Prevalence of asymptomatic visceral occlusive disease in patients admitted for chronic lower limb ischemia: A cross-sectional study.

INTRODUCTION: Occlusive disease of the visceral vessels, when complicated, may lead to a high mortality rate. Current data regarding the co-prevalence of atherosclerotic disease of the lower limbs and visceral vessels is scarce. The aim of this study was to analyze the prevalence of splanchnic and renal visceral occlusive disease in patients admitted for chronic lower limb ischemia (CLLI). METHODS: A cross-sectional study was performed including 100 aleatory patients admitted for CLLI between 2015 and 2020, without previous or current history of mesenteric ischemia, and who were submitted to an abdominal computer tomography angiography (CTA) as part of the pre-operative work-up. The presence of splanchnic (celiac artery, superior and inferior mesenteric arteries) and renal atheromatous disease was defined as mild (30- 50% stenosis), moderate (50-70%) and severe (>70% or occlusion), measured by CTA. Outcomes analyzed included prevalence of splanchnic and renal visceral occlusive disease, evaluation of predictive factors for visceral occlusive disease and its relationship with the pattern of lower limb atherosclerotic disease. RESULTS: Mean age was 68.5 years old (SD: 9.7) and 77% were men. Admission diagnosis was incapacitating claudication (Rutherford stage 3) in 19%, and chronic lower limb threating ischemia (CLTI) in 81% (21% with stage 4 Rutherford and 60% with stage 5/6). Seventy-five percent presented aorto-iliac disease (AOID) and 97% presented infra-inguinal disease. Overall prevalence of visceral disease (mild, moderate or severe) was 65%. Severe disease was seen in at least one vessel in 60%. 34% of patients presented severe disease in only one visceral artery, 26% presented in ≥2 visceral vessels and 22% presented severe disease in all three splanchnic arteries. Regarding renal disease, 33% presented severe disease in at least one renal artery and 20% presented with bilateral disease. CLTI was significantly associated with a higher prevalence of severe stenosis in ≥2 splanchnic vessels, p=0.004. After logistic regression, we observed as predictive factor associated with severe disease in ≥2 splanchnic vessels the age, with an OR of 2.01 for every 10-year difference, p= 0.039; and AOID, OR: 14.6 (p=0.011). When analyzed the presence of at least one severe splanchnic vessel stenosis, AOID (OR 5.4, p=0.008) and coronary disease (OR:3.9, p=0.035) were predictive factors. Regarding renal disease, and association was found with age (OR of 3.90 for every 10-year difference, p<0.001); AOID (OR of 25.6, p=0.004) and carotid artery disease (OR: 9.24, p=0.005). CONCLUSION: Our study showed a high prevalence of multi-visceral and renal occlusive disease in patients admitted for chronic lower limb ischemia. We found an association between coronary and carotid disease with splanchnic and renal disease, respectively. Age was also associated with more severe stages of visceral and renal artery disease. More studies are needed to analyze the clinical impact of our findings regarding planning and follow-up for these patients.

Synchronous and metachronous thoracic aortic aneurysms in patients with abdominal aortic aneurysms : a systematic review and meta‐analysis

© 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are madeBackground: The prevalence of thoracic aortic aneurysms (TAA) in patients with known abdominal aortic aneurysms (AAA) is not well known and understudied. Our aim was to conduct a systematic review and meta‐analysis of the overall prevalence of synchronous and metachronous TAA (SM‐TAA) in patients with a known AAA and to understand the characteristics of this sub‐population. Methods and Results: We searched MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) from inception to November 2019 for all population‐based studies reporting on the prevalence of SM‐TAAs in a cohort of patients with AAA. Article screening and data extraction were performed by 2 authors and data were pooled using a random‐effects model of proportions using Freeman‐Tukey double arcsine transformation. The main outcome was the prevalence of SM‐TAAs in patients with AAAs. Secondary outcomes were the prevalence of synchronous TAAs, metachronous TAAs, prevalence of TAAs in patients with AAA according to the anatomic location (ascending, arch, and descending) and the differences in prevalence of these aneurysms according to sex and risk factors. Six studies were included. The pooled‐prevalence of SM‐TAA in AAA patients was 19.2% (95% CI, 12.3–27.3). Results revealed that 15.2% (95% CI, 7.1–25.6) of men and 30.7% (95% CI, 25.2–36.5) of women with AAA had an SM‐TAA. Women with AAA had a 2‐fold increased risk of having an SM‐TAA than men (relative risk [RRs], 2.16; 95% CI, 1.32–3.55). Diabetes mellitus was associated with a 43% decreased risk of having SM‐TAA (RRs, 0.57; 95% CI, 0.41–0.80). Conclusions: Since a fifth of AAA patients will have an SM‐TAA, routine screening of SM‐TAA and their clinical impact should be more thoroughly studied in patients with known AAA.info:eu-repo/semantics/publishedVersio

