Vascular

2019, Vol. 27(1S) 2

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CICE (Congresso Internacional de Cirurgia to improve their research skills and to make relevant
Endovascular) organization is committed to introduc- clinical and scientific contributions to endovascular
ing and spreading high education standards and train- surgery.
ing patterns in endovascular surgery in Brazil. We have
pioneered over the last 19 years all new education ini-
tiatives in this field in our country. Our legacy includes
the first and long-lasting Continuing Medical
Education Program in Endovascular Surgery
(CECE), the first dedicated fellowship, a Parallel
Technique for complex aneurysm repair (Sandwich
Technique), the first Best Abstract Award in
Endovascular Surgery (Edward B. Diethrich Award),
the first book, currently in the third edition and serving
as official reference for the Vascular, Endovascular and
Cardiovascular Surgery Board Exams and the first ded-
icated meeting (CICE Meeting).
CICE is the leadership meeting in endovascular sur-
gery in South America and has gained national and
international recognition for its innovative and creative
features, its scientific commitment, interactive lectures,
and live case demonstrations packed with scientific and
technological innovations, delivered by some of the
world best experts in this field.
This supplement to the Vascular Journal represents
an unparalleled and pioneering initiative in our coun-
try. CICE was the first and is currently the only
Brazilian Vascular Surgery Meeting to publish the pre-
sented abstracts in an international periodic with
impact factor. We are proud to have been the first to
“push the envelope” toward taking Brazilian Armando C. Lobato
Endovascular Community scientific production to the CICE 2019 Chairman
next level and hope our efforts may stimulate attendees

Abstracts
SESSION 07
EDWARD B. DIETHRICH BEST
ABSTRACT AWARD
OAHU/TAVARUA ROOM 12:21 – 13:55
SESSION 07: 19014 – COMPARISON OF
OUTCOMES OF THREE DIFFERENT
ENDOVASCULAR REPAIR
TECHNIQUES IN ELECTIVE
BILATERAL AORTOILIAC ANEURYSMS
Marcelo Cury1 and Armando C. Lobato1,2
1
UNIFESP, São Paulo, Brazil
2
ICVE-SP, São Paulo, Brazil
Background: Endovascular repair (EVAR) is currently
the first-line treatment for abdominal aortic aneurysms
(AAA) due to decreased operative mortality and morbid-
ity rates. Twenty to forty percent of the patients with AAA
may present also with unilateral or bilateral common iliac
artery aneurysms (CIAA). These aortoiliac aneurysms
(AIA) add complexity to EVAR especially in regards to
ensuring adequate distal landing zone for the stentgraft
limb(s), a potential site for endoleak.
Aim: To compare the outcomes of three different endo-
vascular techniques for elective bilateral aortoiliac aneur-
ysms: sandwich technique (ST), Hypogastric Occlusion
(HO) and “Bell-Bottom” technique (BBT).
Material & Methods: A total of 122 consecutive
patients (100 men, mean age: 73) undergoing elective
EVAR to treat bilateral AIA (mean diameter: 57,7 mm),
in our institution, from January 2000 to December 2016,
were enrolled in the present prospective study. 244 CIAA
were treated using one or two of the endovascular tech-
nique(s) mentioned above. Patients were split in three
different groups according to the EVAR technique used:
ST (Group I), HO (Group II) and BBT (Group III). Follow-
up assessments included routine office visits and imaging
tests performed at 1, 6, and 12 months and every 6
months thereafter.
Results: Early and late related mortality rates were 2,1%
and 3%, respectively. Only late mortality comparisons
were statistically significant among the groups with poten-
tial higher risk for patients submitted to BBT (group III,
Log Rank p-value: 0,000). Overall, early buttock claudica-
tion, was observed in 35 (31,2%) patients, the majority
Vascular
2019, Vol. 27(1S) 3–56
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(94%) was related to HO (Group II, p-value: 0,0079).
Late buttock claudication rates were 0% in the ST group
as opposed to 14.3% in the coil embolization group
(Group II). Aneurysm rupture was higher in Group III
(Log Rank p-value: 0,002). Thirty-two patients underwent
early re-intervention: Group I: 5 cases, Group II: 9 cases
and Group III: 18 cases; no statistical significance was
reached for this comparison. Late type II endoleak was
more common in Group II and late type Ib endoleak
was more common in Group III. Actually, patients under-
going HO procedure had 80% more chance of developing
type II endoleak when compared to other techniques (Log
Rank p-value: 0,04). Iliac limb endograft migration was also
more common in Group III (Log Rank p-value: 0,000).
Conclusion: The ST expands the limits of EVAR for bilat-
eral aortoiliac aneurysms in a safe, easy to perform, and
cost-effective manner.
SESSION 07: 19035 – EFFECTS OF
VITAMIN C IN THE PREVENTION OF
CEREBRAL ISCHEMIA-REPERFUSION
INJURY: AN EXPERIMENTAL STUDY
IN RATS
Kelston Paulo Felice de Sales1,
Sebastião Barreto de Brito Filho1 and Flávio Nigri2
1
Serviço de Cirurgia Vascular e Endovascular do HU, UFMA, São
Luis, Brazil
2
Serviço de Neurocirurgia do Hospital Pedro Ernesto – UERJ,
Rio de Janeiro, Brazil
Background: Cerebral reperfusion syndrome is current-
ly acknowledged as a rare serious complication developing
after carotid revascularization procedures, such as endar-
terectomy or carotid angioplasty. Evolving as a conse-
quence of cerebrovascular self-regulation in a chronically
hypoperfused cerebral scenario, it can ultimately lead to
severe neurological damage. Vitamin C has been recog-
nized as a vital antioxidant in brain metabolism and
some of its neuroprotective actions have been previously
reported.
Aim: To investigate the potential effects of vitamin C in
the treatment of cerebral reperfusion in rats.
4 Vascular 27(1S)
Material & Methods: This experimental prospective-
controlled study comprised 12 male wistar rats split into
the following 3 groups: i) Sham (n ¼ 4), animals undergoing
carotid arteries dissection without clamping; ii) Control
(n ¼ 4), animals receiving intraperitoneal injection of
0.9% saline solution (0.1 mL/kg) followed by carotid arter-
ies dissection with temporary clamping of the two arter-
ies; iii) Vitamin C (n ¼ 4), animals submitted to intraperi-
toneal injection of vitamin C (750mg/kg), followed by
carotid arteries dissection with temporary clamping.
Behavioural assessment including the open field, the
Morris watermaze and the rotarod tests was carried out
in all rats. The levels of malondialdehyde (MDA) in hippo-
campus and striatum were measured using fluorometry.
Results: Vitamin C and sham rats presented similar
motor behaviours (p > 0.05) at the rotarod test. The
rats treated with saline, on the other hand, showed a
more compromised motor behaviour when compared to
the other groups (p < 0.05). The vitamin C group rats also
performed similarly to the sham group ones at the open
field test, regarding the number of total crosses and
peripheral square entries of (p > 0.05). These results
were statistically different from the control group
(p < 0.05). The number of central square entries, on the
other hand, did not differ between the three groups
(p > 0.05). It was observed at the Morris watermaze test
that the time spent on the correct quadrant was lower in
the group treated with saline as compared to either the
sham or the group treated with vitamin C (p < 0.05). MDA
levels in both hippocampus and striatum were also
decreased in the vitamin C group as compared to placebo
(p < 0.05).
