Angiologia e Cirurgia Vascular最新文献

Objective

Comparative and descriptive analysis of the outcomes of percutaneous access for EVAR (pEVAR) compared to the control group submitted to surgical femoral access (cEVAR).

Methods

Retrospective case–control analysis between January 2013 and January 2015 of the outcomes of pEVAR (group 1) compared to a control group of cEVAR (group 2) taking into account the demographic data and the primary endpoints: Access complication and surgical time; and secondary endpoints: type of anaesthesia, length of hospital stay and hematic loss. The statistical analysis was performed with the SPSS 23.0 programme using the X2 test for categorical variables and t test for continuous variables.

Results

A total of 6 pEVAR cases were performed in the selected period. A random selection of 20 cEVAR control cases was obtained. The mean age was 75 years, 85% were male. There were no significant differences in comorbidities between the two groups; the most frequent were arterial hypertension, dyslipidaemia, COPD/CID and CRD. There were no differences in major access complications (haemorrhage, lymphatic drainage, pain and oedema), however more frequently in cEVAR, with a significant rate of minor complications such as bruising in pEVAR (3.5% vs. 11.5%, p = 0.008). The surgical time was not significantly higher in cEVAR (p = 0.21), but the median is greater than in pEVAR with equally high in-group variance (cEVAR vs. pEVAR: 169 vs. 209 min; ANOVA: p < 0.05). Analysing secondary endpoints, the most widely used anaesthesia was the epidural (p = 0.03), hospital stay was higher in cEVAR (6.15 vs. 3.17; p = 0.022), a fact not observed in hematic loss (p = 0.17) despite the trend towards greater loss in cEVAR (group 1 and 2: 1.4 vs. 2.8 mg/dl).

Conclusion

Percutaneous access for EVAR demonstrates equal efficacy and safety compared to surgical femoral access, with shorter surgical time and hospitalization and less hematic loss without increasing local complications.

The aberrant origin of the right subclavian artery, one of the most common anomalies of the aortic arch, occurs in approximately 0.5% to 1% of the population.

Usually asymptomatic, when symptoms are present they result from compression of the esophagus by the aberrant artery, aneurysmal degeneration or occlusive atherosclerotic disease. Occlusive symptoms are usually treated by surgical revascularization.

The authors present a case of a patient with a history of progressive claudication in the right upper limb, associated with dizziness. The imagiologic study revealed a stenosis of the right subclavian artery. The right subclavian artery had an aberrant course, behind the esophagus and trachea.

He underwent percutaneous treatment with primary stenting of the subclavian stenosis, without complications on the postoperative period. The patient still asymptomatic 4 years after the procedure.

Endovascular treatment has been used with excellent results in the treatment of occlusive disease of the subclavian artery, with few cases described of subclavian artery with aberrant origin.

Endovascular treatment of complex thoracoabdominal aneurysms with branched and fenestrated grafts (B/F-EVAR) has become the first option for patients with suitable anatomy and very high risk for open surgery, who would likely be refused for open repair. We present a case of a patient with a type III thoracoabdominal aneurysm submitted to endovascular repair with a custom-made endograft with branches to the celiac trunk and SMA, and a fenestration to the left renal artery. During the procedure there was the need to do a laparotomy to allow for retrograde catheterization of the SMA, with technical success. In this case, the retrograde access was of utmost importance for the completion of the procedure. Different techniques for target vessel catheterization, such as the one we describe, should be part of a vascular surgeon's resources in B/F-EVAR procedures.

Introduction

Tuberculous aortitis is a rare entity first described by Weigert in 1882.

Report

A 73-year-old male under regular imagiologic surveillance due to a 4 cm abdominal aortic aneurysm, was referred to our department for suspected contained rupture. He was asymptomatic and his CT scan showed an inflammatory mass surrounding the aneurysm. During elective conventional surgery, aneurysm wall infiltration and adenopathies were identified. The histological analysis was compatible with tuberculosis. Eight months after surgery the patient is well, under tuberculostatic therapy.

Conclusion

The combination of surgical treatment and long duration tuberculostatic therapy is the best treatment option for tuberculous aortitis.

Introduction

The updated Glasgow Aneurysm Score (uGAS), designed to predict mortality/morbidity perioperative after rAAA, proved to be a good predictor of short term results after treatment with conventional surgery (CC) and EVAR. The objectives were to characterize patients operated at rAAA and evaluate the applicability of uGAS in the population of a national tertiary institution with rEVAR capacity.

Methods

We did a retrospective analysis of patients operated in our service to rAAA between February/2011 to February/2015. The variables were obtained through a search in a database of the institution and included age; sex; presence of heart disease, cerebrovascular disease, acute/chronic kidney disease and preoperative shock. Perioperative mortality (30‐day or in‐hospital) was obtained. The risk score was applied retrospectively and expected mortality compared with the mortality that was obtained.

Results

89 patients were included. 49 (55%) were treated by CC and the remaining 40 (45%) by EVAR. 35% had heart disease, 12% cerebrovascular disease, kidney disease 45% and 25% preoperative shock. The average uGAS was 90.6 ± 16.7. There were no statistically significant differences between patients undergoing EVAR or CC respecting to uGAS (p = 0,105). Mortality at 30 days was 39.8% and was significantly lower in patients undergoing EVAR than in those undergoing CC (20% vs 55%; p = 0.001).

Patients who died were significantly younger (70 vs. 76 years, p = 0.031), had a higher prevalence of kidney disease (55% vs 45%; p = 0.008), shock (59% vs 41%; p = 0.033) and a higher uGAS (100 ± 12,5 vs 84.6 ± 16,3; p < 0.001). The mortality of patients with uGAS < = 85 was 14.3% and patients with uGAS > 85 was 56.6%.

Conclusion

The results demonstrate the applicability of the uGAS score for risk stratification in a National cohort of patients with RAAA that EVAR is an alternative available. However, since it was not possible to identify a cut‐off able to provide a mortality of 100% We point out that the use of scores comprises the risk of treating patients refusing that could possibly survive. Additionally, these results suggest that treatment of RAAA by EVAR is associated with better outcomes.

In Portugal, the number of abdominal aortic aneurisms (AAA) treated in relation with its population is among the lowest in the literature. This phenomenon can be explained by a low diagnostic rate or a reduced prevalence of AAA in our population. To date, no systematic population screening was conducted in Portugal. The opportunistic screening “A aorta não avisa” described a prevalence of 2.4% in our population. Several studies have shown the benefit of population screening for AAA, by describing a significant decrease in specific and all‐cause mortality. In that way, the screening is already recommended in men over 65 years by the leading international Vascular Surgery societies ‐ European Society for Vascular Surgery (level 1 recommendation) and Society for Vascular Surgery (level 2 recommendation). In addition to its academic and scientific justification, based on the current evidence, the benefits of an AAA screening program in terms of public health are undeniable and irrefutable.