RCAAP Repository

Introduction: Unfractionated heparin (UFH) has been used for decades to prevent thrombotic events during vascular surgery. Although it is known that UFH has a complex and nonlinear pharmacokinetics, with great individual variability, anticoagulation monitorization in vascular surgery is not routine and a standard empirical dose is often used. Activated clotting time (ACT) has been shown to be a simple, reliable and inexpensive way to monitor UFH anticoagulant effect, being routinely used during cardiac surgery. However, heparinisation remains a dilemma in vascular surgery and few studies emphasized the role of anticoagulation monitoring in this setting.Objectives: To investigate whether a fixed heparin dose of 5000 IU in arterial vascular surgery results in adequate and homogeneous heparinisation in all patients. Secondary endpoints: to identify preoperative factors for heparin response, intraoperative events and outcomes.Methods: This observational prospective pilot study included 30 consecutive patients undergoing arterial vascular surgery. ACT monitoring was performed before clamping and at 3, 30 and 60 minutes after 5000 IU UFH bolus. Preoperative and intraoperative data were also accessed. A target ACT of ≥ 200 s was set, taking in account of the lowest ACT value admitted by vascular surgery recommendations.Results: The average ACT value increased to 210.20 ± 28.82 s (1.61 ± 0.25 times vs baseline) 3 minutes after bolus, then declined to 191.60 ± 21.86 s and 173.4 ± 21.37 s after 30 and 60 minutes, respectively. Three minutes after UFH bolus, 53% patients had ACT ≥ 200 s, decreasing to one third and 7% at 30 and 60 minutes, respectively. Even when weight-based, a correlation between heparin dose per kilogram and ACT change was not found (r = 0.187; p = 0.322). There was also no correlation between ACT values and preoperative hemoglobin, platelet count, creatinine clearance or INR. There was a positive correlation between preoperative aPTT and intraoperative ACT measurements (r = 0.432; p = 0.017). There was no difference between ACT values and previous antithrombotic/anticoagulant therapy and between intraoperative ACT and intraoperative blood loss.Conclusions: This study confirms that administrating a fixed or even a weight-based heparinisation is insufficient to provide consistent anticoagulation levels in all patients. Perioperative anticoagulation should be monitored and ACT-based. Larger clinical RCT's are warranted.

Endovascular techniques are currently the treatment of choice for complicated type B aortic dissection (cTBAD). Among them is the STABILISE technique, which goal is to achieve, in a single surgical time, an immediate remodeling of the thoraco-abdominal aorta with consequent obliteration of the false lumen through the reaposition of the dissection flap to the outer layers of the aorta. This is a relatively recent technique, with few published series. Therefore, this review aims to systematize the information to date on this technique of increasing importance in the treatment of acute type B aortic dissections.

Introduction: Renal autotransplantation (RA) is a safe and effective procedure to reconstruct the urinary tract which first successful surgery was performed by Hardy in 1963. The main indications reported to perform a RA generally include renovascular disease, ureteral pathologies and neoplastic disease. Furthermore, RA may be useful as an ultimate recourse in preventing kidney loss in highly selected patients, especially when conventional methods have failed. Materials and Methods: The authors describe four total different situations where the RA was the key solution for the pathology initially presented. Clinical case I – A 52 years old male with a previous history of left nephrectomy due to a preceding exacerbation of his basal Crohn's disease and also a right ureter cutaneostomie, presented now with repetitive urinary tract infections that led to renal function impairment; Clinical case II – A 57 years old female with the diagnosis of renal artery aneurysm while being studied as a potential kidney donor; Clinical case III – A 49 years old male admitted in the emergency room after a penetrating trauma which conditioned bowel and ureteral lesions with postoperative consecutive and recurrent peritoneal infections that compounded a necessity for a left ureterostomy, that the patient vehemently refused; Clinical case IV – A 24 years old female with the diagnosis of Nutcracker syndrome identified after being studied regarding repetitive urgency admissions with frank haematuria. Results: Every patient was submitted to laparoscopic nephrectomy, ex-vivo reconstruction, if necessary, and kidney transplantation to the iliac fossa. The interventions were uneventful and only one patient faced a minor post-operative complication (surgical wound dehiscende). We performed an ultrasound and renal scintigraphy evaluation on following days after each procedure to attest normal renal perfusion. Discussion: The RA were conducted in two patients with ureteral cutaneostomie because there was no viable alternative but kidney loss. The other two clinical cases were treated with RA because they concerned a complex renovascular disease (one arterial and the other venous). Despite the existence of an endovascular option for these patients, long term follow-up studies are still lacking. Conclusion: The RA is a viable option in specific situations for kidney salvage. The recent development of laparoscopic nephrectomy significantly decreased the surgical hostility to the patient and promoted the RA as a value option for the treatment of complex vascular pathologies, traumatic disease and specific medical situations. It represents a credible alternative with attested results already described in the literature thus requiring a vast Institutional experience withconventional renal transplantation.  

