Angiologia e Cirurgia Vascular

Covered versus uncovered stents for malignant superior vena cava syndrome: a systematic review and meta-analysis

2024-10-13T02:56:48-07:00

INTRODUCTION: In recent years, endovascular stenting has emerged as a promising palliative therapeutic modality for carefully selected patients with Superior Vena Cava Syndrome (SVCS) secondary to intra-thoracic malignancies. However, a lack of data hinders procedure standardization, particularly regarding the dichotomy of covered versus uncovered stents. This study aims to compare the outcomes of malignant SVCS treated with covered versus uncovered stents. To the best of our knowledge, no past review has directly attained this dichotomy in malignant SVCS.

METHODS: A systematic review and meta-analysis were performed based in the PRISMA guidelines. COCHRANE and PUBMED databases were searched up to February 2024. Only original studies including 10 or more patients were considered. Primary outcomes were defined as technical and clinical success. Secondary outcomes were defined as primary and secondary patency, complications, recurrence of symptoms, reinterventions, and mean survival.

RESULTS: Our search yielded 17 studies, encompassing 1123 participants (109 submitted to covered stents and 1014 to uncovered stents). Technical success was very high in covered and uncovered stents: pooled data 100% (95% confidence interval [CI] not estimable [NE]) versus 97.9% (95% CI 96.5-99.3), respectively. A single study compared clinical success with a trend towards best results in the covered group, but it was not significant: OR 1.59 (95% CI 0.25-10.13). The complication rate was 0% (95% CI NE) versus 6.2% (95% CI 0.6-11.8), and the re-intervention rate was 1.7% (95% CI 0.0-28.2) versus 9.0% (95% CI 2.7-15.4) for covered and uncovered stents, respectively. A single study directly compared primary patency between groups, with no difference at one month: OR 1.03 (95% CI 0.06-17.09). However, the difference became statistically significant at 6 and 12 months, favoring covered stents: OR 8.75 (95% CI 1.79-42.67) and OR 19.56 (95% CI 4.08-93.82), respectively. Pooled primary patency at 12 months was 90.9% (95% CI 45.9-100) and 77.1% (95% CI 46.0-100) for covered and uncovered stents, respectively.

CONCLUSIONS: Our findings suggest that endovascular implant of covered stents represents a promising approach with superior primary patency rates (versus uncovered). However, limited data from heterogeneous studies hinders definite conclusions, and further investigation is necessary.

TEVAR for primary aortic mural thrombus: when and how?

2024-05-17T02:06:55-07:00

INTRODUCTION: Primary aortic mural thrombus (PAMT) is a rare cause of peripheral embolization that has been associated with hypercoagulable states. Anticoagulation is usually the first-line strategy, but has been associated with a significant risk of recurrent embolization.

CASE-REPORT: A 51-year-old male patient with a history of right lung carcinoma underwent a follow-up computed tomography angiography (CTA) scan that revealed an incidental thrombus in the descending thoracic aorta. Conservative treatment with full-dose enoxaparin was initiated. A week later, the patient presented symptoms of pain and paraesthesia of the left lower limb. A new CTA scan revealed extension of the thrombus, with two pedunculated floating thrombi in the descending thoracic aorta. Thus, a diagnosis of left acute limb ischemia due to embolization originating from a PAMT was assumed. Thoracic Endovascular Aortic Repair (TEVAR) was performed to control the embolic source and prevent new events. To prevent visceral embolization during the TEVAR procedure, low-pressure angioplasty balloons were positioned in the visceral arteries. The thrombi were excluded using a Valiant® endoprosthesis 30x150mm. Subsequently, a left transfemoral thrombectomy was performed, achieving normal blood flow to the foot. No adverse events occurred in the postoperative period. The patient was discharged on aspirin and rivaroxaban and continues to be followed in outpatient care, remaining asymptomatic to date.

