Angiologia e Cirurgia Vascular最新文献

Introduction

Rupture has a negative impact on abdominal aortic or iliac pathology. Endovascular aneurysm repair (EVAR) is an established treatment in the elective setting which has increasingly been applied in urgent patients and may be associated with a decrease in perioperative mortality.

Objectives

Our primary outcome was perioperative/early mortality. Secondary outcomes include perioperative hemodynamics and procedure‐related complications.

Methods

A prospectively maintained single center database was retrospectively enquired. Patients who underwent rEVAR between March 2008 and March 2014 were included. Rupture was defined as the presence of a retroperitoneal hematoma or extraversion of contrast on a CTA. Although there's no institutional capacity to offer EVAR to all ruptured aneurysms, it is given preference to endovascular repair over open surgery in patients with suitable aortic anatomy for EVAR.

Demographic, perioperative hemodynamics and laboratorial data were assessed. Primary outcome was perioperative/early mortality. Secondary outcomes include procedure‐related and systemic complications.

Results

Forty‐nine patients were included, 43 of whom (88%) were males and mean age was 73.7 ± 10,61 years (range 47 to 90).

Thirty‐five patients presented rAAA (72%) and 9 ruptured iliac aneurysms (18%). Mean aneurysm diameter was 7.6 ± 1.7 cm. Other indications for rEVAR were spontaneous/iatrogenic aortic rupture (6%; n = 3), late aneurysm rupture following EVAR (n = 1) and a case of an anastomotic pseudoaneurysm. Deployed endograft configuration was aortic bi‐iliac in 26 cases (53%), aortic mono‐iliac in 18 (37%) and embolization and endovascular exclusion with iliac branch (10%). Deployed devices were Endurant Medtronic^® in 59%, Excluder Gore^® in 12%, Zenith Cook^® in 22%, Excluder C3 Gore^® in 5%, e Talent Medtronic^® in 2%. 32% were treated under local anesthesia. The 30 dias/intrahospitalar mortality rate was 26.5%, which progressively decreased during the study period. The 30‐day complication rate was local in 20.4%, systemic in 53%. Abdominal compartment syndrome occurred in 10 cases (20.4%), and was found to be a negative prognostic factor. Median hospitalization duration was 7 days (0‐92) and median stay in the intensive care unit was 2 days (0‐65).

Conclusion

EVAR is a valid treatment in the urgent setting for patients with abdominal aortic or iliac rupture. Our results are comparable to the randomized controlled studies

Objective

The independent occurrence of aneurysms in the thoracic aorta (TAA) and abdominal aorta (AAA), simultaneously (synchronous aneurysms – SA) or sequentially (metachronous aneurysms – MA) occurs in 20–25%.

Endovascular or open repair (OR) of SA may be simultaneous or staged, while interventions for MA always involves two procedures.

In both cases, an increase of spinal cord ischemia (SCI) rates was reported.

The present study analyzes our experience in the management of SA and MA.

Methods

In a retrospective analysis, all the patients submitted to thoracic endovascular aneurysm repair (TEVAR) between March 2009 and February 2015, were identified. From these, those who had TEVAR + EVAR or TEVAR + OR of AAA in the same period of time (Group-1: synchronous) and those who had TEVAR and had previous repair of AAA (Group-2: metachronous) were selected.

All surgeries were performed under strict haemodynamic control, cerebrospinal fluid (CSF) drainage and pressure monitoring and the patency of the left subclavian artery was assured.

The endpoints were: incidence of SCI, stroke, acute kidney injury and mortality.

Results

TEVAR was performed in 58 patients of which 5 had SA (Group-1: 8.6%) and 6 had MA (Group-2: 10.3%).

Group-1 included 3 patients treated with EVAR + TEVAR simultaneously, one patient who had a TEVAR and OR of a type-4 thoracoabdominal aneurysm (TAAA) in the same hospitalization and, finally, a fifth patient that underwent TEVAR due to a contained rupture of a proximal TAA. This patient also presented a type-4 TAAA, whose treatment was deferred due to poor medical condition, but ruptured 1 month after.

Group-2 included 6 patients. Five had OR of AAA in the past and underwent TEVAR. The sixth patient had a previous EVAR with an abdominal debranching. One patient was submitted to a supra-aortic debranching and another to a chimney procedure of the superior mesenteric artery. The median of the initial to current intervention time was 6.5 years.

There were no reports of SCI or early mortality but 1 patient in Group-1 died due to non-procedural complications.

Conclusion

The prevalence of SA and MA in all the TEVAR cases was 18.9%.

With implementation of a surgical and anesthetic protocol, there were no cases of SCI or surgical mortality.

Introduction

Endovascular surgery is an effective way to treat below the knee disease in critical limb ischemia patients. It has been described to have high limb salvage rates with low associated morbidity and mortality. The purpose of this work is to review our results in below the knee endovascular procedures, focusing on complex below the knee lesions, particularly when it is uncertain if and which below the ankle and foot arteries are patent.

Material and methods

We did a retrospective analysis of our Department's experience in endovascular treatment of below the knee disease, including patients submitted to first procedures for a de novo critical limb ischemia, during the period from January/2010 to August/2014 (275 patients). We reviewed both clinical files and patients angiograms. The primary outcomes were: technical success rate, reintervention rate, limb salvage rate and lesion healing time. We did a subanalysis of the outcomes related to the treatment of long below the knee occlusions.