Introduction: Right sided aortic arch is a rare condition and half of the cases are associated with an aberrant left subclavian artery that can become aneurysmal (Kommerell´s diverticulum). Fewer than 50 cases have been reported in literature and a number of operative strategies are described. The authors report a case of a right aortic arch with Kommerell diverticulum of the aberrant left subclavian artery corrected through a hybrid approach. Clinical case: The patient was a 51-year-old female with a prior history of hypertension, cervical herniated disc requiring surgery and hysterectomy. The angio CT showed a right aortic arch with a 30 mm Kommerell diverticulum, with mild esophageal compression but no associated symptoms. The patient was referred to surgical treatment through a hybrid approach. The intra and post operatory period were without any complication and patient was discharged 3 days later. Conclusion: An endovascular hybrid approach may significantly reduce the morbidity and mortality of the repair of these aneurysms and, if effective and durable, could become an important surgical strategy for these patients. However, long term outcomes of such therapy are not yet established so, cautious follow up is needed.

Introduction: Most thoracoabdominal aneuryms (AATA) have a degenerative etiology, non the least, about 20% can be a consequence of chronic dissection, and from those, 40% will require surgical treatment regardless the initial optimal medical treatment. Clinical case: Male patient, 68 years old, with previous history of hypertension and smoker. Angio TC showed a chronic aortic dissection with a complex thoracoabdominal aneuryms and the patient was proposed to a surgical hybrid solution. The first surgery was a Frozen Elephant Trunk followed, days later, by a thoracic endograft to the celiac trunk with distal extension with a dissection stent. Then, a thoracooabdominal endograft (Zenith® t-Branch®). The post operative period was without complications and the follow-up CT showed the normal patency of all endografts and no endoleaks. Conclusion: Staged endovascular treatment of complex AATA looks promising specially when it comes to lower morbidity rates. However, these results can vary depending on patient selection and surgeon skills. Also important is the fact that long term outcomes of such therapy in these specific group of patients are not yet established so, cautious follow-up is needed.

Introduction: Most of the deep femoral artery (DFA) pseudoaneurysm (PSA) present asymptomatically or as a pulsatile mass. Clinical signs are variable and, normally, result from compression from adjacent structures but when ruptured it may present as haemorrhagic chock Symptomatic PSA should be treated. However, the decision to treat asymptomatic PSA is controversial. The majority of small PSA (less than 20–30 mm in diameter) are prone to spontaneous thrombose within 4 weeks, so literature recommends observing small, asymptomatic PSA and treating only if they enlarge, do not thrombose, or become symptomatic. Materials and methods: The authors present two cases of PSA from a DFA branch after an orthopedic procedure. Clinical case I – 83-year-old female admitted in the emergency department with left femoral shaft and lateral condyle trauma. Submitted to trochanteric osteosynthesis, complicated with deep vein thrombosis but no diagnosis of PSA by that time, so she was discharged with anti-coagulation. Re-admitted two months later with thigh pain and a diagnosis of DFA PSA. She was submitted to selective coil embolization with 2D Helical-35® of 3x52mm and one VortXTM Diamond® of 3x23mm. Clinical Case II – 70-year-old female electively admitted for a total right hip replacement. Post procedure, she developed thigh hematoma, persistent hypotension and 2gr/dL haemoglobin decrease, not responsive to conservative measures. After diagnosed of a DFA PSA, she was submitted to selective embolization with two Tornado Cook® embolization coil of 2-5x50mm. Discussion: Accurate diagnosis of DFA PSA is difficult, not only due to its rarity but also to a frequent delayed presentation. It has an incidence of 2% of all peripheral arterial wounds being more common after orthopaedic and vascular procedures. An endovascular approach has emerged as a minimum invasive technique that allows a precise localization and exclusion of the lesion identified. It has a successful rate near 100% when anatomically feasible.

