Angiologia e Cirurgia Vascular

Oncovascular surgery: first two case reports and teamwork perspective

2023-10-29T06:09:37-07:00

BACKGROUND: Surgical resection remains the cornerstone for the curative treatment of malignant tumors, such as pancreatic adenocarcinomas. Pancreaticoduodenectomy with vascular reconstruction is a promising approach for tumors invading the portomesenteric vein, and an aggressive surgical approach can improve survival in the mid- and long terms. Thus, vascular surgeons have an increasing role in these surgeries. Therefore, we describe our recent and initial experience and efforts to grow as a true team to offer a better and more systematic response to these patients.

CASE REPORTS: We present two cases of 68 and 69-year-old female patients, both with pancreatic head adenocarcinoma. In the first case, during the pancreaticoduodenectomy, a 4 cm long involvement of the portomesenteric vein in 50% of its circumference was denoted. The choice for reconstruction after tumor resection was a primary repair with a Dacron patch. In the second case, the resection was programmed after neoadjuvant chemotherapy, and a circumferential involvement of the portomesenteric vein in a long extension was observed, requiring an extensive venous reconstruction with an interposition graft (Dacron - 8mm) with splenic vein reimplantation.

In both cases, disease-free margins were achieved, and no mortality was registered within 30 days after surgery.

CONCLUSIONS: With these two initial cases, we concluded that good results can be achieved. Our center's team is working to preoperatively delineate our strategy for treating these complex patients, choosing optimal vascular reconstructive options tailored to each patient. Recently, a bovine pericardium patch became available in our institution, which is a good alternative to avoid additional operative time and reduce the infection risk associated with synthetic material use.

Management of spontaneous carotid artery rupture: navigating life-threatening challenges and persistent risks

2024-05-12T03:30:57-07:00

BACKGROUND: Carotid pseudoaneurysms are extremely rare, and their inherent instability and unpredictability require prompt evaluation and intervention to mitigate potential neurological complications or prevent life-threatening bleeding and airway obstruction. We present a case report of spontaneous internal carotid artery (ICA) rupture.

CASE REPORT: An eighty-eight-year-old male with a history of non-Hodgkin lymphoma and adenocarcinoma of the rectum presented with a spontaneous rupture of the left ICA. Bleeding control was achieved by deploying a 7mm self-expandable stent graft (Viabhan®) in the ICA through a transcervical approach. Control computed tomography angiography at 24 hours revealed a "type 1 endoleak" with contrast leak filling from the proximal landing zone. A transfemoral approach was used for external carotid artery ostial occlusion using an 8mm vascular plug, followed by stent graft extension to the common carotid artery. Blood cultures were positive for Pseudomonas aeruginosa and the patient completed nine weeks of directed antibiotic therapy. There was a recurrence of rupture by the 5th month of follow-up, controlled once again with a distal extension with an 8mm Viabahn®. The patient died on the 7th postoperative day due to nosocomial pneumonia.

CONCLUSION: This report highlights the complexity of managing carotid ruptures and pseudoaneurysms, emphasizing the potential of endovascular therapy to reduce morbidity. While endovascular treatment is a viable option for frail patients, considering long-term implications is essential. Balancing short-term benefits with potential medium- and long-term complications remains critical to the decision-making process.

In-situ needle fenestration technique for preserving the left subclavian artery in emergent TEVAR

2024-05-17T04:45:15-07:00

BACKGROUND: Open aortic repair is the gold standard in the treatment of diseases involving the aortic arch, but high-risk patients are often not suitable candidates for surgical repair. Thoracic endovascular aortic repair (TEVAR) is less invasive; however, endovascular repair including the aortic arch remains a challenge. LSA revascularization is linked with reduced risk of cerebrovascular events, spinal cord ischemia, and upper limb ischemia at the cost of complications associated with carotid-subclavian bypass. In-situ fenestration (ISF) seems an effective, safe, and feasible method for the totally endovascular aortic arch repair avoiding the risks associated with bypass surgery. This technique allows for rapid, “off-the-shelf” repair of arch lesions with minimal physiologic disturbances and lower perioperative complications.

CASE REPORT: An 86-year-old man is admitted to the emergency room due to chest pain and hoarseness. There was a previous medical history of TEVAR (proximally implanted in zone 3) for penetrating thoracic aortic; 8 months prior. Computed tomography angiography revealed aneurysmal dilation of the lesser curvature of the aortic arch with a maximum diameter of 65mm. The patient was submitted to TEVAR with proximal sealing in zone 2 of the arch (Ankura™ stent-graft) and revascularization of the left subclavian artery (LSA) was achieved using an ISF by needle fenstration with the deployment of a balloon-expandable covered stent. No complications were registered. Patient initiated broad spectrum antibiotics and underwent positron emission tomography revealing several metabolically active lymph nodes suggesting underlying neoplasm.

