Angiologia e Cirurgia Vascular

Frailty and outcomes of vascular access for hemodialysis – a scoping review

2024-10-09T03:17:31-07:00

INTRODUCTION: Frailty is an age-related condition related to the decline of physiologic capacity and the increased vulnerability to stressors. It is associated with increased mortality, hospitalizations, and healthcare costs. Dialysis patients, due to age and comorbidities, are especially vulnerable to frailty. The aim of this review was to assess the impact of frailty on outcomes of vascular access for haemodialysis.

METHODS: A search was conducted on PubMed, Scopus and Cochrane to identify articles reporting on frailty and outcomes of vascular access in dialysis patients.

RESULTS: A total of seven studies were included. Patients included ranged from 40 to 41471, and frailty prevalence ranged from 24 to 53%. There was considerable heterogeneity in frailty assessment. Three studies reported higher mortality in frail patients. Frailty was also associated with recurring vascular access failure, higher risk of non-maturation and access thrombosis in included studies. Higher perioperative complications in frail patients were also reported.

CONCLUSION: Frailty is associated with adverse outcomes of vascular access in dialysis patients, including thrombosis, longer time to functional use of access, and reintervention. Frail patients also have higher mortality after vascular access construction when compared to non-frail patients. Frailty assessment might be a valuable tool in shared decision-making regarding vascular access in dialysis population.

Splenic artery aneurysms – a systematic review of the literature

2024-10-13T08:40:57-07:00

INTRODUCTION: Splenic artery aneurysms (SAA) are the most frequent (50 to 75%) abdominal visceral arterial aneurysms. In autopsy studies, the overall incidence is 0.01%, increasing to 10.4% with age. Due to their rarity, there is a lack of data, so we aimed to perform a systematic review of available SAA data.

METHODS: A systematic review was performed according to the PRISMA guidelines. A literature search was performed using the Medline database from January 2019 to January 2024. Only full-text articles were considered, including patients with true SAA treated by endovascular (ET) and/or open surgical (OS) means. Only articles published in English or Portuguese were considered. The investigated outcomes were postoperative complications, reinterventions, and mortality..

RESULTS: Of the 289 articles identified during the initial literature search, 87 were included in qualitative synthesis. One thousand sixty-one patients were identified with 1085 reported SAAs. The mean age was 51.62 years +/- 14.57, with older patients in the OS group (OS 54.49 years +/-15.95 vs. ET 51.92 years +/-12.83) and 39.8% (range 29.5-50.0) were male (OS 34.5% [16.2-52.8] / ET 41.7% [27.0-56.3]). A total of 12.6% (0.3-24.9%) were detected during pregnancy, with a higher frequency of pregnancy also in the OS group (OS 29.5% [0.0-9.3])/ ET 7.2% [0-14.6%]).

The mean diameter was 3.18cm +/- 2.07 (OS 4.95cm +/- 3.74 vs. ET 3.10cm +/- 1.92). The frequency of rupture was 2.8% (0.0-8.9%) and much higher in the OS group (OS 37.5% [0-100%] vs. ET 6.5% [0.0-23.4]). The types of intervention reported were ET (744 patients) and OS (317 patients: 281 conventional open reconstruction, 25 laparoscopic, and 11 robotic).

Postoperative complication rates were 12.4% (2.1-22.6) in the ET group and 9.1% (5.6-12.6) in the OS. The reintervention rate at 30 days was 5.2% (1.6-10.4) in the ET group. Reintervention after OS was 4.7% (2.2-7.2). Overall, there were three perioperative deaths, all in the OS group (mortality: 23.0 [95% CI 0.0-96.3].

CONCLUSION: SAAs rupture is associated with high mortality, so timely diagnosis and management are essential to attain a satisfactory outcome. A detailed and individualized analysis of each case and a sufficient understanding of the anatomy and hemodynamics of a particular aneurysm should guide the therapeutic decision. OS has good results in treating SAA with lower morbidity and reintervention than ET. However, ET should be a viable alternative in high-risk patients with favorable anatomy.

