Angiologia e Cirurgia Vascular

Arterial access complications in patients with extracorporeal membrane oxygenation – literature review

Leandro Nóbrega — 2024-11-02

INTRODUCTION: The use of extracorporeal membrane oxygenation (ECMO) has been increasing in recent years. Veno-Arterial ECMO (ECMO-VA) is usually deployed in refractory cardiac failure and is mostly cannulated through the common femoral artery. When present, arterial access complications may have important consequences in these patients. Therefore, this work aims to narratively review the available evidence regarding the impact of arterial access complications in patients undergoing ECMO-VA.

METHODS: A Medline search was performed to identify articles focused on arterial access complications in patients undergoing ECMO-VA since 2010. The keywords were “extracorporeal membrane oxygenation,” “arterial access,” and “complications.” The primary endpoints were the description of the arterial complication with demographic characteristics and the short- and long-term prognosis.

RESULTS: The incidence of vascular complications in patients undergoing ECMO-VA ranges from 9.4% to 43.9%. In the majority of retrospective studies, their presence isn’t associated with increased mortality. However, in a meta-analysis, there was an increased mortality in patients with complications (RR 1.36; CI 95% 1.15-1.60; P=0.0004). The main risk factors are peripheral artery disease and female sex, while the reduced case volume can be associated with increased complications.

CONCLUSION: Most available evidence on managing arterial complications associated with ECMO derives from retrospective studies. To decrease the risk of access complications, protocols for cannulation, surveillance, and decannulation should be elaborated. Prospective studies are needed to improve the prevention and management of vascular access complications in patients under ECMO-VA.

Endovascular treatment versus open surgery for iliac artery aneurysms: a systematic review and meta-analysis

Marta Machado — 2024-11-02

INTRODUCTION: Due to their relative rarity, the natural history of iliac artery aneurysms and treatment outcomes are poorly understood. However, IAA treatment has evolved, and nowadays, there are a variety of open surgery, endovascular therapy, and hybrid options. This study aimed to compare the outcomes of endovascular treatment versus open surgery for patients with iliac artery aneurysms.

METHODS: A systematic review was performed according to the PRISMA statement. An online search was conducted using the Medline database from January 2014 to January 31st, 2023. Only original articles in English or Portuguese, reporting on a minimum of 5 cases, were considered. Studies were included if reporting at least one of the following outcomes: peri-operative complications, length of stay (LS), and 30-day mortality. The software Review Manager 5.4 was used for data analysis.

RESULTS: The database search identified 418 articles, of which 413 records were excluded by screening by title/ abstract, and five were read in full and subsequently included.
A total of 1837 patients were included. Open surgery was performed in 29.02% (442/1523) and endovascular in 70.58% (1075/1523). More than half of endovascular cases included internal iliac artery preservation techniques (iliac branch design grafts).

Patients undergoing endovascular treatment were significantly older (mean difference [MD]: 5.49, 95% confidence interval [CI]: 2.34 to 8.65) and more likely to have congestive heart failure (odd ratio [OR]: 3.74, 95% CI: 1.24-11.27). On the other hand, patients undergoing open surgery were more often smokers (OR: 0.59, 95% CI: 0.42-0.82). The primary outcome - 30-day mortality - was significantly higher for open surgery (OR 0.34, 95% CI 0.19-0.61). Considering other peri-operative outcomes, patients undergoing open surgery presented with longer length of hospital stay (MD: -4.68, 95% CI: -6.43 to -2.92), higher risk of surgical wound infection (OR: 0.31, 95% CI: 0.10- 0.94), renal failure (OR: 0.37, 95% CI: 0.18-0.75) and respiratory infection (OR: 0.19, 95% CI: 0.11-0.33). No significant differences regarding buttock claudication and leg and bowel ischemia were found. The 30-day reintervention rates weren ́t significantly different for open and endovascular surgery (OR 0.83, 95% CI 0.33-2.1).

CONCLUSION: Endovascular treatment of iliac artery aneurysms can reduce 30-day mortality, peri-operative complications and length of hospitalization. No differences were identified regarding 30-day reintervention rates. Consequently, endovascular treatment has gained preference over open surgery as the initial approach for patients with suitable anatomy.

No other meta-analysis in the literature compares the results of open surgery and endovascular treatment, particularly the results of new endovascular techniques (iliac branch design grafts). Comparing long-term reintervention rates will be essential in the future.

Carotid artery stenting and improvement of cognitive function in patients with asymptomatic carotid artery stenosis

Filipa Jácome — 2024-11-02

INTRODUCTION: Several studies unveiled an association between asymptomatic carotid artery stenosis and cognitive impairment, questioning the “asymptomatic” nature of carotid stenosis. Although there is increasing evidence of the impact of carotid artery stenting (CAS) on cognition, the current literature still contains some unclear data and conflicting results. This study aimed to examine the impact of CAS on various domains of cognitive function in patients with asymptomatic carotid artery stenosis.