CONCLUSIONS: Although rare, PAMT should be suspected as a possible embolic source, especially in patients with hypercoagulable states such as neoplasms. Our case highlights that in cases of recurrence embolization despite anticoagulation, the use of TEVAR to exclude aortic thrombi is effective in preventing additional embolization.

What is hidden behind persistent Inferior vena cava thrombosis?

2024-05-17T02:01:24-07:00

BACKGROUND: Primary tumors of the inferior vena cava (IVC) are rare. They most commonly arise from the smooth muscle of the IVC walls, known as leiomyomas.

CASE REPORT: A 49-year-old male patient presented to the emergency department with right leg swelling. He had undergone varicose vein extraction surgery one month before presentation. Doppler ultrasound revealed thrombosis of the right iliac and femoral veins. Permeability of the IVC was presumed, since symptoms were unilateral. The patient was discharged with anticoagulation therapy, rivaroxaban 15mg bid. During follow-up, complaints of right leg swelling and discomfort persisted, raising the suspicion of post-thrombotic syndrome. A computed tomography angiography scan revealed a 12 cm-long thrombus in the infrarenal IVC. Despite ongoing anticoagulation, symptoms persisted with intermittent improvements and worsening. Consequently, additional investigation with phlebography, magnetic resonance, and positron emission tomography (PET) scan was performed, which raised a high suspicion of a leiomyoma of the IVC. An endovascular biopsy with a Cordis ® biopsy catheter confirmed the diagnosis of an IVC leiomyoma. Open surgical resection of the tumor was proposed and accepted by the patient. After the operation, the patient spent three days in intensive care and was discharged from the hospital after one week. At the one-month follow-up appointment, the patient remained asymptomatic.

CONCLUSIONS: While rare, it is crucial to keep in mind the existence of IVC leiomyomas, which often occur with nonspecific symptoms. In this clinical case, the sole symptom was thrombosis of the femoral, iliac, and inferior vena cava, refractory to anticoagulation therapy. To confirm the diagnosis, biopsy is mandatory, with endovascular biopsy being an efficient and safe method.

Open repair of type IV thoracoabdominal aortic aneurysms: a real-world experience in the endovascular era.

2024-10-09T04:06:46-07:00

INTRODUCTION: Currently, type IV thoracoabdominal aortic aneurysms (TAAA-IV) are treated primarily by endovascular repair. Despite the increased morbidity, there is still a role for open surgery in selected patients.

This paper aims to present a descriptive analysis and outcome evaluation of open repair for TAAA-IV in our institution, where endovascular repair is generally the first-line treatment option.

METHODS: An observational, descriptive, and retrospective cohort analysis was conducted, including all patients treated for asymptomatic TAAA-IV in the last 15 years (2008-2023). Demographic data, comorbidities, procedure protocols, complications, and early mortality were described and analyzed.

RESULTS: The initial cohort included 38 patients. Ten emergent cases and four due to inconsistent records were excluded, resulting in a final population of 24 subjects. Twenty-two were men (92%), with a mean age of 68 years (standard deviation, 8 years) and a mean aortic diameter of 70mm (standard deviation, 15mm). All patients were submitted to paramedian laparotomies with medial visceral rotation. The approach to visceral and renal arteries varied, primarily due to the left renal artery (bypass in five, abandoned due to atrophied kidneys in two, reimplantation in 16 patients). The median length of hospital and ICU stay was 7 and 20 days, respectively. The most frequent complication was acute kidney injury (AKI) in 87%, being transient in 75%. Hemodialysis was needed in 21%, but permanent need for hemodialysis was only noted in 4%. Infectious complications occurred in 29%, mainly lower respiratory infections (17%). Two patients (8%) had cardiac complications (acute myocardial infarction and non-ischemic cardiogenic shock). The overall intra-hospital mortality rate was 21% (5/24), with the following time frame: intra-operative – two cases; first 24 hours, one case; between day 1 and day 30, one case; and beyond 30 days, one case.

