Ruptured abdominal aortic aneurysm (RAAA) is an arterial emergency with an overall mortality of 80%-90% secondary to massive hemorrhage. If a patient with RAAA presents in a primary hospital without resolution capacity, survival will depend on early transfer to a center with adequately trained specialists. This article reviews the evidence supporting the centralization of AAAR treatment in qualified centers, specifying the criteria used for the selection of referral centers and the role of a coordinating unit. Our current referral system, which is based primarily on costs, is also described. Patients with AAAR who consult in non-resolving centers should be rapidly transferred to a qualified referral center, following a transfer protocol, and guided by a coordinating unit acting according to technical and established criteria based on results, quality, and costs. Qualified referral centers should have an accredited vascular surgeon and a high institutional aortic surgery volume, adequate infrastructure, endovascular resolution capacity, support services (intensive care, hemodialysis, etc.) and specialized personnel permanently available.

Background: Telemedicine became a relevant means to provide healthcare without face-to-face medical evaluation during the COVID-19 pandemic. Aim: To describe the effectiveness of telemedicine in vascular surgery. Materials and Methods: Review of medical records of all vascular surgery consultations carried out in a clinical hospital between April and October 2020. The main outcome measured was the resolution of the reason for consultation. Secondary outcomes were the need to request laboratory tests or imaging, the need to evaluate the patient in person, and the need for referral to hospitalization or emergency service. Results: One hundred-six new consultations and their follow-up (remotely or in person) were analyzed. A definitive diagnosis could be reached in 74% of consultations, treatment could be instituted or modified in 69% of them, and the reason for consultation could be resolved in 74% of cases. Laboratory and imaging tests were requested in 36 and 63% of consultations, respectively. Four percent of patients were referred to the emergency department or hospitalization. Conclusions: In the vast majority of consultations, it was possible to achieve a definitive diagnosis, prescribe a treatment and resolve the reason for consultation without the need for a face-to-face medical evaluation.

Resumo A embolização endovascular das artérias que alimentam os sequestros pulmonares é uma opção terapêutica em crescimento. Uma mulher de 51 anos com dor torácica e hemoptise foi internada. Durante a internação, ela apresentou hemoptise de 150 mL, hipotensão e queda do hematócrito para 23,3%. A tomografia computadorizada com contraste confirmou um sequestro pulmonar irrigado por uma artéria aneurismática originária da aorta abdominal. A paciente foi submetida a embolização endovascular da artéria que alimentava o aneurisma com uso de coils e dispositivo Amplatzer no terço proximal da artéria sequestrante. A tomografia subsequente confirmou a trombose completa da artéria aberrante que alimentava o aneurisma e a ausência de irrigação dentro do sequestro pulmonar. No seguimento de 56 meses, a paciente permanecia assintomática, e a tomografia mostrou involução do sequestro e trombose completa da artéria aberrante. Os desafios apresentados pelas diferentes alternativas de tratamento são discutidos neste artigo.

Abstract Endovascular embolization of arteries feeding pulmonary sequestrations is a growing therapeutic option. A 51-year-old woman with chest pain and hemoptysis was admitted. During hospitalization she presented 150 mL hemoptysis, hypotension, and hematocrit fell to 23.3%. Contrast-enhanced computed tomography confirmed a pulmonary sequestration irrigated by an aneurysmal artery from the abdominal aorta. The patient underwent endovascular coil embolization of the artery feeding the aneurysm and an Amplatzer device was deployed in the proximal third of the sequestration artery. Subsequent contrast-enhanced computed tomography confirmed complete thrombosis of the aberrant artery feeding the aneurysm and absence of irrigation of the pulmonary sequestration. At 56 months follow-up the patient remains asymptomatic, tomography showed involution of the sequestration and complete thrombosis of the aberrant artery. The challenges presented by the different treatment alternatives are discussed.