Chronic limb-threatening ischemia under the age of 50 – a single-center 12-year retrospective study

2024-09-20T08:30:08-07:00

INTRODUCTION: Premature peripheral artery disease (PAD), defined as occurring before or at the age of 50, is a poorly studied subset of PAD due to its low incidence. It has been associated with a higher risk of progression to chronic limb-threatening ischemia (CLTI), major adverse limb events and mortality. Etiology is multifactorial, with genetics and environmental causes at play, with the most common risk factors being smoking, diabetes, and hypertension.

METHODS: A single-center retrospective study was conducted in a Portuguese tertiary center, including all patients up to the age of 50 submitted to a revascularization procedure for CLTI from May 2011 to November 2023. The primary endpoint was a composite outcome of mortality, amputation and/or reintervention. The secondary endpoints were reintervention, amputation and mortality rates, and amputation-free survival (AFS).

RESULTS: Ninety-one patients were included (74% male, median age 48). The most common risk factors were smoking (69%), diabetes (45%) and hypertension (44%). Most patients presented as Fontaine grade IV (79%). Thirty-two patients (35%) had aortoiliac lesions, while 38 (42%) had femoropopliteal, and 21 (23%) had infra-popliteal disease. During the median follow-up period of 7.4 years (IQR 4.3-10.3), 57 patients (63%) underwent reintervention, amputation, or died. The reintervention rate was 40%, while amputation was performed on 25% of patients, and 29% of patients died. Median AFS was 4.7 years (IQR 0.8-7.8). Subgroup analysis comparing diabetic and non-diabetic patients and endovascular vs. open surgery were performed. The 30-day amputation rate was significantly higher in diabetics (12% vs. 2%, p=.05), but there were no other significant differences in subgroup analysis.

CONCLUSION: Premature CTLI is associated with poor outcomes and high mortality rates, with most patients undergoing reintervention or amputation. Further studies are needed to identify non-traditional risk factors to improve outcomes in this young population.

High-dependency unit care after carotid endarterectomy for asymptomatic stenosis

2024-09-21T05:41:56-07:00

INTRODUCTION: Asymptomatic patients benefit from 3 to 6 hours of neurological and invasive blood pressure (BP) monitoring following carotid endarterectomy (CEA). Only a minority of patients will benefit from a prolonged stay in a high-dependency unit (HDU). The aim of this study was to externally validate previously described predictive variables of postoperative need for prolonged HDU stay.

METHODS: To identify patients needing HDU stay, a composite outcome (CO) was created, including cardiac events, neurologic deterioration, postoperative aminergic/ventilatory support, and prolonged use of intravenous (IV) BP control therapy. A retrospective study was performed in one center: increased clamping time, preoperative systolic BP, systolic BP during pre-anesthetic procedure, maximum intraoperative mean arterial pressure (MAP), and eversion technique were significant predictors for the CO. We aimed to ascertain the validity of these factors in an independent population. Consecutive patients submitted to asymptomatic CEA in the same period were retrospectively analyzed in a second independent center.

RESULTS: A total of 51 procedures were included (86.3% male; 69.2±7.9 years) and 11 (21.6%) presented with the CO. The presence of diabetes was associated with a higher incidence of the CO (p=0.011), and acetaminophen as intraoperative analgesia demonstrated an inverse correlation with the CO (p<0.001). Receiver operator characteristic curve analysis of predictive factors revealed that intraoperative maximum MAP had a strong correlation with the CO (area under the curve – AUC – 0.739, p=0.017). The remaining variables also did not reach statistical significance.

CONCLUSIONS: In this analysis, the risk for CO development was consistently increased in patients who developed high MAP intra-operatively, highlighting the need for scrupulous BP management to reduce potential complications.

However, we identified two previously unidentified associations: first, diabetics were more prone to develop complications and were more likely to benefit from HDU stay. Second, acetaminophen as intraoperative analgesia could have a protective role against CO development.

