Incidental abdominal aortic aneurysms are largely undocumented and unmonitored.

BACKGROUND: In countries without organized population screening, incidental detection remains the major form of abdominal aortic aneurysm (AAA) diagnosis. Despite the presumed homogeneity in AAA prevalence, its rate of repair is highly variable, with Portugal treating 2 to 6 times fewer AAA per habitant than other western countries. OBJECTIVES: To evaluate the detection rate and monitoring of incidental AAA in a multicentre cohort from Portuguese hospitals. METHODS: All abdominal CT scans performed in men ≥ 65 years old in three major Portuguese hospitals between January and June 2018 were selected for review. CT scans prescribed by the Vascular Surgery or Emergency Departments were excluded. Patients with previously known AAA were also excluded. Subjects with newly detected aneurysms were assessed for the two primary outcomes: the description of the finding by the radiologist in the written report; the effective follow-up recommendations by the prescriber of the CT or by the general practitioner (GP). Patients with newly found AAA that met criteria for monitoring or treatment and failed to be given guidance were contacted and included in surveillance programs. RESULTS: Overall, 3292 abdominal CT scans were selected for review. A total of 133 newly found aneurysms were detected (4.2% prevalence in the cohort). Of those, 48 cases (36%) were not described by the radiologist in the written report. Further 42 patients (32%) were not successfully oriented by the ordering physician or GP, despite having had their AAA mentioned. Overall, only 32% (n = 42) of the newly diagnosed AAA were correctly identified and referred to monitoring. CONCLUSIONS: Incidental AAA is a common occurrence in in-hospital abdominal CTs. A significant number is not documented by the radiologist and the vast majority is not referred to monitoring. This could be a major reason for the low elective treatment rate of AAA in Portugal.

Impact of Gradual Adoption of EVAR in Elective Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study from 2009 to 2015.

INTRODUCTION: The recommendations about the preferred type of elective repair of abdominal aortic aneurysm (AAA) still divides guidelines committees, even nowadays. The aim is to assess outcomes after AAA repair focusing on differences between endovascular aneurysm repair (EVAR) and open surgical repair (OSR). METHODS: The observational retrospective cohort study of consecutive patients submitted to elective AAA repair at a tertiary center, 2009-2015. Exclusion criteria were as follows: nonelective cases or complex aortic aneurysms. Primary outcomes were postoperative complications, length of hospital stay, survival, freedom from aortic-related mortality, and vascular reintervention. Time trends were assessed along the period under analysis. RESULTS: From a total of 211 included patients, those submitted to EVAR were older (74 ± 7 vs. 67 ± 9 years; P < 0.001), presented a higher prevalence of hypertension (83.5% vs. 68.5%, P = 0.004), obesity (28.7% vs. 14.3%, P = 0.029), previous cardiac revascularization (30.5% vs. 14.7%, P = 0.005), heart failure (17.2% vs. 5.2%, P = 0.013), and chronic obstructive pulmonary disease (32.8% vs. 13.3%, P = 0.002). Patients were followed during a median of 49 months. EVAR resulted in a significantly shorter length of hospital stay (median 4 and interquartile range 3 vs. 8 (9); P < 0.001), lower 30-day complications (10.6% vs. 22.8%, P = 0.017), lower aortic-related mortality, and similar reintervention after adjustment with a propensity score. Along the time under analysis, EVAR became the predominate type of repair (P = 0.024), the proportion of complications decreased (P = 0.014), and the 30-day mortality (P = 0.035). CONCLUSIONS: Although EVAR was offered to patients with more comorbidities, better and durable outcomes were achieved after EVAR, favoring its adoption for elective AAA repair.

Nationwide Analysis of Ruptured Abdominal Aortic Aneurysm in Portugal (2000-2015).

