Armando Mansilha

Percutaneous Endovascular Aortic Repair with Local Anesthesia – One Day Surgery

INTRODUCTION To evaluate the results of the abdominal aortic aneurism endovascular treatment (EVAR), percutaneously and with local anesthesia, according to the concept of one day surgery. MATERIAL AND METHODS Unicentric, retrospective analysis of patients with aorto-iliac aneurysmal disease, consecutively treated by EVAR with percutaneous access trough the Preclose technique (pEVAR), according to the outpatient criteria, with one overnight stay in the hospital. The technical success, exclusion of the aneurysmal sac, endoleak, re-intervention and mortality were evaluated. RESULTS Twenty consecutive patients (all male; mean age 74.65 years) were treated by EVAR with percutaneous access and local anesthesia, from which 95% (19) presented with abdominal aortic aneurysm and 5% (1) common iliac aneurysm. All implants were sucessfully performed, with an initial endoleak rate of 10% (2), determined by one type 1a endoleak successfully corrected intra-operatively and one type 2a endoleak diagnosed in the first imaging control, which sealed spontaneously on the second control. Initial technical success for percutaneous closure was 97.5%, with one case reported of femoral pseudo-aneurism, posteriorly treated by percutaneous thrombin injection. Median length of stay was one day [1-10], with a mean follow-up of 11.4 months [1-36]. Both the re-intervention and mortality rate are 0% for the selected period. CONCLUSION Our one day surgery model for the outpatient treatment of abdominal aortic aneurysm by the pEVAR technique is innovative, safe and effective, as long as the selection criteria are respected.

Pathophysiological Mechanisms of Chronic Venous Disease and Implications for Venoactive Drug Therapy

Chronic venous disease (CVD) is a common pathology, with significant physical and psychological impacts for patients and high economic costs for national healthcare systems. Throughout the last decades, several risk factors for this condition have been identified, but only recently, have the roles of inflammation and endothelial dysfunction been properly assessed. Although still incompletely understood, current knowledge of the pathophysiological mechanisms of CVD reveals several potential targets and strategies for therapeutic intervention, some of which are addressable by currently available venoactive drugs. The roles of these drugs in the clinical improvement of venous tone and contractility, reduction of edema and inflammation, as well as in improved microcirculation and venous ulcer healing have been studied extensively, with favorable results reported in the literature. Here, we aim to review these pathophysiological mechanisms and their implications regarding currently available venoactive drug therapies.

Digital ulcers in systemic sclerosis: role of flow-mediated dilatation and capillaroscopy as risk assessment tools

AimThe aim of this study was to evaluate macrovascular endothelial dysfunction and microvascular damage as clinical markers of peripheral microangiopathy in patients with Raynaud’s phenomenon (RP).Patients and methodsSeventy-seven secondary RP with systemic sclerosis, 32 primary RP and 34 healthy controls were included in our study. Secondary RP patients were divided into two subgroups: 39 with digital ulcers (DU) and 38 without digital ulcers (non-DU).ResultsPatients with DU had significantly lower flow-mediated dilatation values (5.34 ± 7.49%) compared to non-DU patients (16.21 ± 11.31%), primary RP (17.96 ± 12.78%) and controls (20.17 ± 8.86%), p<0.001, favouring macrovascular endothelium dysfunction. Regarding microvascular damage, the DU group had a predominately capillaroscopic late pattern (71.1%) whereas non-DU patients had an active pattern (56.4%). The microangiopathy evolution score was significantly higher in the DU group compared to the non-DU group (4.79 ± 1.82 vs. 1.79 ± 1.56, p<0.001). Flow-mediated dilation was significantly lower in late pattern (6.13 ± 7.09%) compared to active (12.58 ± 10.66%) and early patterns (17.72 ± 14.90%), p = 0.016 and p = 0.044 respectively.ConclusionsLow flow-mediated dilatation and microvascular damage in capillaroscopy are early clinical markers of DU risk in RP patients.

Vasospastic Disorders of the Upper Extremities

Raynaud’s syndrome is named after Maurice Raynaud, who first identified it in 1862 [12]. It is characterized by recurrent episodes of digital numbness, tingling and a skin tricolour sequence:pal- lor, cyanosis and rubor. Formerly subcategorized into Raynaud’s disease and Raynaud’s phenomenon Raynaud’s disease is a benign form with no underlying disease Raynaud’s phenomenon is an aggressive form, associ- ated with vascular collagen diseases or other concomitant processes. Nowadays patients tend to be currently diagnosed simply with Raynaud’s syndrome, since long periods of time may elapse between the vasospastic episodes and any underlying first identifiable features of this condition.