Conclusion: Behavioural changes as well as variations in
enzymatic dosages obtained in the present experimental
model may point out towards ongoing cerebral oxidative
stress as well as some neuroprotective effect of Vitamin C
in the setting of cerebral reperfusion brain injury in adult
rats. Further studies are certainly warranted.
SESSION 07: 19047 – DEVELOPMENT
OF A SIMULATOR MODEL FOR
SCLEROTHERAPY
TRAINING PURPOSES
Luis Carlos Uta Nakano,
Rafael Bernardes de Avila,
Wellington Gianotti Lustre,
Beatriz Urbani Pessutti, Gabriela Araujo Attie,
Carolina Martines Estrutti,
Vladimir Tonello de Vasconcelos,
Jorge Eduardo de Amorim,
Henrique Jorge Guedes Neto and
Ronald Luiz Gomes Flumignan
UNIFESP, São Paulo, Brazil
Background: Sclerotherapy is accepted as the mainstay
treatment for telangiectasias. Adequate sclerotherapy
training is necessary prior to performing intravascular
applications. Currently, this training is conducted on
patient-models, despite serious ethical considerations.
The increasing use of simulators for medical education is
notorious worldwide. Unfortunately, the high cost associ-
ated with this development often prevents its use in devel-
oping countries.
Aims: 1: To develop an easily-reproduced, low-cost and
user-friendly simulator for sclerotherapy training. 2: To
establish a feasible training protocol.
Material & Methods: Phase 1: The simulator was
assembled using low-cost materials commonly available
in the Brazilian market such as colored and transparent
silicone and copper wires. Twenty 0.24 mm copper wires
were inlaid inside a transparent silicone model to simulate
telangiectasias. The copper wires were further removed
one after the other and the remained paths were used to
simulate a venule. For the sake of obtaining a more real-
istic effect, these paths were further tinted with a blue ink.
The simulator was then ready for use. Phase 2: The train-
ing protocol developed included theory classes and prac-
tice sessions with the use of the simulator. After the
theory classes, all participants were provided with a train-
ing kit containing: one simulator; one bottle of ink, one
bottle of the sclerosing fluid; one 3 ml syringe; one 30 G 1=2
inch needle, and an instruction manual. After completing
the training sessions, the participant was evaluated by
three experienced examiners to ascertain his training
skills. An accuracy of more than 70% of the attempts at
the tenth sclerosing session was required and granted by
all three examiners.
Results: Phase1: We were able to create a simulator that
met all the requirements: low-cost, reproducibility and
user-friendliness. The cost per training kit was estimated
at US$5. Phase 2; A total of 50 participants (30 men and
20 women, mean age: 26 years, age range: 24–29 years)
Abstracts
were evaluated. All participants completed the protocol,
which consisted of 10 sessions with 10 applications per
session. The mean score in the first session was 4, ranging
from 3 to 6 in the following 8 sessions. The mean score in
the last session was 8.8, ranging from 7 to 10. All partic-
ipants, therefore, achieved a score above 7 in the last
session, demonstrating the effectiveness of the training
protocol developed.
Conclusion: The assembled simulator met all three
requirements. The training protocol put together in this
study, proved helpful to develop the participants’ scleros-
ing skills
SESSION 07: 19076 – ANGIOPLASTY
AND STENTING VERSUS BYPASS
GRAFT SURGERY FOR THE
TREATMENT OF SIMULTANEOUS
FEMOROPOPLITEAL AND
INFRAPOPLITEAL COMPLEX (TASC C
OR D) ARTERIAL DISEASE IN
PATIENTS WITH CRITICAL
LIMB ISCHEMIA
Lethicia M. Valladão, Ivan Benaducci Casella,
Calogero Presti, Camila M. Sartori,
Carolina B. Faustino, Maria P. Mariz,
Pedro Puech-leão and Nelson de Luccia
HCFMUSP – Hospital das Clı́nicas, Faculdade de Medicina da
Universidade de São Paulo, São Paulo, Brazil
Background: Critical limb ischemia ((CLI) occurs in 1 to
2% of patients with peripheral artery disease (PAD) who
are 50 years of age or older. Bypass graft using the saphe-
nous vein was considered the gold standard treatment for
this disease but has been progressively replaced by the
endovascular approach on account of patients’ comorbid-
ities and higher mortality rates.
Aim: To compare the results of simultaneous femoropo-
pliteal and infrapopliteal percutaneous angioplasty (PTA/S)
of complex (TASC C or D) lesions with distal bypass graft
surgery (BGS).
Material & Methods: A total of 668 revascularization
procedures for CLI were performed in our Institution
between years 2011 and 2017. Ninety seven patients
with simultaneous femoropopliteal and infrapopliteal
extensive (TASC C or D) lesions were retrieved from
this database and included in this retrospective study.
Forty nine (50,5%) of these patients were submitted to a
single procedure PTA/S and the remaining 48 (49,5%)
underwent a BGS with autogenous veins. Primary out-
comes were limb salvage and survival. All patients pursued
5
our follow-up protocol including regular duplex
scan imaging.
Results: The mean follow-up time for this study was 20.1
months. PTA/S patients were older (mean age: 69 y vs. 64
y for BGS) and included morefemales. Perioperative death
rates were 8.7% for BGS and 8.3% for PTA/S group. The
36-month survival rate (Kaplan-Meier) was 73.4% for the
BGS and 53.4% for the PTA/S group (Log-Rank, p ¼ 0.11).
The cumulative limb salvage rate was similar in both
groups. The 36-month freedom from amputation rates
was 53.3% and 49.0% for BGS and PTA/S, respectively
(Log-Rank, p ¼ 0.93). Univariate analysis identified diabe-
tes and poor runoff status as risk factors for limb loss in
the PTA/S group (P ¼ 0.03 and.015, respectively) and the
Cox-regression analysis added younger age as another risk
factors for limb loss in this group.
Conclusion: The outcomes for endovascular therapy and
bypass graft surgery were similar for both limb salvage and
survival in CLI patients with simultaneous femoropopliteal
and infrapopliteal complex arterial disease in the pre-
sent study.
SESSION 07: 19061 – DEVELOPMENT
OF A SIMULATOR FOR TEACHING
ULTRASOUND-GUIDED CENTRAL
VENOUS ACCESS
Luis Carlos Uta Nakano, Beatriz Urbani Pessutti,
João Manoel Silveira Lara,
Ronald Luiz Gomes Flumignan,
Libnah Leal Areias, Carolina Martines Estrutti,
Giulianna Barreira Marcondes,
Rafael Bernardes de Avila,
Rebeca Mangabeira Correia,
Matheus Leme de Marchi,
Jorge Eduardo de Amorim,
Gabriel Cambraia Pereira and
Henrique Jorge Guedes Neto
UNIFESP, São Paulo, Brazil
Background: Health education protocols are constantly
undergoing revisions to unravel teaching methods able to
optimize the skills of health professionals in a faster, user-
friendly and efficient way. The high-cost associated with
this new developments however, cannot be absorbed by
all medical teaching facilities around the world. The
Division of Vascular Surgery at UNIFESP, São Paulo,
Brazil has created a nuclei dedicated to development
and research in Health training for budget-restricted med-
ical education Institutions.