OBJECTIVE: Ruptured abdominal aortic aneurysm (rAAA) is a lethal condition that requires acute repair to prevent death. This analysis aims to assess the nationwide trends in rAAA admission, repair and mortality in a country, Portugal, without national screening for AAA. METHODS: rAAA registered in the hospital administrative database of the National Health Service and all nationally registered deaths due to rAAA based on death certificate data were analysed. Three time periods (2000-2004, 2005-2009, and 2010-2015) were compared in patients ≥ 50 years old to assess the variations over time. RESULTS: A total of 2 275 patients ≥50 years old with rAAA were identified in the two databases from 2000 to 2015. The age standardised incidence of rAAA was 2.78 ± 0.24/100 000/year in 2000-2004, 3.17 ± 0.39/100 000/year in 2005-2009 and 3.21 ± 0.28/100 000/year in 2010-2015 (p < .001). When comparing the time periods 2000-2004 to 2005-2009, the age standardised rate of admission (n = 1460) increased from 1.57 ± 0.25/100 000/year to 2.24 ± 0.32/100 000/year (p < .001). The operative mortality rates decreased during this time period (from 55.3 ± 4.7% to 48.8 ± 4.7%, p < .001). In 2010-2015, the age standardised rate of admissions due to rAAA decreased (1.98 ± 0.22/100 000/year). Operative mortality remained stable (48.9 ± 6.2%). The rate of patient deaths outside the hospital decreased from the first to the second period (1.21 ± 0.10/100 000/year and 0.93 ± 0.29/100 000/year, respectively) but later increased (1.14 ± 0.22/100 000/year). This resulted in a higher overall rAAA related mortality in Portugal in the third period (2.20 ± 0.18/100 000/year, 2.21 ± 0.27/100 000/year and 2.26 ± 0.26/100 000/year in 2000-2004, 2005-2009, and 2010-2015, respectively, p < .001). CONCLUSION: Overall, the incidence of rAAA in Portugal has been stable over the past 10 years. The rates of admission, repair, and death due to rAAA repair seem to have reached an inflection point and are now decreasing. Mortality outside the hospital remains a matter of concern, warranting further planning of streamlined transfer networks and vascular surgical departments.

Nationwide Analysis of Intact Abdominal Aortic Aneurysm Repair in Portugal from 2000 to 2015.

BACKGROUND: Results on the management of infrarenal abdominal aortic aneurysm (AAA) from Mediterranean countries are scarce. The aim of this study was to evaluate trends in rate of and mortality after repair of intact AAA (iAAA) in Portugal. METHODS: iAAA repairs registered in the hospitals' administrative database of the National Health Service from 2000 to 2015 were retrospectively analyzed regarding demographics (age and gender) and type of repair (open surgery [OS] or endovascular repair [EVAR]). Rate and mortality were compared among three time periods: 2000-2004, 2005-2009, and 2010-2015. RESULTS: Age-standardized rate of iAAA repair increased consistently across the time periods under analysis from 3.6 ± 0.6/100,000/year in 2000-2004, to 5.6 ± 0.4/100,000/year in 2005-2009 and to 7.1 ± 0.9/100,000/year in 2010-2015 (P < 0.001). The percentage of EVAR among all iAAA repairs rose steeply from 0 to 21 ± 19% and then to 58 ± 7% (P < 0.001). The rate of OS also increased from the first to the second period, but there was a decrease in the third period (P < 0.001). The in-hospital mortality after iAAA repair decreased from 7.5 ± 1.3% to 6.6 ± 1.6% and then to 5.1 ± 1.9% (P < 0.001). This variation corresponded to a decrease in in-hospital mortality after EVAR (from 4.0 ± 3.5% to 2.8 ± 0.9%, P < 0.001) and increased in-hospital mortality after OS (7.5 ± 1.3% to 7.4 ± 1.1% to 8.3 ± 3.7%, P < 0.001). Low-volume centers (< 15 repairs/year) did not present higher mortality rates. The number of EVARs per year in a center presented a positive association with EVAR mortality (Spearman correlation of 0.696, P = 0.004). CONCLUSIONS: The rate of repair of iAAA continues to grow, especially in patients aged ≥ 75 years and did not reach an inflection point yet. This is happening along with decreased repair mortality mainly because of the increased use of EVAR. Hospital mortality for iAAA repair is still a matter of concern, warranting further investigation and planning of vascular surgical services.

Impact of Video-Assisted Thoracoscopic Sympathectomy and Related Complications on Quality of Life According to the Level of Sympathectomy.

