Ataque cerebrovascular isquémico agudo de territorio anterior: Tratamiento endovascular / Acute ischemic stroke in anterior territory: endovascular treatment

La terapia endovascular (TEV) es el tratamiento estándar del ataque cerebrovascular isquémico (ACVi) con oclusión de gran vaso (OGVC). Aún no se conoce si esos resultados pueden generalizarse a la práctica diaria. Se describen los resultados de la TEV en pacientes con ACVi por OGVC dentro de las 24 horas, en un análisis retrospectivo entre enero 2013 y diciembre 2017 que incluyó 139 casos consecutivos con ACVi y OGVC en arteria cerebral media (ACM), hasta 24 horas del inicio de los síntomas, que recibieron TEV en nuestra institución. El resultado primario medido fue la escala de Rankin modificada (mRS) ≤ 2 a 90 días. Se evaluaron también: reperfusión exitosa, según la escala modificada de trombólisis en infarto cerebral (mTICI) 2b/3, hemorragia intracraneal sintomática (HIS) y mortalidad a 90 días. La edad media: 67.5 ± 15.0, siendo el 51.8% mujeres. La mediana basal de National Institute of Health Stroke Scale (NIHSS) fue 14 (IIC 8-18); la mediana del tiempo desde inicio de síntomas hasta punción inguinal: 331 min (IIC 212-503). El 45.3%, 63 pacientes, fueron tratados > 6 horas después del inicio de síntomas. La tasa de mRS ≤ 2 fue 47.5%. Se logró una reperfusión exitosa en el 74.8%. La tasa de mortalidad a 90 días fue del 18.7% y la HIS del 7.9%. Nuestro registro de pacientes de la vida real con ACVi por OGVC tratados con TEV dentro de las 24 horas mostró altas tasas de reperfusión, buenos resultados funcionales y pocas complicaciones, acorde con las recomendaciones internacionales.

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke (AIS) with proximal large vessel occlusions (LVO). However, it is still unknown whether these results can be generalized to clinical practice. We aimed to perform a retrospective review of patients who received EVT up to 24 hours, and to assess safety and efficacy in everyday clinical practice. We performed a retrospective analysis, from January 2013 to December 2017, on 139 consecutive patients with AIS for anterior circulation LVO strokes up to 24 h from symptoms onset, who received EVT in our institution. The primary outcome measured was a modified Rankin scale (mRS) ≤ 2 at 90 days. Secondary outcomes included successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, mortality rate at 90 days and symptomatic intracranial hemorrhage (sICH). The mean age was 67.5 ± 15.0, with 51.8% female patients. Median baseline National Institute of Health Stroke Scale (NIHSS) was 14 (IQR 8-18); median time from symptom onset to groin puncture was 331 min (IQR 212-503). Sixty-three patients (45.3%) were treated beyond 6 hours after symptoms onset. The rate of mRS ≤ 2 was 47.5%. Successful reperfusion was achieved in 74.8 %. Mortality rate at 90 days was 18.7 % and sICH was 7.9 %. Our registry of real-life patients with AIS due to LVO who received EVT within 24 hours showed high reperfusion rates, and good functional results with few complications, according to international recommendations.

Single-center study comparing short and mid-term results of evar in old and young populations

Abstract Objective: The purpose of this study was to compare the operative mortality rate and outcomes of endovascular aneurysm repair (EVAR) between young and geriatric people in a single center. Methods: Eighty-five patients with abdominal aortic aneurysms who underwent EVAR between January 2012 and September 2016 were included. Outcomes were compared between two groups: the young (aged < 65 years) and the geriatric (aged ≥ 65 years). The primary study outcome was technical success; the secondary endpoints were mortality and secondary interventions. The mean follow-up time was 36 months (3-60 months). Results: The study included 72 males and 13 females with a mean age of 71.08±8.6 years (range 49-85 years). Of the 85 patients analyzed, 18 (21.2%) were under 65 years old and 67 patients (78.8%) were over 65 years old. There was no statistically significant correlation between chronic disease and age. We found no statistically significant difference between aneurysm diameter, neck angle, neck length, or right and left iliac angles. The secondary intervention rate was 7% (six patients). The conversion to open surgery was necessary for only one patient and only three deaths were reported (3.5%). There was no statistically significant difference in the mortality and reintervention rates between the age groups. The three deaths occurred only in the geriatric group and two died secondary to rupture. Kidney failure was observed in three patients in the geriatric group (4.5%). Conclusion: Our single-center experience shows that EVAR can be used safely in both young and geriatric patients.

