Sistema Regional de Información
en línea para Revistas Científicas de América Latina,
el Caribe, España y Portugal

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.

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.

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.

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.

INTRODUCTION: acute mesenteric ischemia (AMI) presents a life-threatening emergency, requiring a high degree of suspicion for timely diagnosis. Despite advancements in the management of these patients, in-hospital mortality rates remain high. This study aims to assess the outcomes and prognostic factors in patients with AMI. METHODS: A retrospective single-center analysis of all patients undergoing emergent surgery for arterial occlusive AMI between January 2020 and February 2024 was conducted. The primary outcome was 30-day survival. Correlations between survival and laboratory biomarkers at admission were investigated. RESULTS: Thirty patients underwent emergent surgery for occlusive AMI. The overall 30-day survival rate was 33%. Pre-operative arterial HCO3-to-lactate ratio ≤ 10 and neutrophil-to-lymphocyte ratio > 16 correlated with lower survival, showing 83% and 59% sensitivities, respectively, and 100% specificity for 30-day mortality. CONCLUSION: Despite advancements in patient management strategies, AMI mortality rates remain high. The neutrophil-to-lymphocyte ratio has been proposed as a diagnostic and prognostic marker in AMI. While the HCO3-to-lactate ratio has not yet been described, it may serve as a more sensitive and specific predictor of mortality than lactate alone.

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.

INTRODUCTION: Currently, type IV thoracoabdominal aortic aneurysms (TAAA-IV) are treated primarily by endovascular repair. Despite the increased morbidity, there is still a role for open surgery in selected patients. This paper aims to present a descriptive analysis and outcome evaluation of open repair for TAAA-IV in our institution, where endovascular repair is generally the first-line treatment option. METHODS: An observational, descriptive, and retrospective cohort analysis was conducted, including all patients treated for asymptomatic TAAA-IV in the last 15 years (2008-2023). Demographic data, comorbidities, procedure protocols, complications, and early mortality were described and analyzed. RESULTS: The initial cohort included 38 patients. Ten emergent cases and four due to inconsistent records were excluded, resulting in a final population of 24 subjects. Twenty-two were men (92%), with a mean age of 68 years (standard deviation, 8 years) and a mean aortic diameter of 70mm (standard deviation, 15mm). All patients were submitted to paramedian laparotomies with medial visceral rotation. The approach to visceral and renal arteries varied, primarily due to the left renal artery (bypass in five, abandoned due to atrophied kidneys in two, reimplantation in 16 patients). The median length of hospital and ICU stay was 7 and 20 days, respectively. The most frequent complication was acute kidney injury (AKI) in 87%, being transient in 75%. Hemodialysis was needed in 21%, but permanent need for hemodialysis was only noted in 4%. Infectious complications occurred in 29%, mainly lower respiratory infections (17%). Two patients (8%) had cardiac complications (acute myocardial infarction and non-ischemic cardiogenic shock). The overall intra-hospital mortality rate was 21% (5/24), with the following time frame: intra-operative – two cases; first 24 hours, one case; between day 1 and day 30, one case; and beyond 30 days, one case. CONCLUSION: In this low-volume cohort, treated over a long time period, a high mortality rate was observed, which may confirm the dependence between results and surgical/post-operative care volume and experience. AKI was the most frequent complication, being transient in most cases. The main limitations of this study are the use of different treatment strategies over a long period of time, reporting bias, and the small sample size. Finally, we deem it necessary to report the results of open repair, thereby raising the issue of how to manage small cohorts of patients requiring open repair in an era where such cases are becoming increasingly rare.

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.

INTRODUCTION: Chronic mesenteric ischemia (CMI) is a rare but life-threatening disease. This study aimed to analyze the safety and effectiveness of open (OR) and endovascular (ER) revascularization and respective outcomes in a consecutive series of CMI patients. METHODS: From 2013 to 2023, all CMI patients treated with OR and ER were retrospectively identified. Demographics, comorbidities, clinical presentation, preoperative imaging, and revascularization modalities were analyzed. Patients were grouped according to the type of revascularization (OR and ER) and compared for the study’s endpoints. The primary endpoint was the reintervention rate, and the secondary endpoints were overall survival and reintervention-free survival. RESULTS: Thirty-three patients with CMI (60% male, mean age 67, range 45-88 years) were treated by ER (27 patients) or OR (6 patients). The median follow-up was 38 (9-72) months. The ER of the superior mesenteric artery (SMA) included the deployment of covered balloon-expandable stents in 85 % (n=23) of the patients. The OR included SMA bypass using prosthetic conduit and iliac artery inflow in 83 % (n=5) of the patients. Long SMA lesions (>20mm) were present in 100 % of the OR group patients and 44 % of the patients in the ER group (p=.027). Reintervention due to symptom recurrence and target artery restenosis or re-occlusion was performed in four patients in the ER group, of which one patient underwent open surgery and three underwent endovascular surgery. The three-year reintervention rate was 18% in the ER and 0% in the OR group (p=.374). Thirty-day and 3-year overall survival in the OR and ER groups were 67% vs. 93% and 44% vs. 87%, respectively (p=.015). Three-year reintervention-free survival in the OR and ER groups was 50 % vs. 70%, respectively (p=.103). CONCLUSIONS: According to this study, we should expect lower survival in CMI patients who undergo OR, probably related to the higher burden of atherosclerotic disease observed in this group. However, the improved survival observed after ER is offset by a trend towards higher reintervention rates.

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.