BACKGROUND: Primary hyperhidrosis is defined as excessive sweating of idiopathic etiology, associated with sympathetic hyperactivity, which greatly impacts patients' quality of life (QoL). The definitive treatment for palmar and axillary hyperhidrosis (PAH) is video-assisted thoracic sympathectomy (VATS). The objective of this study was to evaluate the quality of life of patients with PAH before and after VATS according to the level of sympathectomy performed, as well as the presence of compensatory hyperhidrosis (CH) and other complications. METHODS: All patients who underwent VATS in our vascular surgery department between January 2011 and December 2016 were included in the analysis. From 120 contact attempts, 88 interviews were carried out. Patients were divided into 2 groups according to the intervened thoracic level: high thoracic ganglion (HTG; T2, T2-T3, T2-T3-T4; n = 68) and low thoracic ganglion (LTG; T3, T3-T4, T4; n = 20). The questionnaire evaluated preoperative PAH severity, the presence of CH, preoperative and postoperative QoL, and postoperative satisfaction. RESULTS: The median age of patients was 29 years, and the median follow-up period was 32 months (IQR of 34 months). Most patients had severe or very severe PAH (97.7%) and preoperative QoL was bad or very bad (95.5%). Postoperatively, QoL was significantly improved in all domains evaluated, with no differences observed between the groups. The overall percentage of complications was 11.4%, mostly pneumothorax, but there was a significantly lower incidence of complications in the HTG group (P = 0.029). Compensatory hyperhidrosis developed in 85.2% of cases, but it was only considered intolerable in 10.2%. The incidence of CH was 82.4% in the HTG group and 95% in the LTG group, with no statistically significant differences between the groups (P = 0.147). CONCLUSIONS: Palmar and axillary hyperhidrosis severely affects QoL, and video-assisted thoracic sympathectomy was proven to be effective regardless of the target ganglion resected. Although CH was frequent, it was tolerated in most cases.

Disparities in Contemporary Treatment Rates of Abdominal Aortic Aneurysms Across Western Countries.

OBJECTIVE/BACKGROUND: Several abdominal aortic aneurysm (AAA) screening programs have demonstrated a similar prevalence of this disease in Westerns countries, ranging from 1.2% to 2.8%. However, the annual rate of AAA repair is significantly less even, and its relationship to AAA prevalence is not clear. The objective was to perform a systematic review, describing an international overview in the yearly rate of AAA repairs. METHODS: The number of elective and emergency AAA repairs was obtained via thorough review of publications indexed in PubMed and Scopus from 2010 to October 2018. Portuguese data were obtained from the national administrative database of health care. Data from the UK were extracted from the National Vascular Registry's 2015 annual report. Each country's population was assessed from published national censuses, thus allowing estimation of the number of AAAs treated per 100,000 habitants. RESULTS: Data from 14 countries were obtained. The yearly number of elective operations per 100,000 habitants was 2.2 in Hungary, 3.8 in Portugal, 5.3 in Spain, 5.9 in Iceland, 6.5 in Finland, 7.0 in New Zealand, 7.8 in the UK, 10.0 in Denmark, 10.2 in Sweden, 13.3 in the USA, 14.8 in Norway, 15.3 in the Netherlands, 15.6 in Italy, and 17.3 in Germany. The yearly rate of ruptured repairs was 0.5 in Hungary, 1.5 in Portugal, 1.8 in Spain, 1.7 in Iceland, 1.7 in Finland, 1.3 in New Zealand, 1.8 in the UK, 3.3 in Denmark (2013), 2.7 in Sweden (2013), 1.7 in the USA, 2.1 in Norway, 3.1 in the Netherlands, 2.3 in Italy, and 2.7 in Germany. CONCLUSION: The rate of AAA treatment is highly variable, with a nearly eightfold variance between the countries with the highest and lowest rates of elective repair. Correlation between elective and ruptured repairs was not clear. A deeper understanding of the reasons for the disparities in AAA treatment among Western countries is of the utmost importance.

First Population-Based Screening of Abdominal Aortic Aneurysm in Portugal.