6 Vascular 27(1S)
Aim: To develop a low-cost, reproducible and user-
friendly simulator for teaching ultrasound-guided deep
venous access.
Material & Methods: The central venous access
demands and requirements of our Institution were care-
fully reviewed to establish specific needs and priorities.
Besides, easily available low-cost materials were pro-
spected in the Brazilian market and submitted to bench
performance testing in order to build a pilot model.
Results: Injectable polyurethane foam, latex, ballistic gel-
atin and Artificial silicone skin were submitted to bench
performance testing to ascertain their resemblance with
real models as well as resistance to multi punctures and
structure identification by duplex-scan. Internal jugular
and subclavian veins were made of latex, inside the poly-
urethane foam and connected to taps for filling with col-
ored liquid to facilitate visualization. Artificial silicone skin
allowed several punctures without markings on its surface.
Four simulators were produced and tested by 6th grade
medical students and residents. The cost per unit was
R$250,00, that is 100 times cheaper than the market
simulator (R$25.000,00).
Conclusion: The development of a low-cost, easy-to-
assemble and user-friendly simulator was accomplished.
As cost is no longer a limitation, this simulator will cer-
tainly be a good teaching tool for budget-restricted med-
ical education Institutions.
SESSION 07: 19089 – LABORATORY
PERFORMANCE OF A NEW INFUSION
DEVICE (HAND-CRANK) FOR IMAGE
ACQUISITION DURING
ENDOVASCULAR PROCEDURES
Bruno Pagnin Schmid,
Giovani Jose Dal Poggetto Molinari and
Fábio Hüsemann Menezes
Universidade Estadual de Campinas, Campinas, Brazil
Background: Precise deployment of endografts during
endovascular aneurysm repair requires precise images of
the landing zone. Mechanical injection pump is the gold
standard method to inject the contrast with the necessary
pressure and flow to generate a satisfactory image.
Nevertheless, when the procedure is performed outside
the radiological suite, usually in a regular operating room
of community hospitals, the mechanical injector is often
unavailable. Consequently, the manual injection method is
the alternative. Manual injection may not generate the
required pressure and flow for a satisfactory anatomy
visualization. Additionally, manual injection poses the risk
of hand injury and fatigue due to the effort applied on
the syringe.
Aim: Evaluate the injection characteristics of a new
mechanical device designed to facilitate t manual injection
of contrast media during arteriography with 5F, 100 cm
long catheters (pigtail).
Material & Methods: It was constructed a PVC-tube
system in order to simulate the pressure (120 mmHg) in
the aorto-iliac terrirtory. Tests were conducted to com-
pare the injection of contrast material (Henetix 300) using
the new device, that we called Hand-Crank, and manual
standard injection. The following data were analyzed: total
volume until the maximum pressure is reached, pressure
variation according to time of injection, maximum pres-
sure achieved, total time of injection, time to reach the
maximum pressure. Three general surgery residents were
invited to perform the injections. Each one performed
nine tests using the conventional manual injection and
nine tests using the Hand-Crank, totalizing 54 injections
for analyzes. Data were submitted to statistical analyzes to
compare the two methods.
Results: There was statistical difference between the two
methods (p
Conclusion: The new device proved effective l to
improve pressure and speed of contrast media injection
in bench test. Values t are comparable to those of an
injection pump. It is a simple, low cost and effective tool
that certainly deserves to be tested during endovascu-
lar procedures.
SESSION 07: 19048 – COMPARATIVE
ANALYSIS OF BIOMECHANICAL
PROPERTIES OF AORTAS WITH
NORMAL DIAMETERS AND AORTAS
WITH ANEURYSM: THE IMPACT
OF AGE
Erasmo Simão da Silva1 and Ml Raghavan2
1
HCFMUSP -Hospital das Clı́nicas, Faculdade de Medicina da
Universidade de São Paulo – Lim02, São Paulo, Brazil
2
Depto Bioengenharia Universidade de Iowa, Estados Unidos
Background: The biomechanical properties of the wall of
the Abdominal Aortic Aneurysms contribute to the devel-
opment of mathematical models used in the prediction of
aneurysm growth and rupture. The comparison of these
properties in non-aneurysmal aortas demarcates the dif-
ferences and establishes a control parameter for the accu-
rate analysis of these results. Two biomechanical aspects
are generally contemplated: tissue resistance to traction
and elasticity.
Abstracts
Aim: To compare the resistance and elasticity of the aorta
wall without dilatation to that of aneurysms through uniax-
ial biomechanical tests of specimens obtained at necropsy.
Material & Methods: Samples of 40 abdominal aortic
aneurysms, 19 of the abdominal aorta of individuals over
60 years and 11 of the abdominal aorta of individuals
under 60 (collected at necropsy) were analyzed with uni-
axial destructive test. Fragments removed form aortas and
abdominal aortas were collected from anterior portion of
the vessels. This methodology was established in LIM 02
HCFMUSP since 2001 in a cooperative study between the
Department of Surgery FMUSP and the Bioengineering
Department of the University of Iowa.
Results: From the point of view of wall resistance, the seg-
ments removed from abdominal aortas without aneurysms
in individuals older than 60 years compared to the segments
collected from the aneurysms showed a similar behavior
(respectively failure rate: 11.77 N/cm  12.16 N/cm, p ¼
0.66). The aortic segments of individuals under 60 years of
age were more resistant than the abdominal aorta segments
without dilatation over 60 years and with aneurysm (respec-
tively, failure rate: 23.52 N/cm, 11.77 N/cm and 12.16 N/
cm, p ¼ 0.003).
Conclusion: The premise that abdominal aortic aneu-
rysm is determined by a weakness of the aortic wall was
not corroborated by this study. Multiaxial and inflated
tests of whole specimens need to be performed to con-
firm the results of the present study
SESSION 15
TL 01 – THORACIC
AORTIC ANEURYSM
BONETE ROOM 12:10 – 13:22
SESSION 15: 19058 – ENDOVASCULAR
TREATMENT OF ACUTE TYPE B
AORTIC DISSECTION COMPLICATED
BY MALPERFUSION SYNDROME –
CASE REPORT
Pedro Henrique Olivo Kronfeld,
Adamastor Humberto Pereira,
Luiz Francisco Machado Costa,
Marco Aurelio Grudtner, Alexandre Araújo Pereira,
Ricardo Bocchese Paganella,
Sharbel Mahfouz Boustany, Joel Alex Longhi,
Ivana Sá Brito, Guilherme Luis Fernandes,
Gustavo Júlio Dreher, Rebeca Bosse de Jesus and
Pedro Henrique Cardoso Borges
Hospital de Clı́nicas de Porto Alegre, Porto Alegre, Brazil
7
Background: Acute aortic dissection is the most
common of all acute aortic syndromes and is associated
to a high mortality rate. Malperfusion syndrome results
from end-organ ischemia in the setting of an aortic dissec-
tion and can affect nearly all major vascular beds, including
the carotid, spinal cord, visceral, renal, and lower extrem-
ity branch vessels with varying frequency and severity.
