RESUMEN

INTRODUCTION: Repair of thoracoabdominal aortic aneurysms (TAAAs) represents a technical challenge regardless of which technique is used. Open surgical repair (OSR) is the time-tested option against which novel techniques must be compared and it is still considered the gold standard option for younger, fit patients with heritable aortic diseases. Endovascular repair offers a less-invasive alternative in patients with suitable anatomy. This article aims to present a tabular review of the contemporary published data on endovascular repair of TAAAs using fenestrated-branched techniques. EVIDENCE ACQUISITION: The published literature for single-center and multicenter studies evaluating the outcomes of FB-EVAR for TAAAs was searched using MEDLINE and Embase databases. Studies published between January 1st 2010 and July 11th 2024, in the English language which provided data on FB-EVAR of TAAAs with more than fifty reported cases were included. EVIDENCE SYNTHESIS: The average patient age at time of repair was 71 years old with majority of males (65.5%). Most patients presented with a Crawford Extent II TAAAs (21.6%), followed by Extent III (21.2%). Early mortality was 4.9% for the entire cohort. The most prevalent adverse event was acute kidney injury (9.4%), followed by spinal cord injury (8.0%). CONCLUSIONS: FB-EVAR of TAAAs continues to evolve. Pooled analysis of early mortality and morbidity is lower in this tabular review than historical outcomes of open TAAA repair.

RESUMEN

OBJECTIVES: The Iliac Sandwich is an off-label technique that uses parallel stent grafts to treat aortoiliac aneurysms. The purpose of this experimental study is to evaluate the conformability and juxtaposition of stent grafts combinations used in this technique through in-vitro mechanical evaluation, computed tomography (CT) analyses, and a controlled pulsatile flow system. METHODS: The combinations of two Viabahn® ("V-V") or Viabahn® and Excluder® iliac extension ("V-E") were analysed using CT imaging with measurement of the gutter area by two independent analysts before and after balloon angioplasty. In a second phase, the parallel stent combinations were also evaluated using CT imaging after being implanted in the aortic aneurysm model with a pulsatile flow system with controlled temperature, viscosity, and density. RESULTS: The "V-E" group had a better conformability when compared to the "V-V" group, ensuring smaller gutter areas (0.0064 cm2 ± 0.01 vs. 0.0228 cm2 ± 0.03, p < 0.001). Post dilatation with two non-compliant balloons resulted in enlargement of the gutter area (Area A, p 0.065; Area B, p 0.071). Conversely, post dilatation with a non-compliant balloon for the internal iliac component and a compliant balloon for the external iliac device reduced the gutter area (Area A, p 0.008; Area B, p 0.010). CONCLUSION: The combination of Viabahn® and Excluder® iliac extension device ("V-E") had a smaller gutter area compared to two Viabahn® parallel stents for the Iliac Sandwich Technique. Post dilatation using a non-compliant balloon for the internal iliac device and a compliant balloon for the external iliac provided superior conformability and juxtaposition.

Asunto(s)

Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma Ilíaco , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Humanos , Aneurisma Ilíaco/cirugía , Diseño de Prótesis , Stents , Resultado del Tratamiento

Asunto(s)

Cirujanos/tendencias , Enfermedades Vasculares/cirugía , Procedimientos Quirúrgicos Vasculares/tendencias , Brasil/epidemiología , COVID-19/mortalidad , Educación de Postgrado en Medicina/tendencias , Humanos , Internado y Residencia/tendencias , Cirujanos/educación , Enfermedades Vasculares/diagnóstico , Enfermedades Vasculares/mortalidad , Procedimientos Quirúrgicos Vasculares/educación

RESUMEN

Purpose: To demonstrate an off-the-shelf multibranched (t-Branch) modification to allow intercostal arteries preservation during juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aortic aneurysm repair. Technique: The t-Branch is an off-the-shelf device not customized for specific patient anatomy and may be offered for urgent endovascular repair for patients with complex aortic aneurysms. However, a concern when treating patients who do not aneurysms extending above the celiac axis is that the more proximal extension which is required with this device may render patients at high risk for spinal cord injury. We report a novel technique with t-Branch modification performing a 180° fabric back windows at the first 2 sealing stents that allow perfusion to the intercostal arteries. Conclusion: T-Branch-PIA (preserving intercostal arteries) modification limits intercostal arteries coverage while optimizing proximal seal zone in juxtarenal, pararenal, paravisceral, and extent IV thoracoabdominal aneurysms, thereby may decrease the risk of spinal cord injury.