CONCLUSION: ISF, due to its relative simplicity, is also suitable in urgent and emergent settings. It is a simple, quick technique to be added to our arsenal of endovascular procedures on the aortic arch. It may avoid the carotid-subclavian bypass as well as intentional embolization of the LSA in urgent/emergent patients. Prospective studies with long-term clinical follow-up are still lacking to fully assess the durability of these fenestrations.

Risk factors for type 2 endoleak following endovascular aneurysm repair of abdominal aortic aneurysms

2024-10-08T23:22:47-07:00

INTRODUCTION: Type 2 endoleaks (T2EL) are common complications following endovascular aneurysm repair (EVAR), potentially leading to adverse outcomes such as aneurysm sac growth and reintervention. Although current guidelines recommend surveillance and conservative management for most T2EL cases, there's growing interest in prophylactic measures, including embolization of lumbar (LA) and inferior mesenteric arteries (IMA) during EVAR. This study aims to investigate the impact of LA and IMA on the development of T2EL after EVAR and to identify associated risk factors.

METHODS: A retrospective analysis was conducted on patients who underwent elective EVAR for infrarenal aortic aneurysms at our institution between January 2020 and December 2022, without embolization of LA or IMA. All patients had preoperative and one-month post-operative computed tomography angiography (CTA).

Patient demographics, aneurysm characteristics, LA and IMA patency and diameter were registered. Evidence of T2EL was assessed at one and 12 months after surgery, in addition to sac growth.

RESULTS: Fifty-eight patients were included, with a median age of 75 and mean aneurysm size of 64mm at the time of treatment. Most patients were male (n=56). Eighteen patients (31%) exhibited a T2EL on follow-up. Aneurysm shape was associated with T2EL, with 62% of saccular aneurysms developing T2EL, whilst only 26% in fusiform aneurysms (p=0.039). Patients with T2EL had a higher number of covered LA than patients without (5.33 and 5 vs 4.6 and 3.45, respectively), yet only patent covered LA achieved statistical significance for T2EL (p=0.195 and p=0.025, respectively). Additionally, T2EL showed significant association with covering > three patent LA (78%, p=0.020); similarly, IMA patency was associated with T2EL (100% vs 65% without T2EL, p=0.003). Presence of lumbar and inferior mesenteric arteries with ≥ 3 mm, mean LA and IMA diameter, as well as sum of combined diameters did not reach significance, despite being slightly higher in the T2EL group. Among the 18 patients with T2EL, three (17%) had sac growth and two (11%) sac shrinkage (defined as variation ≥ 5mm) at 12 months, none of which required reintervention. One patient had concomitant type 3 endoleak, and underwent endograft relining.

CONCLUSION: This study reveals a substantial incidence of T2EL following elective EVAR, emphasizing the importance of further understanding associated risk factors. Saccular aneurysm morphology, more than three patent covered LA, and patent IMA were identified as significant predictors of T2EL, whilst collateral vessel diameter did not achieve significance. While prophylactic embolization of LA and IMA may benefit certain patients, the lack of association between vessel diameter and T2EL warrants additional investigation to refine embolization strategies.

Impact of type 2 diabetes on postoperative outcomes after endovascular aortic aneurysm repair – a cohort study

2024-11-19T00:20:07-08:00

INTRODUCTION: Although the incidence of abdominal aortic aneurysms (AAA) has declined over the last two decades, this condition has high mortality rates when symptomatic or ruptured. Paradoxically, diabetes seems to slow AAA progression or rupture. However, there is little and contradictory data regarding the postoperative setting. This study aims to evaluate the clinical impact of diabetes after standard EVAR.

MATERIALS AND METHODS: We performed a retrospective cohort study with consecutively enrolled patients who underwent EVAR at a tertiary center between January 2013 and April 2022. Patients were categorized according to the presence of type 2 diabetes. The primary outcome was the incidence rate of aortic events (aortic reinterventions, rupture, and mortality). Secondary outcomes comprised overall mortality, endoleak rate and sac diameter variation during follow-up. Pearson’s Chi-squared test was performed for descriptive analysis. Survival and multivariable analyses were performed through Cox proportional regression models.

RESULTS: A total of 381 patients comprised this cohort, with 82 (21%, 95% CI 17.5-26) identified as diabetic. The average follow-up duration was 27±24 months. Diabetic patients showed a higher prevalence of dyslipidemia (91.4% vs. 74.3%, p<0.001) and hypertension (95.1% vs. 85.1%, p =0.016). Most patients were treated with oral antidiabetics (86.6%), primarily metformin (62.1%). Additionally, 9% of diabetics received insulin therapy. A non-significant trend indicated that diabetic patients experienced a higher incidence of aortic events, particularly after 12 months (adjusted hazard ratio [aHR]: 1.39, 95% confidence interval [CI] 0.71-2.73). Notably, mortality rates were significantly higher among diabetic patients (aHR: 1.86; p=0.02). However, diabetes did not affect sac shrinkage or endoleak rate.