Prompt consideration of malperfusion syndrome following
the diagnosis of aortic dissection is important, as the inci-
dence approaches 25–30% despite improvements in med-
ical therapy.
Case Description: A 61-year-old hypertensive and
smoking male was admitted to the Hospital de Clı́nicas
de Porto Alegre complaining of severe interscapular
chest pain radiating to the abdomen, over the past 24 hs.
The patient was hypertensive on admission but presented
no overt clinical sign of dissection. The angiotomography
revealed a Stanford type B as well as a type IIIb DeBakey
Aortic Dissection. An intense abdominal pain starting on
the tenth day was accompanied by an increase in the false
lumen diameter, as well as extension of the aortic dissec-
tion to the superior mesenteric artery, with significant
true lumen stenosis seen at angiotomography. The patient
was reported to surgery on account of intestinal malper-
fusion. A Left carotid-subclavian bypass with a 6 mm
Dacron prosthesis, as well as TEVAR with two thoracic
endoprothesis (Cook Medical) deployed from the ostium
of the left subclavian artery to the origin of the celiac
trunk and coil embolization of the proximal segment of
the subclavian artery was performed under general anes-
thesia. Tear point repair was undertaken at the left renal
artery with Advanta V12 stent. A bifurcated endoprosthe-
sis (Cook Medical) with free flow removal was deployed in
the abdominal aorta for repairing tear points in the
abdominal aorta and iliac arteries. A Biotronik stent was
implanted in the mesenteric artery due to stenosis greater
than 50% secondary to dissection of the vessel origin. No
renal function or neurological deficits were observed. The
CSF drainage catheter was withdrawn on the third post-
operative day. An angiotomography performed on the sev-
enth postoperative day demonstrated complete thrombo-
sis of the false lumen and patency of the visceral branches.
The patient was put on a follow-up protocol. The patient
was asymptomatic in his 30-day reassessment.
Conclusion: Endovascular treatment is the main form of
intervention in malperfusion syndromes caused by acute
aortic dissection. The success of the treatment depends
on the individualization and planning according to the anat-
omy and clinical manifestations of each patient.
8 Vascular 27(1S)
SESSION 15: 19069 – ENDOVASCULAR
TREATMENT OF
THORACOABDOMINAL ANEURYSM IN
TAKAYASU ARTERITIS.
Jorge Eduardo de Amorim,
João Manoel Silveira Lara, Gabriela Gomes Prates,
Vinicius Bignatto Carvalho,
Rebeca Mangabeira Correia,
Carolina Dutra Queiroz Flumignan,
Vladimir Tonello de Vasconcelos,
Wellington Gianotti Lustre,
Henrique Jorge Guedes Neto,
Ronald Luiz Gomes Flumignan,
Luis Gustavo Schaefer Guedes and
Luis Carlos Uta Nakano
UNIFESP, São Paulo, Brazil
Background: Takayasu arteritis (TAK) is a chronic gran-
ulomatous inflammatory vasculitis of unknown origin,
which affects mainly the aorta and its majpr branches.
The most common vascular lesions include: stenosis,
occlusion and, aneurysm formation. Aortic aneurysm is
one of the major cardiovascular complications of TAK.
Aneurysm rupture though, is a rare occurrence. Medical
treatment with corticosteroids and other immunosupres-
sive agents are the mainstay treatment for this disease.
However, the surgical approach should be considered in
the setting of aortic aneurysms larger than 5.5 centi-
meters, due to the increased risk of rupture. Open surgi-
cal approach is traditionally the one of choice, but endo-
vascular repair has gained acceptance over the past two
decades. According to Cochrane systematic review
(2014), comparing endovascular repair to open surgical
approach, endovascular surgery is associated with lower
short-term mortality rates and higher reintervention rate.
The great majority being related to the endovascular tech-
nique used and associated with low mortality risk.
Endovascular intervention is therefore a viable alternative
to open surgery provided the patient is included in a close
clinical and imaging postoperative follow-up protocol.
Patients with associated comorbidities should undergo
conservative treatment first to optimize medical condi-
tions before being submitted to any surgical intervention.
This measure aims at ensuring a more favorable outcome.
Case Description: A 38-year-old female with a pulsatile
abdominal mass over the past 6 months was seen at our
Institution. A 5.3  4.9 cm thoracoabdominal aneurysm
was diagnosed on imaging exam. The diagnosis of
Takayasu Arteritis was confirmed and immunosuppressive
therapy was initiated to control disease activity.
Endovascular repair with a branched endoprosthesis
implant evolved with left iliac occlusion, treated with a
left femoral iliac graft. Occlusion of the left renal artery
was also observed but renal function was preserved. At th
6-month follow-up visit the patient had no sign of activity
of Takayasu arteritis and presented regression of the aneu-
rysm on imaging exams.
Conclusion: Endovascular repair of thoracoabdominal
aneurysm in Takayasu arteritis is feasible but requires
close postoperative monitoring to detect asymptomatic
disease progression and subclinical complications.
SESSION 15: 19112 – RUPTURED
AORTIC ANEURYSM DEGENERATION
FROM PREVIOUS TYPE B DISSECTION
COMPLICATED WITH
AORTO-BRONCHIAL FISTULAE
Pedro Henrique Cardoso Borges,
Rebeca Bosse de Jesus, Guilherme Luis Fernandes,
Gustavo Júlio Dreher,
Pedro Henrique Olivo Kronfeld,
Marco Aurelio Grudtner,
Sharbel Mahfouz Boustany,
Alexandre Araújo Pereira, Joel Alex Longhi,
Ricardo Bocchese Paganella,
Luiz Francisco Machado Costa and
Adamastor Humberto Pereira
Hospital de Clinicas de Porto Alegre (HCPA), Porto Alegre,
Brazil
Background: Acute aortic dissection have an estimated
incidence of 2.9 to 3.5/100.000 person/year. Stanford type
B dissection is the most common type, accounting for
approximately 40% of the cases. Untreated acute dissec-
tion is associated with extremely high mortality (>68%).
Aneurysmatic degeneration is the most common compli-
cation of the conservative approach. Up to 30% of these
patients will need some intervention during the five-year-
follow-up period. Therefore, there is a trend in literature
to recommend invasive intervention in the acute phase, in
selected cases, to promote aortic remodeling and avoid
degeneration.
Case Description: A 64-year-old female was admitted to
HCPA emergency unit complaining of thoracoabdominal
pain and hemoptysis. Past medical history included hyper-
tension and stroke with mild paresis of the left leg. Physical
examination at admission revealed low blood pressure and
respiratory distress. The abdomen was innocent and
peripheral pulses were symmetric. Angiotomography diag-
nosed a ruptured degenerative aneurysm, secondary to a
type B dissection, with the entry tear close to the subcla-
vian artery. The celiac trunk and the mesenteric arteries
were located in the true lumen while the right renal artery
was emerging from the false lumen. The left kidney was
Abstracts
atrophic. The infrarrenal aorta was spared. Other findings
included a left hemothorax and an aorto-bronchial fistulae.