BACKGROUND: The incidence of abdominal aortic aneurysm (AAA) repairs in Portugal is one of the lowest mentioned in the literature. This phenomenon can be justified either by a low prevalence of the disease or by its low detection rate. To date, the prevalence of the pathology is unknown. The objective of the study was to estimate the prevalence of AAA and its associated risk factors, in men aged ≥65 years and to evaluate the population's disease awareness. METHODS: All males aged ≥65 years registered in a Portuguese primary health care unit were invited to participate. The abdominal aorta was measured by ultrasound (inner to inner method). Concomitant risk factors and patient's AAA awareness were also assessed. An aortic diameter >30 mm was considered aneurysmatic. RESULTS: Nine hundred thirty-three patients were invited for the screening. Of these, 715 participated in the study (participation rate of 76.6%). The AAA prevalence in this sample was 2.1%. Eighty-five percent of the evaluated patients had never heard of the disease before. The mean age of the assessed population was 72.3 years; Multiple logistic regression analysis showed a positive association between AAA and history of smoking (odds ratio [OR] 8.8, P = 0.037) and history of dyslipidemia (OR 9.6, P = 0.035). A negative association was found between diabetes and AAA (OR 0.33, P = 0.045). CONCLUSIONS: The found prevalence shows that a significant number of potentially fatal AAAs remains to be diagnosed in Portugal. These results highlight the need for an effective program of AAA detection in Portugal. The lack of awareness in the Portuguese population for this pathology should also prompt reflexion.

Type B Aortic Dissection - A Single Center Series.

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.

Clinical outcomes after digital subtraction angiography versus computed tomography angiography in the preoperative evaluation of lower limb peripheral artery disease.

INTRODUCTION: Digital subtraction angiography (DSA) was considered the gold standard method for peripheral artery disease (PAD) evaluation. Notwithstanding, recent developments of computed tomography angiography (CTA) have improved the specificity and sensibility of this method. The main objective of this study is to characterize a cohort of patients with lower limb PAD and clarify if there are differences upon groups using different preoperative imaging methods (DSA or CTA). METHODS: This retrospective study focused on patients with PAD that underwent surgical intervention (endovascular revascularization or open surgery). CTA group included all patients submitted to this method as their pre-operative exam, between March 2009 and April 2017. DSA group included patients submitted to DSA as their pre-operative exam within the same period. The groups were compared regarding intervention details, ankle-brachial index (ABI) variation, reintervention, major amputation and mortality rates, and hospital length of stay. RESULTS: One hundred and two patients were included (33 CTA and 69 DSA). DSA group presented more below the knee lesions with TASC C or D classification (p=0.002), as well as runoff vessels scarcity (p=0.001). There were no differences in the endovascular/open surgery ratio (p=0.308), ABI alteration with intervention (p=0.860), reintervention rates (p=0.236), major amputation (p=0.999), mortality (p=0.574), or hospital length of stay (p=0.933). CONCLUSION: CTA seems to achieve equivalent performance to DSA for morphological and therapeutic planning of PAD. Nevertheless, extrapolation to patients with TASC C or D distal lesions cannot be performed.

Introdução: A Angiografia de Subtração Digital (ASD) era considerada o gold-standard para avaliação da Doença Arterial Periférica (DAP). O desenvolvimento da angiotomografia computadorizada (ATC) melhorou a sensibilidade e especificidade deste método. O objetivo principal deste trabalho é caraterizar uma coorte de doentes com DAP dos membros inferiores e perceber se há diferenças clínicas entre os doentes avaliados pré-operatoriamente por ASD ou ATC. Métodos: Este estudo retrospetivo incidiu sobre doentes com DAP submetidos a intervenção cirúrgica (revascularização endovascular ou cirurgia aberta). No grupo ATC foram incluídos todos os doentes que realizaram ATC como exame de avaliação pré-operatória, entre março de 2009 e abril de 2017. O grupo ASD incluiu doentes submetidos a ADS como exame pré-operatório durante o mesmo período. Os grupos foram comparados quanto a detalhes da intervenção, alteração do índice tornozelo-braço (ITB) com a intervenção, taxas de reintervenção, de amputação major e de mortalidade, bem como tempo de internamento. Resultados: Foram incluídos 102 doentes (33 ATC e 69 ASD). O grupo ASD apresentou mais lesões no setor distal com classificação TASC C ou D (p=0.002) e maior escassez de vasos de runoff (p=0.001). Não se registaram diferenças no rácio intervenção endovascular/cirurgia aberta (p=0.308), na alteração do ITB com a intervenção (p=0.860), nas taxas de reintervenção (p=0.236), de amputação major (p=0.999) ou de mortalidade (p=0.574), nem no tempo de internamento (p=0.933). Conclusão: Os resultados deste trabalho sugerem que a ATC possa ter um desempenho semelhante à ASD no estudo morfológico e planeamento terapêutico da DAP. Contudo, estes resultados não podem ser extrapolados para os doentes com lesões graves do setor distal.