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Background: Colon ischemia (CI) is an underdiagnosed complication of the abdominal aortic aneurysms (AAA) treatment. Objectives: The aim of this study was to analyze its frequency in patients treated for AAA and to identify predisposing factors for its occurrence to enable early diagnosis and appropriate therapeutic intervention in a timely manner. Methods: Retrospective study which analyzes all patients’ files with infrarenal, pararenal or justarenal AAA operated in an institution in the period from 1 October 2012 to 1 October. The diagnosis of CI was confirmed by endoscopy and/or surgical intervention. The risk factors and determinants of morbidity and mortality were analyzed in 17.0 SPSS program. Results: 161 patients underwent surgical treatment in this period, of which 117 for conventional surgery and 44 for endovascular, 119 electively and 42 in rupture. 92% were male with a mean age of 72 years. Eight of these patients had IC, 4.2% elective and 7.1% emergency. In patients with rupture, hypotension on admission was the most important determinant of IC (119 vs 68 mm Hg, p = 0,03), whereas in patients treated electively the most relevant factors were renal dysfunction (Cr 3.9 vs 1.2 mg / dL, p = 0.002 OR 2,04) and prolonged use of amines in the immediate postoperative period (40% vs 8.2%, p = 0.001 OR 22). The overall 30-day mortality was 13%, but in those with IC was 25%. Conclusions: In our series, ruptured aneurysms, patients with severe hypotension and / or renal insufficiency at the time of admission as well as patients requiring significant intraoperative aminergic and transfusional support were more likely to suffer from IC in postoperative treatment of AAA; although, in this case, this is a less frequent complication compared to other series.

Introduction: Advanced age negatively impacts the outcomes of abdominal aortic aneurysm (AAA) repair. Nowadays, endovascular procedures enable vascular surgeons to treat elderly patients who cannot be submitted to open surgery. Aims: We report our experience with endovascular aneurysm repair (EVAR) in nonagenarians. Methods: We retrospectively reviewed our prospectively maintained aneurysm database in order to obtain records of all patients more than 90 years-old, who were submitted to EVAR over a 12 years period at our institution. Patients’ comorbidities, functional status, aneurysm size, perioperative complications, endoleaks, reinterventions and long-term survival were recorded. Results: 171 EVAR procedures were performed. Three (1,75%) nonagenarians underwent aneurysm repair (3 male; mean age 91.3 ± 1.25 years). Mean aneurysm diameter was 8.2 ± 1.68 cm with a median size of 8.1 cm (range 6.2–10.3 cm). There were 1.7 mean comorbidities per patient. Technical success rate was 100%. Mean hospital length of stay was 4.3 ± 0.47 days with a median of 4 days (range 4–5 days). Thirty-day mortality was 0%. Mean follow-up and mean survival were 28 months. There were no complications and all patients returned to their preoperative functional status. No endoleaks were identified on the follow-up imaging. Conclusions: We have shown, in a small and carefully selected group, that EVAR is associated with good outcomes in nonagenarian patients. EVAR is, in our opinion, the best treatment option for AAA in nonagenarians with good functional status.