Asunto(s)

Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aorta Torácica , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Humanos , Diseño de Prótesis , Stents , Resultado del Tratamiento

RESUMEN

OBJECTIVE: This study reports the technical aspects and 30-day outcomes of the prospective, multicenter early feasibility study designed to evaluate the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz). METHODS: Thirteen patients with pararenal or extent IV thoracoabdominal aortic aneurysms were prospectively enrolled at five U.S sites and one non-U.S. site from 2014 to 2016. The TAMBE included four portals with either retrograde or antegrade renal portal configuration and used GORE VIABAHN Balloon-Expandable Endoprosthesis (W. L. Gore & Associates) for stenting of the renal and mesenteric arteries. The primary end point was procedural safety at 30 days, defined by absence of major adverse events, including any-cause mortality, myocardial infarction, stroke, paraplegia, bowel ischemia, respiratory failure, severe acute kidney injury (>50% decline in estimated glomerular filtration rate), dialysis, and procedural blood loss >1000 mL. RESULTS: There were 11 male and two female patients with a mean age of 69 ± 8 years. Mean aneurysm diameter was 61 ± 13 mm. A total of 52 renal and mesenteric arteries were incorporated (4 vessels/patient). Technical success was achieved in 12 patients (92%). One patient had inadvertent occlusion of a right renal artery due to dissection. There was no mortality, aneurysm rupture, conversion to open repair, dialysis, or spinal cord injury. Mean length of hospital stay was 5 ± 3 days. At 30 days, four patients (31%) had major adverse events, all due to procedural blood loss >1000 mL. One patient had a type I endoleak at the distal renal branch, which was successfully treated by placement of an additional renal stent before dismissal. Computed tomography angiography at 30 days showed patent target vessels and no type I or type III endoleak. CONCLUSIONS: This study confirms the early feasibility of the TAMBE for treatment of pararenal and extent IV thoracoabdominal aortic aneurysms. The high technical success, no mortality, and low morbidity rate support continuation of clinical investigation in a larger population of patients.

Asunto(s)

Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Implantación de Prótesis Vascular/efectos adversos , Brasil , Procedimientos Endovasculares/efectos adversos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados no Aleatorios como Asunto , Complicaciones Posoperatorias/terapia , Estudios Prospectivos , Diseño de Prótesis , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos

Asunto(s)

Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Humanos , Resultado del Tratamiento

RESUMEN

OBJECTIVE: The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) and present a new classification system for assessment of AWT burden. METHODS: The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F-BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal-mesenteric (C). Volumetric measurements (cm3) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30-day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease [RIFLE]), and solid organ infarction. RESULTS: The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016). CONCLUSIONS: AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F-BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients.

Asunto(s)

Aneurisma de la Aorta Torácica/cirugía , Aortografía/métodos , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/instrumentación , Stents , Trombosis/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Implantación de Prótesis Vascular/efectos adversos , Embolia/etiología , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Riñón/fisiopatología , Enfermedades Renales/etiología , Enfermedades Renales/fisiopatología , Masculino , Valor Predictivo de las Pruebas , Diseño de Prótesis , Interpretación de Imagen Radiográfica Asistida por Computador , Estudios Retrospectivos , Factores de Riesgo , Trombosis/clasificación , Trombosis/complicaciones , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

PURPOSE: To describe a novel endovascular bailout technique for successful completion of target vessel stenting during branched stent-graft repair of thoracoabdominal aortic aneurysms (TAAA) after encountering difficulties with standard catheterization techniques. TECHNIQUE: Technical difficulties when using fenestrated and branched grafts should be expected, especially in difficult anatomy or when an off-the-shelf device (eg, standard 4-branch device) is used that does not perfectly "match" the anatomy. The "snare-ride technique" facilitates antegrade transaxillary side branch catheterization and stent placement during TAAA branched grafting using a snare via a transfemoral approach. The branch of the graft is catheterized from an axillary access. The respective target vessel is then catheterized via a femoral access. An Indy snare is advanced over the transfemoral wire and positioned near the entrance of the target vessel. The transaxillary wire inside the branch of the graft is then advanced, snared, and pushed inside the target vessel with the snare. The procedure is thereafter continued with antegrade bridging of the target vessel in routine fashion. CONCLUSION: The snare-ride technique can be a useful maneuver to catheterize target vessels with difficult anatomy in TAAA branched stent-graft repair. Early experience shows safety and feasibility.

