificity. Conclusion: Admission NLR and PLR levels were important risk factors and independently associated with in-hospital mortality of type A AAD patients.

Caracterización de los pacientes con diagnóstico precoz de aneurisma de la aorta abdominal / Characterization of patients with early diagnosis of abdominal aortic aneurysm

Introducción: la incorporación de la ecografía a los métodos diagnósticos de los aneurismas aórticos abdominales favorece su detección precoz. Objetivo: Describir las características de los pacientes a quienes se les detectó precozmente un aneurisma aórtico abdominal. Métodos: Estudio descriptivo de corte transversal en 243 pacientes pertenecientes al área de salud del Hospital Clinicoquirúrgico "General Freyre de Andrade", clasificados como población de riesgo (hombres > 50 años y mujeres > 60 años). El periodo de estudio: noviembre de 2016 a octubre de 2017. Resultados: Se realizó el diagnóstico de aneurisma aórtico abdominal en 2,1 por ciento (n= 5); en estos pacientes prevaleció el grupo de edad de 70 a79 años (80 por ciento) y el sexo masculino (60 por ciento). Los factores de riesgo predominantes fueron el tabaquismo, la hipertensión arterial y la enfermedad arterial periférica, todos con igual porcentaje (100 por ciento). El segmento aórtico más afectado fue el infrarrenal (100 por ciento), los diámetros aórticos predominantes fueron: transversal (3-3,9 cm), longitudinal (5-10 cm) y antero-posterior (3-3,9 cm). La proteína C reactiva estuvo incrementada (mayor de 5 mg/L) en el 100 por ciento de los casos. La claudicación intermitente fue la más frecuente. Conclusiones: A pesar de la baja prevalencia porcentual encontrada, destaca en todos los pacientes con aneurisma aórtico abdominal la presencia de factores de riesgo relevantes como es el tabaquismo, la hipertensión arterial y la enfermedad arterial periférica; incremento en la concentración de la proteína C reactiva, afectación en el segmento infrarrenal así como alto porcentaje con edades por encima de 70 años(AU)

Introduction: The incidence of abdominal aortic aneurysms in the population benefits from the incorporation of ultrasound to diagnostic methods due to the importance of their early detection. Objective: To describe the characteristics of patients who are early detected with an abdominal aortic aneurysm. Method: A descriptive, cross-sectional study was conducted in 243 patients belonging to the health area of "General Freyre de Andrade" Clinical- Surgical Hospital that were classified as a risk population (men > 50 years and women > 60 years). The study was conducted from November 2016 to October 2017. Results: The diagnosis of abdominal aortic aneurysm was performed in 2.1 percent (n= 5); in these patients predominated the age group of 70 to 79 years (80 percent), male sex (60 percent) and white skin color (80 percent). The predominant risk factors were smoking habit, arterial hypertension and peripheral arterial disease; all with equal percentage (100 percent). The most affected aortic segment was the infrarenal (100 percent), the predominant aortic diameters were: transversal (3-3.9 cm), longitudinal (5-10 cm) and anterior-posterior (3-3.9 cm). The C-reactive protein increased (greater than 5 mg/L) in 100 percent of the cases. Intermittent claudication was the most frequent. Conclusions: Although the percentage prevalence of the disease was low, it was present in all the patients with abdominal aortic aneurysm, risk factors that are favorable to aneurysms, high concentrations of C-reactive protein, affectation in the infrarenal aortic segment, and high percentage of ages of more than 70 years(AU)

Manejo de un aneurisma infeccioso / Treatment of infected aneurysm

Resumen Introducción: Los aneurismas infecciosos constituyen una patología poco frecuente y se caracterizan por presentar infección de la pared del vaso implicado. El mejor tratamiento no está definitivamente establecido. Objetivo: Describir un caso de aneurisma infeccioso con manejo endovascular. Caso clínico: Presentamos un paciente de sexo masculino de 75 años que ingresa por cuadro compatible con abdomen agudo y que en el posoperatorio se pesquisa un aneurisma infeccioso del tronco celíaco, el cual se trata mediante una endoprótesis y manejo antibiótico. Discusión: El manejo tradicional del aneurisma infeccioso es la cirugía abierta que incluye la extirpación o exclusión del aneurisma y de su tejido perivascular infectado, pero conlleva gran morbimortalidad. Conclusión: El aneurisma infeccioso puede ser manejado de forma mínimamente invasiva con técnica endovascular, con baja morbilidad inmediata, pero con resultados a largo plazo aun no concluyentes.