The presence of abdominal or back pain, weight loss and elevated erythrocyte sedimentation rate is characteristic of the inflammatory abdominal aortic aneurysms. Low-grade fever is sometimes identified. Other inflammatory markers, such as white blood cell count, C reactive protein, anti-nuclear antibody and IgG4 levels can be elevated. Computed tomography is the exam of choice, showing characteristically the mantle sign. Steroids improve the symptomatology and reduce inflammation, but do not treat the aneurysm. The choice of interventions: open surgical repair or endovascular aneurysm repair can be considered according to the available expertise, patient risk factors, anatomic aneurysm criteria and presence of hydronephrosis.

Introduction/Objectives: Type A aortic dissection (AD) usually requires urgent surgical treatment and aortic segment replacement remains the gold standard. However, it is a very aggressive procedure and some patients are considered too frail for this treatment. Nowadays, endovascular repair represents an alternative treatment but still without precise indications. Our objective is to present a case of hybrid treatment of a type A AD with resource a transapical cardiac access. Material/Methods: Clinical case and literature review. Results: A 65-year-old man with history of chronic pulmonary obstructive disease, atrial fibrillation and hypertension came to the emergency department with abdominal pain. He underwent angio-CT that revealed type A AD with an PAU in the ascending aorta (AA). After evaluation by cardiac surgery, he was considered too frail for conventional surgery. Angio-CT was repeated after two weeks of medical treatment and revealed false aneurysm growth, with imminent risk of rupture. We thought about endovascular treatment and different options were considered, the final decision was to propose the patient for an hybrid treatment. The procedure was started with a femoro-rigth axilar bypass and embolization of the brachyocephalic trunk. Then an endoprosthesis (Valiant®) was delivered below the left subclavian artery and two periscopes (Viabahn®) were progressed form left carotid and axillar arteries and the second endoprosthesis (Valiant®) was released into the aorta, inside the first, with coverage of the left common carotid and subclavian, and the Viabahn® were released. After multiple attempts, it was not possible to progress the third endoprosthesis AA because of lack of support and hemodynamic instability whenever the guidewire was progressed for the left ventricle and the procedure was interrupted. Subsequently performed angio-CT revealed permeable AA dissection and untreated false aneurysm. We discussed other options and an anterograde (transapical) approach was considered to progress a guidewire on through-and-through to achieve the support we need to progress the endoprothesis. With the support of the cardiac surgery the cardiac apex was punctured and using the through-and-through technique the guide wire was progressed to femoral artery which allowed advancement of the endoprosthesis (Valiant®) through the retrograde pathway and release under rapid-pacing in the AA with good final result. Discussion/Conclusions: Endovascular treatment is an alternative in patients of high clinical risk and adequate anatomical characteristics, yet technically challenging. When the retrograde progression of the endoprosthesis is not achieved, the transapical cardiac approach is an alternative to be considered.

Introduction: The presence of symptomatic atherosclerotic stenosis of the innominate artery is an uncommon condition. The authors report the use of kissing stent technique in right subclavian and common carotid arteries with covered stents and cerebral protection by direct clamping of common carotid artery, as a hybrid endovascular alternative to treat symptomatic stenosis of the innominate artery. Case Report: A 75-year-old male was admitted to Vascular Surgery Department with repeated transient ischemic attacks (TIA’s) of the right cerebral hemisphere, resulting in transitory left hemiparesis. Computerized tomography angiography (CTA) excluded significant carotid lesions and revealed stenosis of the innominate artery associated with mural thrombus that extended to the bifurcation. The right common carotid artery and axillary artery were surgically exposed. Brain protection was achieved by direct clamping of the common carotid artery and subsequently carotid and axillary retrograde endovascular access was obtained. Two balloon-expandable covered stents were placed in the innominate, subclavian and right common carotid arteries, using the kissing stent technique. At the end of the procedure, a good permeability of the revascularized arteries was verified and a direct expulsion of eventual embolic material was performed prior to declamping. The postoperative period was uneventful. Conclusion: The kissing stent technique, with covered stents, in innominate, right subclavian and common carotid arteries with direct protection of the common carotid by clamping is a possible and minimally invasive solution for the treatment of symptomatic stenosis of the innominate artery.