Quality of life after open surgical versus endovascular repair of abdominal aortic aneurysms

Abstract Objective: This study aims to compare open surgical and endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms in terms of their effects on quality of life, using Short Form-36 (SF-36). Methods: A total of 133 consecutive patients who underwent EVAR or open surgical repair for infra-renal abdominal aorta aneurysm between January 2009 and June 2014 were included in the study. Twenty-six (19.5%) patients died during follow-up and were excluded from the analysis. Overall, 107 patients, 39 (36.4%) in the open repair group, and 68 (63.6%) in the EVAR group, completed all follow-up visits and study assessments. Quality of life assessments using SF-36 were performed before surgery and at post-operative months 1, 6, and 12. Results: The mean duration of follow-up was 29.55±19.95 months. At one month, both physical and mental domains of the quality of life assessments favored EVAR, while the two surgical approaches did not differ significantly at or after six months postoperatively. Conclusion: Despite anatomical advantages and acceptable mid-phase mortality in patients with high- or medium-risk for open surgery, EVAR did not exhibit a quality of life superiority over open surgery in terms of physical function and patient comfort at or after postoperative six months.

Endovascular abdominal aneurysm repair in women: what are the differences between the genders?

ABSTRACT Introduction: Abdominal aortic aneurysm has a lower incidence in the female population, but a higher complication rate. It was been hypothesized that some anatomical differences of abdominal aortic aneurysm in women could be responsible for that. We proposed to analyze our data to understand the differences in the clinical and anatomical characteristics and the outcomes of patients undergoing endovascular aneurysm repair, according to gender. Methods: A retrospective analysis of patients undergoing endovascular aneurysm repair between 2001-2013 was performed. Patients were divided according gender and evaluated regarding age, atherosclerotic risk factors, aneurysm anatomic features, endograft type, anesthesic risk classification, length of stay, reinterventions and mortality. Two statistical studies were performed, first comparing women and men (Group A) and a second one comparing women and men, adjusted by age (Group B). Results: Of the 171 patients, only 5.8% (n=10) were females. Women were older (P<0.05) and the number of women with no atherosclerotic risk factor was significantly higher. The comparison adjusted by age revealed women with statistically less smoking history, less cerebrovascular disease and ischemic heart disease. Women had a trend to more complex anatomy, with more iliac intern artery aneurysms, larger aneurysm diameter and neck angulations statistically more elevated. No other variables were statistically different between age groups, neither reintervention nor mortality rates. Conclusion: Our study showed a clear difference in the clinical characteristics of women. The female population was statistically older, and when compared with men adjusted by age, had less atherosclerotic risk factors and less target organ disease. Women showed a more complex anatomy but with the same outcomes.

Endovascular treatment of internal iliac artery aneurysms: single center experience