Physician modified endograft to treat a symptomatic juxta-renal aortic aneurysm: report of the first case at our center

2024-09-21T05:00:54-07:00

BACKGROUND: Symptomatic or ruptured juxta-renal aortic aneurysms can be managed through open surgical repair or endovascular approaches, including chimney endovascular aortic repair (chEVAR), off-the-shelf branched devices, or physician-modified endograft (PMEG). PMEG has proven to be a feasible alternative with satisfactory long-term outcomes for such conditions.

CASE REPORT: We document the inaugural case of PMEG performed at our center for a 69-year-old man with a symptomatic juxta-renal aortic aneurysm. This custom-made device included fenestrations for renal arteries and a scallop for the superior mesenteric artery. The patient was discharged home on the ninth postoperative day. A six-month follow-up CTA confirmed the AAA's exclusion, with maintained patency of all visceral vessels and no evidence of endoleak.

CONCLUSION: The complexity of the PMEG procedure varies based on the surgeon’s expertise and the patient’s anatomical challenges. This underscores the importance of meticulous patient selection, a process that ensures the safety and success of the procedure.

Complete resection of the superficial femoral artery and superficial femoral vein due to forceful trauma: a case report

2024-06-15T10:38:15-07:00

BACKGROUND: The incidence of superficial femoral artery trauma with or without involvement of superficial femoral vein, in the absence of organ injury or fractures, is rare. We present a case of superficial femoral artery and vein resection caused by high-energy blunt trauma.

CLINICAL CASE: A 60-year-old male was transferred to our hospital due to forceful trauma of the superficial femoral artery and vein. The injured portion of the artery was resected, and a reversed ipsilateral great saphenous vein graft interposition was performed. The superficial femoral vein was ligated. No post-operative complications were noted, and the patient was discharged three weeks after the operation without any relevant sequelae

CONCLUSION: This case report highlights the clinical presentation, diagnostic workup, management, and outcomes of traumatic blunt injuries to the femoral vessels.

Surgical repair of cervical internal carotid artery aneurysm in a patient with suspected connective tissue disorder

2024-04-13T02:50:07-07:00

BACKGROUND: We present an uncommon case of open surgical treatment of an impacting extra-cranial internal carotid artery aneurysm in a 65-year-old female patient which represented the tip of a large iceberg, in this case, presence of a connective tissue disorder (CTD).

CASE REPORT: Data regarding medical and family history were collected. The patient was referred to our institution due to left latero-cervical mass. Computed tomography angiography showed a large saccular aneurysm of the left internal carotid artery. Open surgical treatment was performed by aneurysmorrhaphy and end-to-end anastomosis. A section of the carotid aneurysmal wall was sent for histological investigation. The patient was discharged with no neurological issues or cranial nerve injuries. Histological examination of the tissue revealed morphological findings suggestive of a severe degenerative disease.

CONCLUSION: The successful treatment for extracranial carotid artery aneurysm (ECAA) is determined by the carotid artery anatomy and aneurysm properties. The need for early diagnosis and extensive examination in patients with ECAA, as well as clinical suspicion of CTD, plays a crucial role in identifying individuals at risk and guiding optimal management strategies and follow-up.

Arterio-ureteral fistula: A case-based review of significant hematuria

2023-10-16T02:54:36-07:00

BACKGROUND: Arterio-ureteral fistula (AUF) is a rare but life-threatening cause of hematuria. Most AUFs are secondary to malignancy or extensive pelvic/ vascular surgery

CASE REPORT: A case of an 84-year-old patient who developed significant hematuria 4 months after pelvic surgery due to urothelial carcinoma is presented.

CONCLUSION: Active surveillance of patients with predisposing risk factors and sensitivity to other differential diagnoses of hematuria such AUF, is important to avoid mortality of these patients. Percutaneous endovascular stent graft is life-saving procedure that is effective and safe.

Conquering complex anatomy: EVAR success in a zig zagging aortic aneurysm

2024-09-21T05:24:47-07:00

Recanalization of chronic total ilio-caval occlusion

2024-01-15T15:18:55-08:00