METHODS: Studies published up to February 2023 that evaluated cognitive function in patients with asymptomatic carotid artery stenosis who underwent CAS were searched in PubMed and Scopus databases. All original studies assessing pre- and post-operative cognitive functions in patients with asymptomatic carotid stenosis undergoing CAS were considered eligible for inclusion. Editorials, letters, case reports, review articles, and animal studies were excluded.

RESULTS: A total of 1155 articles were identified in our search. After screening, 12 studies were eligible for our review, including 273 CAS in asymptomatic patients. Eleven articles were prospective cohort studies, and one was a randomized controlled trial. The mean age of included patients was 70.1%3.4 years, and approximately 63% of patients were male (n=170 male patients), although two studies did not mention gender. Only seven articles reported the type of anesthesia, and locoregional techniques were used in all cases. Regarding cerebral protection, in eight studies, a distal filter was used; one study used flow reversal; in another, no protection device was used; three studies did not mention if any technique for cerebral protection was used during the procedure.

CONCLUSION: The included studies on cognitive performance after CAS exhibit wide variations in the timing of assessment, specific tests performed, and the use of cerebral protection devices. Additionally, the study populations are small, and several possible confounding factors exist. Thus, a limitation in the analysis is evident, and several attempts to assess the effect of CAS on cognitive function have yielded conflicting conclusions. The debate over the optimal management of asymptomatic carotid patients is ongoing.

Leriche syndrome after visceral aortic revascularization – what now?

Rita Bento — 2024-11-02

INTRODUCTION: Thoraco-bifemoral bypass (TBF) is an alternative to aorto-bifemoral bypass (ABF) or axilobifemoral bypass for severe aortoiliac occlusive disease. TBF may be particularly useful in select patients with concurrent visceral aortic branch vessel disease, infrarenal aortic occlusions, or after failed ABF. We describe a clinical case of a symptomatic Leriche syndrome in the presence of concurrent visceral aortic branch vessel disease.

CASE REPORT: A 57-year-old male patient with a history of Leriche syndrome and acute thrombosis of the right renal artery with acute kidney injury underwent parallel grafting of the celiac trunk, superior mesenteric artery, and right renal artery 12 months before the current episode.

He developed intermittent claudication for very short distances (around 5 meters), with significant limitations for activities of daily living and an inability to carry out his work activity.

We decided to perform a TBF bypass through a left thoracotomy, which was uneventful. The patient is asymptomatic and has palpable pedal pulses at the 24-month follow-up. Postoperative computed tomography angiography revealed visceral aorta branches and TBF bypass patency.

CONCLUSION: TBF bypass can be performed with good outcomes for patients with severe AIOD, especially if concomitant visceral/infrainguinal reconstruction is warranted. These results support a continued role for TFB in selected patients.

A giant arteriovenous malformation of the abdominal wall

Adriana Figueiredo — 2024-11-02

INTRODUCTION: Arteriovenous Malformations (AVMs) are high-flow anomalous connections between the arterial and venous systems composed of dysplastic vessels resulting from aberrant angiogenesis. They are congenital and when symptomatic they rarely manifest before adolescence. Depending on the location, size, stage and severity of the symptoms, treatment options vary from conservative management to surgical resection. We report a case of a giant arteriovenous malformation of abdominal wall (tipe IIIb of Yakes Classification) treated with surgical resection after prior attempts of scleroembolization..

CLINICAL CASE: 54-year-old woman with known history of osteoarticular pathology and dyspepsia presented a mass on the left side of the abdominal wall with hard consistency, warm, slightly pulsating and tenderness to touch with several years of evolution. The mass showed infiltration of the internal and external oblique muscles sparing the transverse muscle. Clinically she presented easy fatigue with efforts. Due to the risk of abdominal wall herniation after excision of the AVM, scleroembolization was considered first-line treatment in this case. This strategy resulted in regression of the mass and symptoms improvement. Four years after the last intervention, the patient presented lesion growth, recurrence and worsening of symptoms with severe interference in the quality of life (QoL). After multidisciplinary discussion, she was proposed for complete resection of the AVM. She was first submitted to scleroembolization with Onyx of identified arterial afferents and sclerosis of the lesion nidus with 2% polidocanol. One month after she underwent successfully total resection of the AVM with the collaboration of General Surgery.

CONCLUSION: No unified agreement exists on the best treatment of these complex high flow lesions and it is difficult to establish a comprehensive strategy given the pathology’s clinical variability, complex stratification and the risk of relapse. A case-by-case approach is needed in managing these types of lesions.

