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- To Keep Watching or Let It Go: Can We Achieve an Optimal Trade Off Between Costs and Effectiveness for Post-EVAR Follow Up?Publication . D’Oria, M; Bastos Gonçalves, F
- Cirurgia Aberta de Aneurisma da Aorta Abdominal por Internos de Cirurgia Vascular: à Beira da Extinção?Publication . Bento, R; Rodrigues, G; Camacho, N; Catarino, J; Correia, R; Vieira, I; Garcia, R; Pais, F; Ribeiro, T; Cardoso, J; Ferreira, R; Bastos Gonçalves, F; Ferreira, MEINTRODUÇÃO: Nas últimas duas décadas, a abordagem de tratamento de aneurisma da aorta abdominal (AAA) mudou drasticamente de cirurgia aberta para cirurgia endovascular. A diminuição de cirurgia de AAA convencional , open aneurysm repair (OAR), levanta preocupações relativamente à competência dos futuros cirurgiões vasculares para executar este procedimento complexo e de alto risco. O principal objetivo deste estudo foi avaliar as tendências de tratamento de AAA entre internos de Cirurgia Vascular, ao longo de 15 anos, a nível nacional.MÉTODOS:Identificação dos médicos que terminaram o internato de Angiologia e Cirurgia Vascular entre 2002 e 2017, inclusive, a nível nacional e colheita dos dados através da consulta dos currículos para a prova final de conclusão do internato complementar. Foram avaliados o total de cirurgias por AAA, tanto por OAR e por EVAR e contabilizadas aquelas realizadas como 1º cirurgião. A correlação entre o número de cirurgias abertas de AAA e o ano de conclusão do internato complementar foi testada usando o coeficiente de correlação de Spearman. RESULTADOS:Em Portugal, de 2002-2017, apesar de não se verificar variabilidade no número total de OAR realizados, verificou-se um decréscimo marcado naqueles realizados como 1º cirurgião (rho=-0,363; P<0.02). No final do internato em 2007, um interno de Cirurgia Vascular realizava em média 15 casos de OAR e em 2007 a média foi de apenas 7 casos. Por outro lado, constatou-se um aumento marcado no número total de procedimentos de EVAR (rho=0,478; P<0.02) bem como aqueles realizados como 1ºcirurgião (rho=0,540; P<0.01).CONCLUSÃO:O presente estudo revela que os internos de Cirurgia Vascular, a nível nacional, se encontram expostos a progressivamente menos casos de OAR e verifica-se uma diminuição significativa nos procedimentos de OAR como 1º cirurgião.
- Visceral Pseudoaneurysms and the Role of Endovascular Treatment – a Case ReportPublication . Figueiredo, A; Camacho, N; Ferreira, MEIntroduction: Visceral pseudoaneurysms are pathological dilations of the visceral arteries and/or their branches. They are a rare entity but with devastating consequences given their high potential for rupture and hemorrhage. The evolution of endovascular techniques has changed the paradigm in the treatment of this entity, making it the preferred option for the elective treatment of visceral pseudoaneurysms. Clinical case: The authors described the case of a pancreatic pseudoaneurysm in a young male patient, with past medical history of chronic pancreatitis and pancreatic pseudocyst, marked smoking and alcoholic habits, which presented with an abdominal pain and a drop in hemoglobin. After discussing the case with the Vascular Surgery department, it was decided towards an endovascular treatment given the patient's clinical stability and appropriate anatomical location for the proposed intervention. Coil embolization via humeral artery was performed with immediate angiographic success, and clinical, analytical and imaging improvement in the postoperative period. Conclusion: In addition to open surgical repair and laparoscopic surgery, there are also endovascular procedures for the treatment of visceral pseudoaneurysms, so the vascular surgeon must be aware with the available strategies, taking into account the patient, the characteristics and location of the visceral pseudoaneurysm.
