Scielo RSS http://scielo.pt/rss.php?pid=1646-706X20240001&lang=en vol. 20 num. 1 lang. en http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100004&lng=en&nrm=iso&tlng=en http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100005&lng=en&nrm=iso&tlng=en http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100007&lng=en&nrm=iso&tlng=en http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100008&lng=en&nrm=iso&tlng=en Abstract Introduction: Spinal cord ischemia (SCI) is an uncommon but one of the most terrifying complications associated with the treatment of extensive aortic aneurysms. Its pathophysiology, risk factors, and event characteristics must be clarified. This study aimed to perform a descriptive analysis of the cases of SCI after complex aortic repair at our center and to understand which factors contributed to the event. Methods: A retrospective, single-center, cohort study of prospectively collected data was performed. From January 2013 to October 2022, we included all consecutive patients with thoraco-abdominal aneurysms (TAAA) and complex abdominal aneurysms submitted to an endovascular procedure using fenestrated or branched endografts. According to the Society for Vascular Surgery (SVS) reporting standards, SCI was defined as the development of new motor or sensitive deficits after endovascular treatment. Results: One hundred and thirty-five patients (87% male) were included, with a median age of 72. A total of 53,7% (n=72) had thoraco-abdominal aneurysms (type I-V), of which 63 were extent I-III\V and 9 were extent IV. In total, 12 (9%) SCI events were identified; 7 patients had a grade 2 SCI, 5 had a grade 3 injury, and all of them had a TAAA. Of these, 10 had pre-procedure cerebrospinal fluid (CSF) drainage. Five (42%) developed symptoms after 48 hours (delayed SCI), and seven patients developed early SCI, being identified on the first evaluation after surgery. Five cases received rescue CSF drainage (after the beginning of symptoms), with some degree of improvement observed in all cases. Among patients with grade 2 SCI (n=7), five recovered completely, one recovered partially (maintaining sensitive symptoms - grade 1), and one did not recover. This corresponded to an overall incidence of permanent SCI of 5.2% (n=7, any grade) and 1.5% of permanent paraplegia (n=2, grade 3, 2.8% only in TAAA). Conclusion: In this study, SCI only occurred in patients with TAAA, and the incidence of permanent paraplegia in this group was 2,8%. In five patients, rescue CSF drainage was applied, with some degree of clinical improvement. The small number of events precluded the investigation of predictors. Notably, 42% of SCI cases happened after 48 hours, showing a high prevalence of delayed SCI in this population. Consequently, more extended monitoring of these patients should be considered. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100015&lng=en&nrm=iso&tlng=en Abstract Introduction: Heterogeneity in the epidemiology, management, and in-hospital outcomes of patients with acute aortic syndromes can be found among male and female populations. This study aims to analyze sex-related differences in a cohort of patients treated in a tertiary university center. Methods: All patients admitted with acute aortic syndromes between January 2012 and January 2023 were retrospectively analyzed. A descriptive analysis of the data was performed, and the results were queried to explore sex-related differences according to the type of aortic syndrome, type of treatment (medical or surgical - conventional or endovascular), and the temporal phase of the disease in which this treatment occurred. A multivariable logistic regression was undertaken to identify variables associated with higher in-hospital mortality. Variables were included if statistically significant in the univariable analysis or if considered medically relevant. Results: A total of 116 patients (69% male) were included. Women were older (median age [interquartile range]: 64.6 years [40-85 years], n=36 versus 58.7 [23-84], n=80; P=0.034), had a higher proportion of intramural hematoma (19.4% versus 5.0%, P=0.014) and a lower proportion of aortic dissection (72.2% versus 88.8%, P=0.026) compared to men. Both sexes were more frequently treated with medical therapy alone (33.6%). However, women had a trend towards a lower proportion of open surgical management compared to men (16.7% versus 23.8%, P=0.391), as well as higher in-hospital mortality associated with this type of treatment (50.0% versus 21.1%, P=0.169). Additionally, women were associated with a higher conversion to endovascular or open surgery when first managed conservatively (13.9% versus 3.8%, P=0.046). In binary logistic regression, age was associated with higher in-hospital mortality (OR 1.056 [95% CI, 1.01-1.10]; P=0.014), but not female sex (OR 1.133 [95% CI, 0.39-3.30]; P=0.819). Conclusion: Women were older, had more intramural hematoma, and were associated with a higher conversion from medical to surgical treatment. After multivariable regression, age was associated with higher in-hospital mortality, but female sex was not. Larger cohorts are needed to understand if intervention in female patients will have an impact on intra-hospital mortality. