The Bell-Bottom Technique versus Branched Stent Grafts in Endovascular Treatment of Diseased Common Iliac Artery: A Systematic Review and Meta-Analysis.

OBJECTIVES: To evaluate whether the use of iliac branched endoprosthesis reduces perioperative complications compared to the bell-bottom technique in patients with common iliac artery aneurysm or ectasia. METHODS: We conducted a systematic search of studies in the PubMed, Embase, and Cochrane databases up to March 2024. Following the PRISMA protocol, 91 articles were analyzed. A restricted maximum likelihood model with random effects with odds ratios and 95% confidence intervals was applied for binary outcomes. Heterogeneity was assessed using the Cochrane Q test and Higgins and Thompson's I2 statistic. Significance was defined as a p-value < 0.05. RESULTS: Six cohort studies involving 2,899 patients were included, of which 863 underwent repair with branched endoprosthesis. There was no statistically significant difference observed for endoleaks: of any type (OR 0.41; 95% CI 0.10 to 1.60; p=0.20), type 1a (OR 1.12; 95% CI 0.20 to 6.40; p=0.90), type 1b (OR 0.63; 95% CI 0.20 to 1.97; p=0.42), and type 2 (OR 0.52; 95% CI 0.10 to 2.71; p=0.44). However, type 3 endoleaks were less frequent in the bell-bottom group (OR 9.00; 95% CI 1.09 to 74.17; p=0.04) . Additionally, perioperative mortality (OR 0.73; 95% CI 0.41 to 1.27; p=0.26), mesenteric ischemia (OR 0.14; 95% CI 0.01 to 2.54; p=0.18), iliac artery injury (p=0.06) and buttock claudication (OR 0.14; 95% CI 0.02 to 1.08; p=0.06) also did not statistically differ between the two groups. CONCLUSIONS: Branched endoprosthesis and bell-bottom techniques did not differ regarding perioperative mortality rates, internal iliac artery occlusion, and mesenteric ischemia rates. However, the use of branched endoprostheses was associated with a higher incidence of type 3 endoleaks compared to the bell-bottom technique.

Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot.

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

Editor's Choice - In Hospital and Long Term Outcomes After Repair of Subclavian and Axillary Artery Injuries.

OBJECTIVE: To evaluate the in hospital and long term outcomes after open or endovascular repair of subclavian and axillary artery injuries. METHODS: This was a retrospective, single centre study. Data were reviewed from patients with subclavian and or axillary injuries who presented to the authors' centre between January 2009 and December 2022. Outcome data included complications, death, amputations, and re-interventions. A p value < .050 was considered to be statistically significant. RESULTS: Over the study period, 62 patients with subclavian or axillary trauma were admitted to the study hospital. Patients were young (median age 32.5 years, range 12 - 53) and most were men (85%); 32 patients experienced blunt trauma, and 30 penetrating trauma. The median injury severity score was 18 (interquartile range [IQR] 9, 34), and 47% of patients had a brachial plexus injury. The arterial injury was occlusion in 62% of patients, and the median ischaemia time was 12.5 hours (IQR 7.13, 24). All patients with subclavian injuries (n = 37) and 13 of 25 patients with an axillary injury underwent endovascular repair (stent graft placement). Open repair was performed in 12 patients with axillary injury (axillobrachial bypass in seven patients). At hospital discharge, the amputation free survival rate was 82% vs. 92% (p = .67), the mortality rate was 10% vs. 8% (p = 1.0), and the amputation rate was 10% vs. 0 (p = .57) for endovascular and open repair, respectively. The mean follow up time was 4.1 ± 3.5 years. After the seven year follow up, the stent primary patency was 42%. No re-interventions or amputations were performed after hospital discharge. Disability was related to fractures and soft tissue and brachial plexus injuries. CONCLUSION: Endovascular treatment was preferred for patients with subclavian artery injuries. Open repair was preferred for patients with penetrating axillary injuries. In hospital and long term complications were related to fractures and soft tissue and brachial plexus injuries, rather than the treatment of arterial injuries. Measures are needed to reduce ischaemia time and improve brachial plexus injury repair.

Imaging Signs of May-Thurner Syndrome in Asymptomatic Patients: Computed Tomography Angiography Analysis of Kidney Donors.