Introduction: Infectious aneurysms are a rare disease and are characterized by infection of the involved vessel wall. The best treatment is definitely not established. Aim: To describe a case of infectious aneurysm with endovascular management. Case report: We present a 75-year-old male patient admitted to a table compatible with acute abdomen and that an infectious aneurysm of the celiac trunk is investigated in the postoperative period, treated with an endoprosthesis and antibiotic management. Discussion: The traditional management of the infectious aneurysm is open surgery that includes the removal or exclusion of the aneurysm and its infected perivascular tissue, but it leads to great morbidity and mortality. Conclusion: The infectious aneurysm can be managed minimally invasively with endovascular technique, with immediate low morbidity, but with long-term results that are still inconclusive.

Bleeding risk of small intracranial aneurysms in a population treated in a reference center / Risco de sangramento de aneurismas intracranianos pequenos em uma população tratada em um centro de referência

ABSTRACT Large multicenter studies have shown that small intracranial aneurysms are associated with a minimal risk of bleeding. Nevertheless, other large series have shown that most ruptured aneurysms are, in fact, the smaller ones. In the present study, we questioned whether small aneurysms are indeed not dangerous. Methods: We enrolled 290 patients with newly-diagnosed aneurysms at our institution over a six-year period (43.7% ruptured). We performed multivariate analyses addressing epidemiological issues, cardiovascular diseases, and three angiographic parameters (largest aneurysm diameter, neck diameter and diameter of the nutrition vessel). Risk estimates were calculated using a logistic regression model. Aneurysm size parameters were stratified according to receiver operating characteristic (ROC) curves. Finally, we calculated odds ratios for rupture based on the ROC analysis. Results: The mean largest diameter for the ruptured versus unruptured groups was 13.3 ± 1.7 mm versus 22.2 ± 2.2 mm (p < 0.001). Multivariate analysis revealed a positive correlation between rupture and arterial hypertension (p < 0.001) and an inverse correlation with all three angiographic measurements (all p < 0.01). Aneurysms from the anterior cerebral artery bled more often (p < 0.05). According to the ROC curves, at the largest diameter of 15 mm, the sensitivity and specificity to predict rupture were 83% and 36%, respectively. Based on this stratification, we calculated the chance of rupture for aneurysms smaller than 15 mm as 46%, which dropped to 25% for larger aneurysms. Conclusion: In the population studied at our institution, small aneurysms were more prone to bleeding. Therefore, the need for intervention for small aneurysms should not be overlooked.

RESUMO Grandes estudos multicêntricos demostram que aneurismas intracranianos pequenos são associados a risco de sangramento mínimo. Outras grandes séries têm evidenciado que aneurismas rotos são em sua maioria os pequenos. Neste estudo questionamos até que ponto os aneurismas pequenos não são perigosos. Métodos: Avaliamos 290 novos casos de aneurismas tratados em nossa instituição durante 6 anos (43,7% rotos). Realizamos análises multivariadas com aspectos epidemiológicos dos pacientes, doenças cardiovasculares e três parâmetros angiográficos: maior diâmetro, diâmetro do colo e diâmetro do vaso nutridor do aneurisma. Estimativas de risco foram calculadas utilizando-se modelo de regressão logística. Parâmetros do tamanho aneurismático foram estratificados de acordo com curvas ROC. Também calculamos a razão de chances (odds ratios) de ruptura baseadas nas análises das curvas ROC. Resultados: O maior diâmetro médio para os grupos de aneurismas rotos e não-rotos foi 13.3 ± 1.7mm e 22.2 ± 2.2 (p < 0.001). Análises multivariadas revelaram uma correlação positiva entre ruptura aneurismática e hipertensão arterial (p < 0.001) e uma correlação inversa entre ruptura e as três medidas angiográficas (p < 0.01). Aneurismas da artéria cerebral anterior foram os que mais sangraram (p < 0.05). Análises das curvas ROC demonstram que no maior diâmetro de 15mm, a sensibilidade e especificidade para se predizer ruptura são de 83% e 36%. Baseando-se nessas estratificações, calculamos uma chance de ruptura para aneurismas menores de 15mm de 46% e de 25% para aneurismas maiores. Conclusão: Na população estudada, aneurismas pequenos são mais propensos a romper. Desta forma, a necessidade de intervenção para aneurismas pequenos não deve ser relevada.