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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.
- Clinical aspects and present challenges of the seat belt aortaPublication . Melo, Ryan; Amorim, Pedro; Soares, Tony; Fernandes E Fernandes, Ruy; Ministro, Augusto; Garrido, Pedro; Fernandes e Fernandes, José; Pedro, Luís MObjective: Seat belt aorta is rare and difficult to manage. The lack of data and follow-up increases the complexity of treating such patients. We aimed to create a decision algorithm by reviewing our current experience and analyzing the presentation and management of our patients. Methods: We performed a descriptive case series based on retrospective analysis of all consecutive patients admitted with the diagnosis of seat belt aorta from 2008 to 2018. Seat belt aorta was defined as any blunt abdominal aortic lesion resulting from a seat belt compression mechanism after a car accident. Results: Nine consecutive patients were admitted with the diagnosis of seat belt aorta, all of whom developed lesions in the infrarenal aorta. Eight patients were assessed in the acute phase and one patient presented with late-onset symptoms. Associated injuries were present in all acute patients, and seat belt sign and small bowel injury were present in 88%. One patient presented with a small intimal tear and was treated conservatively. All other patients diagnosed with large intimal flaps (seven patients) and pseudoaneurysm (one patient) underwent open repair in five cases and endovascular repair in three cases. In-hospital mortality for the acute cases was 38%, with no mortality seen during follow-up. Two patients submitted to endovascular repair required reinterventions. Conclusions: Seat belt aorta is a deadly condition, frequently associated with blunt thoracoabdominal trauma with concomitant injuries; the presence of a seat belt sign or lower limb ischemia must lead to a high diagnostic suspicion. Management must take into account the other concomitant injuries. Follow-up is crucial as most patients are young; they may develop complications and subsequently require further intervention.
- A single-center experience in the eversion femoral endarterectomyPublication . Soares, Tony; Amorim, Pedro; Manuel, Viviana; Lopes, Alice; Fernandes E Fernandes, Ruy; Martins, Carlos; Pedro, Luís MObjectives: Endarterectomy is the treatment of choice for arterial occlusive disease of the femoral bifurcation. Longitudinal arteriotomy and prosthetic patch angioplasty is the standard technique but, due to the increasing concerns with prosthetic-related infections and multidrug-resistant pathogens our group adopted an alternative approach. We present our experience with eversion femoral endarterectomy. Methods: All patients submitted to eversion femoral endarterectomy in a single institution during 2016-2019 were retrospectively analyzed. Patient demographics, surgical data, and complications were captured from medical records. Results: Nineteen patients, 84.2% male and a median age of 67 years (IQR 62-78) were submitted to eversion femoral endarterectomy with a median follow-up of 180 days (IQR 71-395). Seventeen (89.4%) patients were treated for chronic limb ischemia and the other two were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Most of the patients had smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). Only 3 patients (15.8%) were submitted exclusively to endarterectomy, 13 (68.4%) were submitted to endarterectomy as an adjuvant for peripheral endovascular treatment, 2 (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm, and 1 (5.3%) was complemented with thrombectomy of the femoro-popliteal sector. Primary patency rates were 100% and 87.5% (CI (38.7-98.1)) at 6 and 12 months, respectively. Primary-assisted and secondary patency rates were 100%. The 30-day mortality rate was 5.3% (n = 1) and complication rate 10.5% (n = 2). One patient complicated with acute renal disease related to rhabdomyolysis. Another patient developed a wound-related hematoma treated with surgical drainage, but died three days after consequent to ischemia-reperfusion injury. Conclusions: Eversion femoral endarterectomy is a safe and feasible technique, with good patency results and respecting the concept of leaving nothing behind. A careful control of the proximal and distal endpoints is essential for the success of the technique.
- 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.
- 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.