BACKGROUND: The current study aimed to evaluate the distance between the right common iliac artery (RCIA) and lumbar vertebra in asymptomatic patients in order to determine whether such distance was statistically correlated with the left common iliac vein (LCIV) diameter (LCIVD) and to investigate if both measures were related to demographic characteristics and anthropometric data, such as sex, age, height, and body mass index (BMI). METHODS: In this descriptive and uncontrolled anatomic study, data from high-definition computed tomography (CT) angiography images of living kidney donors without a medical history of chronic venous insufficiency or past deep vein thrombosis (DVT) were analyzed. The RCIA crossed over the LCIV in 311 individuals, who were then included in this study. CT scans were reviewed to measure (1) the narrowest space between the RCIA and fifth lumbar vertebral body and (2) the LCIVD. Measures were subjected to normality tests and were divided according to the sex of the study population. Correlations of measures with age, BMI, and height were calculated. RESULTS: Of the 311 patients analyzed, 66.6% (n = 207) were female. The mean lumbar vertebral body-iliac artery distance (LVBIAD) was 7.2 mm, whereas the mean LCIVD was 8.5 mm; both were higher in men (P < 0.001). The statistical analysis of LVBIAD and LCIVD distributions revealed no normality pattern (P < 0.05). The analysis of the correlation between them showed a weak statistically significant relationship with age. A linear regression model considering the normality percentile interval indicated a strong positive correlation between LVBIAD and LCIVD (R2 = 0.884). CONCLUSIONS: The LVBIAD was <5 mm and <3 mm in 25% and 5% of asymptomatic individuals, respectively. The LCIVD correlated with the space between the RCIA and lumbar vertebra. The distance between the RCIA and lumbar vertebra and the LCIVD were higher in male subjects and older patients, but did not correlate with BMI and height.

The Distensibility of the Human Vena Cava and Its Importance to In Vitro Studies of Venous Compression Syndromes: A Search for a Suitable Polymer for 3-Dimensional Printing.

BACKGROUND: Venous compression syndromes are clinical conditions in which the large veins are compressed by other anatomical structures. Laboratory simulations may help us better understand the hemodynamics in venous compressions by creating situations similar to those seen in vivo. The aim of this study is to produce a model of the caval bifurcation using a polymer with distensibility similar to the human vena cava. METHODS: Fragments of the inferior vena cava were collected from 13 deceased kidney donors (aged 15-37 years) and were tested for deformation (strain) when subjected to distension at 50 N/cm2. Strips of 5 different polymers-thermic polyurethane and Agilus30 with Vero Magenta (AV) (in 3 different hardnesses) and silicone-were subjected to the same biomechanical tests and compared with the vena cava. A model of the caval bifurcation was produced with 3-D printing. RESULTS: The deformation (strain) of the vena cava wall was 0.16 ± 0.9 when submitted to stress close to 50 N/cm2. Silicone showed a strain higher than the standard deviation of venous fragments. The strain of AV resin 95 Shore was lower than the standard deviation of the venous fragments. AV Resins 70 and 85 Shore showed strains within the standard deviation of the venous specimen, with 70 Shore being closest to the mean venous strain. Therefore, this material was selected for modeling the caval bifurcation. The computed tomography scan image generated a computer model of the caval bifurcation and was printed in 3 dimensions. In addition, the segments of 2 adjacent vertebrae were also printed to reference the compression site. CONCLUSIONS: The 3-D printing of large veins can produce models with anatomy and biomechanics similar to those of human veins and opens a field of investigation into the hemodynamics of venous compression syndromes. Polymers with Shore A70 appear to have biomechanical properties similar to those of the vena cava wall. The model obtained in this study can be used in several in vitro studies of May-Thurner Syndrome.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm.

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

A Sociedade Brasileira de Angiologia e Cirurgia Vascular, por meio do projeto Diretrizes, apresenta as novas Diretrizes de Aorta Abdominal, referentes aos cuidados de pacientes com aneurisma de aorta abdominal. Para sua elaboração, foram priorizadas diretrizes descritivas, utilizando as bases EMBASE, LILACS e PubMed. As referências incluem ensaios clínicos randomizados, revisões sistemáticas, metanálises e estudos de coorte. A qualidade das evidências foi examinada por uma dupla de coordenadores, com auxílio da ferramenta RoB 2 da Colaboração Cochrane e dos formulários da Newcastle Ottawa Scale. Aneurismas justarrenais, infectados e novas técnicas terapêuticas, principalmente no âmbito endovascular, estão entre os temas estudados. A versão atual das Diretrizes apresenta importantes recomendações para os principais itens que envolvem o diagnóstico, tratamento e acompanhamento de pacientes com aneurisma de aorta abdominal, oferecendo um guia objetivo para prática médica, construído a partir de evidências científicas e amplamente acessível em todo o território nacional.