[Perspectives and research challenges in abdominal aortic aneurysm calcification]. / Perspetivas e desafios do estudo da calcificação no aneurisma da aorta abdominal.

Abdominal aortic aneurysm (AAA) remains a relevant cause of mortality in Western countries. There is a need for continuous identification of risk factors for aneurysmal progression and predictors of treatment response to optimize the therapeutic strategy to be offered to these patients. Vascular calcification has been studied in several capillary beds as a cardiovascular risk factor. However, the importance of abdominal aortic calcification (AC) in AAA remains incompletely clarified, and the available evidence is scattered and heterogeneous. The objective of this review is to describe the possible impact of AC on aneurysmal progression and rupture, as well as on the response to endovascular correction. It should be noted that the establishment of a validated, quick and easy to use method for assessing AC would be of great clinical and/or research utility.

O aneurisma da aorta abdominal (AAA) permanece uma causa relevante de mortalidade nos países ocidentais. É premente a contínua identificação de fatores de risco de progressão aneurismática bem como de preditores de resposta ao tratamento na otimização da estratégia terapêutica a oferecer a estes doentes. A calcificação vascular tem sido estudada em diversos leitos capilares como um fator de prognóstico cardiovascular. Contudo, a importância da calcificação da aorta abdominal (CA) no AAA permanece incompletamente esclarecida, sendo a prova científica disponível dispersa e heterogénea. O objetivo desta revisão é descrever o eventual impacto da CA na progressão e rutura aneurismática, bem como na resposta à correção endovascular do AAA. Salienta-se que o estabelecimento de um método validado, rápido e fácil de usar para avaliar a CA seria de grande utilidade clínica e/ou investigacional.

Strategies to prevent TEVAR-related spinal cord ischemia.

Spinal cord ischemia remains the Achilles' heel of thoracic and thoracoabdominal diseases management. Great improvements in morbidity and mortality have been obtained with the endovascular approach TEVAR (Thoracic Endovascular Aortic Repair) but this devastating complication continues to severely affect the quality of life, even if the primary success of the procedure - dissection/aneurysm exclusion - has been achieved. Several strategies to deal with this complication have been published in the literature over the time. Knowledge and technology have been evolving from identification of the risk factors associated with spinal cord ischemia, including lessons learned from open surgery, and from developments in the collateral network concept for spinal cord perfusion. In this comprehensive review, the authors cover several topics from the traditional measures comprising haemodynamic control, cerebrospinal drainage and neuroprotective drugs, to the staged-procedures approach, the emerging MISACE (minimally invasive selective segmental artery coil-embolization) and innovative neurologic monitoring such as NIRS (near-infrared spectroscopy) of the collateral network.

Predictors of Prognosis in Patients with Type B Aortic Dissection.