The patient was reffered for a hybrid repair. A TEVAR
using two Zenith stent grafts (TX2 34  209 mm, TX2
44  125 mm) introduced through the subclavian artery
and extending to the celiac axis was performed and fol-
lowed by an iliac-renal bypass through a median laparoto-
my. Additionaly an EVAR with Zenith TBE 32  80 mm was
undertaken at the infra-mesenteric aorta to address the
native right renal artery reentry tear. Mechanical ventila-
tion was suspended at first PO. Liquoric drainage was
started at the second PO and withdrawn at the 7th PO
on account of paresthesia and paresis of the lower
extremities. A postoperative pneumonia was treated
with Ampicilin-sulbactan. The renal function was stable.
ICU discharge occurred at the 10th PO and hospital dis-
charge at 12th PO. Control angiotomography at 10th PO
showed complete false lumen thrombosis, resolution of
aorto-bronchial fistulae and patency of iliac-renal bypass.
Ambulatory revision was performed in 3 and 6 months
with excellent clinical evolution.
Conclusion: Hybrid repair is an interesting approach to
ruptured degenerative aortic aneurysm secondary to type
B dissection
SESSION 15: 19115 – ENDOVASCULAR
TREATMENT OF RUPTURED ACUTE
TYPE B DISSECTION WITH AORTO-
BRONCHIAL FISTULAE
Pedro Henrique Cardoso Borges,
Rebeca Bosse de Jesus, Guilherme Luis Fernandes,
Gustavo Júlio Dreher,
Pedro Henrique Olivo Kronfeld, Joel Alex Longhi,
Marco Aurelio Grudtner,
Sharbel Mahfouz Boustany,
Alexandre Araújo Pereira,
Ricardo Bocchese Paganella,
Luiz Francisco Machado Costa and
Adamastor Humberto Pereira
Hospital de Clinicas de Porto Alegre (HCPA), Porto Alegre,
Brazil
Background: Type B aortic dissections are primarily
managed conservatively. Interventional support is indicat-
ed when acute complications such as rupture supervene.
Literature review suggest early invasive procedures should
be carried out in selected cases to promote aortic remod-
eling and avoid aneurysmatic degeneration.
Case Description: A 77-year-old male was admitted to
the HCPA emergency ward complaining of a week-long
severe epigastric pain and hemoptysis. Past medical
9
history included hypertension and atrial fibrillation, anti-
coagulant use without proper laboratory control. The
patient was referred to ICU for anticoagulation reversal
with infusion of 4 Frozen Fresh Plasma units and vitamin K.
Medical exam at admission, revealed high blood pressure
(170/92 mmHg), tachycardia (115 bpm) and dyspnea. The
abdomen was innocent at examination and the peripheral
pulses were symmetric. Hemoglobin level was 7,5g/l and
the INR was 1,62. Angiotomography demonstrated a rup-
tured type B aortic dissection extending to the infrarenal
aorta, with the entry tear close to subclavian artery and
various reentry tears along the dissection path. Other
findings included left hemotorax and aorto-bronchial fis-
tulae. Initial conservative approach for anemia and coagu-
lation improvement was undertaken. The endovascular
intervention was carried out on the following day using
two thoracic Zenith TX2 endoprothesis (46/42  179 mm
and 42/38  173 mm), to cover the aorta from the subcla-
vian artery to the celiac axis, followed by an endovascular
abdominal aortic repair with a Zenith Flex endoprothesis
36  98 mm. A Liquoric drainage device was placed during
anesthesia to be used immediately after the procedure.
Postoperatory follow-up was uneventful. Renal function
was stable and mechanical ventilation was suspended at
the first PO. ICU discharge occurred at third PO, when
liquoric drainage catheter was withdrawn (drainage was
less then 100ml/24 h). Hospital discharge occurred at
tenth PO. Control angiotomography was performed at
the sixth PO and demonstrated complete false lumen
thrombosis and resolution of aorto-bronchial fistulae.
Ambulatory revision was performed at 1 and 4 months
with excellent clinical evolution.
Conclusion: Total endovascular approach is a feasible
method to treat ruptured type B dissection. Closing all
reentry tears is important to seal the false lumen
completely and prevent aortic degeneration.
SESSION 15: 19121 – CHIMNEY
TECHNIQUE FOR AORTIC ARCH
REPLACEMENT
Jean Marc Vinagre Prado de Olivera,
Cledicyon Eloy da Costa,
Gustavo Calado de Aguiar Ribeiro, Francisco Dias,
Mauricio Rocco de Oliveira and
Guilherme Vieira Meirelles
IMV -Instituto Meirelles de Cirurgia Vascular, Campinas, Brazil
Background: Nevertheless total aortic arch replacement
surgery is a well-established procedure, the cardiac hypo-
thermic circulatory arrest is not well tolerated by all
patients. Other treatment options such as the
10
custom-made or branched off-the-shelf endoprosthesis
are either commercially unavailable or take a long time
to be delivered to our country. Chimney with parallel
endograft technique is currently the best cost-wise and
time-wise treatment alternative for total aortic arch
replacement in Brazil.
Aim: Present the results of this series of patients submit-
ted to endovascular repair of aortic aneurysms and dis-
sections extending up to the ascending aorta with chim-
ney approach.
Material & Methods: A series of 14 patients treated by
the endovascular approach in our institution, from
September 2013 to September 2018, is reviewed. The
reasons for the endovascular repair are: dissection
(5/36%), penetrating ulcer (5/36%), aortic arch aneurysm
(2/14%) and pseudo aneurysm (2/14%). All patients under-
went endovascular repair from the ascending to the
descending aorta using various stentgrafts (Medtronic,
COOK, WLGORE). Viabahn stents were implanted at
the supra aortic branches. In two cases a carotid-left sub-
clavian artery bypass with PTFE was performed, and in one
case embolization of the left carotid artery was carried
out. The transfemoral approach was used for the main
aortic body in all cases except in one female on account
of narrow femoral vessels. The transapical access was
used in this patient. Follow-up extended from 6–66
months (mean 28 months).
Results: All, but one subclavian artery were revascular-
ized. Primary success rate was 93%. No early mortality or
major complications were observed. Unrelated late mor-
tality occured in two patients (14%) (gastric haemorrhage
and sepsis with renal failure). The brachiocephalic trunk
and the left carotid artery were revascularized from the
ascending aorta and left subclavian artery in a periscope
way from the descending aorta.
Conclusion: Chimney technique is good option for total
arch replacement in patients that are not suitable for open
repair and/or are not fit to distal custom-made devices.