Background: Thoracoabdominal aortic aneurysm (TAAA) is an infrequent disease and demands a highly specialized and experienced management. Open repair (OR) is the gold standard but it is associated with significant morbidity and mortality. Paraplegia and renal failure are the most important complications. Aim: To report our results with OR treatment of TAAA. Material and Methods: Descriptive study including all patients with TAAA operated electively and consecutively by OR between 1983 and 2019. Main outcomes are operative mortality, renal and neurological morbidity, and long-term survival. Results: We report 45 operated patients aged 33 to 84 years, 74% males. Aneurysm extension according to Crawford classification was I in 18%, II in 18 %, III in 36% and IV in 29%. Operative mortality was 4%. The frequency of paraplegia or paraparesis at discharge was 9%. No patient was discharged on hemodialysis. Survival at 5 and 10 years were 60% and 40% respectively. Conclusions: OR of TAAA is a complex procedure. Our results show perioperative mortality rates comparable to highly experienced centers. Although being a major procedure, OR remains an alternative to treat this serious condition.

Abstract Introduction: aortic graft infection (AGI) after aortic open repair is an unusual (0.7-3 %) and potentially lethal complication. Standard treatment has been excision of infected graft and extra anatomic bypass, although currently there are in situ repair techniques. Global perioperative mortality is 4-40 % according to the series and the repair technique. Objectives: to report our experience with extra anatomic revascularization and excision of infected graft in AGI. Methodology: retrospective study between 1977 and 2020. Were included patients with AGI treated with extra anatomic revascularization and excision of infected graft only. Demographics, morbidities, clinical presentation and microbiological agents were considered. Primary outcome was postoperative mortality. Secondary outcomes were reinterventions, postoperative complications, major amputations, bypass patency and long-term survival. Descriptive statistics were performed and dycotomical asociations were established with chi-squared test. Results: sixteen patients, all male. Average age 69.2 years (55-82). Average time to infection from surgery was 27.8 months (1-84). AGI was more frequent in patients with ruptured aortic aneurysm (p < 0.05). Eleven patients (68.8 %) had fever, 6 (37.5 %) consulted with abdominal or lumbar pain, 5 (31.3 %) had inflammatory changes of local skin. Twelve patients (75 %) had aortoduodenal communications. Three patients (18.8 %) had lower limb ischemia. Seven patients (43.8 %) presented postoperative complications and 2 patients expired (12.5 %). Actuarial one-year and five-year survival were 86.7 % and 64.3 %, respectively. Five-year primary and secondary patency of the axillofemoral bypass were 77.8 % and 100 %, respectively. Conclusions: AGI is a serious condition, which treatment carries significant morbidity and mortality. Axillofemoral bypass grafting and infected graft excision currently is a safe alternative of treatment.

Resumen Introducción: la infección de prótesis después de cirugía abierta de aorta abdominal es infrecuente (0,7-3 %) y potencialmente mortal. El manejo clásico ha sido mediante revascularización extraanatómica y retiro del material protésico, y actualmente existen alternativas de reparación in situ. La mortalidad perioperatoria global es entre 4 y 40 % dependiendo de la serie y del tipo de reparación. Objetivos: reportar nuestra experiencia con revascularización extraanatómica y resección de la prótesis infectada. Metodología: estudio retrospectivo entre 1977 y 2020. Se incluyeron solo pacientes con infección de prótesis tratados mediante resección y reconstrucción extraanatómica. Se consideraron variables demográficas, comorbilidades, presentación clínica y agente microbiano. Como resultado primario utilizamos mortalidad posoperatoria y para resultados secundarios: reoperaciones, complicaciones precoces y tardías, amputación mayor, permeabilidad y sobrevida alejada. Se realizaron estadísticas descriptivas y asociaciones dicotómicas con chi-cuadrado. Resultados: dieciséis pacientes, todos masculinos. Edad promedio 69,2 años (55-82). Tiempo promedio de cirugía a infección de 27,8 meses (1-84). Fue más frecuente la infección en pacientes intervenidos por aneurisma roto que por otras causas (p < 0,05). Once pacientes (68,8 %) presentaban fiebre, 6 (37,5 %) debutaron con dolor abdominal o lumbar, 5 (31,3 %) con signos inflamatorios cutáneos (región inguinal o lumbar). Doce pacientes (75 %) presentaron comunicación aortoduodenal: 6 fístulas y 6 erosiones. Tres pacientes (18,8 %) debutaron con isquemia de miembros inferiores. Siete pacientes (43,8 %) presentaron complicaciones posoperatorias mayores y 2 pacientes fallecieron en el posoperatorio (12,5 %). La sobrevida actuarial al año y a 5 años fue de 86,7 % y 64,3 % respectivamente. Las permeabilidades primaria y secundaria de la reconstrucción extraanatómica a 5 años fue 77,8 % y 100 %, respectivamente. Conclusiones: la infección de prótesis aórtica es una entidad grave, cuyo tratamiento conlleva una morbimortalidad significativa. La revascularización extraanatómica y resección de prótesis infectada continúa siendo una alternativa de manejo y permite solucionar de forma segura y efectiva el foco séptico.