Abstract Objective: Internal iliac artery aneurysms (IIAA) are rare, representing only 0.3% of aortoiliac aneurysms. Its treatment with open surgery is complex and associated with high morbidity and mortality, which led to increasing application of endovascular solutions. In this study, we aimed to evaluate outcomes of endovascular aneurysm repair (EVAR) of IIAA in one institution. Methods: We retrospectively reviewed all cases of IIAA treated with endovascular techniques between 2003 and 2014. Endpoints were morbidity, mortality, freedom from pelvic ischemic symptoms (buttock claudication, ischemic colitis, and spinal cord injury), and need for reintervention. Results: There were 16 patients, 13 males and 3 females, with mean age of 75.1±7 years. A total of 20 IIAA (4 cases were bilateral), with mean diameter of 37.9 mm, were treated. EVAR was performed in 13 (81.3%) patients, with associated internal iliac artery's outflow occlusion in 2. Iliac branch device was used in one patient. Two patients underwent endovascular IIAA embolization alone. One patient underwent percutaneous, transgluteal, IIAA embolization. IIAA flow preservation in at least one internal iliac artery was possible in 9 (56.3%) patients. Early mortality was 7% (1 case). Early morbidity was 18.8%. Pelvic ischemic complications occurred in 1 (7%) patient with buttock claudication. Late reintervention was needed in 3 patients, none of them for IIAA related complications. Conclusion: Endovascular treatment of IIAA is technically feasible and durable. Although overall morbidity is relatively high, major complications are infrequent and perioperative mortality is low. internal iliac artery flow preservation is technically challenging and, in a significant number of cases, not possible at all.

Institutional impact of EVAR's incorporation in the treatment of abdominal aortic aneurysm: a 12 years' experience analysis

Abstract Introduction: Endovascular aneurysm repair (EVAR) was introduced as a less aggressive treatment of abdominal aortic aneurysms (AAA) for patients ineligible for open repair (OR). Objective: To analyze EVAR's incorporation impact in the treatment of infra-renal abdominal aortic aneurysms in our institution. Methods: A retrospective study of the patients with diagnostic of infra-renal AAA treated between December 2001 and December 2013 was performed. The choice between EVAR and OR was based on surgeon's experience, considering patient clinical risk and aneurysm's anatomical features. Patients treated by EVAR and by OR were analyzed. In each group, patient's and aneurysm's characteristics, surgical and anesthesia times, cost, transfusion rate, intraoperative complications, hospital stay, mortality and re-intervention rates and survival curves were evaluated. Results: The mean age, all forms of heart disease and chronic renal failure were more common in EVAR group. Blood transfusion, surgical and anesthesia times and mean hospital stay were higher for OR. Intraoperative complications rate was higher for endovascular aneurysm repair, overall during hospitalization complication rate was higher for open repair. The average cost in endovascular aneurysm repair was 1448.3€ higher. Re-interventions rates within 30 days and late re-intervention were 4.1% and 11.7% for endovascular aneurysm repair versus 13.7% and 10.6% for open repair. Conclusions: Two different groups were treated by two different techniques. The individualized treatment choice allows to achieve a mortality of 2.7%. Age ≥80 years influences survival curve in OR group and ASA ≥IV in EVAR group. We believe EVAR's incorporation improved the results of OR itself. Patients with more comorbidities were treated by endovascular aneurysm repair, decreasing those excluded from treatment. Late reinterventions were similar for both techniques.

Results of Open and Endovascular Abdominal Aortic Aneurysm Repair According to the E-PASS Score

Abstract Introduction: Endovascular repair (EVAR) of abdominal aortic aneurysm has become the standard of care due to a lower 30-day mortality, a lower morbidity, shorter hospital stay and a quicker recovery. The role of open repair (OR) and to whom this type of operation should be offered is subject to discussion. Objective: To present a single center experience on the repair of abdominal aortic aneurysm, comparing the results of open and endovascular repairs. Methods: Retrospective cross-sectional observational study including 286 patients submitted to OR and 91 patients submitted to EVAR. The mean follow-up for the OR group was 66 months and for the EVAR group was 39 months. Results: The overall mortality was 11.89% for OR and 7.69% for EVAR (P=0.263), EVAR presented a death relative risk of 0.647. It was also found a lower intraoperative bleeding for EVAR (OR=1417.48±1180.42 mL versusEVAR=597.80±488.81 mL, P<0.0002) and a shorter operative time for endovascular repair (OR=4.40±1.08 hoursversus EVAR=3.58±1.26 hours,P<0.003). The postoperative complications presented no statistical difference between groups (OR=29.03% versusEVAR=25.27%, P=0.35). Conclusion: EVAR presents a better short term outcome than OR in all classes of physiologic risk. In order to train future vascular surgeons on OR, only young and healthy patients, who carry a very low risk of adverse events, should be selected, aiming at the long term durability of the procedure.