Asunto(s)

Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Cateterismo Periférico/métodos , Procedimientos Endovasculares/métodos , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/fisiopatología , Aortografía , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/instrumentación , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Humanos , Diseño de Prótesis , Stents , Factores de Tiempo , Resultado del Tratamiento , Dispositivos de Acceso Vascular

RESUMEN

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Asunto(s)

Pérdida de Sangre Quirúrgica , Tumor del Cuerpo Carotídeo/cirugía , Traumatismos del Nervio Craneal/etiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Puntos Anatómicos de Referencia , Brasil , Tumor del Cuerpo Carotídeo/complicaciones , Tumor del Cuerpo Carotídeo/diagnóstico por imagen , Tumor del Cuerpo Carotídeo/patología , Colombia , Angiografía por Tomografía Computarizada , Traumatismos del Nervio Craneal/diagnóstico , Bases de Datos Factuales , Europa (Continente) , Femenino , Hong Kong , Humanos , Modelos Logísticos , Angiografía por Resonancia Magnética , Masculino , México , Persona de Mediana Edad , Oportunidad Relativa , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Base del Cráneo/diagnóstico por imagen , Resultado del Tratamiento , Carga Tumoral , Ultrasonografía , Estados Unidos , Adulto Joven

RESUMEN

Symptomatic occlusion of the superior mesenteric artery can be treated by open repair, hybrid procedure, or endovascular revascularization. In most cases, endovascular procedures are done by the antegrade approach. We report a case of a 67-year-old woman who presented with acute-on-chronic mesenteric ischemia successfully treated by retrograde endovascular recanalization of an occluded common hepatomesenteric trunk through the inferior mesenteric artery and arc of Riolan.

RESUMEN

OBJECTIVE: Percutaneous endovascular aortic repair (PEVAR) has been increasingly used to treat infrarenal abdominal aortic aneurysms, but few studies have evaluated the results in complex aortic aneurysms. We reviewed the technical success and clinical outcomes of PEVAR using large-diameter sheaths for the treatment of complex aortic aneurysms with thoracic, fenestrated, and branched stent grafts. METHODS: The clinical data of patients who underwent total PEVAR for descending thoracic aneurysm, thoracoabdominal aortic aneurysm, pararenal, and aortoiliac aneurysms using thoracic, fenestrated, and branched stent grafts between 2009 and 2014 were reviewed. Repairs with fenestrated-branched stent grafts were performed using commercially available or investigational devices under a physician-sponsored investigational device protocols. Percutaneous closure was performed using ultrasound guidance and two Perclose devices (Abbott Vascular, Santa Clara Calif) per femoral puncture site. End points were technical success, access-related complications, morbidity, and mortality. RESULTS: There were 102 patients, 77 male and 25 female, with a mean age of 75 ± 8 years. Aneurysm extent was pararenal in 48 patients (47%), thoracoabdominal aortic aneurysm in 27 (26%), descending thoracic aneurysm in 19 (19%), and aortoiliac in 8 (8%). Fenestrated or branched endografts, or both, were placed in 72 patients (71%). Total percutaneous closure was performed in 170 femoral arteries using ≥20F-diameter sheaths in 163 (96%). Technical success was obtained in 161 femoral arteries (95%). There were no factors associated with technical failure. Access-related complications occurred in five patients (5%), including femoral artery thrombosis in three (3%), and retroperitoneal hematoma or pseudoaneurysm in one patient each (1%). There were no 30-day deaths. Freedom from access-related complications was 97% ± 1% at 30 days and 1 year. No access-related complications occurred >30 days. CONCLUSIONS: Total percutaneous technique can be safely performed with a high technical success rate and low rate of access complications in patients with thoracic and complex aortic disease requiring large-diameter sheaths. The rate of access-related complications (5%) is similar to that reported for PEVAR of infrarenal abdominal aortic aneurysms using smaller-profile devices.

