Angiologia e Cirurgia Vascular最新文献

Background

Limb occlusion is an important complication of endovascular aneurysm repair (EVAR). We intend to conduct a systematic review of the literature to assess the occurrence and the average time of limb occlusion and identify associated risk factors.

Material and methods

A literature search was performed using the query EVAR LIMB OCCLUSION, limited in time to the last ten years, to articles written in Portuguese and English. We selected twenty articles with original data; fourteen from the literature and six from the reference lists of articles read during the selection process.

Results

The frequency of limb occlusion varies between 0% and 24%. In most studies, the elapsed time to limb occlusion rarely exceeds six months. Age, body mass index, tortuosity of the iliac vessels, stenosis of the iliac or femoral artery> 70%, graft type and configuration, limb kinking, anchoring in the external iliac artery (EIA), tertiary hospital, absence of primary stenting during the index procedure and failure to comply to the specific instructions for use were identified as risk factors for limb occlusion.

Conclusions

Demographic/co‐morbidities factors seem to have a minor impact in outcome limb occlusion compared to risk factors related to arterial anatomy and related to the surgical technique. The type of graft, the anchoring zone in the EIA and the tortuosity of the iliac vessels seem to be the most important risk factors.

Intraprosthetic thrombus accumulation is a common event following EVAR. However, its’ natural course and clinical impact have remained controversial. Consequently, optimal treatment is yet to be established. This article provides a review of the literature which focuses highlighting the available evidence regarding the pathophysiology, clinical significance and therapeutic approach of this entity.

Extrarenal pseudoaneurysms are a rare complication of kidney transplantation, but result in graft loss in a majority of cases. The authors present the case of a 49 year old female patient who received a deceased‐donor kidney graft with arterial anastomosis to the right common iliac artery. Investigation for intermittent claudication of the right thigh at 5 months post‐transplant revealed an anastomotic pseudoaneurysm with distal occlusion of the external iliac artery. Treatment consisted of aneurysm resection and common iliac‐to‐renal artery bypass with great saphenous vein. The surgical specimen was positive for Candida albicans and the patient started on long‐term antifungal therapy. Routine Doppler ultrasound follow‐up revealed a new anastomotic pseudoaneurysm of the vein graft, with progressive enlargement to a diameter of 24 mm. The patient underwent endovascular exclusion of the pseudoaneurysm with a Viabahn® peripheral endograft (W.L. Gore and Ass. Inc., Flagstaff, AZ, USA), with good angiographic result and preservation of graft function. The described case illustrates how the use of different solutions in the vascular surgeon's armamentarium allows the successful treatment of kidney transplant complications while preserving graft function and contributing to a longer graft survival.

About 75% of the Abdominal Aortic Aneurysms (AAA) are currently repaired by endovacular means (EVAR). Aneurysm sac shrinkage post‐EVAR represents the principal marker of absence of rupture or mortality aneurysm related. However, in about 40% of cases aneurysm sac does not shrink or even enlarges.

Several pre‐operative risk factors may predict aneurysm sac enlargement post‐EVAR. The aim of this review is to summarize all risk factors that may condition an aneurysm sac enlargement so that one could adapt the best follow‐up method to each patient according to the risk score.

Most of those risk factors are described in this review: advanced age, hostile necks, endoleak occurrence or even systemic inflammation. These constitute important determinants that predict a worst prognosis pre‐operatively.

The early identification of these risk factors have remarkable implications in the follow up strategy. Patients with none or only one risk factor may be suitable for a US‐Dupplex follow‐up, while those patients with several pre‐operative risk factors could be good candidates for Angio‐Computed Tomography surveillance, which presents more sensivity in the detection of complications, despite its greater iatrogeny.

Objectives

Estimate the frequency, risk factors and survival rate in amputated patients.

Methods

Retrospective single center analysis of the electronic clinical data of 297 consecutive patients who underwent amputation between January 2008 and August 2009. Time‐dependent event rates were estimated by the Kaplan‐Meier method. The differences between groups were evaluated with the Log Rang test. The age impact on mortality was estimated by a Cox regression model. A P value below 0,05 was considered statistically significant.