True aneurismal dilatation of the azygos vein is a rare entity which has been reported in the literature on only a few occasions. We report a case of azygos vein aneurysm dilatation that was incidentally discovered on a computed tomography angiogram (CTA), during imagiologic study for hemoptyses, on an anticoagulated female 82 year-old patient. A repeat CTA after one month revealed complete thrombosis of the aneurysm. She was managed conservatively with outpatient follow-up.

Introduction: Cystic adventitial disease is a rare cause of intermittent claudication. Its presentation as acute limb ischemia is exceedingly rare. This disease is caused by the growth of multiple cysts within the adventitia. Although its etiopathogeny isn’t fully understood most evidence supports an embryonic defect during the development of non-axial arteries. Treatment includes several options: adventitial layer excision, percutaneous aspiration of the cysts and segmental arterectomy with bypass. Methods: We present a case of acute limb ischemia caused by popliteal cystic adventitial disease. Clinical Case: A 60 years old male presented with acute limb ischemia of the right leg. Duplex ultrasound showed a tight stenosis of the popliteal artery caused by adventitial cysts. The patient was intervened: from a posterior approach an excision of the cysts and adventitial layer was performed with total recovery of foot’s perfusion and pedal pulse. After 18 months of follow-up the patient is asymptomatic without imagiological evidence of recurrence. Conclusions: Due to the disease’s rarity there are no studies designed to compare the different treatment strategies for this pathology. However, the available data from case series shows that the surgical technique chosen for this patient presents very good results and, therefore, it seems to be a good therapeutic option assuming a patent popliteal artery without intimal lesion. Clinical presentation as acute limb ischemia isn’t described in the literature and isn’t today understandable because the factors affecting mucin secretion rate by cyst’s mesenchymal cells are unknown.

Although rare, the persistence of a sciatic artery is a clinically significant vascular variant, since it is often associated with complications such as aneurysm formation, thrombosis and ischaemia. We present the case of a patient with signs of subacute ischaemia on the right lower limb and a pulsatile mass in the right inferior gluteal region. CT angiography revealed a bilateral persistent sciatic artery (PSA) complicated by aneurysm formation and embolization of distal popliteal artery. Treatment included a femoro-popliteal bypass, ligation of the popliteal artery above the anastomosis and embolization of the aneurysmal lesion.

Pseudoaneurysms of the superficial temporal artery are uncommon but mainly result secondary to blunt or penetrating trauma of the frontotemporal region of the head. The authors report a clinical case of a young male with a false aneurysm of superficial temporal artery. Five weeks before he had a blunt trauma of the head. The authors did surgical resection via proximal and distal artery ligation.

Retroperitoneal fibrosis (RF) is a rare disease, characterized by inflammation and fibrosis in the periphery of the abdominal aorta which spreads within the retroperitoneal space, invading adjacent structures. In about two thirds of the cases this condition is idiopathic presenting a identified cause in the rest. In the majority of cases, secondary forms are associated with drugs and neoplasia, but there are more situations that can lead to the development of the disease. Recently, evidence has emerged that RF is related with angioplasty, stenting or implantation of endoprosthesis in aortoiliac axes, however, literature is very scarce. We present our experience with two patients with grade IIb arteriopathy, one with preocclusive stenosis of the left common iliac artery treated with angioplasty and stenting of the lesion, other with morphologically significant stenosis of the infrarenal abdominal aorta where angioplasty and placement of two aortoiliac stentgrafts in the form of kissing the stent was performed. Both patients have manifested marked lumbar pain with a periaortic inflammatory process suggestive of retroperitoneal fibrosis visualized in CT angiography that evolved to abdominal inflammatory aortic aneurysm. The pathophysiology of this findings is not known; however, we may assume that angioplasty and stenting can disturb plaque integrity with antigen exposure triggering a local inflammatory response. On the other hand, an immune reaction directly against the stent may arise. It is important to think about this occurrence, since there is a good response to steroid therapy in this patients and because of the possible progression to inflammatory aortic aneurysm.

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