The End of Wire Wrapping: A Technique to Avoid Intertwining Preloaded Guidewires for Endovascular Aortic Arch Repair.

PURPOSE: The purpose of this study was to present a new technique for endovascular aortic arch repair for 1, 2, or 3 vessels using preloaded wires and precannulated target vessels without wire wrapping. TECHNIQUE: This technique uses a prototype catheter with 2 parallel lumens to position through-and-through guidewires in the supra-aortic branches and an extra-stiff guidewire in the ascending aorta with no wrapping. This allows the introduction and advancement of the device with the already precannulated target vessels. The endograft is advanced to the aortic arch without twisting or wrapping. Covered stents are deployed to align the graft and target vessels. CONCLUSION: To our knowledge, a technique that avoids wire wrapping has not been previously described. This technique allows safer and faster endovascular arch procedures and opens up new possibilities by enabling multi-vessel endovascular aortic arch repair with all precannulated target vessels.

The Use of a Low-Fidelity Simulator to Improve Vascular Anastomosis Skills of Residents during the COVID-19 Pandemic.

BACKGROUND: To evaluate a workshop using a low-fidelity simulator for training vascular surgery residents in vascular anastomosis during the COVID-19 pandemic. DESIGN: Prospective, controlled, single-center. METHODS: Vascular surgery residents at the São Paulo University Medical School were enrolled in the COVID Group (five post graduation year 3 residents) or Control Group (five PGY-4 residents). The COVID Group was trained via a vascular anastomosis workshop. The residents were evaluated using Objective Structured Assessment of Technical Skills (OSATS), Final Product Analysis and time to perform the procedure. The number of anastomoses performed by the residents were calculated. Data were subjected to statistical analysis, and P < 0.05 was considered significant. RESULTS: There was a significant reduction in the number of vascular anastomoses performed by the residents between the COVID group and the control group (mean 22.6 ± 7.76 vs. 35.2 ± 3.9, P = 0.01, Student's t-test). Before the workshop, 80% of the residents from the COVID group failed to perform a vascular anastomosis on the simulator. During the workshop, there was improvement in the Objective Structured Assessment of Technical Skills (OSATS) score (initial: 16.5, interquartile range (IQR) 0, under supervision: 25, IQR 5, and at the end of the workshop: 26.5, IQR 2.5; P = 0.049, Friedman's test) and in the Final Product Analysis (initial: 14.5, IQR 6, under supervision: 26.5, IQR 4.625, end of the workshop: 27, IQR 4, P = 0.049, Friedman's test). Time was not significantly different (initial: 35.6, IQR 2.77; under supervision: 25.8 min, IQR 4.53; P = 0.07, Friedman's test). The residents' technical scores were stable 6 months after the training, and there was no difference between their final scores and those of the control group. The residents from the COVID Group reported an improvement in their knowledge, technical skills and confidence after the workshop. CONCLUSIONS: A workshop using a low-fidelity simulator improved vascular surgery residents' skills and confidence in vascular anastomosis during the pandemic year, when they performed fewer surgical procedures.

Differences in procedural metrics and clinical outcomes among patients treated by fenestrated-branched endovascular repair of thoracoabdominal aortic aneurysms using infrarenal aortic versus iliac sealing zones.