Primary aortoenteric fistula is the spontaneous communication between the lumen of the aorta and a portion of the digestive tract. The most common cause is the erosion of an abdominal aortic aneurysm into the 3rd or 4th portion of the duodenum. It manifests clinically as gastrointestinal bleeding, with or without abdominal pain and a pulsatile abdominal mass on physical exam. Gastrointestinal bleeding is initially recurrent and self-limiting and progresses to fatal exsanguinating hemorrhage. Endoscopic examination diagnoses only 25% of aortoenteric fistulas because these are usually located in the distal duodenum. Contrast computed tomography of the abdomen and pelvis is diagnostic in only 60% of cases. We report three cases with this condition. A 67-year-old male presenting with an upper gastrointestinal bleeding. He was operated and a communication between an aortic aneurysm and the duodenum was found and surgically repaired. The patient is well. A 67-year-old male with an abdominal aortic aneurysm presenting with abdominal pain. He was operated and anticoagulated. In the postoperative period he had a massive gastrointestinal bleeding and a new CAT scan revealed an aorto enteric fistula that was surgically repaired. The patient is well. An 82-year-old male with an abdominal aortic aneurysm presenting with hematochezia. A CAT scan revealed a communication between the aneurysm and the third portion of the duodenum, that was surgically repaired. The patient died in the eighth postoperative day.

Background: Chronic limb ischemia can lead to high rates of limb loss and mortality. Open surgery is the gold standard for treatment of distal disease. Endovascular surgery should have less complications with similar outcomes. Aim: To report a cohort of patients with distal arterial disease treated with endovascular surgery at our institution. Material and Methods: Review of angioplasty records of patients undergoing distal lower extremity endovascular procedures between 2016 and 2019. Demographics, comorbidities, form of presentation, type of intervention, perioperative complications, and length of stay were analyzed. The primary outcomes were wound healing, reinterventions and freedom from major amputation. Secondary outcomes were overall survival and amputation-free survival. Results: Forty-eight limbs of 41 patients with a mean age 75 years (78% males) were treated. Ninety-three percent had hypertension, 88% diabetes, 30% chronic kidney disease. 73% presented with major wounds. Plain balloon and drug coated balloon angioplasties were carried out in 65 and 31% of procedures respectively, with no difference in results. In 46% of the cases, only chronic total occlusions were treated. Wound healing was achieved in 85% of procedures and 90% of patients were free from amputation at one year of follow up. Complications were observed in 18% of procedures, perioperative mortality was 2% and one-year survival was 76%. Conclusions: Endovascular therapy achieves high rates of wound healing and freedom from amputation with low perioperative mortality and moderate complication rates.

Giant cell arteritis is more common in women older than 60 years, is associated with systemic inflammation symptoms and mainly involves the aortic arch and cranial arteries, specially the temporal artery. Symptomatic lower extremity arterial stenosis or occlusion is uncommon and can lead to limb loss. We report a 73-year-old woman presenting with a one-month history of lower extremity intermittent claudication of sudden onset. She also complained of fever, malaise, headache and weight loss. A non-invasive vascular study showed moderate femoral popliteal occlusive disease, with and abnormal ankle-brachial index (0.68 and 0.83 on right and left sides, respectively). An angio-computed tomography showed thickening of the aortic wall and severe stenosis in both superficial femoral arteries. Steroidal treatment was started, and a temporal artery biopsy was performed confirming giant cell arteritis. Six weeks after steroid therapy the patient had a complete remission of symptoms. A serologic exacerbation was subsequently treated with a humanized monoclonal antibody against the interleukin-6 receptor Tocilizumab, obtaining long time remission.