SESSION 15: 19179 – COMPLEX
THORACOABDOMINAL ANEURYSM
REPAIR WITH PARALLEL
STENT TECHNIQUE
Luiz Antônio de Azevedo Accioly,
Luis Eduardo Maiorquin,
Vinicius Brazil Correa da Cunha and
Daniel Barreto Gomes
Hospital de Base Ary Pinheiro, Porto Velho, Brazil
Background: The parallel stent technique represents a
low cost user-friendly alternative to approach complex
Vascular 27(1S)
thoracoabdominal aneurysms in a safe and straight-
foward way. Customized stentgrafts are expensive, take
a long time to be prepared and delivered to our country
and demand specific skills.
Case Description: ALM is a 65-year-old male complain-
ing of intermittent, progressively worsening epigastric pain
over the past two years. Dyspepsia was excluded. Past
medical hystory includes hypertension treated with valsar-
tan 160 mg 12/12 h and Nifedipine 20mg 12/12 h and,
smoking for 50 years. Angiotomography revealed a thor-
acoabdominal aortic aneurysm measuring 7 cm in diame-
ter, starting at 18 cm from the origin of the left subclavian
artery and extending up to 7 cm from the origin of the
inferior mesenteric artery with occlusion of celiac trunk
and superior mesenteric artery. The right kidney artery
measured 3.5 mm and the left measured 7 mm with severe
stenosis, starting at 2 cm from its origin. A vicariant infe-
rior mesenteric artery measured 7 mm. The arcade of the
Drumond was very evident Laboratory results at admis-
sion: Creatinine 1.35 mg/dL, Urea 74 mg/dL. We opted
for the endovascular approach with TEVAR with parallel
stents and left renal artery revascularization with the
“Sandwich” technique. Revascularization of the right
renal artery was not planned because it had a diameter
of 3.5 mm. The endoprosthesis (Apollo 34  155 mm) was
introduced through the right femoral artery into the
descending aorta and placed 3 cm from the left renal
artery origin. Renal artery catheterization was initially
attempted via the left axillary artery without success and
then acomplished through the femoral artery. The parallel
technique was changed to “Snorkel”. A 08  100 mm
Viabahn was placed in the renal artery and followed by
the stentgraft deployment 3 cm from the origin of the
inferior mesenteric artery. The Viabahn was released
2 cm below the endoprosthesis and the left renal artery
angioplasty was performed using a Viatrac balloon
06  20 mm. Control angiography demonstrated both
inferior mesenteric artery and left renal artery were suc-
cessfully revascularized without endoleak. Follow-up lab-
oratory tests included Urea:36 mg/dL and Creatinine:
0.68 mg/dL. Control angiotomography demonstrated
complete aneurysm exclusion without endoleaks and
patency of both left renal artery and inferior mesenter-
ic arteries.
Conclusion: The parallel stent technique is a good, flex-
ible and safe alternative to address complex thoracoabdo-
minal aneurysms.
Abstracts
SESSION 15: 19181 – TWO-YEAR
OUTCOME ASSESSMENT OF
ENDOVASCULAR REPAIR OF AORTIC
DISEASES IN A REFERENCE HOSPITAL
IN COLATINA, ESPÍRITO
SANTO, BRAZIL
Danilo Heringer Alcure Quarto,
Moriane Barcelos Lorenzoni Zago,
Wallace Medeiros de Aguiar,
Guilherme Luchine de Almeida and
Ricardo de Souza Divino
Hospital Maternidade São José, Colatina, Espı́rito Santo, Brazil
Background: The annual incidence of new Abdominal
Aortic Aneurysms is 55 per 100.000 person-years for
those aged 65–75 years. Age significantly impacts inci-
dence increasing to 112 per 100.000 person/years for
men aged 75–85 years. A further increase to 298 per
100.000 person/years is reported for those older than
85 year. Other risk factors include male sex, Caucasian
race, positive family history, smoking, presence of other
large vessel aneurysms and atherosclerosis. Thoracic
aortic aneurysms, as well as rupture, dissection, intramu-
ral hematoma, penetrating ulcer are part of the large spec-
trum of aortic diseases.
Aim: To present our casuistry and report the outcomes
for endovascular repair of aortic diseases (thoracic and
abdominal aortic aneurysms, coarctation of the thoracic
aorta, penetrating ulcer of the aorta and aortic dissec-
tions) in a reference Hospital in Colatina, Espı́rito Santo,
Brazil, from January 2017 to February 2019.
Material & Methods: A total of 66 patients submitted to
endovascular repair of aortic disease in our Institution,
had their charts reviewed in this retrospective study.
The analyzed parameters comprised associated comorbid-
ities, symptomatology, treatment approach, postoperative
complications and mortality rate. Thirty-eight (58%)
patients had abdominal aortic aneurysms, 8 (12%) had
thoracic aortic aneurysms, 5 (7,5%) had thoracoabdominal
aneurysms, 8 (12%) had type B dissections, 4 (6%) had
aortic coarctation, 2 (3%) had a penetrating ulcer of the
thoracic aorta, and 1 (1,5%) had aortic fistula.
Results: The mean age was 67.4 years (65% males).
Comorbidities included hypertension and smoking in
76.5% and 46% of the patients, respectively. 56% of the
patients presented related symptomatology. Postoperative
results comprised some type of endoleak in 16% of the
patients, type II being the most common (54.5%). Renal
failure, cardiorespiratory arrest and shock were also
observed. The mortality rate was 7.6%, with shock being
the main cause (61.5%). Endoleak was present in only of
the patients who died.
11
Conclusion: This retrospective study supports the safety
and efficiency of endovascular intervention to address
aortic diseases previously reported in the international
literature. Therefore, we may conclude that early endo-
vascular interventions with precise indications is the key
for successful outcomes.
SESSION 16
TL 02 – COMPLEX AORTIC
ANEURYSM 1
BONETE ROOM 13:30 – 14:29 PM
SESSION 16: 19031 – TREATMENT OF
TYPE II ENDOLEAK WITH ONYX
AFTER ENDOVASCULAR REPAIR OF
RUPTURED ABDOMINAL
AORTIC ANEURYSM
Gabriella Lucas Richards2, Igor Rafael Sincos1,
Anna Paula W. Baptista1, Walter Campos Jr.2,
Vitor C. Gornati2, Manoel Lobato3,
Vinicius Bertoldi4, Carolina Mardegan3,
Alexandre de A. Melo1 and André M. Chacon3
1
Hospital Paulistano, São Paulo, Brazil
2
Hospital das Clı́nicas FMUSP, São Paulo, Brazil
3
Hospital São Camilo, São Paulo, Brazil
4
Hospital Edmundo Vasconcelos, São Paulo, Brazil
Background: Type 2 endoleak is the most common com-
plication of endovascular abdominal aortic aneurysm
repair (EVAR). It can ultimately lead to sac expansion
and/or rupture. Currently, there is no consensus regarding
treatment of type 2 endoleak. Most experts agree it
should be managed conservatively for its benign course,
unless there is evidence of sac enlargement or persistence
for more than 6 months. Some authors, on the other
hand, advocate early treatment to avoid rupture.
Treatment options include intra-arterial embolization
with either coils, glue, gelatin foam, Amplatzer vascular
plug, sclerosing agents or liquid embolization system.
Laparoscopic or open surgery are alternative options.