CONCLUSION: In this low-volume cohort, treated over a long time period, a high mortality rate was observed, which may confirm the dependence between results and surgical/post-operative care volume and experience. AKI was the most frequent complication, being transient in most cases. The main limitations of this study are the use of different treatment strategies over a long period of time, reporting bias, and the small sample size. Finally, we deem it necessary to report the results of open repair, thereby raising the issue of how to manage small cohorts of patients requiring open repair in an era where such cases are becoming increasingly rare.

The challenging management of acute mesenteric ischemia - too frail or too late?

2024-10-08T23:30:20-07:00

INTRODUCTION: acute mesenteric ischemia (AMI) presents a life-threatening emergency, requiring a high degree of suspicion for timely diagnosis. Despite advancements in the management of these patients, in-hospital mortality rates remain high. This study aims to assess the outcomes and prognostic factors in patients with AMI.

METHODS: A retrospective single-center analysis of all patients undergoing emergent surgery for arterial occlusive AMI between January 2020 and February 2024 was conducted. The primary outcome was 30-day survival. Correlations between survival and laboratory biomarkers at admission were investigated.

RESULTS: Thirty patients underwent emergent surgery for occlusive AMI. The overall 30-day survival rate was 33%. Pre-operative arterial HCO3-to-lactate ratio ≤ 10 and neutrophil-to-lymphocyte ratio > 16 correlated with lower survival, showing 83% and 59% sensitivities, respectively, and 100% specificity for 30-day mortality.

CONCLUSION: Despite advancements in patient management strategies, AMI mortality rates remain high. The neutrophil-to-lymphocyte ratio has been proposed as a diagnostic and prognostic marker in AMI. While the HCO3-to-lactate ratio has not yet been described, it may serve as a more sensitive and specific predictor of mortality than lactate alone.

Comparing outcomes after open and endovascular chronic mesenteric ischemia revascularization –10-year single-center experience

2024-10-09T00:51:35-07:00

INTRODUCTION: Chronic mesenteric ischemia (CMI) is a rare but life-threatening disease. This study aimed to analyze the safety and effectiveness of open (OR) and endovascular (ER) revascularization and respective outcomes in a consecutive series of CMI patients.

METHODS: From 2013 to 2023, all CMI patients treated with OR and ER were retrospectively identified. Demographics, comorbidities, clinical presentation, preoperative imaging, and revascularization modalities were analyzed. Patients were grouped according to the type of revascularization (OR and ER) and compared for the study’s endpoints. The primary endpoint was the reintervention rate, and the secondary endpoints were overall survival and reintervention-free survival.

RESULTS: Thirty-three patients with CMI (60% male, mean age 67, range 45-88 years) were treated by ER (27 patients) or OR (6 patients). The median follow-up was 38 (9-72) months. The ER of the superior mesenteric artery (SMA) included the deployment of covered balloon-expandable stents in 85 % (n=23) of the patients. The OR included SMA bypass using prosthetic conduit and iliac artery inflow in 83 % (n=5) of the patients. Long SMA lesions (>20mm) were present in 100 % of the OR group patients and 44 % of the patients in the ER group (p=.027). Reintervention due to symptom recurrence and target artery restenosis or re-occlusion was performed in four patients in the ER group, of which one patient underwent open surgery and three underwent endovascular surgery. The three-year reintervention rate was 18% in the ER and 0% in the OR group (p=.374). Thirty-day and 3-year overall survival in the OR and ER groups were 67% vs. 93% and 44% vs. 87%, respectively (p=.015). Three-year reintervention-free survival in the OR and ER groups was 50 % vs. 70%, respectively (p=.103).

CONCLUSIONS: According to this study, we should expect lower survival in CMI patients who undergo OR, probably related to the higher burden of atherosclerotic disease observed in this group. However, the improved survival observed after ER is offset by a trend towards higher reintervention rates.

Dois anos de mandato - 25 anos da SPACV

2025-06-30T02:04:22-07:00

4 anos ao serviço da SPACV: a reflexão que se impõe

2025-08-11T19:50:41-07:00

Acknowledgment of reviewers in 2024

2025-06-15T08:09:24-07:00