- Post-Endovascular Aneurysm Repair Surveillance Needs Convergence on “Whom” and “How Often”Publication . Bastos Gonçalves, F; Mani, K
- Risk of Death After Paclitaxel Exposure During Femoropopliteal Artery Angioplasty – Narrative ReviewPublication . Ribeiro, T; Soares Ferreira, R; Cardoso, J; Figueiredo, A; Fidalgo, H; Bastos Gonçalves, F; Ferreira, MEPaclitaxel molecule has been on the market since 1991 and is indicated for the treatment of multiple neoplasms. Since 2012 has been used in endovascular devices for the treatment of peripheral artery disease and have become a mainstay in the treatment of symptomatic femoro-popliteal lesions, in particular for preventing arterial restenosis. They have a proven benefit in patency and freedom-from re-intervention up to 5 years. A recent meta-analysis of RCT showed an increased late-mortality rate, however, real-life cohorts analyses presents contradictory results. RCT meta-analysis is comprised mainly by claudicants, and CLTI patients are underrepresented. Further studies are needed to clarify this matter, in particular with a higher percentage of CLTI presentation. For now, patients should be advised about risks and benefits of paclitaxel exposure and a shared decision-making process should be followed.
- Nationwide Outcomes of Octogenarians Following Open or Endovascular Management After Ruptured Abdominal Aortic AneurysmsPublication . Alberga, A; de Bruin, J; Bastos Gonçalves, F; Karthaus, E; Wilschut, J; van Herwaarden, J; Wever, J; Verhagen, H; PJ, A; GJ, A; GP, A; WL, A; MG, A; CH, A; JA, A; OJ, B; R, B; WB, B; JA, B; MH, B; BL, B; M, B; P, B; RJ, B; JD, B; RJ, B; JJ, B; AS, B; ME, B; KE, B; AP, B; MH, B; BL, B; GJ, B; WT, B; J, B; JM, B; LH, B; V, B; MT, B; JL, B; P, B; JP, B; SE, B; MA, B; MG, B; DH, B; HC, B; E, C; PH, C; G, C; AM, C; PH, C; JH, D; I, D; JE, D; ML, D; J, D; MK, D; M, D; DE, D; RC, D; LM, D; JW, D; MM, E; D, E; GJ, E; JW, E; BH, E; A, E; MI, E; RG, E; MJ, F; WM, F; B, F; TM, F; FA, F; WM, F; PH, F; RH, G; WB, G; GJ, G; B, G; RP, G; HG, G; RF, H; EF, H; GF, H; JF, H; ES, H; CE, H; PP, H; JN, H; LG, H; JM, H; JA, H; JM, H; JW, H; RJ, H; GH, H; PT, H; MT, H; F, H; R, H; WH, H; W, H; AW, H; EJ, H; M, H; CJ, H; LC, H; RG, H; KM, H; MM, I; MJ, J; MF, J; JR, J; RJ, J; HH, J; SC, J; TA, J; V, J; MR, K; BP, K; A, K; JK, K; PL, K; P, K; NA, K; MJ, K; JL, K; GG, K; OH, K; R, K; AG, K; RM, K; RH, K; RR, K; L, L; n MJ, L; JH, L; GW, L; DA, L; JH, L; GJ, L; BJ, L; DA, L; VJ, L; MS, L; MM, L; MA, L; RC, L; FT, L; PF, L; MJ, L; MC, L; KM, L; DE, M; CG, M; EC, M; R, M; BM, M; GC, M; TP, M; R, M; RC, M; JC, M; MJ, M; YC, M; MJ, M; RH, M; W, M; SK, N; CC, N; JH, N; AM, N; AJ, N; DH, N; J, N; RC, N; D, N; VJ, N; AP, O; BI, O; J, O; HW, P; AG, P; AS, P; BJ, P; ME, P; AJ, P; RA, P; ED, P; IC, P; PP, P; A, P; S, R; JT, R; M, R; BL, R; MM, R; JA, R; A, R; MJ, R; RA, R; EV, R; BR, S; PB, S; MR, S; MG, S; HP, S; J, S; PM, S; DM, S; MR, S; A, S; PM, S; FJ, S; FP, S; VP, S; O, S; MA, S; GW, S; CJ, S; Slaa A; HJ, S; L, S; RR, S; AA, S; PC, S; TM, S; MG, S; AO, S; MJ, S; TJ, S; SM, S; DA, S; RA, S; RP, S; GN, S; JE, S; JA, T; BJ, T; M, T; MJ, T; T, T; RM, T; WJ, T; I, T; IF, T; RB, T; RJ, T; E, T; M, T; K, T; RP, T; Ç, Ü; RH, V; AA, V; AC, V; EJ, V; HT, V; MG, V; S, V; HJ, V; BA, V; CF, V; EG, V; BP, V; RJ, V; MJ, V; JA, V; CJ, V; R, V; JR, V; AW, V; B, V; CG, V; GA, V; MT, V; BH, V; PW, V; AC, V; DK, V; JP, V; M, V; C, W; EJ, W; BM, W; LA, W; JL, W; MC, W; W, W; V, W; AM, W; GM, W; RJ, W; JJ, W; AM, W; OR, W; WI, W; J, W; MC, W; EM, W; ED, W; W, W; ME, W; CH, W; CY, W; R, W; O, Y; KK, Y; CJ, Z; ML, ZPurpose: Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data. Methods: All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians. Results: The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8-3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2-2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1-3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8-2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4-0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4-0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6-0.8). Conclusion: Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.
