Endovascular Treatment of Aortic Aneurysms with Complex Proximal Anatomy

Background: There are few publications on patients with juxta or pararenal aneurysms, defined as abdominal aortic aneurysms without a proximal neck suitable for standard endovascular anchoring. We present our experience for their endoluminal repair. Methods: This was an observational and prospective study. The results were evaluated at 30 days and up to 2 years in patients consecutively treated with fenestrated or chimney endografts. Results: Between July 2015 and July 2017, 21 complex endovascular procedures were performed. Thirteen industrially tailored fenestrated devices and 4 physician-fenestrated devices were implanted. Four patients were treated using the chimney technique. Thirty-three fenestrations (2.5 fenestrations/patient) and 15 chimneys (1.8 stents/patient) were manufactured. Events at 30 days included 4.7% mortality and 9.4% branch occlusions, which were re-permeabilized. Among these patients, 2 presented type I endoleak that was repaired. Mean follow-up time was 15 months. In the 2-year Kaplan-Meier analysis, overall survival was 91.7%; primary blood vessel patency was 85.7% and secondary patency 100%. Type I or type III endoleak-free survival was 91.7% at 1 year, and 81.5% at two years. No mortality associated with the aneurysm or its rupture was recorded during follow-up. Conclusions: These results show a current, effective and safe option for patients with complex aortic aneurysms, using a minimally invasive tailored approach. Probably, these results have consolidated a more important role of these techniques in the treatment of patients with complex aortic aneurysms.Introducción: Existen pocas publicaciones sobre pacientes con aneurismas yuxta o pararrenales, definiendo así a los aneurismas de aorta abdominal sin un cuello proximal adecuado para el anclaje endovascular estándar. Presentamos nuestra experiencia para su reparación endoluminal. Material y métodos: Estudio observacional y prospectivo. Se evaluaron los resultados a 30 días y hasta 2 años en los pacientes consecutivamente tratados mediante endoprótesis fenestradas o endoprótesis en chimeneas. Resultados: Entre julio de 2015 a julio de 2017 realizamos 21 procedimientos endovasculares complejos. Se implantaron 13 dispositivos fenestrados hechos industrialmente a medida, 4 dispositivos fenestrados por los cirujanos. Fueron tratados 4 pacientes mediante técnica de chimenea. Se confeccionaron 33 fenestraciones (2,5 fenestraciones/paciente) y 15 chimeneas (1,8 stents/paciente). Eventos a 30 días: 4,7% mortalidad; 9,4% oclusión de rama, ambas repermeabilizadas. De esos pacientes, 2 presentaron un endoleak tipo I, y ambos fueron reparados. El tiempo medio de seguimiento fue de 15 meses. En el análisis de Kaplan-Meier a 2 años, la supervivencia global fue de 91,7%; la permeabilidad primaria del vaso fue de 85,7% y, la secundaria, de 100%. La supervivencia libre de endoleak tipo I o III fue de 91,7% al año, y de 81,5% a dos años. No se registró mortalidad asociada al aneurisma o a su ruptura mismo durante el seguimiento. Conclusiones: Estos resultados muestran una opción actual, efectiva y segura, para pacientes con aneurismas aórticos complejos, mediante un abordaje mínimamente invasivo, diseñado a medida. Es probable que estos resultados hayan consolidado un papel más importante de estas técnicas en el tratamiento de los pacientes con aneurismas aórticos complejos

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2