Introduction: Endovascular aortic repair (EVAR) has significantly altered the therapeutic strategy for abdominal aortic aneurysm (AAA), due to less invasiveness and lower perioperative morbi-mortality. However, specific complications such as type 1a endoleak (T1aE) and persistent type 2 endoleak (pT2E) have been associated with adverse outcomes including aneurismal rupture. We present a case of AAA rupture due to both T1aE and pT2E treated in our institution. Case Report: The patient is a 73-year-old male, submitted to EVAR at another institution for infra-renal AAA with no apparent complications. He was admitted in the emergency department, 7 years post-EVAR, with abdominal pain and loss of consciousness with spontaneous recovery. A CTA was performed and revealed aneurysmal sac growth, spontaneous hiperdensity of the thrombus, high density in the fat in the right retroperitoneum and a pT2E. Intra-operatively, after opening the aneurysmal sac, both pT2E and T1E were detected. He was submitted to partial aneurismectomy, suture of the ostia of the lumbar arteries, filling of the aneurysm sac with prothrombotic products and closure of the aneurysm sac with adjustment of the proximal sealing zone. The patient was discharged 15 days post-procedure. CTA performed 1 month after the procedure revealed no endoleak, aneurismal sac stability filled with prothrombotic products. At 2-year follow-up the patient remained asymptomatic and the CTA findings remained unchanged. Discussion: Rupture post-EVAR is a significant therapeutic challenge for vascular surgeons. In this case, pre-operative CTA findings lead to plan an open surgery with endoaneurismorrhaphy of collaterals. Intra-operative finding of T1aE in the context of aneurismal rupture and hemodynamic instability, forced us into an inventive solution aiming to regain proximal sealing. This was essentially a variant of previously described proximal banding for T1aE. Endoprosthesis explantation was considered too time-consuming and aggressive in an already unstable patient. Results at 2-year follow-up were encouraging.

Introduction: Post-implantation syndrome (PIS) is characterized by fever, flu-like symptoms, leukocytosis and elevation of reactive C protein in the postoperative period of EVAR. The authors aim to estimate the incidence of PIS after EVAR in their institution, identify risk factors and determine the association with clinical events. Materials and Methods: A retrospective study was designed at a tertiary center. All patients undergoing EVAR between July 2014 and December 2016 were included. Data were collected through electronic clinical records, as leukogram, reactive C protein and body temperature. The primary endpoint evaluated was the incidence of PIS, defined as fever> 38 ° and reactive C protein > 75mg / L. The association with demographic and procedural characteristics, length of hospitalization and perioperative clinical events (death or major complications) was assessed. Results: 205 patients were identified in this period. After analysis of the clinical records, 25 patients were excluded due to the use of branched or fenestrated endografts; 11 patients were excluded due to EVAS; in 17 patients, the indication wasn’t a primary aneurysm or it was a mycotic aneurysm and; in 46 patients the time of surgery wasn’t elective. In the remaining 106 patients, the incidence of PIS was 19% (n = 20). A statistically significant association was found between PIS and smoking (p = 0.005), COPD (p = 0.005) and statin therapy (p = 0.031). The multivariate logistic regression analysis, correcting for smoking and statin therapy, revealed that smoking is an important risk factor (OR 7.26, p = 0.03) and statin therapy a protective factor (OR = 0.341, p = 0.049). Regarding for the characteristics of the procedure, percutaneous approach, amount of contrast, intraoperative complications and need for complementary procedures, no differences were observed. A significant difference was found between groups in hospitalization length, with a median of 5 days in the group without PIS and 7 days in the PIS group (p = 0.034). No significant differences were found in cardiovascular events, complications or death within 30 days postoperatively between the groups. Conclusion: The incidence of PIS was 19%, which is concordant with literature. The results suggest that smoking is a risk factor. There was also an increase in hospitalization length in 2 days in PIS group. Statin therapy at the time of surgery is a modifiable factor that has been shown to be protective with respect to PIS, reinforcing the benefit of this therapy in the perioperative period of AAA patients.