- Octopus Endograft Technique in Complex Aortic Pathologies - a Retrospective Single-Center StudyPublication . Ribeiro, T; Soares Ferreira, R; Garcia, R; Bento, R; Pais, F; Ferreira, ME; Bastos Gonçalves, F; Ferreira, MEINTRODUCTION: Fenestrated/branched EVAR (f/bEVAR) are associated with lower peri-operative major complications, when compared to open repair in complex aortic pathologies. However, f/bEVAR is limited by the waiting time for customized graft production and has specifc anatomic limitations. Alternatively, adapting outside instructions-for-use, readily available off-the-shelf devices has been used with variable success. Among these options is the Octopus technique, which consists of parallel stent grafts originating inside a larger external stent graft. Despite being an off-label combination of devices, it can play a role when f/bEVAR is unavailable or inapplicable. METHODS: Single center retrospective study, including all consecutive patients treated with the Octopus technique. Baseline characteristics, peri-procedural and follow-up data was obtained. Primary endpoint is clinical success. Secondary endpoints are complications and secondary interventions in follow-up. RESULTS: Between 2015 and February 2022, six patients with a mean of 74±9 years were identifed. Treatment indications included three type 1A endoleaks and 3 thoracoabdominal aortic aneurysms (TAAA) without prior intervention, one of which was mycotic. Four procedures were elective and the remaining two emergent. In the elective cases, the Octopus technique was chosen due to anatomical constraints and because waiting time for customization was considered excessive. Excluder and Incraft endografts were used in 5 and 1 cases, respectively. Thirteen visceral branches were revascularized (6 superior mesenteric, 4 renal and 3 celiac arteries). Gutter endoleaks were observed in 2 patients. Mean blood loss, surgery and hospitalization duration was 483 (300) mL, 288 (73) minutes and 26 (19.5) days. One perioperative death occurred, in a patient treated in the context of post EVAR rupture due to type 1A endoleak. The most frequent postoperative complications were temporary acute renal failure (2/6), paraplegia (2/6) of which one was completely resolved, and non-graft related infection (2/6). One early reintervention, consisting of branch relining due to kinking and gutter embolization was necessary. On follow-up, there were no new endoleaks or endoleak-related interventions. Four patients died within two years, one with an aneurysm-related complication (spondylodiscitis in the context of a mycotic TAAA). The remaining deaths were not aneurysm related. CONCLUSION: The Octopus technique may offer a valuable off-the-shelf solution for complex aortic diseases, particularly due to anatomical constraints or in the emergent setting. Despite a high technical success rate, there is signifcant early morbidity and high mid-term mortality. In our series, durability was reasonable for this challenging group of patients, and our outcomes are in accordance with other reports.