Results

Technical success in treating below the knee stenosis was 98.9%. Below the knee occlusions were detected in 54.9% of the patients (39.4% with at least one vessel with a long occlusion). Antegrade recanalization was attempted in all patients and achieved in 92.8%. Distal retrograde recanalization was successful in another 5.4% of the patients. In 23.6% of the patients a long occlusion recanalization was performed (27.6% of these patients had no aparent foot outflow before the recanalization). Failure rate was 3.6%. Reintervention rate was 26.2%. Limb salvage rate was 91.3% (one‐year). The mean time for ulcer healing was 5.3 months. More tibial vessels patent at the end of the procedure was associated with higher limb salvage rate (p = 0.026) and faster ulcer healing time (p = 0.015). For these parameters the angiossomic revascularization had a tendency to be associated with better results (p = 0.090 and 0.097 accordingly).

Conclusion

Hence we present favourable results in the endovascular treatment of below the knee disease, comparable to specialized centres. The treatment of long below the knee occlusions can be achieved, even when there is doubt of below the ankle arteries patency, thus presenting good short and medium term results.

Portal venous aneurysms are a rare condition characterized by dilatation of the portal venous system. These aneurysms can be congenital or acquired and usually do not require any treatment unless they are symptomatic–symptoms depend on the aneurysm size, location and complications, such as thrombosis.

We report a case of a 68 year‐old man, who was incidentally diagnosed with an asymptomatic 37 mm portal vein aneurysm, with the involvement of the splenic vein confluence with the superior mesenteric vein. A conservative approach with annual monitoring by Doppler ultrasound was recommended.

Arteriovenous fistula is a rare vascular complication of cardiac catheterism, especially in radial approach, an access site increasingly used due to lower rate of complications. The article presents the therapeutic management of a rare arteriovenous fistula as an early complication of coronary angiography with transradial access, in a young patient. The ligation of the fistula was performed under local anesthesia, with immediate resolution of symptoms. Literature review was carried and we support that surgical management is reserved for complications or patients with long term worsening potential.

Introduction

The peripheral vascular atherosclerotic disease is a characteristic complication in patients with end‐stage renal disease (ESRD) and shows a particular predilection for diffuse, calcifying and infra‐popliteal involvement. Despite the advances in endovascular revascularization, the clinical efficacy in these patients is limited and poor results are expected.

Purpose

Determine the clinical outcomes after endovascular revascularization for chronic limb ischemia in patients with ESRD on dialysis and compare the results with patients not on dialysis.

Material and methods

We retrospectively evaluate the results of patients who underwent endovascular revascularization for chronic limb ischemia, between January 2010 and December 2013. The patients were divided into two groups: those with normal renal function and those with end stage renal disease on dialysis. The primary end points were: limb salvage and mortality and the secondary endopoints: technical success, wound healing rate, time for wound healing and complications.

Results

Of the total of 217 patients, 32 patients were excluded due to absence of data and 9 patients with renal insuficiency but not end‐stage. 176 patients underwent endovascular revascularization (a total of 182 limbs, median age of 65 years old, 78% males). 45 patients were on dyalisis program. Median follow‐up was 26,6 months.

In patients with Rutherford categories 4, 5 and 6, the limb salvage rate, at 12 months, was 90,4% in patients not on dialysis, and 69,6% in patients on dialysis. The survival rate at 12 monts was lower in patients on dialysis (86% vs 97,1%)

The wound healing rate was also lower in patients on dialysis (60% vs 80%) and with longer median healing times (96 vs 61 days)

Discussion

The presence of end stage renal disease is associated with a higher rate of limb loss and mortality. Despite the discouraging results, for these patients, it should be offered the less invasive endovascular revascularization treatment and an earlier referral.

Introduction

The occlusion of internal iliac artery may be necessary in Endovascular Aortic Aneurysm Repair (EVAR). The intentional hypogastric occlusion may have several ischemic complications. The Iliac Branch Devices (IBD) are an alternative to hypogastric occlusion in patients at high risk to pelvic ischemia. The authors report a case of early IBD occlusion with serious clinical consequences.

Case Report

A 74‐year‐old man presented a 55‐mm abdominal aortic aneurysm with bilateral involvement of iliac bifurcation and proximal hypogastric arteries (maximum diameter of 31 and 32 mm). He underwent EVAR, left hypogastric revascularization by IBD and coiling + overstenting of contralateral hypogastric. There wasńt intraoperative complications and final angiography showed hypogastric patency and poor pelvic collateral circulation. Postoperatively, the patient complained of bilateral lumbar and gluteal pain and presented with ischemic skin alterations and left lower limb monoparesis. As his clinical state deteriorates in the first 24 hours and computed tomography angiogram revealed left hypogastric stent occlusion, he underwent hypogastric revascularization again with good angiographic results. Despite successful revascularization, there was a progressive clinical deterioration with irreversible pelvic ischemia and rhabdomyolysis. Death on 5th postoperative day.

Conclusion

The acute pelvic ischemia is a serious complication and often a fatal outcome, which may result of bilateral hypogastric artery occlusion. As IBD revascularization failure may be fatal, the authors advise an extra caution in final angiography and a high level of suspicion for postoperative complications. Bilateral hypogastric preservation using IBD may be recommended, if there is a higher risk of technical failure, embolization or poor pelvic collateral circulation.

Thrombosis is one of the major causes of death worldwide. Continous increase in the knowledge about the pathophysiological changes associated with thrombosis led to the development of effective therapies (anti‐platelet, anticoagulant and fibrinolytics) for the prevention and treatment of the thromboembolic disease.

However, better understanding of the underlying processes is still crucial for the development of more effective and safer antithrombotic drugs.

The aim of this review is summarize the current treatment, as well as the new agentes and to highlight their proven or possible role in Vascular Surgery.