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

BACKGROUND: Open aortic repair is the gold standard in the treatment of diseases involving the aortic arch, but high-risk patients are often not suitable candidates for surgical repair. Thoracic endovascular aortic repair (TEVAR) is less invasive; however, endovascular repair including the aortic arch remains a challenge. LSA revascularization is linked with reduced risk of cerebrovascular events, spinal cord ischemia, and upper limb ischemia at the cost of complications associated with carotid-subclavian bypass. In-situ fenestration (ISF) seems an effective, safe, and feasible method for the totally endovascular aortic arch repair avoiding the risks associated with bypass surgery. This technique allows for rapid, “off-the-shelf” repair of arch lesions with minimal physiologic disturbances and lower perioperative complications. CASE REPORT: An 86-year-old man is admitted to the emergency room due to chest pain and hoarseness. There was a previous medical history of TEVAR (proximally implanted in zone 3) for penetrating thoracic aortic; 8 months prior. Computed tomography angiography revealed aneurysmal dilation of the lesser curvature of the aortic arch with a maximum diameter of 65mm. The patient was submitted to TEVAR with proximal sealing in zone 2 of the arch (Ankura™ stent-graft) and revascularization of the left subclavian artery (LSA) was achieved using an ISF by needle fenstration with the deployment of a balloon-expandable covered stent. No complications were registered. Patient initiated broad spectrum antibiotics and underwent positron emission tomography revealing several metabolically active lymph nodes suggesting underlying neoplasm. CONCLUSION: ISF, due to its relative simplicity, is also suitable in urgent and emergent settings. It is a simple, quick technique to be added to our arsenal of endovascular procedures on the aortic arch. It may avoid the carotid-subclavian bypass as well as intentional embolization of the LSA in urgent/emergent patients. Prospective studies with long-term clinical follow-up are still lacking to fully assess the durability of these fenestrations.

BACKGROUND: Primary tumors of the inferior vena cava (IVC) are rare. They most commonly arise from the smooth muscle of the IVC walls, known as leiomyomas. CASE REPORT: A 49-year-old male patient presented to the emergency department with right leg swelling. He had undergone varicose vein extraction surgery one month before presentation. Doppler ultrasound revealed thrombosis of the right iliac and femoral veins. Permeability of the IVC was presumed, since symptoms were unilateral. The patient was discharged with anticoagulation therapy, rivaroxaban 15mg bid. During follow-up, complaints of right leg swelling and discomfort persisted, raising the suspicion of post-thrombotic syndrome. A computed tomography angiography scan revealed a 12 cm-long thrombus in the infrarenal IVC. Despite ongoing anticoagulation, symptoms persisted with intermittent improvements and worsening. Consequently, additional investigation with phlebography, magnetic resonance, and positron emission tomography (PET) scan was performed, which raised a high suspicion of a leiomyoma of the IVC. An endovascular biopsy with a Cordis ® biopsy catheter confirmed the diagnosis of an IVC leiomyoma. Open surgical resection of the tumor was proposed and accepted by the patient. After the operation, the patient spent three days in intensive care and was discharged from the hospital after one week. At the one-month follow-up appointment, the patient remained asymptomatic. CONCLUSIONS: While rare, it is crucial to keep in mind the existence of IVC leiomyomas, which often occur with nonspecific symptoms. In this clinical case, the sole symptom was thrombosis of the femoral, iliac, and inferior vena cava, refractory to anticoagulation therapy. To confirm the diagnosis, biopsy is mandatory, with endovascular biopsy being an efficient and safe method.

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.

INTRODUCTION: Primary aortic mural thrombus (PAMT) is a rare cause of peripheral embolization that has been associated with hypercoagulable states. Anticoagulation is usually the first-line strategy, but has been associated with a significant risk of recurrent embolization. CASE-REPORT: A 51-year-old male patient with a history of right lung carcinoma underwent a follow-up computed tomography angiography (CTA) scan that revealed an incidental thrombus in the descending thoracic aorta. Conservative treatment with full-dose enoxaparin was initiated. A week later, the patient presented symptoms of pain and paraesthesia of the left lower limb. A new CTA scan revealed extension of the thrombus, with two pedunculated floating thrombi in the descending thoracic aorta. Thus, a diagnosis of left acute limb ischemia due to embolization originating from a PAMT was assumed. Thoracic Endovascular Aortic Repair (TEVAR) was performed to control the embolic source and prevent new events. To prevent visceral embolization during the TEVAR procedure, low-pressure angioplasty balloons were positioned in the visceral arteries. The thrombi were excluded using a Valiant® endoprosthesis 30x150mm. Subsequently, a left transfemoral thrombectomy was performed, achieving normal blood flow to the foot. No adverse events occurred in the postoperative period. The patient was discharged on aspirin and rivaroxaban and continues to be followed in outpatient care, remaining asymptomatic to date. CONCLUSIONS: Although rare, PAMT should be suspected as a possible embolic source, especially in patients with hypercoagulable states such as neoplasms. Our case highlights that in cases of recurrence embolization despite anticoagulation, the use of TEVAR to exclude aortic thrombi is effective in preventing additional embolization.

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.

INTRODUCTION: Peripheral arterial calcification is typically most prominent in the femoropopliteal (FP) segment, and its effect on endovascular treatment (EVT) processes and outcomes is poorly understood. This study aimed to evaluate the impact of the pattern of FP calcification on EVT outcomes. METHODS: We designed a retrospective, single-center, comparative study. From January 2023 to February 2024, all patients with peripheral arterial disease who underwent EVT by a single operator as a first limb revascularization procedure for FP lesions only were considered. The calcification pattern was assessed through a qualitative fluoroscopic and angiographic evaluation. According to the degree of calcification, the patients were grouped into mild to moderate calcification (MC) and severe calcification (SC). Both groups were compared regarding the primary endpoints: reintervention rates, amputation and overall survival. RESULTS: The study included 45 patients, of which 8 (18%) presented with intermittent claudication and 37 (82%) with chronic limb threatening ischemia. The median time of follow-up was 7 months. The MC group included 71% of the patients and the SV group included 29%. The median femoropopliteal GLASS classification was 4 in both groups. No statistically significant differences were found between groups in rates of reintervention (p=0.97), amputation (p=0.86) and overall survival (p=0.45). There were two major amputations in the MC group and one in SV group after eleven months of follow-up. Higher rates of subintimal angioplasty (38% vs. 12%, p=0.048) and contralateral retrograde access (54% vs. 22%, p=0.03) were found in the SC group. CONCLUSIONS: In our cohort, highly calcified FP lesions were statistically related to contralateral retrograde access and subintimal cross-lesion pathway. However, the degree of calcification did not influence the most relevant clinical outcomes.