Introduction: Despite significant advancements, ruptured abdominal aortic aneurysm (rAAA) remains a life-threatening condition, and the decision whether or not to proceed with surgical intervention is extremely difficult in daily practice. Previous risk prediction models of rAAA mortality developed before EVAR was an option, had their validity questioned in an era where both open repair (OR) and EVAR are available. In 2017, Healey CT et al and von Meijenfeldt GC et al (Dutch Aneurysm Score) published two new mortality prediction models, both based on easily obtained clinical variables and validated in a population submitted to either OR or EVAR. The purpose of this paper was to describe the evolving experience in rAAA management in our centre, and to validate the applicability of the aforementioned scores in our practice. Methods: The clinical data of all patients admitted in our hospital from 2010 to 2016 with the diagnosis of rAAA were retrospectively reviewed and statistical analysis using SPSS V.22 was performed. Results: A total of 71 patients were considered, including 19 EVARs and 52 ORs. There was a significant increase over time in repairs performed by EVAR, and in 2015 the annual rate of EVAR exceeded that of OR. The population of patients submitted to EVAR and OR were comparable in gender, age and co-morbidities with the exception of smoking, more common in the EVAR group (73.7% Vs 36.5%; p=0.005). No cases of intra-operative mortality were registered in the EVAR group, as opposed to 17% in the OR group (p=0,049). 30-day mortality reached 49% in the OR group and 31,6% in the EVAR group (p>0.05). Several pre-operative predictors of outcome were identified: smoking (p=0.005), pre-operative hemodynamic instability (p=0.003) and international normalized ratio (INR) at admission (p<0.0001). As for post-operative preditors of outcome, hemodynamic instability in the ICU was statistically significant (p<0,0001). Binary logistic regression concluded elevated INR and post-operative instability were independent risk predictors of outcome (p<0.05). The mortality score prediction models aforementioned were applied to our population and estimated mortality significantly correlated with real mortality (estimated mortality 41% and 45.3% Vs real mortality 45%; both p<0.0001). Pearson correlation was applied to compare scores and concluded a correlation coefficient of 0.775 (p<0.001), describing a significant positive linear correlation between scores. Conclusions: In recent years, EVAR has increasingly become the procedure of choice for rAAA in our institution. With this evolving approach to rAAA, both score prediction models were retrospectively applied and both accurately predicted mortality in the study population (p<0.001).

Abdominal aortic aneurysm (AAA) is a focal dilatation of at least 1,5 times the normal aortic diameter at the level of the renal arteries or, in absolute value, it is a diameter superior to 30 mm. The global prevalence is 2% in men older than 65 years, which is 4 times higher than the prevalence of AAA in women. The major risk factors for AAA are smoking, age, ethnicity, male gender and familiar history. There is a known association between coronary artery disease and AAA, probably because they share similar risk factors. The authors aim to perform a review about the association between these diseases and about the advantages of doing a screening in this subgroup of patients. Besides AAAs are not a result or manifestation of atherosclerosis, neither a dose-response effect, the atherosclerosis seems to be an important risk factor to the development of AAA, hence the association between AAA and coronary artery disease. The AAA prevalence is significantly higher in patients with known coronary disease; it varies between 1,8 and 9,5% in the coronary disease subgroup comparing to 2% in general population. The severity of coronary disease also seems related to AAA prevalence. However, there are no sufficient data to support AAA screening in this subgroup of patients, mainly because the decrease of morbidity and mortality with screening is not yet determined.

