Scielo RSS http://scielo.pt/rss.php?pid=1646-706X20230003&lang=es vol. 19 num. 3 lang. es http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300163&lng=es&nrm=iso&tlng=es http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300167&lng=es&nrm=iso&tlng=es Abstract Introduction: Chimney EVAR (ChEVAR) for the treatment of complex abdominal aortic aneurysm (AAA) has been largely relegated for when fenestrated endografts are unavailable, especially due to durability concerns. However, the off-the-shelf nature of ChEVAR makes it a good option for emergent AAA repair. We report our institutional experience in ChEVAR in an urgent setting. Methods: ChEVAR procedures were collected f rom 2019 to 2023 in a tertiary hospital, and a retrospective analysis was performed. This includes gathered information f rom electronic medical records, surgical reports and the picture archiving system. Descriptive statistics were applied. The main endpoints were technical success,30-day and 1-year survival. Results: Five patients were submitted to urgent aneurysm repair using the chEVAR technique. Average age was 73,4 years and all patients were male. Arterial hypertension was present in 100% patients and all patients were ASA 4. Indications for surgery were post EVAR type 1a endoleak with associated rupture or abdominal pain in two patients; symptomatic/contained rupture of pararenal AAA in two patients; and contained rupture of a thoracoabdominal aneurysm in one patient. A total of eight target vessels were catheterized: two patients required single-vessel chimney and the remainder two-vessel chimney. Target vessels were two superior mesenteric arteries and six renal arteries. Technical success rate was 100% and 30-day mortality was 0%. There were no major complications. Follow-up time is 20.2 months (4.7-38). Target vessel patency during the follow-up period was 87.5%. Three patients (60%) died due to non-aortic related pathologies, on average 18 months after surgery (4.7-38), with a 1-year survival of 80%. Conclusion: Our experience with ChEVAR for emergent AAA repair is satisfactory, with high technical success rates and low short-term mortality. Sac regression, low rates of target vessel occlusion and type 1a endoleaks reveal a favourable profile for aneurysm exclusion. ChEVAR is a viable option in emergent setting for patients unfit for open repair. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300171&lng=es&nrm=iso&tlng=es Abstract Introduction: Peripheral arterial disease has become a worldwide problem, with chronic limb-threatening ischemia(CLTI) being its most extreme manifestation. Recently, endovascular strategies evolved and became the first approach in many revascularization procedures. However, infrapopliteal (IP) disease is still a therapeutic challenge. This study aims to present a surgical technique, named inverted T bypass, that can be applied to patients with: an IP artery with poor collateralization to the foot, an infra-malleolar artery with poor runoff and availability of only a short venous graft. Methods: A single-center retrospective analysis of all patients submitted to inverted T bypass. The end points of the present study were limb-based patency (LBP), primary patency (PP) and secondary patency (SP) rates, freedom from CLTI, recurrence of CLTI, freedom from major index limb amputation, amputation free-survival, and overall survival. Results: A total of twenty-five patients with CLTI (68% male) with a median age of 77 years were submitted to 25 inverted T bypasses. The median follow-up was 25 months (interquartile range of 32). Twenty-one preoperative angiographies were performed. Severe femoropopliteal (FP) and IP anatomic patterns (GLASS FP and IP grade 4) were predominant (57% and 86%, respectively) with 100% of limbs classified as GLASS stage III. Three patients (12%) had previously failed endovascular treatment. LBP, PP and SP were, respectively, 75%, 75% and 79% at 1 year, and 61%, 61% and 64% at 2 years. After one year, 86% of the limbs were free from CLTI and 79% of them remained without recurrences during a follow-up of 2 years. Eighty-one percent of the patients were free from major index limb amputation at 2 years. Conclusion: The inverted T bypass is a creative surgical solution for CLTI patients with poor runoff and lacking an adequate venous graft. The results are promising, rendering this technique a viable option for distal and ultra-distal revascularization in complex cases. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300178&lng=es&nrm=iso&tlng=es Abstract Introduction: The descending thoracic aorta (DTA) has been used as inflow mostly as a secondary option for revascularization after either graft failure/infection or other intra-abdominal pathologies contraindicating a standard abdominal aortic approach. The objective of this review is to summarize current evidence on the use of this inflow site for revascularization procedures. Methods: A comprehensive electronic literature search was performed, using PubMed and Embase databases. All literature published in English in the last 30 years was considered. The main goal was to assess the feasibility and practicality of implementing this approach in cases of severe and complex aortoiliac lesions. Results: Our review comprised 11 articles. DTA has been used predominately as a secondary option. The 30-day mortality rate was 4% (9/222). Secondary graft patency at 5-years was generally high across all studies. The use of DTA as inflow has been shown to be a safe and effective option for aorto-iliac reconstruction. Conclusion: DTA can be used safely as an inflow for lower-limb revascularization and it remains an important tool in the vascular surgeon's armamentarium. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300183&lng=es&nrm=iso&tlng=es Abstract Introduction: Spontaneous isolated visceral artery dissection is a quite rare condition and designates a dissection that originates in the visceral artery itself with no involvement of the aorta. The objective of this revision article is to summarize the current evidence on this rare pathology. Methods: A non-systematic literature search was performed using the PubMed database. Only English literature was considered. A narrative review was constructed, with the following headings: epidemiology; etiology; diagnosis; treatment; and follow-up. Results: The celiac trunk is very rarely affected by isolated dissection. Simultaneous isolated celiac and splenic artery dissection are even rarer with less than 50 cases described so far. Even if there are associated with several possible risk factors, their definitive etiology remains unknown. The clinical presentation is quite variable ad most of the patients can be handled medically. Nonetheless, careful follow-up appears to be recommended and endovascular or open surgery should be performed in case of complications. Conclusions: Spontaneous isolated celiac and splenic artery dissection are very rare and definitive etiology remains unknown. Individualized treatment and careful follow-up are recommended. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300186&lng=es&nrm=iso&tlng=es Abstract Introduction: Endovascular aortic repair (EVAR) has become the technique of choice in most vascular centres for abdominal aortic aneurysms (AAA). However, due to its low incidence, literature regarding secondary aortoenteric fistula (AEF) as an EVAR complication is still scarce. We aim to summarise the latest evidence on the topic through a narrative review. Methods: We conducted a MEDLINE literature search and included studies on secondary aortoenteric fistula, abdominal aortic aneurysms and endovascular aneurysm repair. Relevant studies were selected by reading of the titles and abstracts. Only English literature was considered. Results: Despite secondary AEF after EVAR first being reported in 1998, its incidence is hard to calculate, but is recognized to be lower (<0.5%) when compared to open aortic repairs (up to 1.6%). Aetiology may be categorised into local infection factors (pre-existent or associated with the procedure), mechanical factors associated with the aneurysm (such as anatomical shape and size) or mechanical factors associated with the stent graft (such as kinking, endoleak or endotension). Most common symptoms include abdominal or back pain, nausea, fever and gastrointestinal bleeding. Haemodynamic instability and shock at presentation is only present in less than a fifth of patients. Patients should be thoroughly submitted to a laboratory work-up, cultures and imaging tests, particularly CT scan and upper endoscopy. There are no guidelines regarding management, but it should include total graft excision along with arterial reconstruction (either in-situ or extra-anatomical), bowel repair and prolonged antibiotic therapy. Nonetheless, AEF is associated with a high mortality rate, even if adequate treatment is performed. Conclusion: Secondary AEF is an uncommon life-threatening complication after EVAR. Clinical presentation is non-specific, so a high level of suspicion is necessary to rapidly reach diagnosis. Treatment requires infection source control and prolonged antibiotic therapy. Considering the increasing use of endovascular devices, there is a need for future studies providing more insight on the most adequate treatment for this complication. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300191&lng=es&nrm=iso&tlng=es Abstract Background: Axillary artery aneurysms are rare. Due to their anatomical peculiarities, their therapeutic management is individualized. Minimal invasive endovascular treatments are gaining increased popularity. However, surgical solutions are associated with better long-term patency. Case report: We describe two cases of isolated axillary artery aneurysm, managed with surgical resection and graft interposition. The patients had not experienced any ischemic symptoms, pain or disabling swelling of the upper extremity. One patient underwent in situ reconstruction with a venous graft and the other with a prosthetic graft. The early postoperative recovery was uneventfull. After a follow-up time of 12 months, both reconstructions remain patent and with not upper limb symptoms. Conclusion: Surgical repair of axillary artery aneurysms is associated with good results, but larger cohorts are necessary to confirm our experience. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300195&lng=es&nrm=iso&tlng=es Abstract Background: Delayed arterial injury after total hip arthroplasty is unusual and the consequences of this complication are serious and potentially life threatening. Case report: We present a case of pseudoaneurysm of the external iliac artery occurring 6 years after total hip replacement revision due to infected acetabular cup protrusion. Due to the presence of prosthetic infection, the patient was managed with urgent ligation of external iliac artery and femoro-femoral bypass. Afterwards, a Girdlestone procedure was performed. This was selected according to patient comorbidities and previous interventions. The patient recovered ambulatory function and no late complications were observed. Conclusion: This report suggests that a careful and long-term follow-up of patients who have undergone hip surgery should be considered, as well as patient information regarding possible late complications. Moreover, treatment decision must be made according to patient circumstances, resources available and surgical experience. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300198&lng=es&nrm=iso&tlng=es Abstract Background: Endovascular mechanical thrombectomy (MT) changed acute ischaemic stroke management and is considered the standard of care for patients with proximal anterior circulation occlusion. MT improves functional independence, without an increase in mortality. Despite its advantages, up to 20% of patients treated with MT do not have successful recanalization, leading to poor clinical outcome. We present a case of an acute ischaemic stroke of the anterior circulation due to occlusion of the common carotid artery successfully submitted to surgical thrombectomy after failed MT. Case report: A 43-year-old male, with prior history of diabetes, hypertension, dyslipidaemia and heart failure was admitted at the emergency unit with acute bilateral lower limb ischaemia, due to cardioembolic phenomena. He was submitted to bilateral femoral thrombectomy and started endovenous unfractionated heparin. On the fifth postoperative day he developed sudden depression of cognitive status and left side hemiplegia of brachial predominance. Computed tomography angiography revealed an occlusion of brachiocephalic trunk, right subclavian artery and common carotid artery, preserving its branches. MT, performed by interventional neuroradiology, was unsuccessful (no recanalization or clinical improvement). After multidisciplinary discussion, the patient underwent urgent surgical thrombectomy through carotid and transaxillary approaches. Postoperatively, the patient’s mental status and left sided motor function recovered progressively over time. Three months after, patient maintains anticoagulation with warfarin, without neurological sequalae. Conclusion: The low rate of recanalization and poor clinical outcome after MT failure underlines the need for alternative rescue approaches. Surgical thrombectomy could represent a lifeline. More studies are needed to corroborate its efficacy in patients with anterior circulation acute ischaemic stroke. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000300201&lng=es&nrm=iso&tlng=es Abstract Background: Endovascular mechanical thrombectomy (MT) changed acute ischaemic stroke management and is considered the standard of care for patients with proximal anterior circulation occlusion. MT improves functional independence, without an increase in mortality. Despite its advantages, up to 20% of patients treated with MT do not have successful recanalization, leading to poor clinical outcome. We present a case of an acute ischaemic stroke of the anterior circulation due to occlusion of the common carotid artery successfully submitted to surgical thrombectomy after failed MT. Case report: A 43-year-old male, with prior history of diabetes, hypertension, dyslipidaemia and heart failure was admitted at the emergency unit with acute bilateral lower limb ischaemia, due to cardioembolic phenomena. He was submitted to bilateral femoral thrombectomy and started endovenous unfractionated heparin. On the fifth postoperative day he developed sudden depression of cognitive status and left side hemiplegia of brachial predominance. Computed tomography angiography revealed an occlusion of brachiocephalic trunk, right subclavian artery and common carotid artery, preserving its branches. MT, performed by interventional neuroradiology, was unsuccessful (no recanalization or clinical improvement). After multidisciplinary discussion, the patient underwent urgent surgical thrombectomy through carotid and transaxillary approaches. Postoperatively, the patient’s mental status and left sided motor function recovered progressively over time. Three months after, patient maintains anticoagulation with warfarin, without neurological sequalae. Conclusion: The low rate of recanalization and poor clinical outcome after MT failure underlines the need for alternative rescue approaches. Surgical thrombectomy could represent a lifeline. More studies are needed to corroborate its efficacy in patients with anterior circulation acute ischaemic stroke.