Endovascular treatment of proximal lower extremity deep vein thrombosis – experience of a center

Miguel Queirós — 2024-11-02

INTRODUCTION: Proximal lower extremity deep vein thrombosis (DVT) occurs in 5-10/10000 patients annually. Left untreated, there's a notable risk of pulmonary embolism development and the onset of long-term limb complications linked to post-thrombotic syndrome (PTS). Traditionally, these patients were treated with conservative therapy, namely anticoagulation and compression stockings. Nowadays, new and more aggressive treatments have emerged. Endovascular therapies, such as thrombectomy devices, catheter-directed thrombolysis (CDT), percutaneous transluminal angioplasty (PTA), and stent placement, provide a highly effective treatment option with minimal patient risk of complications.

METHODS: We retrospectively studied all patients with proximal lower extremity DVT who were treated with endovascular therapy in our center between the years of 2018 and 2021. We choose as primary outcomes symptoms of PTS (Villalta Score) and quality of life (VEINES-QoL/Sym questionnaire) and as secondary outcomes treatment efficacy (grade of thrombolysis), treatment safety, and primary patency.

RESULTS: A total of 20 patients were treated by endovascular treatment. The majority of these patients were women (95%); 60% of them had DVT of the left limb, and 30% had phlegmasia alba dolens. Seven patients were treated with the AngiojetTM system (35%), four with the PenumbraTM system (20%) and nine with CDT alone (45%).

Two patients presented with mild PTS symptoms, and the mean VEINES-QoL/Sym questionnaire score was 84.8% +/- 13.6%. There were no cases of major bleeding or pulmonary embolism after the procedure. Two patients had small vein ruptures with no need for additional treatment. The average length of stay in a high surveillance unit for vigilance was 2.2 days. At the end of treatment, 75% of the patients had complete thrombolysis, 15% had partial thrombolysis (50–99% thrombus removal), and 10% showed minimal or no thrombolysis (< 50% thrombus removal). The primary patency rate was 88% after 12 months.

CONCLUSION: Our experience has shown that endovascular therapy for acute proximal lower extremity DVT is a safe and effective treatment associated with a very low incidence of PTS and recurrent venous thromboembolism. However, life-threatening complications such as major bleeding can occur. As such, while under treatment, close monitoring of these patients in a high surveillance unit is mandatory.

Blunt traumatic injuries of thoracic aorta, a retrospective study

Leonor Baldaia — 2024-11-02

INTRODUCTION: Blunt thoracic aortic injuries (BTAI) are defined as a tear in the thoracic aorta caused by a high energy blunt trauma with sudden deceleration and increased intravascular pressure. The most common reported mechanism of injury is motor vehicle accidents, and it can be potentially lethal. The purpose of this study was to analyze and report our center’s experience in the treatment of blunt traumatic injuries of thoracic aorta and supra-aortic trunks.

METHODS: A retrospective review of a single center's database was done to identify all patients treated for BTAI, in a four-year period, from January 2018 to December 2021. Follow-up period ranged from three to 24 months. Patients’ demographics, injury mechanism, location and grade of aortic injury, treatment details, timing of intervention, length of hospital stay, follow-up time, and postoperative morbidity and mortality were extracted from patients’ medical records. A descriptive analysis of all the data was performed.

RESULTS AND DISCUSSION: We identified six patients to include in the study. Mean age was 29 years and 83.3% of patients were male. The mechanism of injury was motor vehicle accident for all cases. The most common injury grade was type III (pseudoaneurysm) in five patients (83.3%), and one patient presented with a type IV aortic injury with rupture. All injuries were in the aortic isthmus and all patients were suitable for TEVAR. Mean time to intervention was 17 days. Mean oversizing was 11%. Two patients had coverage of their LSA. No deaths occurred in the hospital or during the follow-up period, and there were no registered vascular procedure-related morbidities.

CONCLUSION: This study reports a level one trauma center experience in management of BTAI. All patients underwent CTA for diagnosis and grading of aortic injury. TEVAR proved to be effective in the treatment of BTAI, with few complications and good outcomes at short and mid-term follow-up, and it should be the first-line treatment for these patients. OSR should be an option when a patient’s injury is not suitable for endovascular approach.

Prof. José Fernandes e Fernandes 1o editor da revista Angiologia e Cirurgia Vascular distinguido pela Society for Vascular Surgery (SVS) as a world leader in vascular surgery

Rui Machado — 2024-11-02

Aneurysm of the thoracic duct – a rare cause of supraclavicular mass

Hugo Rodrigues — 2024-11-02

Abstracts of the 23nd SPACV National Meeting

ACV Journal — 2024-11-02