OBJECTIVE: The purpose of the present study was to assess the outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) using infrarenal aortic vs iliac sealing zones. METHODS: We reviewed the clinical data of 430 consecutive patients enrolled in a prospective nonrandomized study to evaluate FB-EVAR from 2013 to 2020. The outcomes were analyzed for patients with extent I to IV thoracoabdominal aortic aneurysms who had undergone FB-EVAR with distal implantation in the native infrarenal aorta. The minimum anatomic criteria for the use of infrarenal aortic seal was a >3-cm length of parallel aorta with a diameter of 18 to 32 mm without excessive thrombus or calcification. A control group matched for the extent of aortic disease with an iliac artery seal was used to compare the following endpoints: 30-day mortality, major adverse events, freedom from type Ib endoleak (TIbE), freedom from secondary interventions, and changes in the infrarenal aortic diameter. RESULTS: A total of 110 patients (55 men; mean age, 73 ± 8 years) were included in the present study, 55 with an infrarenal aortic distal seal and 55 with the iliac arteries as the sealing zone. Both groups had similar clinical characteristics and aneurysm extent and diameter, except for a greater number of men and higher serum creatinine in the iliac seal group. Technical success was obtained in 106 patients (96%) and was greater for the iliac sealing zone group (100% vs 93%; P = .04). The use of the infrarenal aortic sealing zone was associated with shorter endovascular (148 ± 56 minutes vs 191 ± 61 minutes; P < .001) and fluoroscopy (76 ± 28 minutes vs 96 ± 32 minutes; P < .001) times and lower radiation exposure (cumulative air kerma, 1.4 ± 1.4 Gy vs 2.1 ± 2.0 Gy; P = .02; dose area product, 147 ± 75 Gy ∙ cm2 vs 208 ± 102 Gy ∙ cm2; P = .006). One patient had died (1%) within 30 days. No differences were found in the major adverse events among the patients treated with infrarenal aortic vs iliac sealing zones (22% vs 18%; P = .63), including any spinal cord injury (13% vs 9%; P = .54) and grade 3 spinal cord injury (7% vs 7%; P = 1.0). The mean clinical follow-up was 24 ± 18 months. TIbE occurred in one patient in each group (P = 1.0). The 3-year freedom from TIbE and freedom from secondary intervention rate was 98% ± 2% and 67% ± 8% for the infrarenal aortic seal group and 97% ± 3% and 67% ± 8% for the iliac seal group, respectively (P = NS). Among the patients treated with infrarenal aortic sealing zones, the mean enlargement of the infrarenal aortic diameter was 5 ± 3.2 mm at 3 years. No late TIbE due to disease progression had developed in the infrarenal aorta. CONCLUSIONS: Infrarenal aortic and iliac artery seal zones are safe and effective during FB-EVAR, provided the patients have suitable segments. The use of the infrarenal aortic sealing zone had modest procedural advantages such as shorter endovascular and fluoroscopy times and lower radiation exposure. No differences were found in the clinical outcomes or development of TIbEs.

Removal of Intravascular Foreign Bodies With a Simple Low-Cost Method: A Report of 5 Cases.

PURPOSE: Intravascular embolization of hemodialysis and central venous catheters is a rare but potentially serious complication. With the increasing use of catheters in medical practice, we are often faced with this type of complication. Novel, simple, and low-cost techniques are needed for foreign body extraction in order to reduce cardiovascular risks. CASE REPORT: We describe the approach of 5 foreign body embolization cases. Case 1: a 57-year-old woman with end-stage renal failure with a complete fracture and migration of the distal extremity of a hemodialysis catheter. Case 2: a 55-year-old man with an accidental embolization of the distal portion of a hemodialysis catheter. Case 3: a 76-year-old woman with stage IV breast cancer and an accidental embolization of a central venous catheter guidewire. Cases 4 and 5: a 71-year-old woman and a 2-year-old boy with a port-a-cath embolization. All the patients underwent successful minimally invasive removal of the foreign bodies from the thoracic site using 5Fr pigtail catheters. Additional surgery was not required. No further complications, such as damage to the vascular wall, were noted. CONCLUSION: Our experience with the interlacing and traction pigtail show that it is a simple, practical, and low-cost technical alternative and its benefits should be widespread.

Natural History of Splanchnic Artery Aneurysms.

INTRODUCTION: Splanchnic artery aneurysms (SAAs) represent a rare and potential life-threatening disease with a documented incidence of 0.1-2.0%. The risk of rupture and the diameter to recommend surgery are still controversial. The purpose of this study was to review surveillance computed tomography scans (CTs) at a high-volume institution in order to better define the natural history of the SAA. METHODS: Between January 2000 and February 2019, all SAAs patients in follow-up at a single center institution were selected for analysis. CTs from patients managed nonoperatively and CTs before surgery from patients submitted to surgery were studied. The first CTs were used to determine aneurysm size, morphology, and anatomic characteristics, and the last CTs performed during nonoperative follow-up were used to compare the diameter with the previous CTs. Primary endpoint included growth rate for all SAAs location, and secondary endpoint included the clinical or anatomical characteristic associated with a faster growth rate. RESULTS: In total, 116 consecutive patients were identified with SAAs and 74 patients with 87 SAAs who had at least 2 CTs during follow-up were analyzed. From those 74 patients, 12 were submitted to surgery and only their preoperative CTs were analyzed. The SAAs' locations were: splenic (55.4%), hepatic (12.2%), superior mesenteric artery (17.6%), celiac trunk (27.0%), gastric and gastroepiploic arteries (1.4%), pancreaticoduodenal and gastroduodenal arteries (4.1%). The median follow-up for all patients was 46.7 months (±35.3), and the median of growth for all aneurysms was 0.63 mm/year (±2.19). Only the splenic aneurysms presented growth with statistic significance of 1.08 mm per/year (±1.99) (P < 0.001). Only portal hypertension showed statistically significance to splenic aneurysm growth (P = 0.002). Multivariate analysis for variables associated with splenic aneurysm growth ≥1 mm/year showed that portal hypertension was the only variable with statistical significance (P < 0.01, IC 95% 2.0-186.9, ß = 19.5). CONCLUSIONS: Although longer-term follow-up and larger sample size are needed to better understand the natural history of SAAs, the majority of SAAs tends to remain stable in size through follow-up. Portal hypertension was the only risk factor found for true splenic aneurysm growth, and so those patients must have a closer follow-up.

