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- Hybrid surgery in lower limb revascularization : a real-world experience from a single centerPublication . Soares, Tony; Manuel, Viviana; Amorim, Pedro; Martins, Carlos; Melo, Ryan; Ministro, Augusto; Sobrinho, Gonçalo; Silvestre, Luís; Fernandes E Fernandes, Ruy; Pedro, Luís MBackground Through the association of endovascular and open procedures, hybrid surgery for lower limb revascularization allows the treatment of multilevel occlusive disease with a lower risk when compared to extensive open interventions. The aim of this study is to evaluate the immediate and midterm clinical outcomes of hybrid techniques for lower limb revascularization in a cohort of patients with multilevel arterial disease. Methods Data from elective procedures between 2012 and 2017 were retrospectively collected regarding hybrid lower limb revascularization procedures. The outcomes of the study were categorical clinical improvement, patency rates, major amputation rates, and mortality. Results A total of 81 patients, 89 limbs, with a median age of 69 years (interquartile range [IQR] 61–73) were submitted to hybrid lower limb revascularization, with a median follow-up of 10.7 months (IQR 2.5–25.1). Treatment indications were chronic limb-threatening ischemia in 80.9% of the cases (rest pain in 18.0% and tissue loss in 62.9%). One-year primary, primary-assisted, and secondary patency rates were 78.28% (95% confidence interval [CI] 65.20–86.92), 85.12% (95% CI 72.96–92.09), and 90.19% (95% CI 79.13–95.54), respectively. Overall categorical clinical improvement was observed in 56.2%. Major amputation and mortality rates were 14.6% and 16.0%, respectively. Multilevel Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) C or D and stage IV Leriche-Fontaine classification were strongly associated with decreased categorical clinical improvement (adjusted odds ratio [aOR] 0.08, P < 0.0001 and aOR 0.25, P = 0.013, respectively). Multilevel TASC C or D was also related to higher amputation rates, contrary to clinical presentation (adjusted hazard ratio [aHR] 11.37, P = 0.002 and aHR 4.70, P = 0.091, respectively). Primary-assisted and secondary patency rates were associated with higher categorical clinical improvement (aOR 4.30, P = 0.036 and aOR 7.36, P = 0.021, respectively) and decreased major amputation rates (aHR 0.11, P = 0.003 and aHR 0.09, P = 0.001, respectively) but were not related to multilevel TASC and Leriche-Fontaine classifications. Conclusions The present study reports a real-world experience with a large proportion of patients with chronic limb-threatening ischemia. Hybrid interventions for lower limb revascularization revealed to be a potential approach for patients with complex arterial disease that would beneficiate from less invasive procedures.
- An original bailout solution for renal artery dissection after fenestrated/branched EVARPublication . Lopes, Alice; Gomes, Miguel Lemos; Melo, Ryan; Amorim, Pedro; Sobrinho, Gonçalo; Pedro, Luís MBackground: Renal artery (RA) dissection may occur during endovascular treatment of thoracoabdominal aneurysms. The aim of this paper is to report the use of kissing coronary stents in the renal bifurcation as a bailout solution for dissection after fenestraded/branched endovascular aortic repair (F/B-EVAR). Methods/Results: A 73-year-old male with an asymptomatic Crawford type 4 thoracoabdominal aneurysm and a concomitant right common iliac artery aneurysm was proposed for endovascular repair, consisting of thoracic endovascular aortic repair plus custom-made device F/B-EVAR, followed by staged bifurcated EVAR plus right-sided IBD. In the control angiogram of the first procedure, a distal occlusion of the left renal artery was observed and attributed to iatrogenic dissection. The 6F sheath was reintroduced and the two main branches of the RA were catheterized with 0.014 wires. Then, two coronary drug-eluting stents were used for a kissing stenting technique with good angiographic and clinical results. As planned, one week later the patient underwent an uneventful second stage procedure. Follow-up CTA at 1 year showed normal patency of the renal stents as well as aneurysm shrinking and no signs of endoleak. Conclusions: In the reported case, the use of coronary stents was a safe and long-lasting solution to rescue an iatrogenic renal artery dissection during F/B-EVAR.