INTRODUCTION: Type B aortic dissection (TBAD) affects mostly men with an estimated annual incidence between 2.9 and 4.0 per 100,000, and it appears to be increasing. DISSECT classification was published in 2013 aiming to reunite clinical and anatomical characteristics of interest to clinicians involved in TBAD management. In Portugal, the incidence of the condition, as well as its characteristics and outcomes, are not well documented. The aim of this paper is to describe the reality of a tertiary institution with a referral area of about 0,6 million habitants. METHODS: It is a retrospective study that included all patients with TBAD admitted from March of 2006 to 2016. The patients were categorized according to their demographic and clinical characteristics. For each patient, the computerized tomography scan that enable the TBAD diagnosis was classified using DISSECT classification. Overall mortality rates and aorta-related mortality rates were estimated using Kaplan-Meier method. Cox regression was used to study determinants of mortality. RESULTS: We included 35 patients, estimating a TBAD incidence of approximately 0.6 per 100,000 person-year. The majority were men (83%) with a mean age of 60±12 years-old; 71% were hypertensive, 56% were ex-smokers or active smokers and 13% had diabetes. As to DISSECT classification, 76% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum trans-aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental extent), 26% presented with Complications, being rupture and branch vessel malperfusion the most frequent, and 28% had partial Thrombosis of false lumen (versus 66% with permeability of false lumen). Eight patients underwent surgery (24%), 6 of them in acute phase and 2 of them in subacute phase. At 12 months, overall survival of whole series was 73,1%±8,3% and survival free from aortic-related mortality was 83±6,7% (Figure 1 A and B). The presence of complications was identified as an independent risk factor of overall mortality but not to aortic-related mortality. CONCLUSION: The incidence of TBAD verified was lower than what has been described in literature. DISSECT classification can be easily applied to TBAD cases. The presence of complications predicts higher mortality. Further studies are needed to characterize TBAD in Portugal.

Digital Subtraction Angiography or Computed Tomography Angiography in the Preoperative Evaluation of Lower Limb Peripheral Artery Disease - A Comparative Analysis.

INTRODUCTION: For several years, digital subtraction angiography (DSA) was considered the gold standard method for the evaluation of PAD patients. This is an invasive technique and allows a good evaluation of collaterals and the vessel lumen, even in cases with associated calcification. Nevertheless, recent technical development of computed tomography angiography (CTA) has improved its specificity and sensibility, besides the fact that CTA is a fast and non-invasive procedure. OBJECTIVE: To characterize a cohort of lower limb PAD patients and clarify if there are differences among the patients preoperatively evaluated by DSA or CTA. METHODS: This retrospective study focused on PAD patients with a Rutherford classification ≥ 3 and submitted to intervention (endovascular revascularization or open surgery). The CTA group included all patients submitted to this method as their preoperative exam, between March 2009 and April 2017. In the same period of time, patients submitted to DSA as their preoperative exam, were randomly selected. The exclusion criteria were: realization of the exam for a different diagnosis than PAD, amputation not preceded by revascularization, absence of intervention during a period of 1 year after the realization of the exam. The groups were compared upon the type of surgery (open vs endovascular), number of revascularization sectors, reintervention, amputation, mortality and length of hospital stay. RESULTS: 34 CTA patients and 71 DSA patients were included. The groups were demographically and clinically homogeneous. In what regards to arterial lesions, the DSA group showed more often lesions of the distal sector with TASC C or D classification (25% in DSA group and 0% in CTA group; p=0,001), as well as scarcity of runoff vessels (0 or 1 in 72% of DSA patients group and 26% in CTA group; p=0.001). There were no differences about the endovascular and open surgery ratio (1.8 to CTA and 1.4 to DSA; p=0.305), reintervention rates (21% CTA and 16% DSA; p=0.517), major amputation (9% CTA and 11% DSA; p=1), minor amputation (9% CTA and 16% DSA; p=0.541), mortality (18% CTA and 23% DSA; p=0,602), or length of hospital stay (median and (interquartile range) of 14 (27) for CTA and 14 (17) for DSA; p=0.933). CONCLUSION: CTA seems to be a method for morphological and therapeutic planning of PAD that is non-inferior to DSA.

Outcomes After Catheter Direct Thrombolysis for Acute Limb Ischaemia - Single Center Experience.

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.

Endovascular Treatment of Proper Hepatic Artery Aneurysm - Case Report.

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.

True Brachial Artery Aneurysm after Arteriovenous Fistula for Hemodialysis - Case Report.

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.

Co-existence of Abdominal Aortic Aneurysm with Urologic Neoplasm: Which Should Be Treated First in the Endovascular Era?