Vascular surgery in the most populous state in the Amazon: socio-professional profile and aspirations of the specialty.

BACKGROUND: There is a dearth of studies conducted to understand the socio-professional profile of the vascular surgery specialty and the population demands of specific regions, which are needed to support creation of care policies and direct infrastructure improvements in healthcare. OBJECTIVES: The purpose of this study was to describe the socio-professional profile of vascular surgeons in the state of Pará, Brazil, to guide creation of tools for professional improvement. METHODS: A cross-sectional, self-report survey was conducted in Pará using a questionnaire comprising 30 questions covering six main topics. RESULTS: All vascular surgeons actively practicing in the state participated in this study. The total number of specialists was 59, with 71.2% working in the greater Belém area and 16.9% exclusively practicing in the interior of the state. The mean age of these professionals was 48 ± 11.1 years, 86.4% of respondents were men, 64.4% of surgeons had completed medical residency, and 96.6% (n=57) of the surgeons would like to improve their skills in venous surgery, echo-guided vascular access, and endovascular surgery. The method of professional improvement of greatest interest was simulation courses (hands-on), endorsed by 93% of the participants. CONCLUSIONS: Pará has 59 vascular surgeons. These professionals mainly work in the greater Belém (71.2%), in hospitals (100%) or in private clinics or offices (94.9%), performing a wide range of procedures, including venous and arterial surgery, amputations, and provision of hemodialysis access. More than 90% of these surgeons were satisfied professionally and reported that they would choose the specialty again. However, 22% had a pessimistic view of the specialty's future. The vast majority of professionals (96.6%) consider that training or a continuing education program are necessary.

CONTEXTO: Há uma falta de estudos necessários para entender o perfil socioprofissional da especialidade e as demandas específicas da população de uma região específica, a fim de subsidiar a criação de políticas assistenciais e a melhoria na infraestrutura da assistência à saúde. OBJETIVOS: O objetivo deste estudo foi descrever o perfil socioprofissional de cirurgiões vasculares no Pará para orientar a criação de ferramentas de melhoria profissional. MÉTODOS: Foi realizado um levantamento transversal no Pará utilizando um questionário com 30 questões que envolvia seis temas principais. RESULTADOS: Todos os cirurgiões vasculares ativos participaram deste estudo. O número total de especialistas foi de 59, dos quais 71,2% trabalhavam na grande Belém e 16,9% exclusivamente no interior do estado. A idade média dos profissionais foi de 48 ± 11,1 anos, e 86,4% dos entrevistados eram homens. Além disso, 64,4% dos cirurgiões haviam completado a residência médica, e 96,6% (n = 57) deles gostariam de ter melhorias em cirurgia venosa, acesso vascular ecoguiado e cirurgia endovascular. As áreas de maior interesse para melhorias são cursos de simulação (práticos), com 93% dos participantes interessados. CONCLUSÕES: O Pará tem 59 cirurgiões vasculares, os quais trabalham principalmente na grande Belém (71,2%) em hospitais (100%) ou em clínicas privadas ou consultórios (94,9%) e realizam uma ampla gama de procedimentos, incluindo cirurgias venosas e arteriais, amputações e acessos para hemodiálise. Mais de 90% dos cirurgiões estavam satisfeitos e relataram que escolheriam a especialidade novamente; entretanto, 22% tinham uma visão pessimista do futuro da especialidade. A grande maioria dos profissionais (96,6%) considera a necessidade de qualificação ou de um programa de educação continuada.

Successful endovascular correction of common carotid pseudoaneurysm secondary to Behçet's disease: case report and review of the literature.