Introduction: Nellix® endoprosthesis (Endologix Inc., Irvine, CA) is composed by two ballon-expandable stents surrounded by endobags, which are filled with a polymer, thus obliterating the aneurysmal sac – Endovascular Aneurysm Sealing (EVAS). Initially, due to its properties, was introduced with extended IFU, allowing the use in more complex abdominal aortic aneurysms. However, during the initial experience with this endoprosthesis, a high number of poor outcomes have been described, leading to the progressive restriction of IFU. Currently, it has been discontinued and is only available in selected centers for clinical research purposes. Our study aim to report the institutional results of the use of the Nellix® endoprosthesis in the treatment of AAA. Material and Methods: A retrospective study was designed, including patients with AAA treated with Nellix® endoprosthesis treated at a universitary tertiary care facility. Elective and urgent patients we're included, and patients we're identified through the institutional files. Thoraco-abdominal aneurysm we're excluded. Data about baseline characteristics, surgery, hospitalization course and follow-up post discharge was obtained by consulting personal clinical files. Primary endpoints are technical and clinical success at 30 days, as complications and secondary interventions at mid and long-term. Results: Between 2015 and 2017, this endoprosthesis was used in 12 patients, 9 male and 3 female, with a mean age of 71 (±8) years. The most common comorbidities associated we're hypertension (n=12), current or former tobacco use (n=7), coronary heart disease (n=7), peripheral artery disease (n=6) and chronic kidney disease (n=6) In all patients, the treatment indication was primary degenerative aneurysm, with one exception, which was the presence of type 1a EL after EVAR. Ten patients underwent elective and 2 urgent surgery due to symptomatic aneurysm. Three we're aortoiliac aneurysms and the remaining aortic aneurysms (n=9) with three having involvement of at least one renal artery. Nine patients underwent conventional EVAS; the remaining EVAS with chimney (ChEVAS) for the renal artery(ies) or superior mesenteric artery (n=3). The average preoperative diameter was 57(±6.5) mm. One patient was simultaneously submitted to endovascular repair of a popliteal artery aneurysm with covered stent. By 30 days, death occurred in 2 patients, all submitted to ChEVAS. The most common post-operative complications we're respiratory failure (n=3), AKI with dialysis (n=3), being that in two patients there was intentional covering of the renal arteries (patients with pre-dialysis CKD). In this time frame, we verified one reintervention: catheter-directed thrombolysis for acute limb ischemia due to popliteal covered stent thrombosis. After 30 days, 4 deaths occured (2 year survival 60%, SE 0.154). The most common complications were type 1a EL(n=3), type 1b EL(n=1) and aortic stent thrombosis (n=1). Two patients have already been reintervened: one submitted to femoro-femoral crossover bypass and the other to surgical endoprosthesis explantation and in situ reconstruction aortobifemoral bypass. The last was deceased in the early postoperative period. Two patients are waiting reintervention for type Ia EL and aneurysmal sac growth. The average sac diameter in last follow-up or before secondary intervention was 59(±10.6) mm. Mean follow-up time is 2,3(±1,6) years.  Conclusions: In our institution, the use of Nellix® endoprosthesis is associated with a high rate of perioperative morbidity and mid to long-term aneurysm-related complications, being type Ia EL the most common. Although the free use of the endoprosthesis is currently discontinued, patients who have previously undergone EVAS lack a specific and more intensive surveillance plan for the timely detection and correction of complications.

Introduction: Isolated abdominal aortic dissection (IAAD) is a relatively rare event and precise indications for treatment aren't clearly defined. Its natural history is not fully understood due to the rarity of the disease and to the fact that most surgeons have a low threshold to intervene in these patients. Open surgery represents the classical treatment but endovascular intervention has gained wide acceptance in most centers and is now the most frequently adopted treatment option. The largest series of treated patients are from Asian centers with the largest of them comprising only 33 cases whereas in western surgical centers the largest series contains only 21 patients. Methods: Single center, retrospective, observational, study of patients with IAAD who were treated with open or endovascular surgery. Results: We describe eight patients with IAAD who underwent treatment in our institution (four males and four females). Median age at presentation was 78 years and all patients were asymptomatic. Median aortic diameter at presentation was 30mm (14-85mm). All but one patient underwent endovascular treatment. Three patients were treated with bifurcated aortic endografts, three patients had a single stent-graft (iliac limbs of aortic endografts) implanted and one patient underwent a CERAB procedure for coexistent stenotic disease of the aortic bifurcation. There were no perioperative deaths. Median follow-up was 6,2 years (2 months-13 years). Late reintervention was needed in one patient, 8 years after initial surgery, due to a type 1 endoleak. Conclusion: According to our experience, endovascular intervention represents a safe and durable treatment option in IAAD, however, long-term follow-up is mandatory. Larger studies with longer follow-ups are needed to understand this disease.