- Posterior gastric artery aneurysmPublication . Lemos Gomes, Miguel; Lopes, Alice; Sobrinho, Gonçalo; Pedro, Luís MIntroduction: Aneurysms of small abdominal vessels are extremely rare; however, even minor aneurysmal accessory arteries can rupture, leading to potentially fatal consequences. The purpose of this paper is to report a case of coil embolisation of an aneurysmal posterior gastric artery. Case presentation: The authors describe the case of a 66 year old female patient with an aneurysm of the posterior gastric artery. Coil embolisation was performed. The six month follow up computed tomography angiogram revealed exclusion of the aneurysm. Discussion: The presented case is exceedingly rare. This type of aneurysm has to be kept in mind as a possible cause of bleeding, despite the limited information regarding their natural history. Conclusion: Owing to the safety and applicability of the endovascular technique, it is nowadays probably the best treatment alternative for this type of aneurysm.
- Clinical outcomes of aortic arch hybrid repair in a real-world single-center experiencePublication . Soares, Tony; Melo, Ryan; Amorim, Pedro; Ministro, Augusto; Sobrinho, Gonçalo; Silvestre, Luís; Fernandes E Fernandes, Ruy; Martins, Carlos; Fernandes e Fernandes, José; Pedro, Luís MObjective: Aortic arch aneurysmal disease remains a therapeutic challenge. For patients unsuitable for standard open surgery, hybrid repair with debranching of the supra-aortic arteries followed by thoracic endovascular grafting has been shown to be an effective solution. The aim of this study was to report the clinical outcomes of a single-institution experience using hybrid aortic arch repair. Methods: The cases of all consecutive patients submitted to hybrid aortic arch repair between January 2010 and June 2018 were prospectively collected and retrospectively analyzed. The outcomes of the study were 30-day mortality, perioperative complications, 2-year survival, endoleak, and reintervention rates. Results: A total of 35 patients with a median age of 71 years (interquartile range, 62-77 years) were submitted to hybrid aortic arch repair, with a median follow-up of 26.9 months (interquartile range, 2.4-63.6 months). Ten procedures (28.6%) were performed urgently for contained rupture. The most common etiology was degenerative (n ¼ 14 [40.0%]). The proximal landing zones according to the Ishimaru classification were zone 2 in 20 patients (57.1%), zone 1 in 12 patients (34.3%), and zone 0 in 3 patients (8.6%). Early endoleaks were observed in six patients (17.1%), equally distributed between type I and type II. Late endoleaks were identified in 4 of 24 patients (16.7%; type I, n ¼ 2 [8.3%]; type II, n ¼ 1 [4.2%]; and type III, n ¼ 1 [4.2%]). Thirty-day mortality rate was 14.3% (n ¼ 5) with an early death rate of 8.7% (2/23) in elective cases and 30.0% (3/10) in urgent cases (odds ratio [OR], 4.93; confidence interval [CI], 0.68-35.67; P ¼ .128). Except in one patient, 30-day mortality was associated with landing zone 0 or zone 1 (26.7% vs 5.0%; OR, 6.91; CI, 0.68-69.86; P ¼ .141). Three patients (8.6%) suffered a postoperative stroke, and no episodes of spinal cord ischemia were observed. Two-year survival rate was 67.8% (CI, 49.4%- 80.8%). Survival rates were significantly lower with increasing age (hazard ratio [HR], 1.10; CI, 1.03-1.18; P ¼ .004), urgent procedure (HR, 4.80; CI, 1.56-14.80; P ¼ .003), zone 0 or zone 1 (HR, 6.34; CI, 1.73-23.18; P ¼ .001), presence of arrhythmia (HR, 3.76; CI, 1.22-11.62; P ¼ .013), and cerebrovascular disease (HR, 4.12; CI, 1.38-12.35; P ¼ .006). A multivariate analysis identified age (HR, 1.11; P ¼ .047) and zone 0 or zone 1 (HR, 4.93; P ¼ .033) as the only predictors for overall mortality. Conclusions: Hybrid aortic arch repair seems to be an alternative for higher risk patients not suitable for open repair, but selection of patients is crucial and may benefit from further refinement. In this study, worse outcomes were seen in older patients and those who required more proximal landing zones.