Long-term efficacy of endovascular vs open surgical repair for complicated type-B aortic dissection: a single-center retrospective study and meta-analysis

This study aimed to evaluate the long-term survival and risk factors of traditional open surgical repair (OSR) vs thoracic endovascular aneurysm repair (TEVAR) for complicated type-B aortic dissection (TBAD). A total of 118 inpatients (45 OSR vs 73 TEVAR) with TBAD were enrolled from January 2004 to January 2015. Kaplan-Meier curves and Cox proportional hazards analysis were performed to identify the long-term survival rate and independent predictors of survival, respectively. Meta-analysis was used to further explore the long-term efficacy of OSR and TEVAR in the eight included studies using Review Manager 5.2 software. An overall 10-year survival rate of 41.9% was found, and it was similar in the two groups (56.7% OSR vs 26.1% TEVAR; log-rank P=0.953). The risk factors of long-term survival were refractory hypertension (OR=11.1; 95%CI=1.428-86.372; P=0.021] and preoperative aortic diameter >55 mm (OR=4.5; 95%CI=1.842-11.346; P=0.001). Long-term survival rate did not differ significantly between OSR and TEVAR (hazard ratio=0.87; 95%CI=0.52-1.47; P=0.61). Compared with OSR, TEVAR did not show long-term advantages for patients with TBAD. Refractory hypertension and total aortic diameter >55 mm can be used to predict the long-term survival of TBAD in the Chinese Han population.

Surgical treatment of complex aneurysms and thoracic aortic dissections with the Frozen Elephant Trunk technique / Tratamento cirúrgico dos aneurismas complexos e dissecções da aorta torácica utilizando a técnica "Frozen Elephant Trunk"

Abstract Objective: Report initial experience with the Frozen Elephant Trunk technique. Methods: From July 2009 to October 2013, Frozen Elephant Trunk technique was performed in 21 patients (66% male, mean age 56 ±11 years). They had type A aortic dissection (acute 9.6%, chronic 57.3%), type B (14.3%, all chronic) and complex aneurysms (19%). It was 9.5% of reoperations and 38% of associated procedures (25.3% miocardial revascularization, 25.3% replacement of aortic valve and 49.4% aortic valved graft). Aortic remodeling was evaluated comparing preoperative and most recent computed tomography scans. One hundred per cent of complete follow-up, mean time of 28 months. Results: In-hospital mortality of 14.2%, being 50% in acute type A aortic dissection, 8.3% in chronic type A aortic dissection, 33.3% in chronic type B aortic dissection and 0% in complex aneurysms. Mean times of cardiopulmonary bypass (152±24min), myocardial ischemia (115±31min) and selective cerebral perfusion (60±15min). Main complications were bleeding (14.2%), spinal cord injury (9.5%), stroke (4.7%), prolonged mechanical ventilation (4.7%) and acute renal failure (4.7%). The need for second-stage operation was 19%. False-lumen thrombosis was obtained in 80%. Conclusion: Frozen Elephant Trunk is a feasible technique and should be considered. The severity of the underlying disease justifies high mortality rates. The learning curve is a reality. This approach allows treatment of more than two segments at once. Nonetheless, if a second stage is made necessary, it is facilitated. .