Background: Pelvic venous insufficiency may cause pelvic congestion syndrome that is characterized by chronic pelvic pain exacerbated by prolonged standing, sexual activity or menstrual cycle. It may be treated by embolizing the dysfunctional pelvic venous drainage and sometimes resecting vulvar, perineal and thigh varices. Aim: To assess the results of embolization of insufficient pelvic or ovarian veins on pelvic congestion syndrome. Material and Methods: Analysis of 17 female patients aged 32 to 53 years, who underwent subjected to a selective coil embolization of insufficient pelvic and/or ovarian veins through the jugular, basilic or cephalic veins. In the preoperative period, all patients had a lower extremity venous duplex pelvic ultrasound examination and some had an abdominal and pelvic CT angiogram. Results: The technical success of the procedure was 100% and no complications were registered. During a 32 month follow up, no patient had symptoms of pelvic venous insufficiency or relapse of vulvar or thigh varices. Conclusions: Embolization of insufficient pelvic and ovarian veins is a safe and successful procedure for the treatment of pelvic venous insufficiency or vulvar varices.

Background: Conventional treatment of deep vein thrombosis (DVT) is anticoagulation, bed rest and limb elevation. Proximal DVT patients with persisting edema, pain and cyanosis of extremities despite of conventional therapy may develop ischemia. Direct treatment of thrombosis becomes necessary. Aim: To report our experience with mechanical trombolysis of proximal lower extremity DVT. Material and Methods: Retrospective review of medical records of proximal DVT patients treated with thrombolysis between March 2012 and August 2015. Thirteen patients, 14 limbs, median age 34 years (22-85), 8 women, were admitted with pain and swelling of recent onset; one patient with venous gangrene. All patients initially received heparin in therapeutic doses without clinical improvement. Results: In all 13 cases, mechanical thrombolysis was performed using AngioJet®, and associated with single dose thrombolytic agent in 9. Additional angioplasty for residual stenosis was performed in 12 (7 stents) and IVCF were implanted in 8. All patients were subsequently anticoagulated. Early outcomes with disappearance of pain and decrease of edema, with no mortality or bleeding complications. The patient with foot gangrene required amputation. Conclusions: Mechanical thrombolysis with a single dose of a thrombolytic agent is safe and effective in patients with proximal DVT with an unfavorable evolution.

Background: Chronic mesenteric ischemia is observed in older people and is often due to atherosclerosis. Radiotherapy is an important risk factor for atherosclerosis. Aim: To report our experience with chronic mesenteric ischemia secondary to retroperitoneal radiotherapy. Material and methods: Review of medical records of four male patients aged 39 to 65 years, treated for chronic mesenteric ischemia secondary to para-aortic radiotherapy between 1993 and 2011. Results: All of them had the classic symptoms of ischemia characterized by post prandial abdominal pain and weight loss. One had also isolated diarrhea episodes. Revascularization was achieved with open or endovascular surgery, with good results during a follow up period ranging from two to 20 years. Conclusions: Surgical revascularization is a good treatment for chronic mesenteric ischemia secondary to radiotherapy

Introducción: La insuficiencia mesentérica crónica es un diagnóstico infrecuente, generalmente secundario a enfermedad aterosclerótica, siendo considerada una enfermedad de pacientes añosos. Se sabe que la radioterapia es un factor de riesgo importante para aterosclerosis. Describimos nuestra experiencia en el manejo de la isquemia mesentérica crónica secundaria a radioterapia retroperitoneal. Materiales y métodos: Análisis retrospectivo de las fichas clínicas de los pacientes tratados en nuestro centro por insuficiencia mesentérica crónica posterior a radioterapia del territorio para-aórtico entre 1993 y 2011. Resultados: Un total de 4 pacientes de sexo masculino fueron identificados. Edad promedio: 49 ± 12 años (rango 39-65). Todos presentaron los síntomas clásicos de insuficiencia mesentérica caracterizados por dolor abdominal postprandial y baja de peso. Uno de ellos además tenía episodios repetidos de diarrea. La revascularización mesentérica se obtuvo mediante cirugía abierta o endovascular con excelentes resultados a corto y largo plazo con un seguimiento promedio de 9,3 años (rango 2-20). Discusión: El curso acelerado de la aterosclerosis posterior a radioterapia se ha descrito en múltiples territorios vasculares. Síntomas de insuficiencia mesentérica crónica pueden ser malinterpretados en estos pacientes debido a su similitud con los síntomas observados en la ileitis actínica. Un diagnóstico y tratamiento oportuno son críticos para evitar complicaciones mayores y deterioro de calidad de vida de estos pacientes. Conclusión: La insuficiencia mesentérica crónica inducida por radioterapia es una condición infrecuente. El manejo con cirugía abierta o endovascular son seguras y otorgan resolución sintomática a largo plazo.