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100020&lng=en&nrm=iso&tlng=en Abstract Introduction: After endovascular aortic repair (EVAR), many patients develop a systemic inflammatory response called post-implantation syndrome (PIS). AAA and procedure-related characteristics have been linked with increased odds of developing this syndrome. Similarly, some short- and long-term consequences have been associated with PIS. This study aims to review the literature on the diagnosis and predictors of post-implantation after endovascular repair of aortic aneurysms. Methods: A non-systematic review of the MEDLINE and Scopus databases was performed using the keywords "abdominal aortic aneurysm," "inflammation," and "endovascular techniques.” No time or language limitations were imposed. Manuscripts were considered irrespective of study design. Articles of interest were analyzed, and the relevant information was organized in tables. Results: PIS is defined as a combination of constitutional symptoms, including fatigue and fever, and elevated inflammatory markers. There are several proposed diagnostic criteria, most including a combination of fever with leukocytosis and/or elevated C-reactive protein (CRP). These result in discrepant rates, as low as 2% and up to 100%. The typical evolution of this syndrome is spontaneous resolution, although pharmacologic measures for symptom relief may be needed. These symptoms often resolve within two weeks; no significant permanent complications remain. Most PIS cases will present up to the first 72 postoperative hours. Endograft material, particularly polyester-based stent grafts, has been consistently linked to increased odds of PIS, up to five-fold, compared to polytetrafluoroethylene (PTFE) grafts. Aneurysm thrombus load (both pre-existing and new-onset) has also been related to an increased odds of PIS. Bacterial translocation, contrast media, and other patient or procedure-related characteristics have not been linked to an increased risk of PIS. Conclusion: PIS is a common finding after EVAR. Universal diagnostic criteria for diagnosis are required. Polyester-based stent grafts present the highest risk of developing this syndrome. Aneurysm thrombus load may also relate to this increased risk. The impact of other clinical or anatomical factors remains undetermined. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100025&lng=en&nrm=iso&tlng=en Abstract Introduction: Portuguese estimates point out that nearly 20% of aortic aneurysms are treated in a ruptured setting, with in-hospital mortality reaching up to 50%. Although unfractionated heparin (UFH) is routine during elective surgery, this technical point is debatable when treating ruptured aneurysms. The authors aimed to review the literature on the topic of intraoperative heparinization with UFH within the intraoperative period of ruptured aortic aneurysms. Methods: A MEDLINE and Scopus database search using the terms “unfractionated heparin," “aortic aneurysm," and “ruptured aortic aneurysm” was performed. No time or language limitations were imposed. The last search was run in July 2023. Manuscripts were considered irrespective of study design. Additional articles of scientific interest for the purpose of this non-systematic review were included by cross-referencing. Results: In the rupture setting, UFH usage rates have widely varied throughout time and geographical sites, and they are reported to be as low as 16%. Overall, the evidence of UFH in clinical practice in this scenario is limited. Notwithstanding, there is some evidence from observational studies of an increased pro-coagulant activity in this clinical scenario, favoring a theoretical physiologic benefit. A prospective, non-randomized study of 131 OSR patients found that patients treated with UFH had improved 30-day survival (84% vs 67%, P=0.001). Non-significant differences in blood product usage were noted. Therefore, societal guideline recommendations about intraoperative UFH in ruptured aortic aneurysms are often missing. Conclusion: UFH may potentially reduce death after open repair of rAAA. These findings should be carefully interpreted, as the evidence is scarce and heterogeneous and only portrays open repair. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100028&lng=en&nrm=iso&tlng=en Abstract Introduction: Carotid revascularization is a well-established technique for preventing stroke in patients with significant symptomatic or asymptomatic carotid artery stenosis. Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy (CEA), especially in high-risk surgical patients. However, restenosis after CAS is a potentially severe complication that can impact the medium and long-term success of the procedure and increase the risk of cerebrovascular events. Methods: Relevant articles on restenosis after carotid stenting were searched in the PubMed database. The selected studies were evaluated for quality and relevance, and the information was summarized to provide an overview of the causes, risk factors, diagnosis, and treatment options for restenosis after CAS due to atherosclerotic carotid artery disease. Results: Restenosis after CAS can occur due to various factors, including thrombosis, intimal hyperplasia, and stent migration. Several risk factors have been identified, such as age, diabetes, hypertension, dyslipidemia, and smoking. Restenosis can be diagnosed with carotid Doppler ultrasound, contrast-enhanced computed tomography, or arteriography. Treatment options include angioplasty with or without rescue stent placement, CEA associated with stent explantation, or medical treatment. Conclusion: Restenosis after carotid stenting is a potentially serious complication. It is especially important to identify the risk factors for restenosis and maintain close follow-up with patients after the procedure. The treatment of restenosis should be individualized. Further studies are needed to define the best strategies for preventing and treating restenosis after carotid stenting. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100032&lng=en&nrm=iso&tlng=en Abstract Introduction: Vascular migration and venous tumor thrombus are infrequent but unique aspects of renal cell carcinoma, and these features have significant therapeutic and prognostic implications. We report a case of renal neoplasm with a vena cava tumor thrombus treated with surgical resection and adjuvant chemotherapy. Case report: A 53-year-old, otherwise healthy woman presented to the emergency department due to macroscopic hematuria and abdominal pain. A large abdominal mass was noted. A computed tomography angiography was performed, and a right renal tumor (105x207mm) with level II inferior vena cava tumor thrombus and local adenopathy was noted. After a multidisciplinary discussion, she was proposed for surgical resection. Through a bilateral subcostal incision (Chevron), a standard right radical nephrectomy and perivascular lymph node excision were performed. The IVC was exposed, and a thrombectomy was performed through a longitudinal cavotomy. Pathology revealed clear renal cell carcinoma and lymph node metastasis. The postoperative period was uneventful. However, the patient developed multiple liver and lung metastases at early follow-up and was treated with chemotherapy. Discussion: Tumor thrombus can extend up to the right atrium and occurs in nearly 10-25% of renal cell carcinoma patients. The natural history of this condition is poor, with a median survival of 5 months and significant survival improvements following radical nephrectomy and IVC tumor thrombus removal are observed, with 40-60% 5-year survival. Surgical treatment should, therefore, be considered in this group of patients. Such operations can be challenging, particularly when thrombus extent is significant, and the combination of efforts between oncologists, urologists, and vascular surgeons can improve patient safety and perioperative outcomes with significant improvements in overall prognosis. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100035&lng=en&nrm=iso&tlng=en Abstract Background: Vascular malformations are a heterogeneous group of vascular development disorders with historically few treatment options. Recent studies have shown the potential benefit of mTOR inhibitors-such as sirolimus-in their treatment, particularly in low-flow malformations. However, reports on their efficacy in high-flow malformations are scarce and controversial. We report the case of a patient with a combined malformation who benefited from treatment with sirolimus. Report: A three-year-old patient was referred to our center with a diffuse and progressive vascular malformation on her right leg, difficult to classify according to ISSVA, with disabling pain, limb deformity, and walking impairment. The initial MRI showed a diffuse malformation on the deep subcutaneous tissue without muscle or bone involvement, measuring 18cm on the largest axis. A progressive clinical worsening occurred, and after discussion with an international reference center in vascular malformations, it was classified as a diffuse vascular malformation with the involvement of contiguous structures without defined borders, with both a low and high-flow component. The high-flow component now behaves like a type IV Yakes AVM. Nevertheless, long-term therapy with sirolimus was instituted when the patient was nine years old, resulting in complete remission of pain, recovery of walking ability, and partial recovery of knee valgus. No side effects were reported. With 38 months of follow-up, the 13-year-old remains pain-free and has improved quality of life despite no imagological improvement. Conclusion: Although the available evidence for mTOR inhibitors is mainly for low-flow malformations, it may be a safe and effective option for selected high-flow malformations when intervention is not possible or carries significant morbidity risks. Some studies showed a reduction in the size of the malformation with treatment; however, this was not the case in our patient, notwithstanding the clear improvement in quality of life for four years without other intervention. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100038&lng=en&nrm=iso&tlng=en Abstract Introduction: Fenestrated and branched stent graft technology has come a long way over the past few years, enabling the treatment of complex juxtarenal aneurysms, thoracoabdominal aneurysms, and arch pathologies. Many innovations have been developed, namely device and delivery optimization and technical tricks. These concepts have proven to work well when there is sufficient time to plan and manufacture a custom-made device for the patient. However, this is different in urgent or emergent cases. Using parallel graft techniques or off-the-shelf stent grafts may be efficient in urgent situations, but it is also associated with selection limitations. Recent publications have demonstrated similar mid-term technical and clinical results between physician-modified endografts (PMEGs) and customized devices. The authors aim to describe their institutional series of PMEGs. Methods: The clinical files of all patients undergoing PMEGs were consulted, and demographic data as surgery outcomes were collected. Technical success: creating the intended number of fenestrations, target vessel catheterization, and patency. Procedural success: technical success with adequate aneurysm exclusion and without endoleak in the final angiography. 