- The evolution of management of type B aortic dissection in a series of 100 consecutive cases in a tertiary centerPublication . Lopes, Alice; Pedro, Luís M; Melo, Ryan; Moutinho, Mariana; Sobrinho, Gonçalo; Amorim, Pedro; Silvestre, Luís; Fernandes E Fernandes, Ruy; Ministro, Augusto; Martins, Carlos; Almeida, Ana G.; Nobre, Angelo; Pinto, Fausto J.; Fernandes E Fernandes, JoseIntroduction and objectives: Management of aortic dissection is rapidly evolving. The present study aims to assess paradigm shifts in type B aortic dissection (TBAD) treatment modalities and their outcomes according to clinical presentation and type of treatment. We also aim to assess the impact of endovascular technology in TBAD management in order to define organizational strategies to provide an integrated cardiovascular approach. Methods: We performed a retrospective review with descriptive analysis of the last 100 consecutive patients with TBAD admitted to the Vascular Surgery Department of Centro Hospitalar Universitário Lisboa Norte over a 16-year period. Results were stratified according to treatment modality and stage of the disease. The study was further divided into two time periods, 2003-2010 and 2011-2019, respectively before and after the introduction of a dedicated endovascular program for aortic dissections. Results: A total of 100 patients (83% male; mean age 60 years) were included, of whom 59 were admitted in the acute stage (50.8% with complicated dissections). The other 41 patients were admitted for chronic dissections, most of them for surgical treatment of aneurysmal degeneration. Temporal analysis demonstrated an increase in the number of patients operated for aortic dissection, mainly due to an increase in chronic patients (33.3% in 2003-2010 vs. 64.4% in 2011-2019) and a clear shift toward endovascular treatment from 2015 onward. Overall in-hospital mortality was 14% and was significantly higher in the chronic phase (acute 5.1% vs. chronic 26.8%; OR 5.30, 95% CI 1.71-16.39; p=0.003) and in patients with aneurysmal degeneration, regardless of the temporal phase. Only one death was recorded in the endovascular group. Conclusion: Management of TABD carried an overall mortality of 14% during a 16-year period, but the appropriate use of endovascular technology has substantially reduced in-hospital mortality.
- Aortic dissection repair using the STABILISE technique associated with arch procedures : report of two casesPublication . Lopes, Alice; Melo, Ryan; Gomes, Miguel L.; Garrido, Pedro; Junqueira, Nádia; Sobrinho, Gonçalo; Fernandes E Fernandes, Ruy; Leitão, João; Nobre, Ângelo; Pedro, Luís MIntroduction: The stent assisted balloon induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique is being increasingly used for the treatment of complicated aortic dissections. However, as it is a fairly recent technique, the scientific information is limited. Report: In this paper we report two cases of the STABILISE technique associated with procedures in the ascending aorta and supra-aortic trunks, consisting of a “frozen elephant trunk” procedure in one case and in the other, a carotid endarterectomy associated with reimplantation of the vertebral artery and partial arch debranching. Discussion: In conclusion, while acknowledging the need for longer follow up and greater experience to support the safety and efficacy of this procedure, the two cases reported confirm that the STABILISE technique is a valid endovascular alternative in the treatment of complicated aortic dissections.
- Adaptations in the Vascular Surgery Department of the CHULN during the COVID-19 pandemic and impact on overall activityPublication . Duarte, António; Melo, Ryan; Lopes, Alice; Rato, João; Rodrigues, Marta; Henriques, Mickael; Gomes, Miguel; Pinto, Vanda; Ribeiro, Karla; Silva, Emanuel; Moutinho, Mariana; Garrido, Pedro; Manuel, Viviana; Ministro, Augusto; Sobrinho, Gonçalo; Silvestre, Luís; Amorim, Pedro; Fernandes E Fernandes, Ruy; Meireles, Nuno; Martins, Carlos; Pedro, Luís MWith the onset of the SARS-CoV-2 pandemic in early 2020, health services and personnel adapted their resources to mitigate and control the outbreak. These needs inevitably led to adaptations in most medical and surgical departments, including in our Vascular Surgery department. As we are facing a second outbreak of this pandemic, with unpredictable outcomes and repercussions in health services, it is crucial to learn from previous experiences and share strategies to perform the best care to our patients, despite the restrictions that have been imposed. Through this paper, we review the adaptations in Centro Hospitalar Universitário Lisboa Norte and particularly in our department to overcome the pandemic. We also assess the impact of these changes in our activity and compare with the experience of other fellow surgeons. With an upcoming second outbreak, it is crucial to learn from this and other departments’ experiences to overcome a potential health crisis.