ENDOVASCULAR TREATMENT OF A JUXTARENAL AORTIC ANEURYSM WITH THE CHIMNEY TECHNIQUE

Endovascular treatment of juxtarenal aortic aneurysms is a complex challenge to the vascular surgeon. We present a case of an 83 year old man with a large juxtarenal aneurysm treated with an endovascular approach with chimneys to the left renal artery and superior mesenteric artery. Fenestrated aortic endovascular repair has been considered the preferred endovascular approach in juxtarenal aneurysms, however when the risk of rupture is considered high to wait for a manufactured device and/or when the anatomy is not suitable for a fenestrated repair, chimney endovascular repair is a viable and promptly available option.  This case report is an example of the applicability of this treatment with a positive short-term outcome as shown here

Fístula aorto-esofágica em doente com neoplasia do esófago - Caso clínico

As fistulas aorto-esofágicas (FAE) primárias são raras mas com elevada mortalidade devido à hemorragia digestiva substancial, necessitando intervenção rápida para garantir a sobrevivência do doente. Os autores apresentam um caso dum homem de 69 anos com carcinoma esofágico que teve episódio de hematemeses e choque hemorrágico. A endoscopia digestiva alta mostrou lesão ulcerada com hemorragia pulsátil, a angioTC confirmou o diagnóstico de FAE. Foi colocada endoprótese na aorta descendente para controlo da hemorragia; dois dias depois foi colocado stent esofágico para reduzir risco de infecção da endoprótese. O doente teve alta ao décimo terceiro dia, e não foi reportada hemorragia digestiva nos seis meses de seguimento. Este caso mostra como o TEVAR pode ser usado como tratamento paliativo ou temporário duma FAE

Incidence of acute aortic dissections in patients with out of hospital cardiac arrest: a systematic review and meta-analysis of observational studies

© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/Objectives: Acute Aortic dissection (AAD) may present as out-of-hospital cardiac arrest (OHCA). However, the incidence of this presentation is not well known. Our aim was to perform a systematic review and meta-analysis of all observational studies reporting on the incidence of AAD in patients with OHCA. Methods: We searched MEDLINE, CENTRAL, PsycInfo, Web of Science Core Collection and OpenGrey databases from inception to March-2021, for observational studies reporting on the incidence of AAD in patients with OHCA. Data was pooled using a random-effects model of proportions. The primary outcome was the incidence of AAD in OHCA patients. Secondary outcomes were the incidence of type A aortic dissections (TAAD) and type B aortic dissections (TBAD) in OHCA patients, overall mortality following AAD-OHCA and risk of death in AAD-OHCA patients compared to risk of death of non-AAD-OHCA patients. Results: Fourteen studies were included. The pooled calculated incidence of OHCA due to AAD was 4.39% (95 %CI: 2.55; 6.8). Incidence of OHCA due to TAAD was 7.18% (95 %CI: 5.61; 8.93) and incidence of OHCA due to TBAD was 0.47% (95 %CI: 0.18; 0.85). Overall mortality following OHCA due to AAD was 100% (95 %CI: 97.62; 100). The risk of death in AAD-OHCA patients compared with non-AAD-OHCA patients was 1.10 (95 %CI: 0.94; 1.30). Conclusion: AAD as a cause of OHCA is more frequent than previously thought. Prognosis is dire, as it is invariably lethal. These findings should lead to a higher awareness of AAD when approaching a patient with OHCA and to future studies on this matter.info:eu-repo/semantics/publishedVersio