INTRODUCTION: Prevalence of Abdominal Aortic Aneurysm (AAA) with concomitant malignancy rounds 3-13%. Considering only urological neoplasms the prevalence is around 3.6%. Survival at 5 years of bladder carcinoma without extravesical invasion (stage II) rounds 63%. Endovascular Aneurysm Repair (EVAR), due to its minimally invasive profile, is an option for treatment of AAA prior to urological surgery as it does not require laparotomy not conditioning the delay of oncologic surgery. METHODS: Male, 62 years old. History of smoking and coronary artery disease and urothelial carcinoma of the bladder (T2N0M0). In the abdominal CT scan used for neoplasm staging a para-renal AAA with 50 mm of maximum diameter was firstly detected. This aneurysm presented only 5 mm of proximal neck length, insufficient for a safe proximal sealing with standard endografts. In consequence the treatment of choice was a tetra-fenestrated endograft (F-EVAR). RESULTS: F-EVAR occurred without complications: no endoleaks, access complications or branch thrombosis. Three months after F-EVAR, the patient underwent radical cystectomy with jejunocystoplasty, which also occurred without intercurrences. Two days after FEVAR patient was discharged home. After one year of follow-up, abdominal CT scan did not reveal any complications related to the endovascular procedure. The patient died 18 months after the intervention as a consequence of metastatic evolution of bladder primary neoplasm. CONCLUSION: The coexistence of AAA with neoplastic urologic pathology although rare is not negligible. In the above case, the patient presented AAA with about 5 cm (1-11% risk of rupture per year), associated with T2N0M0 bladder urothelial carcinoma (survival at around 63% at 5 years). Given the need for treatment of both pathologies, the doubt persisted about which procedure should be performed first: aneurysm repair or cystectomy. Prior to the advent of EVAR, AAA repair would require laparotomy with a potentially greater risk of complications in the subsequent urologic procedure, prosthesis infection and significant delay of the cystectomy. With the emergence of endovascular techniques, AAA repair occurs without conditioning postponement or significant complications during a subsequent urological procedure and then "EVAR first" was the decision. Two days after FEVAR patient was discharged home and three months latter cystectomy was performed also without complications. IN CONCLUSION: in case of concomitant AAA and abdominal malignancy balance between risk of rupture and progression of the neoplastic disease need to be weighted. With the advent of endovascular disease EVAR prior to the oncologic surgery represents an efficient, prompt and safe solution.

Quality of life and aortobifemoral bypass: The importance of hypogastric arteries.

INTRODUCTION: The aortobifemoral bypass (AFB) is one of the best options to revascularize patients with Aortoiliac Occlusive Disease (AIOD). The impact of this procedure in sexual function (SF) is unpredictable, with 0 to 80% of the patients reporting sexual dysfunction (SD) after surgery. The aim of this study was to evaluate SD after AFB and to assess the importance of patent hypogastric arteries before the procedure. METHODS: The study includes only male population submitted to AFB due to AIOD from between January 2013 and March 2016 in Centro Hospital São João (CHSJ). Patients with major amputations after the surgery or dead were excluded. The development of SD was evaluated by phone call. The quality of life before and after the procedure was evaluated by a standardized index score questionnaire (15D). Pre-operative patency of hypogastric arteries was appraised by assessing the patients imaging file. The arteries with direct anterograde flow were considered patent. RESULTS: Of a total of 53 patients, 40 were included in the study - 37% reported worsening, 26% improved and 37% didn't notice any change in SF after surgery. Exclusion causes were intrahospital death (5.7%), natural cause death (9.4%) and major amputation (11.3%). If at least one of the hypogastric arteries was patent before surgery, 51.1% described worsening in SF compared to only 7.1% in the group with no sustained anterograde flow to the hypogastric arteries (p<0.001). The majority of the group (92.1%), wasn't warned of the possibility of SD after surgery, being that 26.3% of these would have refused the procedure if they knew. CONCLUSION: SD is a prevalent and often overlooked complication after open aortoiliac revascularization and it remains a major taboo in the surgeon/patient relation. The existence of at least one hypogastric artery with preserved anterograde flow before surgery can strongly predict a higher risk of SD after surgery.