30-day complications and mortality were also evaluated. Technical and procedural success were assessed, as well as morbidity and mortality. Results: Between December 2020 and December 2022, 3 patients underwent PMEGs. The indications were a juxtarenal aortic aneurysm, a type V thoracoabdominal aneurysm and a persistent type 1a endoleak. All patients were symptomatic, with one stable rupture. All cases were performed with technical and procedural success and no morbidity and mortality at 30 days. Conclusion: Stent graft modification is a valuable and valid tool in emergencies and should be a vascular surgeon's trump card when dealing with complex aortic pathologies. Nevertheless, due to the absence of long-term evidence, it should be reserved for acute patients unfit for open repair and in aneurysms with unfavorable anatomy for an off-the-shelf device. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100045&lng=en&nrm=iso&tlng=en Abstract Background: Mycotic aneurysm is a rare entity with rapid progression, which can be fatal without adequate treatment. The incidence of rupture is greater than that of degenerative aneurysms and is associated with a high mortality rate. Case report: We report the case of a 58-year-old man with a known history of HIV infection with good immunovirological staging, treated squamous cell carcinoma of the anal canal and chronic gastritis, who presented with a six-day history of intense back pain, malaise, fever, and chills. After examination, he was hospitalized with a clinical suspicion of acute pyelonephritis. During hospitalization, he was diagnosed with pneumonia of the right pulmonary base, infectious spondylodiscitis, and mycotic aneurysm of the abdominal aorta, which involved the visceral plaque. The microbiological workup revealed only positive blood cultures for Klebsiella pneumoniae. After a multidisciplinary discussion of the case and six weeks of antibiogram-oriented antibiotic therapy, the patient underwent an aorto-aortic interposition via left thoracophrenolaparotomy without the need to reimplant visceral vessels due to the patch configuration of the proximal anastomosis. The procedure was performed under left heart bypass. The postoperative course was uneventful, and the patient was discharged four weeks later. At 18 months follow-up, she remained asymptomatic and free of recurrence. Conclusion: In this case, it remains to be defined whether the cause of the mycotic aneurysm was hematogenous dissemination from the identified pneumonia or contiguity from the diagnosed spondylodiscitis. Given the morbidity and mortality associated with this entity, early diagnosis and adequate treatment with surgical correction and antibiotic therapy with sufficient duration and dose are important aspects for improving survival in these cases. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2024000100049&lng=en&nrm=iso&tlng=en Abstract Background: Mycotic aneurysm is a rare entity with rapid progression, which can be fatal without adequate treatment. The incidence of rupture is greater than that of degenerative aneurysms and is associated with a high mortality rate. Case report: We report the case of a 58-year-old man with a known history of HIV infection with good immunovirological staging, treated squamous cell carcinoma of the anal canal and chronic gastritis, who presented with a six-day history of intense back pain, malaise, fever, and chills. After examination, he was hospitalized with a clinical suspicion of acute pyelonephritis. During hospitalization, he was diagnosed with pneumonia of the right pulmonary base, infectious spondylodiscitis, and mycotic aneurysm of the abdominal aorta, which involved the visceral plaque. The microbiological workup revealed only positive blood cultures for Klebsiella pneumoniae. After a multidisciplinary discussion of the case and six weeks of antibiogram-oriented antibiotic therapy, the patient underwent an aorto-aortic interposition via left thoracophrenolaparotomy without the need to reimplant visceral vessels due to the patch configuration of the proximal anastomosis. The procedure was performed under left heart bypass. The postoperative course was uneventful, and the patient was discharged four weeks later. At 18 months follow-up, she remained asymptomatic and free of recurrence. Conclusion: In this case, it remains to be defined whether the cause of the mycotic aneurysm was hematogenous dissemination from the identified pneumonia or contiguity from the diagnosed spondylodiscitis. Given the morbidity and mortality associated with this entity, early diagnosis and adequate treatment with surgical correction and antibiotic therapy with sufficient duration and dose are important aspects for improving survival in these cases.