Asunto(s)

Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular/métodos , Prótesis Vascular , Procedimientos Endovasculares/métodos , Stents , Anciano , Implantación de Prótesis Vascular/instrumentación , Procedimientos Endovasculares/instrumentación , Femenino , Arteria Femoral , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Resultado del Tratamiento

RESUMEN

Vários estudos prospectivos de escolha aleatória confirmaram a eficácia da endarterectomia de carótida na prevenção de novos acidentes vasculares cerebrais (AVC) em pacientes sintomáticos com estenose grave na carótida. Entretanto, o timing da endarterectomia ainda é controverso. A cirurgia precoce pode estar associada à hemorragia intracerebral e à extensão do infarto inicial. A cirurgia tardia pode expor o paciente à recorrência do AVC e à oclusão da artéria carótida. Os estudos que avaliaram o intervalo de tempo para a endarterectomia são retrospectivos e não randomizados. Na ausência de um estudo prospectivo randomizado comparando endarterectomia precoce e tardia, uma abordagem para se interpretar os resultados das séries cirúrgicas é a comparação destes com a história natural do AVC isquêmico. Os autores descrevem os argumentos em favor da cirurgia precoce, a história natural do AVC isquêmico e os fatores de risco associados ao AVC no perioperatório da endarterectomia.

---

Recent randomized clinical trials have confirmed the role of carotid endarterectomy in the prevention of a second stroke in patients with a recent stroke and severe carotid stenoses. However, the timing of the operation is still controvertial. Early surgery has been associated with cerebral hemorrhage and infarct extension. Delayed endarterectomy exposes the patient to recurrent stroke and carotid occlusion. The clinical studies addressing this problem are retrospective and nonrandomized. In the absence of a prospective randomized trial comparing early and late surgery, one approach to interpreting the surgical studies is to compare them with the natural history of stroke. The authors describe the rationale for early surgery, the natural history of ischemic strokes and the risk factors associated with perioperative strokes in patients undergoing endarterectomy.

RESUMEN

O sangramento gastrintestinal macico e uma complicacao incomum da febre tifoide, ocorrendo em 4 por cento dos pacientes com esta patologia. Neste artigo os autores revisam a literatura e relatam o caso de uma paciente jovem com sangramento importante devido a febre tifoide

Asunto(s)

Femenino , Adulto , Fiebre Tifoidea/complicaciones , Hemorragia Gastrointestinal

RESUMEN

Na última década foram descritos cinco casos de síndrome de Mallory-Weiss associada ao preparo colonoscópico com polietilenoglicol ou soluçao salina. Neste artigo, os autores revisam a leteratura e relatam o caso de paciente com essa complicaçao após o preparo com manitol.

Asunto(s)

Humanos , Femenino , Anciano , Colonoscopía/efectos adversos , Manitol/efectos adversos , Síndrome de Mallory-Weiss/etiología

RESUMEN

Säo investigados os hábitos alcoólicos segundo sexo, idade, religiäo, desempenho escolar, estrutura familiar e trabalho de um grupo de adolescentes com idade variando entre 10 e 18 anos, selecionados aleatoriamente em escolas públicas de Porto Alegre, com o objetivo de relacionar o padräo de consumo com o grau de escolaridade dos pais, assumindo este dado como um indicador do nível sócio-econêmico. Padronizaram-se os níveis de ingesta em gramas de álcool por mês ,agrupando-se os adolescentes em näo-bebedores (NB), bebedores experimentais (BE), bebedores regulares moderados (BRM) e bebedores regulares excessivos (BRE). A amostra constitui-se de 571 adolescentes. A prevalência de consumo de álcool em nosso estudo foi de 78,9 por cento, sendo ligeiramente maior nas mulheres (80,1 por cento) do que nos homens (77,3 por cento), porém com maior número de BRE entre os homens (7,7 por cento) do que entre as mulheres (2,2 por cento). Observamos que a ingesta aumenta com a idade em todos os grupos de consumo. Näo foi encontrada relaçäo significativa entre o padräo de consumo e o nível de escolaridade dos pais. A alta prevalência de consumo de álcool em nosso meio e o fato de que 5 por cento dos estudantes apresentam um consumo excessivo permitem concluir que a ingestäo de álcool nesta faixa etária representa näo apenas um problema epidemiológico, mas também clínico, justificando a necessidade imediata de medidas preventivas

Asunto(s)

Humanos , Niño , Adolescente , Consumo de Bebidas Alcohólicas/epidemiología , Conducta del Adolescente , Escolaridad , Factores Socioeconómicos