- Mycotic Aortic Aneurysm: a Ticking Time-Bomb!Publication . Bento, R; Rodrigues, G; Alves, G; Garcia, R; Pais, F; Ferreira, MEINTRODUCTION: Mycotic or primary infected aortic aneurysms comprise aproximately 1.3% of all aortic aneurysms and may be caused by septic emboli to the vasa vasorum, by haematogenous spread during bacteraemia or by direct extension of an adjacent infection leading to an infectious degeneration of the arterial wall and aneurysm formation. The objective of this report is to describe a clinical case of a complicated mycotic aortic aneurysm. CASE REPORT: A male, 69-year-old patient, with medical background of diabetes, hypertension and a bladder carcinoma (surgically ressected 5 years before, complicated at the time with an E.coli septicaemia), presented at the ER with generalised malaise, asthenia, anorexia, abdominal pain, diarrhea and fever, with 1 week of evolution. At admission, clinical examination revealed poor general condition, fever (39ºC), noral blood pressure, and the abdominal examination showed no abnormalities. Laboratory results revealed an stable haemoglobin of 13 g/dL, leukocytosis (19850/UI) and neutrophilia (90%), an a C Reactive Protein of 350mg/dl. A Computed Tomography Angiography (CTA) revealed a 3,5 cm saccular juxtarenal AAA, with peri and intraaortic gas, strongly suggestive of an mycotic AAA (MAA). Hospitalization was indicated and a septic and immunologic screening was perfomed. The patient started a broad-spectrum antibiotic with meropenem and vancomycin and clinical, laboratory and hemodynamic surveillance. Blood and urine cultures revealed a E.Coli infection, and directed antibiotic was started. After 10 days os hospitalization, the patient was haemodinamic stable, presented no fever or abdominal pain, however inflammatory parameters remained elevated, and a new CTA that showed a daunting increase of 4 cm of the AAA (7,5 cm) with signs of contained ruture. An emergency intervention was decided and the patient underwent an thoracophrenolaparotomy and aortoaortic interposition with bovine pericardium patch. After 24h of surgery the patient died of septic shock. CONCLUSION: MAA is a rare and threatening disease with rapid progression and high mortality. Even with broad-spectrum antibiotic and rapid surgical response, the tragic outcome is often the unavoidable result.
- Contemporary Treatment of Popliteal Artery Aneurysms in 14 Countries: a Vascunet ReportPublication . Grip, O; Mani, K; Altreuther, M; Bastos Gonçalves, F; Beiles, B; Cassar, K; Davidovic, L; Eldrup, N; Lattmann, T; Laxdal, E; Menyhei, G; Setacci, C; Settembre, N; Thomson, I; Venermo, M; Björck, MObjective: Popliteal artery aneurysm (PAA) is the second most common arterial aneurysm. Vascunet is an international collaboration of vascular registries. The aim was to study treatment and outcomes. Methods: This was a retrospective analysis of prospectively registered population based data. Fourteen countries contributed data (Australia, Denmark, Finland, France, Hungary, Iceland, Italy, Malta, New Zealand, Norway, Portugal, Serbia, Sweden, and Switzerland). Results: During 2012-2018, data from 10 764 PAA repairs were included. Mean values with between countries ranges in parenthesis are given. The incidence was 10.4 cases/million inhabitants/year (2.4-19.3). The mean age was 71.3 years (66.8-75.3). Most patients, 93.3%, were men and 40.0% were active smokers. The operations were elective in 73.2% (60.0%-85.7%). The mean pre-operative PAA diameter was 32.1 mm (27.3-38.3 mm). Open surgery dominated in both elective (79.5%) and acute (83.2%) cases. A medial surgical approach was used in 77.7%, and posterior in 22.3%. Vein grafts were used in 63.8%. Of the emergency procedures, 91% (n = 2 169, 20.2% of all) were for acute thrombosis and 9% for rupture (n = 236, 2.2% of all). Thrombosis patients had larger aneurysms, mean diameter 35.5 mm, and 46.3% were active smokers. Early amputation and death were higher after acute presentation than after elective surgery (5.0% vs. 0.7%; 1.9% vs. 0.5%). This pattern remained one year after surgery (8.5% vs. 1.0%; 6.1% vs. 1.4%). Elective open compared with endovascular surgery had similar one year amputation rates (1.2% vs. 0.2%; p = .095) but superior patency (84.0% vs. 78.4%; p = .005). Veins had higher patency and lower amputation rates, at one year compared with synthetic grafts (86.8% vs. 72.3%; 1.8% vs. 5.2%; both p < .001). The posterior open approach had a lower amputation rate (0.0% vs. 1.6%, p = .009) than the medial approach. Conclusion: Patients presenting with acute ischaemia had high risk of amputation. The frequent use of endovascular repair and prosthetic grafts should be reconsidered based on these results.
- Improving Care of Mycotic Aneurysms: Can We Identify the Ideal Endovascular Candidate?Publication . Bastos Gonçalves, F