OBJECTIVE: To establish, in a case-control study, the early mortality and long-term survival after surgical correction of sealed rupture abdominal aortic aneurysm, compared to controls who underwent standard, nonruptured abdominal aortic aneurysm repair. PATIENTS AND METHODS: From January 1992 to December 2002, 465 patients underwent infrarenal abdominal aortic aneurysm repair. Of those, 13 had sealed rupture abdominal aortic aneurysm (2.8%). These cases were compared to 26 controlsin which surgical repair was performed immediately preceding or succeeding each one of the sealed rupture abdominal aortic aneurysm surgeries. RESULTS: Age, sex, risk factors for atherosclerosis, associated disease, and cardiac ischemia were similar between groups. Patients with sealed rupture abdominal aortic aneurysm presented a higher incidence of lumbar pain than controls (92.3% versus 3.9%; P < .001); fever and weight loss were detected in 5 (38.5%) patients with SAAA and in none of controls (P = .0022). Mean red blood cell transfusion was greater for sealed rupture abdominal aortic aneurysm than controls (1,516 &plusmn; 697 vs. 773 &plusmn; 463 mL (P = .0003). Postoperative complications were similar between groups. Early mortality was 7.7% for sealed rupture abdominal aortic aneurysm and 0% for controls. Five-year survival was significantly lower for sealed rupture abdominal aortic aneurysm (68.4%) than for controls (84.4%, P = .04). CONCLUSION: We conclude that sealed rupture abdominal aortic aneurysm presents diagnostic and surgical challenges that can be adequately managed, achieving early postoperative mortality and complication rates that are similar to standard abdominal aortic aneurysm. However, patients with sealed rupture abdominal aortic aneurysm present higher mortality in the long term compared with patients having standard abdominal aortic aneurysm.

Abdominal aortic pseudoaneurysms are rare, particularly when they are related to blunt abdominal trauma. The authors report the clinical case of a 65 years old man with an abdominal aortic pseudoaneurysm related to a blunt abdominal trauma, that occurred three years ago. The patient complained of a diffuse abdominal pain, increased while walking. The diagnosis was confirmed by angiography and by angio-CT. An aortic resection and interposition graft was performed, according to the age of the patient and the low operative risk. A discussion on the therapeutic option was made, followed by a revision of the literature on the subject, and the authors conclude by emphasizing the need of a detection of this type of pathology, particularly in patients who had suffered in the past violent trauma.