PC014. Comparison of Long-term Results for the Endurant and Excluder Stent Graft

Objectives: Because endovascular aneurysm repair has become a predominant alternative, it has a high profile how to train young vascular surgeons in open surgery. The objective was to analyze the learning curve and determine the number needed to treat to establish sufficient surgical skills of open surgery for intact abdominal aortic aneurysm. Methods: This was a retrospective study of a prospectively accumulated database at Asahi General Hospital in Japan between 2003 and 2017. A total of 562 consecutive patients who underwent open repair for intact abdominal aortic aneurysm or iliac artery aneurysms either by an attending surgeon or by six young vascular surgeons (>20 experiences) were included. All young vascular surgeons had accomplished general surgery training. Analysis was conducted by every 10-cases experience performed by young vascular surgeons (Y group) to investigate the learning

Vantagens da anestesia locoregional relativamente à anestesia geral na endarterectomia carotídea

Resumo Introducao No sentido de potenciar a tecnica cirurgica preventiva do acidente vascular cerebral, a endarterectomia carotidea, varios estudos tem sido realizados na tentativa de esclarecer qual a tecnica anestesica que se relaciona com melhores resultados quanto a morbilidade, mortalidade, instabilidade hemodinâmica, necessidade de shunt, custos, funcao cognitiva e resultados cardiovasculares. Objetivo Este artigo procura analisar resultados publicados comparando as duas tecnicas anestesicas (locoregional (AL) e geral (AG)) na endarterectomia carotidea, no que concerne aos periodos pre, intra e pos-operatorios. Metodos Foi realizada, uma pesquisa na base de dados MEDLINE® ( http://www.ncbi.nlm.nih.gov/pubmed/ ) com a query “anesthesia carotid endarterectomy” aplicando filtros para obter diferentes tipos de estudos (ensaios clinicos, ensaios clinicos randomizados, estudos multi-centricos, revisoes, revisoes sistematicas e meta-analises) publicados nos ultimos 10 anos nas linguas inglesa e portuguesa. Posteriormente foram feitas pesquisas individuais com os mesmos filtros para cada uma das tecnicas anestesicas e diferentes parâmetros a analisar associados ao procedimento cirurgico em estudo. Resultados Apesar dos resultados evidenciados nao serem estatisticamente significativos, a endarterectomia carotidea com AL parece predominar positivamente na comparacao com a AG, especialmente em doentes com oclusao carotidea contra-lateral. As incidencias de AVC, EAM e mortalidade aos 30 dias mostraram-se ligeiramente inferiores, a utilizacao de shunts e consideravelmente menor, assim como os custos medios associados a menores periodos de internamento. Conclusoes Ambas as tecnicas anestesicas sao seguras, devendo ser utilizada a tecnica mais confortavel pela equipa cirurgica, otimizando o fluxo sanguineo cerebral, minimizando o esforco cardiaco e o risco de isquemia atraves do controlo da pressao-perfusao.

Fístulas aorto-entéricas secundárias: caso clínico

Resumo As fistulas aorto-entericas secundarias sao complicacoes raras, mas potencialmente fatais apos cirurgia da aorta abdominal e permanecem umas das mais desafiantes entidades patologicas vasculares a tratar. Os autores apresentam um caso clinico de uma doente com antecedentes de cirurgia de reconstrucao aortica (bypass aorto-bifemoral realizado ha 6 anos) para tratamento de doenca arterial periferica, que foi admitida no nosso hospital por hemorragia digestiva tendo-se visualizado em esofagogastroduodenoscopia da 3° porcao do lumem duodenal, protese de Dacron ® de bypass aorto-bifemoral previo. Efetuou-se entao, com sucesso, um bypass axilo-bifemoral com duodenectomia segmentar, bypass duodeno-jejunal e remocao parcial do bypass aorto-bifemoral previo. A doente teve alta do nosso hospital, apos longo internamento, do qual resultou isquemia irreversivel do membro inferior direito com consequente necessidade amputacao acima do joelho.

Below the Knee Techniques: Now and Then

Critical Limb Ischemia (CLI) is defined as the presence of ischemic rest pain for more than two weeks or ischemic tissue loss associated with an absolute ankle pressure less than 50 mmHg or great toe pressure less than 30 mmHg (Norgren et al., 2007). Patients with CLI experience high amputation rates, significant morbidity and cardiovascular events exceeding those in patients with symptomatic coronary heart disease (Varu et al., 2010). In spite of recent developments in revascularization techniques and wound care centers, amputations continue to be performed, partly because patients with CLI are referred late to vascular surgeons (Varu et al., 2010). However, revascularization when compared with amputation have an overall lower perioperative mortality and enhanced long-term survival (Brosi et al., 2007; Varu et al., 2010). However, CLI is associated with multisegmental complex arterial lesions and consequently with high rates of revascularization failure (Allie et al., 2009). Specific features of the tibial vessels, such as the small caliber, the remote location, the slow flow of the distal bed, and the need of preserving runoff capacity, make this vascular territory particularly challenging for endovascular treatment (Blevins and Schneider, 2010). Meanwhile, continued technical improvements and very encouraging results have changed the paradigm of CLI therapy, until recently based on vein graft bypass. As so, the endovascular approach is, nowadays, the first-line modality for limb-threatening ischemia for a majority of authors (Allie et al., 2009; DeRubertis et al., 2007).