Behçet's disease (BD) is a chronic, multisystemic, inflammatory disease characterised by recurrent mucocutaneous, ocular, musculoskeletal, central nervous system, gastrointestinal and vascular manifestations, which may affect blood vessels of any size (1). Venous involvement is more common, but arterial involvement accounts for the major cause of mortality (2, 3). Choosing the adequate technique and timing for correcting aneurysms in BD is still challenging. The authors report a case of a 37-year-old male patient with common carotid pseudoaneurysm at the time of diagnosis, which was successfully treated by an endovascular stent placement after adequate immunosuppression. A review of the literature about this issue was also done.

Combined Angioplasty Technique of the Carotid Territory and Supra-Aortic Trunk by Double Access (Cervical and Limbs) for Tandem Lesions.

BACKGROUND: The carotid stent angioplasty (CAS) has been the main option for patients with high cardiovascular risk and carotid stenosis. The common femoral artery is still the most used access site; however, the aortic arch manipulation is a critical moment for cerebral embolization. Carotid transcervical access should be considered as a good alternative access route for CAS. Tandem lesions combining supra-aortic trunks and ipsilateral carotid bulb critical stenosis pose a great challenge for the vascular surgeon. METHODS: This is a retrospective descriptive study based on medical records of our institution. We report 2 cases of complex cerebral vascular insufficiency and discuss therapeutic options and strategies to protect the cerebrovascular territory avoiding microembolization, as well as demonstrate an alternative and safe total endovascular approach for those cases. RESULTS: We describe the approach of 2 complex cerebral vascular insufficiency cases: case 1, a 63-year-old male with previous ischemic stroke, right internal carotid artery (ICA) occlusion, left ICA stenosis >70%, and critical stenosis of the origin of common carotid artery (CCA); case 2, a 68-year-old female with previous ischemic stroke, left ICA occlusion, brachiocephalic trunk critical stenosis, hypoplastic right vertebral artery, and aortobi-iliac chronic occlusion. In both cases reported here a challenging solution was chosen, little described in the literature, with cerebral filter protection as the first step. In addition, a literature review was performed to discuss the different approach options for tandem injuries of the supra-aortic trunk and carotid bulb. CONCLUSIONS: Our initial experience with total endovascular treatment of complex tandem lesions of the carotid territory and supra-aortic trunks show that transcervical access, coupled with distal protection filter device on the first step, is a safe and effective technique for preventing neurological events.

Endovascular Therapy Provides Similar Results of Bypass Graft Surgery in the Treatment of Infrainguinal Multilevel Arterial Disease in Patients with Chronic Limb-Threatening Ischemia in All GLASS Stages.

BACKGROUND: Extensive infrainguinal arterial disease still pose a challenge for technical and clinical success of percutaneous angioplasty. The purpose of this study was to compare the results of concomitant femoropopliteal and infrapopliteal percutaneous angioplasty/stenting (PTA/S) with distal bypass graft surgery (BGS) in patients with chronic limb-threatening ischemia (CLTI). METHOD: In a single-center retrospective investigation between 2011 and 2017, 668 revascularization procedures for CLTI were reviewed. Concomitant femoropopliteal and infrapopliteal disease was identified in 153 CLTI patients, treated with BGS (48) using autogenous veins as substitute or PTA/S in a single procedure (105). A subgroup of patients with complex, extensive arterial lesions (GLASS stage III) received additional analysis. Primary outcomes were limb salvage and survival. RESULTS: The mean follow-up time was 21.4 months. Patients treated with PTA/S were significantly older and with predominance of females, diabetes and chronic kidney disease. Smoking was more common in patients treated with BGS. The BGS group showed a 36-month survival rate of 73.4%, whereas the PTA/S group presented a survival of 61.3% in the same interval (P = 0.25). The 36-month cumulative limb salvage rate was 53.3 and 59.7% for BGS and PTA/S, respectively (P = 0.24). For GLASS stage III patients, 36-month limb salvage rates were 54.4% for the PTA/S group and 50.2% for the BGS group (P = 0.29). Multivariate analysis pointed poor runoff status (all endovascular patients) and diabetes (GLASS III endovascular patients) as risk factors for limb loss. CONCLUSION: PTA/S and BGS presented similar results of limb salvage and survival in the treatment of concomitant femoropopliteal and infrapopliteal arterial disease in patients with CLTI, even for patients with extensive and complex arterial disease.

Study of the Biomechanical and Histological Properties of the Abdominal Aorta of Diabetic Rats Exposed to Cigarette Smoke.