INFEÇÕES VASCULARES PROTÉSICAS — UMA REVISÃO NARRATIVA

As infeções vasculares protésicas continuam a ser um desafio médico complexo. A evolução da flora hospitalar e o desenvol- vimento da cirurgia vascular têm contribuído para uma mudança na realidade das infeções protésicas, tornando imperativo conhecer o contexto microbiológico atual destas infeções para o seu adequado tratamento. Estas infeções dependem de fatores endógenos e exógenos e variam consoante o tempo de apresentação, localização da prótese vascular e ambiente microbiológico do doente. A morbimortalidade associada a este diagnóstico é elevada e o tratamento deve ser adaptado ao doente em questão, sendo necessário conhecer o microrganismo e as várias possibilidades de tratamento existentes. O conhecimento dos fatores predisponentes da infeção protésica vascular, o seu reconhecimento precoce e prevenção deve ser realizada em todos os doentes e num contexto de cuidados de saúde multidisciplinares.

IMPLANTAÇÃO DA ENDOPRÓTESE RAMIFICADA OFF-THE-SHELF COOK® T-BRANCH®: ASPECTOS TÉCNICOS E TIPS AND TRICKS

Introdução: As próteses ramificadas off-the-shelf, como a Cook t-Branch®, surgiram como uma alternativa de rápido acesso no tratamento de aneurismas tóraco-abdominais (ATA). Objetivo/Técnica: Na nossa instituição a utilização da endoprótese Cook T-Branch® tem sido efetuada em casos urgentes e em alguns casos eletivos com anatomia favorável e em que é desaconselhável esperar pela confeção de um custom-made device (CMD). A experiência acumulada justifica o propósito deste artigo de revisão que pretende descrever a forma de implantação, algumas técnicas adjuvantes e algumas tips and tricks que poderão facilitar a curva de aprendizagem em centros com menor contacto com esta plataforma. Conclusão: A utilização de próteses ramificadas off-the-shelf, como a Cook T-Branch®, é uma alternativa segura e viável para o tratamento de ATA cuja principal vantagem é a rápida acessibilidade. Conforme avançamos na curva de aprendizagem e novas técnicas adjuvantes são adquiridas, a sua aplicabilidade aumentada de forma significativa, tanto no contexto urgente como eletivo

SINGLE CENTER REAL-WORLD ANALYSIS OF THE USE OF ILIAC BRANCHED DEVICES FOR AORTO- ILIAC ANEURYSM REPAIR

Introduction: Endovascular repair of aortic aneurysms is widely established. However, aorto-iliac aneurysms pose a challenge, specifically regarding distal sealing. A frequent approach is extending the iliac limb to the external iliac artery (EIA) with occlusion of the internal iliac artery (IIA), often with varying degree of pelvic ischemia causing significant morbidity. Iliac branched devices (IBD) allow for the creation of distal landing zones in the EIA and IIA, maintaining pelvic perfusion. We performed a descriptive analysis and outcome evaluation of IBD use in a single center patient cohort. Methods: An observational, descriptive, retrospective cohort analysis of all consecutive patients intended to treat with IBDs from Jan-2008 to Dec-2020 was performed. Technical success was defined as correct implantation of the IBD with confirmed patency of both EIA and IIA. We included all patients where at least one IBD was deployed, irrespective of additional procedures. Statistical analysis was performed using STATA 16, for Mac. Results: Of the initial 54 patients, 53 were included, (technical success 98,1%). Fifty-two were men (98.2%), mean age 73.5 years (SD 8.1). Mean aortic diameter was 56.4mm (SD 13.4), mean CIA aneurysm diameter 37.0mm (SD 12.7). A total of 60 IBD’s were performed (CookÆ Medical’s ZBIS device), of which 5 as part of complex aortic treatment with fenestrated endografts, 32 EVAR with unilateral IBD, 7 EVAR with bilateral IBD, 6 EVAR with unilateral IBD and contra- lateral extension to the EIA with embolization of the IIA and 3 isolated IBD (for type 1B endoleaks following EVAR or isolated iliac aneurysm). Peri-operative complications included acute kidney injury (AKI) (11,3% - 5/44), paraparesis and intestinal ischemia (1,9% each), one embolic intra-operatory stroke (1,9%) and one acute myocardial infarction (MI) (1,9%). Median follow-up was 9 months (IQR:16, 1-80months), during which 4,9% (2/42) developed type IB endoleaks, 4,9% (2/42) iliac aneurysm enlargement, 2,4% (1/42) limb kinking, 4,9% (2/42) limb occlusion, with a 7,14% (3/42) re-intervention rate. We found no association between limb patency and single, dual-antiplatelet treatment or anti-coagulation (p=0,6). There was no significative difference in AKI incidence between bilateral or unilateral IBD (irrespective of contra-lateral procedure). No in-hospital mortality was registered. There was one case of in-hospital death post-MI (1,9%), overall mortality 17% (9/53). Conclusion: In this cohort we found that the most common complication is AKI, apparently not directly related to the technique itself. Follow-up complications were few and mainly associated to loss of distal seal or limb occlusion, but implying a considerable re-intervention rate