Introdução: O bypass aortobifemoral (BABF) é uma das melhores opções para revascularizar doentes com patologia aorto-ilíaca oclusiva. O impacto deste procedimento na função sexual é particularmente imprevisível, com 0 a 80% dos doentes a relatar deterioração após a cirurgia. Este trabalho tem como objectivo determinar a evolução da função sexual após BABF e avaliar a importância da permeabilidade pré-operatória das artérias hipogástricas. Métodos: No estudo estão incluídos apenas os doentes do sexo masculino que realizaram BABF por patologia aorto-ilíaca oclusiva entre Janeiro de 2013 e Março de 2016 no Centro Hospitalar São João (CHSJ). Foram excluídos os doentes submetidos a amputação major após a cirurgia. A evolução da função sexual foi avaliada por contacto telefónico. A evolução da qualidade de vida, antes e após a cirurgia, foi avaliada por um questionário padronizado (15D). A permeabilidade pré-operatória das artérias hipogástricas foi avaliada por consulta do processo clínico. Foram consideradas patentes as artérias com fluxo anterógrado directo. Resultados: Foram incluídos no estudo 40 doentes de um total de 53 ­ 37% reportaram agravamento, 26% melhoria e 37% não referiram qualquer alteração da função sexual após a cirurgia. As causas de exclusão foram morte intra-hospitalar (5,7%), morte de causas naturais (9,4%) e amputação major (11,3%). Dos doentes que apresentavam no mínimo uma artéria hipogástrica permeável antes da cirurgia, 57,1% agravou a função sexual, em comparação com apenas 7,1% dos doentes em que nenhuma hipogástrica apresentava fluxo anterógrado preservado (p<0,001). A maior parte dos doentes (92,1%) não foi alertado para o facto da sua função sexual poder deteriorar-se após a cirurgia, sendo que 26,3% teria recusado o procedimento caso tivessem obtido essa informação. Conclusão: A disfunção sexual após a cirurgia de revascularização aorto-ilíaca permanece um tema tabu na relação entre o doente e o cirurgião vascular. A existência de pelo menos uma artéria hipogástrica com fluxo anterógrado preservado antes da cirurgia poderá antever um risco significativamente maior de agravamento da disfunção sexual após o procedimento.

[Pelvic congestion syndrome - A clinical report]. / Síndrome de Congestão Pélvica - A Propósito de um Caso Clínico.

Pelvic congestion syndrome is a common disorder that occurs mainly in young multiparous women. It is characterized by a variable combination of chronic (up to 6 months) not cyclical pain, dyspareunia, dysmenorrhea, urinary symptoms and constipation, that may be associated to perineal and lower limbs varicose veins, with pelvic origin. We report the clinical case of a 26 year-old female, G0P0, with lower limbs varicose veins. During the investigation of chronic pelvic pain associated to pelvic heaviness and dyspareunia, a MR was performed and pelvic varicose veins were diagnosed. Findings were confirmed by venography. Imaging findings and symptoms severity mandated treatment and we proceeded to left ovaric vein embolization. Therapeutic success was then reached and patient remains asymptomatic 10 months after treatment.

[Complications of Hypogastric Arteries Embolization in EVAR]. / Complicações Secundárias à Embolização da Artéria Ilíaca Interna no EVAR.

OBJECTIVE: The aim of this paper is dedicated to assess the risks of the embolization of the hypogastric arteries following the endovascular management of aorto-iliac aneurysms, looking at the incidence and nature of the most common complications, in the unilateral "versus" bilateral embolization with coils. METHODS: A systematic review of the literature was made on the subject, including the outcome of patients who underwent unilateral versus bilateral embolization of hypogastric arteries with coils in the EVAR. RESULTS: The most common complications were buttock claudication and erectile disfunction, with an estimation respectively of 28% and 15%, independently of the unilateral or bilateral procedure. Less commonly, colonic ischemia was found in 2%, as well as spinal cord ischemia, also found in 2%. CONCLUSIONS: The embolization of the hypoastric arteries may extend the field of utilization of the EVAR, however it cannot be regarded as an innocuous procedure. This systematic review suggests that more complications can be expected in patients who underwent bilateral versus unilateral embolization, namely related to buttock claudication. However, a similar evidence could not be demonstrated with erectile disfunction.