Case Description: A 65-year-old man complaining of
acute severe abdominal pain was admitted through the
Emergency Unit. The admission CT scan revealed a rup-
tured abdominal aortic aneurysm. The patient was submit-
ted to endovascular repair but remained with pain in the
immediate postoperative period. Laboratory testing dem-
onstrated a decreasing hemoglobin and a type 2 endoleak
was diagnosed on a follow-up CT. The site of the endoleak
though was not clear. There was a doubt whether it came
from the inferior mesenteric artery or from the internal
12
iliac arteries. Selective arteriography of the internal iliac
arteries failed to spot any leakage to the aortic aneurysm
sac. Therefore, we opted for a retrograde catheterization
of the inferior mesenteric artery from the superior mes-
enteric artery with Progreat microcatheter (Terumo
Interventional Systems) to reach the aneurysm sac.
An endoleak from the inferior mesenteric artery was iden-
tified and treated with embolization of its ostium using the
Onyx liquid embolic system (Medtronic) only three days
after the main procedure. Embolization was successful
with a complete seal of the endoleak.
Conclusion: . This case report describes embolization of
an early type 2 endoleak with Onyx, carried out only three
days after endovascular repair of a ruptured abdominal
aortic aneurysm. This early timing may incur in additional
risk for fatal outcome because of the recent rupture tam-
ponade. Type 2 endoleak embolization by micro navigation
with Onyx proved effective and safe in the present case.
Further investigation is warranted to establish the long-
term behaviour of this type of embolizing agent in post
rupture type 2 endoleaks.
SESSION 16: 19066 – USE OF
ENDOANCHOR TO ADDRESS TYPE
1A ENDOLEAK
Jorge Eduardo de Amorim,
Beatriz Urbani Pessutti, Caio Cesar Bovo Delfino,
Ana Alyra Carvalho,
Marcus Vinicius Canteras Raposo da Camara,
Francisco Cialdine Frota Junior,
Arthur Cristiano Baston,
Henrique Jorge Guedes Neto,
Luis Carlos Uta Nakano, Gabriela Araujo Attie
and Ronald Luiz Gomes Flumignan
UNIFESP, São Paulo, Brazil
Background: Aortic aneurysm is estimated to occur in
4–8% of men and 1–2% of women over 65-year-old. It has
been reported that almost 10% of Americans over the age
of 65 have some degree of abdominal or thoracic aortic
enlargement. Rupture is the most important complication
of AAA. Mortality rates of up to 90% have been reported
for untreated cases. Nowadays, Seventy-five percent of
AAA are treated by endovascular repair rather than
open repair, given the decreased peri-procedural mortal-
ity, complications, and length of hospital stay reported for
EVAR. Endoleak is a potential complication of EVAR occur-
ring in nearly one in every four patients at some time
during follow-up. Five types of endoleak have been
described. Type 1 is caused by incomplete attachment of
the graft to the aortic lumen, due to hostile proximal
Vascular 27(1S)
aortic neck anatomy or stentgraft migration. It usually
leads to pressure increase in the aneurysm sac;.
Subtypes A, B and C refers to proximal, distal or iliac
location, respectively. This type of endoleak is associated
with high risk of rupture and requires immediate treat-
ment. The Heli-FX EndoAnchor System was designed to
enhance fixation and sealing at the endograft attachment
site to the aortic wall. This device is said to increase fix-
ation strength up to a surgical hand-sewn anastomosis
level and prevent graft migration. Compatibility with vari-
ous aortic endografts has been previously demonstrated
Case Description: A 72-year-old male with a type 1A
endoleak previously submitted to a successful emboliza-
tion with Onyx was admitted to our Institution for a
reccurring type 1A endoleak at the same location. This
time we opted to implant EndoAnchors at the endoleak
site and at the aneuryms neck with complete endoleak
seal. A 5-month follow-up CT demonstrated aneurysmal
sac regression and no new endoleak formation.
Conclusion: EndoAnchors seems useful for endovascular
endoleak repair. Further studies are required to ascertain
long term outcomes in association to different EVAR tech-
niques and aneurysmal features.
SESSION 16: 19070 – CONVENTIONAL
SURGERY TO MANAGE TYPE
III ENDOLEAK
Jorge Eduardo de Amorim,
Ronald Luiz Gomes Flumignan,
Henrique Jorge Guedes Neto,
Antonio Carlos Moura da Silva,
Bianca Giannetti Moraes, Daniel Hachul Moreno,
Luis Gustavo Schaefer Guedes,
Ana Alyra Carvalho and Luis Carlos Uta Nakano
UNIFESP, São Paulo, Brazil
Background: Endovascular repair of AAA was firstly
described by Parodi et al in 1991. The 2014 Cochrane
Collaboration Systematic Review comparing the endovas-
cular technique with open surgery for AAA repair dem-
onstrated superior outcomes for the endovascular inter-
vention. This approach was associated to reduced short-
term mortality and hospital-length-of-stay. However, the
reintervention rate associated to this procedure was
higher when compared to open surgery. Therefore,
open surgery is still recommend in selected cases.
Endoleak is the most common complication of the endo-
vascular approach of aortic aneurysms, with incidence
ranging from 10 to 25%. This can eventually lead to endo-
tension by increasing the pressure inside the aneurysmal
sac. The Cochrane Collaboration review reported
Abstracts
endoleak type 2 in 14% of the cases. The left subclavian
artery, the bronchial, patent intercostal and lumbar arter-
ies as well as the inferior mesenteric artery were the
vessels most commonly involved. The Guidelines of the
European Society of Vascular Surgery recommends a con-
servative approach for endoleaks type 2. It also advocates
reintervention be restricted to aneurysmal sac increase of
at least 10 mm in diameter. Patients should be reffered to
open surgery only when the endovascular intervention
fails. We currently report the use of conventional surgery
to treat a case of endoleak type 2.
Case Description: A 74-year-old male with a post EVAR
type 1 endoleak was submitted to proximal cuff placement
without success. A type endoleak 2 was diagnosed and the
patient submitted to open surgical treatment with aneu-
rysm neck circlage and ligature of the inferior mesenteric
artery. Endotension supervened and a progressive growth
of the aneurysm diameter up to 9 cm was diagnosed at
angio CT. Lumbar leakage was suspected. The patient was
refferred for a new open surgery (aneurysmotomy and
ligature of lumbar arteries as well as the branches of the
anterior wall of the aneurysm). The patient is currently on
the 4-month follow-up visit and no endoleaks were iden-
tified in the imaging tests.
Conclusion: This case report supports the Guidelines of
the European Society of Vascular Surgery in regards to
endoleak treatment. Conventional surgery is feasible and
can be carried out after unsuccessful endovascu-
lar approach.