Resumo Objetivo: Relatar experiência inicial com a técnica "Frozen Elephant Trunk". Métodos: Entre julho de 2009 e outubro de 2013, 21 pacientes, 66% homens, média de idade de 56±11 anos, 66,7% portadores de dissecção da aorta tipo A de Stanford (9,6% agudas e 57,1% crônicas), tipo B (14,3%, todas crônicas) e aneurismas complexos (19%), foram operados pela técnica Frozen Elephant Trunk. Foram 9,5% de reoperações e 38% com procedimentos associados (25,3% revascularizações do miocárdio, 25,3% troca da valva aórtica e 49,4% tubos valvulados). Remodelamento da aorta foi avaliado com a comparação de angiotomografia pré-operatória e pós-operatória mais recente. Seguimento 100% dos pacientes, tempo médio de 28 meses. Resultados: Mortalidade hospitalar de 14,2%, sendo 50% nas dissecções do tipo A agudas, 8,3% nas tipo A crônicas, 33,3% nas tipo B crônicas e 0% nos aneurismas complexos. Tempos médios de CEC (152±24min), isquemia miocárdica (115±31min) e perfusão cerebral seletiva (60±15min). Principais complicações pós-operatórias foram sangramento (14,2%), acidente vascular encefálico (4,7%), paraplegia (9,5%), intubação>72h (4,7%) e insuficiência renal aguda (4,7%). Houve necessidade de complementação do tratamento (distal ao stent) em 19%. Houve trombose da falsa luz em 80%. Conclusão: Frozen Elephant Trunk é opção técnica a ser utilizada. A gravidade e extensão da doença justificam mortalidade mais elevada. A curva de aprendizado é uma realidade. Esta abordagem permite abordar mais de dois segmentos de aorta em um estágio, mas se necessário segundo estágio, este é facilitado. .

Tratamento híbrido das doenças do arco aórtico / Hybrid treatment of aortic arch disease

Introdução: O manejo das doenças da aorta torácica que envolvem a aorta ascendente, arco aórtico e aorta torácica descendente constituem um desafio técnico e é uma área em constante desenvolvimento e inovação. Objetivo: Analisar os resultados iniciais e a médio prazo do tratamento híbrido das doenças do arco aórtico. Métodos: Estudo retrospectivo de procedimentos realizados no período de janeiro de 2010 a dezembro de 2012, em que foram analisados o sucesso técnico e terapêutico, a morbimortalidade, os desfechos neurológicos, a taxa de vazamentos e de reintervenções. Resultados: Em um total de 95 pacientes tratados por doenças da aorta torácica no período, 18 realizaram o tratamento híbrido e adentraram neste estudo. A idade média foi de 62,3 anos. O sexo masculino esteve presente em 66,7%. O sucesso técnico e terapêutico foi de 94,5% obe 83,3%, respectivamente. A mortalidade perioperatória foi de 11,1%. Não houve óbito durante o acompanhamento de 1 ano. A taxa de reintervenção foi de 16,6%, devido a 2 casos de endoleak tipo Ia e um caso de endoleak tipo 2. Não foi observada oclusão dos enxertos anatômicos ou extra-anatômicos durante o período de seguimento. Conclusão: O tratamento híbrido das doenças do arco aórtico demonstrou ser uma alternativa viável à cirurgia convencional. As taxas de sucesso terapêutico e de reintervenções demonstram a necessidade do seguimento clínico rigoroso desses pacientes a longo prazo. .

Introduction: The management of thoracic aortic disease involving the ascending aorta, aortic arch and descending thoracic aorta are technically challenging and is an area in constant development and innovation. Objective: To analyze early and midterm results of hybrid treatment of arch aortic disease. Methods: Retrospective study of procedures performed from January 2010 to December 2012. The end points were the technical success, therapeutic success, morbidity and mortality, neurologic outcomes, the rate of endoleaks and reinterventions. Results: A total of 95 patients treated for thoracic aortic diseases in this period, 18 underwent hybrid treatment and entered in this study. The average ages were 62.3 years. The male was present in 66.7%. The technical and therapeutic success was 94.5% e 83.3%. The perioperative mortality rate of 11.1%. There is any death during one-year follow- up. The reoperation rates were 16.6% due 2 cases of endoleak Ia and one case of endoleak II. There is any occlusion of anatomic or extra anatomic bypass during follow up. Conclusion: In our study, the hybrid treatment of aortic arch disease proved to be a feasible alternative of conventional surgery. The therapeutic success rates and re- interventions obtained demonstrate the necessity of thorough clinical follow-up of these patients in a long time. .