TREATMENT OF AORTIC DISSECTIONS USING A COMBINATION OF THE STABILISE AND CERAB TECHNIQUES — TECHNICAL NOTE

Introduction: Endovascular treatment of type B aortic dissection has focused on the covering of the proximal entry tear. However, recently, concern has emerged regarding the distal aortic remodeling and new techniques such as the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination (STABILISE) technique have gained more acceptance. We describe a technical note regarding the combination of the STABILISE technique in addition to the Covered Reconstruction of the Aortic Bifurcation (CERAB) technique to achieve complete aortic remodeling. Methods: The authors describe a stepwise approach regarding the endovascular repair of type B aortic dissections. A simple TEVAR is performed first. If the patient still shows signs of true lumen compression, a STABILISE technique is performed in order to achieve true lumen expansion and complete aortic remodeling. However, in some patients, false lumen perfusion and true lumen compression at the very distal aorta is maintained due to distal comunicating tears. In these patients, if there are still signs of infra-renal aortic or iliac compression/occlusion or distal thrombosis of the false lumen, a simultaneous CERAB is performed. Conclusion: By combining these techniques, we aim to cover both the proximal tear and the distal comunicating tears resulting in a complete flap apposition, false lumen obliteration, re-expansion of the true lumen and achieve optimal remodeling

POST-DISSECTION THORACO-ABDOMINAL ANEURYSMS: RESULTS OF OPEN AND ENDOVASCULAR REPAIR

Introduction/Objectives: Repair of post-dissection thoraco-abdominal aortic aneurysms (PD-TAAA) is a complex challenge. Choosing the correct approach to manage these aneurysms is not straightforward as both open and endovascular strategies are valid. Our aim was to analyze and compare the results of PD-TAAA treated by endovascular or open surgery. Methods: A seven-year (January-2013 and May-2020) single-center retrospective cohort study of patients with PD-TAAA treated by endovascular (group-1) or open (group-2) surgery was conducted. Primary outcome was in-hospital mortality. Secondary outcomes were organ lesion, in-hospital infections, length of stay (LOS), endoleaks, branch occlusions, re-interventions and mortality during follow-up. Results: Twenty-one patients (15-men) were treated: 8 in group-1 and 13 in group-2. The mean age was lower in group-2 [68 (SD:11) versus 48 (SD:12), p=0.004]. Three patients had connective tissue disease (CTD). Group-1 patients had a higher ASA score (p<0.001). In group-1, debranching and TEVAR were performed in 2 patients and custom-made fenestrated/ branched-endografts were used in 6. In group-2, there was one thoracic aorta interposition graft and reconstruction involving the visceral arteries ocurred in 12 patients. Seven cases were operated using the Crawford technique with visceral patch, and branched grafts were used in 3 patients with CTD. Intercostal arteries were revascularized in 5 patients. In-hospital mortality was 12% (1 patient) in group-1 and 15% (2 patients) in group-2, LogRank=0.9. The LOS was longer in group-2 (p=0.033), and there was a tendency for a longer stay in intensive care unit in this group. No difference was observed in spinal cord ischemia, acute kidney injury or re-interventions. There were more post-operative infections in group-2 (12% versus 69%, p = 0.017). During follow-up [median 15 months (IQR:55)], there was no mortality after discharge. In group-1, 14% had type-II-endoleaks, without aneurysmal sac dilation. Branch permeability during follow-up was 100% in group-1 and 95% in group-2, LogRank=0.3. Conclusion: Endovascular and open surgery of PD-TAAA allowed treatment of a wide variety of patients in this cohort. Patients treated by the endovascular surgery were older and had higher surgical risk but without repercussions on the outcomes. Open surgery was associated with longer hospital stay and more postoperative complications