Background: The therapeutic range (TR) of activated partial thromboplastin time (aPTT) for unfractionated heparin (UFH) dosing was established in the 1970 decade. Since then aPTT determination has changed. Current TR may be sub or supra-therapeutic depending on the reagents of the test, and therefore, responsible for complications of therapy. Aim: To establish the TR for UFH dosing in our institution using antifactor Xa analysis as reference standard. Material and Methods: After obtaining an informed consent, 43 blood samples were obtained for aPTT determination and antifactor Xa assay in 23 patients treated with intravenous UFH. Samples were processed at Emergency and Hemostasis Labs. We excluded patients receiving other anticoagulants, with thrombophilia, pregnancy or liver disease. Results: Mean aPTT values in the Hemostasis and Emergency labs were 57.1 ± 18.9 and 56.6 ± 18.3 seconds, respectively (p = 0.77). The squared correlation coefficients between aPTT and antifactor Xa at hemostasis and emergency labs were R2 0.5 and 0.45 respectively, p < 0.001. Using a linear regression analysis, therapeutic aPTT range values in our laboratory were established between 50 and 80 seconds, corresponding to antifactor Xa values of 0.3 to 0.7 IU/mL. Conclusions: According to current recommendations, validation of aPTT determination with reference techniques should be done in every institution.

Perforator vein incompetence is a specific form of lower extremitiy venous insufficiency characterized by localized hyperpigmentation, venous ulceration or recurrence of varicose veins. Surgical treatment ranges from the extensive conventional open subfascial ligation to percutaneous radiofrequency or laser techniques with unknown late outcome. A minimally invasive technique of subfascial ligation through small incisions described by Queral, with acceptable results, has been successfully used and improved in recent years by our group. Details of the technique and pre-operative managment are described.

La insuficiencia de venas perforantes es una forma de insuficiencia venosa de extremidades inferiores que se manifiesta por hiperpigmentación cutánea localizada, desarrollo de úlceras venosas o recurrencia de várices previamente operadas. Su tratamiento comprende desde cirugías cruentas como la ligadura subfascial abierta a técnicas percutáneas de radiofrecuencia o láser con resultados alejados desconocidos. Dentro de las técnicas mínimamente invasivas se encuentra la cirugía de ligadura subfascial de perforantes con mini-incisiones descrita por Queral, de eficacia demostrada y que hemos realizado y perfeccionado exitosamente en los últimos años. Se describen detalles de la técnica y de la planificación pre-operatoria de pacientes con esta patología.

Background: Esophageal squamous cell carcinoma can spread locally to neighboring organs in the mediastinum. When it invades the aorta, the patient may develop an aorto esophageal fistula (AEF), complication that carries a high mortality rate. We report a 62-year-old male with stage IV esophageal carcinoma who, after chemo radiation treatment, developed an AEF. He was successfully treated with the use of an aortic endograft. The patient died 13 months later due to progression of his cancer, without evidence of sepsis or new bleeding episodes.

Introduction: An aberrant right subclavian artery is the most frequent aortic arch malformation. It is frequently an incidental finding of imaging studies and serious complications may arise if left untreated. Clinical case: We present a case of a young woman with a dilated aberrant right subclavian artery that was successfully treated by a hybrid approach.

Introducción: La arteria subclavia derecha aberrante es la malformación arterial más frecuente del arco aórtico. Su diagnóstico es habitualmente un hallazgo de estudios de imágenes solicitados por otras causas pero puede tener serias complicaciones si se obtiene en forma tardía. Caso clínico: Presentamos el caso de una mujer joven con diagnóstico de arteria subclavia lusoria dilatada sometida exitosamente a tratamiento híbrido electivo.