Introdução: A correção cirúrgica do aneurisma da aorta abdominal (AAA), por Endovascular Aneurysm Repair (EVAR) ou cirurgia convencional (CC), pode agravar a função renal a curto prazo. Esta complicação, mais frequente nos doentes com insuficiência renal crónica (IRC), associa-se a pior prognóstico a longo prazo. O objetivo deste trabalho foi quantificar o agravamento da função renal após reparação do AAA em doentes com IRC prévia e demonstrar o consequente aumento da morbimortalidade. Métodos: Estudo retrospetivo em doentes com IRC estádios Chronic Kidney Disease 3-4 (TFGe 15-59ml/min), submetidos a correção eletiva de AAA entre fevereiro/2011 e fevereiro/2015 numa instituição terciária. Variáveis estudadas: idade, sexo, tipo de intervenção (convencional/EVAR) e estádio CKD. Endpoints: variação da creatinina e taxa de filtração glomerular com a cirurgia, complicações renais pós-operatórias, necessidade de reintervenção cirúrgica e mortalidade. A análise estatística foi realizada em SPSS. Resultados: Foram incluídos 71doentes. Quinze doentes (21%) foram operados por CC e 56 (78%) por EVAR. À data da intervenção, os doentes encontravam-se nos seguintes estádios da DRC: CKD 3 --- 65 (91%) e CKD 4 --- 6 (9%). A variac¸ão da TFG com a cirurgia foi −1,08±18,01mg/dl. Verificou-se IRC agudizada pós-operatória em 22 (31%) doentes e necessidade de diálise em 5 (7%). A mortalidade global foi 8,5%. Os doentes operados por EVAR tinham DRC mais avançada pré-operatoriamente, mas apresentaram menor agravamento da função renal. Variação TFG: EVAR 1,14±16,26ml/min vs. CC 9,40±22,11ml/min (p=0,022); variação creatinina: EVAR 0,17±1,03mg/dl vs. CC 0,81±1,47mg/dl (p=0,02). A agudização da IRC pós-operatória foi superior no grupo CC (53,3 vs. 28,6%; p=0,072), assim como a necessidade de diálise (20 vs. 3,6%, p=0,06). Os 6 doentes que faleceram (EVAR: 3; CC: 3) apresentaram maior agravamento da função renal (variação da creatinina: 1,41±1,63mg/dl vs. 0,20±1,07mg/dl, p=0,001; variação da TFG: −19,0±16,55ml/min; 0,57±17,34ml/min, p=0,007) e necessidade de diálise (50 vs. 3,1%, p=0,003). Conclusão: Os resultados demonstraram uma tendência para uma menor probabilidade de IRA, menor necessidade de diálise pós-operatória e menor mortalidade nos doentes tratados por EVAR. Contudo, o impacto da administração de contraste a médio/longo prazo, decorrente dos programas de vigilância pós-EVAR, deve ser considerado. Julgamos ser possível considerar que a realização de EVAR para o tratamento de doentes com AAA e IRC é um procedimento pelo menos tão seguro como a CC.

OBJECTIVE: Long-term follow-up after endovascular aneurysm repair (EVAR) is very scarce, and doubt remains regarding the durability of these procedures. We designed a retrospective cohort study to assess long-term clinical outcome and morphologic changes in patients with abdominal aortic aneurysms (AAAs) treated by EVAR using the Excluder endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz). METHODS: From 2000 to 2007, 179 patients underwent EVAR in a tertiary institution. Clinical data were retrieved from a prospective database. All patients treated with the Excluder endoprosthesis were included. Computed tomography angiography (CTA) scans were retrospectively analyzed preoperatively, at 30 days, and at the last follow-up using dedicated tridimensional reconstruction software. For patients with complications, all remaining CTAs were also analyzed. The primary end point was clinical success. Secondary end points were freedom from reintervention, sac growth, types I and III endoleak, migration, conversion to open repair, and AAA-related death or rupture. Neck dilatation, renal function, and overall survival were also analyzed. RESULTS: Included were 144 patients (88.2% men; mean age, 71.6 years). Aneurysms were ruptured in 4.9%. American Society of Anesthesiologists classification was III/IV in 61.8%. No patients were lost during a median follow-up of 5.0 years (interquartile range, 3.1-6.4; maximum, 11.2 years). Two patients died of medical complications ≤ 30 days after EVAR. The estimated primary clinical success rates at 5 and 10 years were 63.5% and 41.1%, and secondary clinical success rates were 78.3% and 58.3%, respectively. Sac growth was observed in 37 of 142 patients (26.1%). Cox regression showed type I endoleak during follow-up (hazard ratio, 3.74; P = .008), original design model (hazard ratio, 3.85; P = .001), and preoperative neck diameter (1.27 per mm increase, P = .006) were determinants of sac growth. Secondary interventions were required in 32 patients (22.5%). The estimated 10-year rate of AAA-related death or rupture was 2.1%. Overall life expectancy after AAA repair was 6.8 years. CONCLUSIONS: EVAR using the Excluder endoprosthesis provides a safe and lasting treatment for AAA, despite the need for maintained surveillance and secondary interventions. At up to 11 years, the risk of AAA-related death or postimplantation rupture is remarkably low. The incidences of postimplantation sac growth and secondary intervention were greatly reduced after the introduction of the low-permeability design in 2004.