INTRODUCTION: In spite of the great relevance of abdominal aortic aneurysm, its etiopathogenesis is not fully understood. The biomechanical and histological study of the aortic wall may contribute to this elucidation. METHODS: Seventy-five male Wistar rats were divided into 4 groups: control (CG), smoker (SG), diabetic (DG), and diabetic + smoker (DSG). The SG and DSG rats were exposed to cigarette smoke for 30 min/day, 5 days a week. Diabetes was induced by the intravenous injection of streptozotocin. After 16 weeks, the abdominal aorta was collected for biomechanical, histological, and matrix metalloproteinase 2 (MMP-2) activity analyses. RESULTS: The valid biomechanical tests of 52 specimens were analyzed: 11 in the CG, 10 in the DG, 16 in the SG, and 15 in the DSG. The biomechanical analysis of the fragments showed no differences between the control, DG, SG, and DSG. Collagen deposition also did not present a significant difference between the studied groups. The total count of elastic fibers was higher in diabetic rats (DG and DSG) than in the SG. The inflammatory response observed in all experimental groups was significantly more intense than in the CG. Compared to the DSG, MMP-2 activity showed a significant decrease in the DG. CONCLUSIONS: Resistance and elasticity did not present a difference between the CG and the DG, SG, and DSG. Compared to the CG, the total count of elastic fibers, fragmentation of the elastic lamina, pericellular matrix deposition, and cell loss/substitution in the tunica media showed significant alterations in the aortic walls of the DG, SG, and DSG. MMP-2 activity was lower in the DG aorta than in the DSG aorta.

Analysis of the Correlation Between Central Obesity and Abdominal Aortic Diseases.

BACKGROUND: Atherosclerosis and abdominal aortic aneurysms (AAAs) have several similar risk factors but different pathogenesis. Inflammation of the arteries is common to both. Central obesity can act as an endocrine organ through the secretion of inflammatory cytokines, and the perivascular fat has a local effect that could contribute to diseases of the abdominal aorta. Although the relation between central obesity and atherosclerosis occlusive arterial disease has been demonstrated, the correlation with AAA has conflicting results. The aim of this study was to analyze the correlation between central obesity and the presence of abdominal aortic diseases using computed tomography. METHODS: Six hundred thirty-nine consecutive patients classified into 3 groups (AAA, aortic atherosclerotic occlusive disease (AAOD), and without aortic disease [control group]) who underwent computed tomography had the aorta diameter, the visceral fat area (VFA), and the subcutaneous fat area (SFA) measured at the level of third and fourth lumbar vertebrae. RESULTS: VFA showed no difference between the groups. SFA was lower in atherosclerotic group (AAOD) than control (P < 0.01 in general and P < 0.04 in male). In AAA group, we found in men that the first tertile of aorta diameter had higher VFA than third tertile (P = 0.02). CONCLUSIONS: There was no difference in VFA between patients in AAA, AAOD, and without aortic disease groups. In men with aneurysm, there was an inverse relationship between VFA and aortic diameter. In AAOD, visceral to subcutaneous ratio is higher due to lower SFA.

The Need for a Vena Cava Filter in Oncological Patients with Acute Venous Thrombosis: A Marker of a Worse Prognosis.

BACKGROUND: Active cancer is found in approximately 20% of patients diagnosed with venous thromboembolism. This condition is more prevalent in patients with advanced and metastatic cancer and is the second largest cause of death among patients with active neoplasm. Many of them have contraindication for anticoagulation and needs an inferior vena cava filter to be implanted, but a large proportion of these patients have very low survival after filter implantation. Our aim was to verify whether the need for filter implantation represents an independent indicator of poor prognosis in oncological patients and to identify subgroups with a greater survival. METHODS: This study included a retrospective analysis of 247 oncologic patients with acute proximal venous thrombosis. We compared survival between 100 consecutive patients who needed vena cava filter (FILTER group) versus a control group of 147 patients in whom anticoagulation was possible (ANTICOAGULATION group). We verified survival, cause of death, filter's indications (clinical and surgical), and factors that might lead to worse prognosis. RESULTS: Risk of death was 8.83-fold higher in the FILTER group than that in the ANTICOAGULATION group, a greater risk than the presence of metastasis (OR: 2.47). Death was significantly more frequent in patients subjected to filter implantation because of clinical indications (93.2%) such as high risk of or recent bleeding and an adjusted risk of death of 2.24-fold higher in a multivariate analysis. CONCLUSIONS: The need to implant a vena cava filter in a patient with cancer is a marker that indicates patient's disease severity and worse prognosis. Survival was longer in the subgroup of patients who underwent filter implantation before oncologic surgery, probably because of a better status performance and less clinical complications.