Results

The predominant surgery etiology was Peripheral Arterial Disease (87%). The survival rate at 30, 90, 365 days and at 5 years in patients who underwent minor amputation was 95% (EP = 0.02), 91% (EP = 0.03), 79% (EP = 0.04) e 55% (EP = 0.05) respectively. In patients who underwent major amputation was 82% (EP = 0.03), 70% (EP = 0.03), 62% (EP = 0.03) e 35% (EP = 0.03) respectively. The presence of ischemic heart disease and cerebrovascular disease had a significant impact as a predictive factor of less survival. There was a higher survival in diabetic patients. The mortality rate at 30, 90, 365 days and at 5 years was 12% (EP = 0.02), 23% (EP = 0.03), 33% (EP = 0.03) and 59% (EP = 0.03) respectively. A statistically significant association between age and mortality was seen (p< 0.05).

Conclusion

There is a high mortality rate in amputated patients, in the first 30 days, being always higher when major amputations are considered. We can associate these results to increasing aging population which carries more comorbidities and lower recoverability. However, we must reflect on the no less significant role of demand and access to specialized care.

Background

The goal of this study is to determine the influence of abdominal aortic aneurysm (AAA) anatomy in endovascular aneurysm repair (EVAR) short and mid‐term outcomes.

Methods

A total of 112 patients underwent programed aorto‐biiliac EVAR at a single center between January 2011 and December 2013. Pre and postoperative imaging follow‐up were retrospectively reviewed and anatomical measures were calculated on Osirix® with center lumen line. Only patients with a postoperative imaging follow‐up of more than 12 months were included, resulting in the exclusion of thirty three (29%) cases. Patients were divided into 2 groups: the “EVAR suitable anatomy” group (f‐IFU) and the “EVAR challenging anatomy” group (df‐IFU).

Results

A total of 35.5% (n = 28) patients were in the df‐IFU group. These patients had larger AAA diameter (64.4 ± 10.1 mm vs 60.6 ± 10.8 mm) and shorter proximal neck (19.8 ± 11.8 mm vs 30.4 ± 14.4 mm) (p < 0.05).

The device preferentially used was Endurant® (54,5%). The df‐IFU group was more likely to be treated with suprarenal fixation devices (85.7% df‐IFU vs 69% f‐IFU, p = .048).

Mean follow‐up was 21,9 ± 9,8 months (12‐46).

Perioperative mortality (0% df‐IFU vs 2% f‐IFU) and all‐cause mortality rates (12% df‐IFU vs 11,9% f‐IFU) were similar between the two groups (p > 0.05). There was no significant difference in endoleak rate (short‐term 25% df‐IFU vs 22% f‐IFU; mid‐term 12% df‐IFU vs 23.8% f‐IFU) and in re‐intervention rates (short‐term 7.2% df‐IFU vs 8% f‐IFU; mid‐term 4% df‐IFU vs 4.8% f‐IFU)(p > 0.05).

Conclusion

Endovascular treatment of AAA patients with challenging anatomy for EVAR provided acceptable short and mid‐term results that are comparable to those in patients with suitable anatomy. Long‐term follow‐up is unreliable necessary to confirm these results.

Renal allograft anastomotic pseudoaneurysms (AP) are rare though associated with high rates of graft loss and mortality. Intrinsic transplantation mechanisms regarding active immunosuppression and/or chronic rejection increase susceptibility for their development, having a prognostic impact. We present a case report of successful surgical treatment of a 6 cm right iliac transplant patch pseudoaneurysm, diagnosed following an episode of acute obstructive renal insufficiency caused by AP ureteral compression. Treatment consisted, by a transperitoneal approach, in partial AP resection, antegrade termino-terminal renal artery re-implantation in the external iliac artery and right lower limb revascularization with extra-anatomical femoro-femoral crossover 8 mm PTFE bypass. There were no post-operative complications and renal function normalized to previous values.