CONCLUSION: While diabetes seems to slow AAA progression, this condition appears to have a negative influence after EVAR, with a higher rate of aortic events and overall mortality. Further studies should explore the interplay between these conditions.

The role of femoropopliteal calcification pattern on outcomes after endovascular treatment of patients with peripheral arterial disease

2024-10-11T01:55:49-07:00

INTRODUCTION: Peripheral arterial calcification is typically most prominent in the femoropopliteal (FP) segment, and its effect on endovascular treatment (EVT) processes and outcomes is poorly understood. This study aimed to evaluate the impact of the pattern of FP calcification on EVT outcomes.

METHODS: We designed a retrospective, single-center, comparative study. From January 2023 to February 2024, all patients with peripheral arterial disease who underwent EVT by a single operator as a first limb revascularization procedure for FP lesions only were considered. The calcification pattern was assessed through a qualitative fluoroscopic and angiographic evaluation. According to the degree of calcification, the patients were grouped into mild to moderate calcification (MC) and severe calcification (SC). Both groups were compared regarding the primary endpoints: reintervention rates, amputation and overall survival.

RESULTS: The study included 45 patients, of which 8 (18%) presented with intermittent claudication and 37 (82%) with chronic limb threatening ischemia. The median time of follow-up was 7 months. The MC group included 71% of the patients and the SV group included 29%. The median femoropopliteal GLASS classification was 4 in both groups. No statistically significant differences were found between groups in rates of reintervention (p=0.97), amputation (p=0.86) and overall survival (p=0.45). There were two major amputations in the MC group and one in SV group after eleven months of follow-up. Higher rates of subintimal angioplasty (38% vs. 12%, p=0.048) and contralateral retrograde access (54% vs. 22%, p=0.03) were found in the SC group.

CONCLUSIONS: In our cohort, highly calcified FP lesions were statistically related to contralateral retrograde access and subintimal cross-lesion pathway. However, the degree of calcification did not influence the most relevant clinical outcomes.

Carotid revascularization for ocular ischemic syndrome – a systematic review

2024-05-22T09:11:40-07:00

INTRODUCTION: The link between extracranial carotid artery disease and visual symptoms is well-established, with amaurosis fugax as a precursor to retinal transient ischemic attacks (TIAs). The presence of cholesterol emboli and fibrin-platelet aggregates in retinal circulation has shown carotid plaque embolization leading to TIAs and strokes. However, not all visual symptoms are embolism related. Ocular ischemic syndrome (OIS) due to hypoperfusion is another potential consequence. This can manifest as visual symptoms similar to classic amaurosis fugax, where severe occlusive carotid lesions may cause ocular hypoperfusion rather than emboli. We aim to study the potential improvement of visual symptoms post-carotid endarterectomy (CEA) in patients with carotid stenosis and hypoperfusion-related ocular issues.

METHODS: We conducted a systematic review of the literature through PubMed and Embase databases using PICO-based keywords: (ocular ischemia OR ocular hypoperfusion*) AND (carotid endarterectomy* OR carotid surgery*) AND (outcomes*). PRISMA guidelines were followed. After removing duplicates and screening, nine were selected for inclusion through meticulous review and reference list examination. The primary outcome assessed postoperative visual improvement, while the secondary outcome focused on ocular blood flow augmentation.

RESULTS: The impact of CEA on visual functions and ocular blood flow in patients with OIS has been investigated in nine studies with a total of 545 patients. Clouse et al. reported that patients with OIS and symptomatic eyes had worse ipsilateral internal carotid artery stenosis. Subjective visual improvement or stabilization following CEA was observed in 40-100% of the symptomatic patients across the studies. Regarding the impact of CEA on ocular blood flow (OBF) and visual function in patients with carotid disease, the peak systolic velocity (PSV) increased significantly in the orbital artery (OA) and central retinal artery (CRA), after CEA. Cohn et al. showed that patients with OIS had significantly lower preoperative PSVs in the CRA than those without visual symptoms. In a study comparing CEA and medical therapy for patients with OIS and significant carotid disease, Yan et al. found that CEA was significantly more effective.

CONCLUSIONS: CEA can improve visual function and alleviate ocular hypoperfusion-related symptoms in patients with carotid artery stenosis. The findings highlight CEA's potential as a therapeutic intervention for enhancing visual outcomes in these patients. Further research is needed to determine specific indications for CEA in patients with OIS.

Radial artery stripping following radial access for coronary angiography

2025-03-16T09:05:40-07:00