Comparison of high-sensitivity cardiac troponin I and T for the prediction of cardiac complications after non-cardiac surgery.

BACKGROUND: We aimed to directly compare preoperative high-sensitivity cardiac troponin (hs-cTn) I and T concentration for the prediction of major cardiac complications after non-cardiac surgery. METHODS: We measured hs-cTnI and hs-cTnT preoperatively in a blinded fashion in 1022 patients undergoing non-cardiac surgery. The primary endpoint was a composite of major cardiac complications including cardiac death, cardiac arrest, myocardial infarction, clinically relevant arrhythmias, and acute heart failure within 30 days. We hypothesized that the type of surgery may impact on the predictive accuracy of hs-cTnI/T and stratified all analyses according to the type of surgery. RESULTS: Major cardiac complications occurred in 108 (11%) patients, 58/243 (24%) patients undergoing vascular surgery and 50/779 (6%, P < .001) patients undergoing non-vascular surgery. Using regulatory-approved 99th percentile cut-off concentrations, preoperative hs-cTnI elevations were less than one-fifth as common as preoperative hs-cTnT elevations (P < .001). Among patients undergoing vascular surgery, preoperative hs-cTnI concentrations, but not hs-cTnT, was an independent predictor of cardiac complications (adjusted odds ratio (aOR) 1.5, 95% confidence interval (95% CI) 1.0-2.1). The area under the receiver-operating characteristics curve (AUC) was 0.67 (95% CI, 0.59-0.75) for hs-cTnI versus 0.59 (95% CI 0.51-0.67, P = .012) for hs-cTnT. In contrast, among patients undergoing non-vascular surgery both preoperative hs-cTnI and hs-cTnT were independent predictors of the primary endpoint (aOR 1.6, 95% CI 1.3-2.0, and aOR 3.0, 95% CI 2.0-4.6, respectively) and showed higher predictive accuracy (AUC 0.77, 95% CI, 0.71-0.83, and 0.79, 95% CI 0.73-0.85, P = ns). CONCLUSIONS: Preoperative hs-cTnI and hs-cTnT concentrations predict major cardiac complications after non-vascular surgery, while, in patients undergoing vascular surgery, hs-cTnI may have better accuracy.

Prevalence of signs of celiac axis compression by the median arcuate ligament on computed tomography angiography in asymptomatic patients.

OBJECTIVE: The increasing use of computed tomography (CT) angiography has led to more frequent diagnoses of celiac artery compression (CAC) by the median arcuate ligament (MAL). The signs of CAC by the MAL have been described as stenosis and a hook or J appearance on sagittal views. The importance of the "hook signal," however, has not been documented by studies of the normal anatomy of the celiac axis. METHODS: CT angiography images of 344 completely asymptomatic, live kidney donors (without history of chronic abdominal pain or weight loss) were reviewed. The angle of emergence (AE) of the celiac axis from the aorta and the angle of upward or downward shifting of the celiac axis before its first branch (fold angle [FA]) were measured. Weight, height, and body mass index were obtained from our electronic database, and correlations with the angles measured were tested. The occurrence of stenosis >50% at the origins of the celiac axis was also determined in the sample. RESULTS: Measurements were possible in 321 cases. The celiac axis was found to leave the aorta at an angle of <90 degrees in all patients (AE range, 7-83 degrees) and <45 degrees in 292 (90%) patients. The FA ranged from 66 to 208 degrees. Before the first branch, the celiac trunk shifted upward in 306 (95%) patients, remained straight in just one of them, and shifted downward in 14 (4%). The AE was positively correlated with weight in women. The FA was negatively correlated with weight in men and women. Body mass index was positively correlated with AE and negatively correlated with FA in both men and women. In 11 cases (3.4%), stenosis >50% was found at the origin of the celiac axis. In only two patients, the celiac axis had an upward slope after the stenosis, which could be interpreted as a hook shape. CONCLUSIONS: The normal anatomy of the celiac axis, when seen on CT angiography images, demonstrates that it exits the aorta downward and then shifts upward. This hook or J shape should not be interpreted as resulting from external compression. CAC by the MAL occurs in 3.42% of the normal asymptomatic population; a hook or J shape is not visible in most cases in that subgroup.