SESSION 16: 19104 – ENDOVASCULAR
TREATMENT OF ABDOMINAL AORTIC
ANEURYSM IN A REFERENCE CENTER
FOR ARTERIAL DISEASES IN CENTRAL
WEST BRAZIL
Heytor Jose de Oliveira Cabral1,
Leticia do Espirito Santo Dias1,
Lilia Kazumi Miyahira1,
Marcelle Naomi Oshiro Shinzato1,
Milena Nakase Takayassu1,
José Valério Librelotto Stefanello Ii2,
Mauricio de Barros Jafar2, Marcos Rogério Couvre2
and Carlos Eduardo Zanoni Consolo2
1
UNIDERP, Campo Grande, Brazil
2
Associação Beneficente de Campo Grande Santa Casa, Campo
Grande, Brazil
Background: Abdominal Aortic Aneurysm (AAA) is a
prevalent disease in the elderly population. Most abdom-
inal aortic aneurysms are asymptomatic, being diagnosed
13
either on routine imaging tests or when evolving to acute
aortic syndromes.
Aim: To report our casuistry and outcomes for EVAR in a
reference hospital in the state of Mato Grosso do
Sul-Brazil.
Material & Methods: This retrospective study was car-
ried out in our Institution from October 2015 to
December 2018. All patients submitted to EVAR in this
period had their charts reviewed in regards to: aneurysm
type, associated comorbidities, surgical time, hospital
length-of-stay, complications and mortality rate.
Results: 87 patients were identified in our database.
56,32% had isolated Infrarenal Aneurysm (IIRA), 19,53%
had simultaneous AAA extending to either right or left
Iliac arteries, 19,54% had Abdominal Aortic Aneurysm
with bilateral iliac involvement, and 4,59% had isolated
Iliac aneurysm (either left or right). Comorbities included
hypertension, smoking, diabetes and alcohol consumption.
Complications comprised 51% Acute Kidney Injury (AKI)
and 6,06% hemorrhage in the IIRA group as opposed to
42,4% AKI associated to hemorrhage. A 9% mortality rate
was reported. All of these were submitted to blood trans-
fusion in association to AKI. Mean surgical time was 2
hours and 22 minutes and mean hospital length of stay
was 12 days among the patients who died. The higher
need for blood transfusion, longer procedure and in-hos-
pital stay, in IRAI pacients was associated to higher mor-
bidity and mortality rates.
Conclusion: Endovascular correction of aortic and iliac
aneurysms is a viable therapeutic option, with good results
and lower complication rates in experienced hands and in
patients with favorable anatomy.
SESSION 16: 19148 – ENDOVASCULAR
MANAGEMENT OF AN ABDOMINAL
AORTIC ANEURYSM WITH SHORT
COMMON ILIAC ARTERY USING THE
DOUBLE-BARREL TECHNIQUE: A
CASE REPORT
Priscilla Matos, Andre Estenssoro,
Lais da Cunha Gamba, Nelson de Luccia and
Pedro Puech-Leão
Universidade de São Paulo (USP), São Paulo, Brazil
Background: Abdominal aortic aneurysms are associat-
ed to 5% prevalence rate in men at the 65–74 age span.
Mortality rates may reach up to 90% in cases of
rupture. The endovascular technique is a minimally inva-
sive method associated to lower mortality and morbidity
rates. Anatomic constraints and device availlability are
importantant issues in third world countries.
14
The double-barrel technique is a novel hypogastric pres-
ervation technique using commercially available endografts
without device modification.
Case Description: A 75-year-old asymptomatic asian
was diagnosed with infrarenal abdominal aortic aneurysm
in routine imaging exams. Comorbidities included hyper-
tension, diabetes and severe coronary disease.
Open surgery was therefore contraindicated on account
of the patients high surgical risk. Short common iliac arter-
ies are more common in asiatic patients. A 60 mm infrare-
nal abdominal aortic aneurysm with a 21 mm neck-length
and an 110 mm extension was diagnosed on a CT-scan.
The right common iliac artery was 15 mm long and the
left common iliac was 53 mm long. There was no favorable
neck to support a bifucarted iliac device. the double-barrel
technique was chosen to provide additional support to the
endoprosthesis positioned in the internal and external iliac
arteries, in close contact with the iliac branch.
Conclusion: It is always a challenge to treat AAA with
inadequate landing zones. Postoperative follow-up was
uneventful and the 1-year CT-scan demonstrated a well
positioned endoprosthesis without signs of endoleak.
We advocate the two-barrel technique as a viable option
in cases of short common iliac arteries without an appro-
priate neck to support a bifurcated iliac device.
SESSION 16: 19150 – INITIAL
EXPERIENCE WITH ENDOANCHOR
Mauricio Rocco de Oliveira,
Jose Dalmo de Araujo Filho, Carlos Sassi,
Nasser Hussein Mahfouz,
Guilherme Vieira Meirelles and
Luis Marcelo Aielo Viarengo
IMV -Instituto Meirelles de Cirurgia Vascular, Campinas, Brazil
Background: Endovascular treatment of aortic aneur-
ysms represents a great advance in vascular surgery.
Short-term follow-up comparisons between the endovas-
cular approach and open surgery for AAA repair has dem-
onstrated superior or similar outcomes for the endovas-
cular intervention. Anatomic constraints such as hostile
necks and long-term duration are issues that need to be
considered when addressing patients with long life expec-
tancy. The fixation forces of the endoprosthesis to the
aortic wall seems to play a negative role in the long-term
durability of endovascular procedures. Fixation forces in
endovascular procedures are reported to be equal to half
the strength of open repair. Neck anatomy (tortuosity,
enlargement or short extension) is associated to type Ia
endoleak and endograft migration. The aim of this study is
to report our experience EndoAnchor in EVAR.
Vascular 27(1S)
Cases Description: Four points of fixation with
EndoAnchrs were necessary in three patients. The first
patient had a thoracic aortic aneurysm with a short
distal neck and an abdominal aortic endograft migrating
down over the last year. So after delivering and fixing
the distal part of the thoracic aorta, the proximal segment
of the abdominal aorta was also stapled. The remaining
two cases presented hostile necks (tortuosity and enlarge-
ment in the first case, and short extension in the second
one). In these cases, the proximal segment of the endo-
prosthesis was fixed with 6 EndoAnchors. The endopros-
thesis that were fixed by EndoAnchors comprised
Medtronic, Gore and Lombard.
Conclusion: We managed to deliver the EndoAnchors
and staple the aorta In all cases. No primary type endoleak
were observed and the short-term follow-up was
uneventful. Literature reviews report good results inr
acute type Ia endoleaks and in endograft migration.
Prophylactic use of EndoAnchors in patients with hostile
aortic neck anatomy, is still under analysis and definitive
conclusions must await longer-term follow-up data.
SESSION 17
TL 03 – PERIPHERAL ANEURYSMS 1
BONETE ROOM 14:30 – 15:33
SESSION 17: 19018 – RUPTURED
POPLITEAL ANEURYSM: A
CASE REPORT
Flávia Araújo de Souza Brazões,
Driely de Amorim Beligoli,
João Felipe Pinheiro Sales, Fabrı́cio Neto Ladeira,
Daniel Einstoss Korman,
Marlon Madson Bonfim Oliveira and
Juliano de Oliveira Barbosa Guedes
Hospital Metropolitano Odilon Behrens, Belo Horizonte, Brazil
Background: Popliteal artery aneurysms (POAA) corre-
spond to 70% of all lower extremities. Reported inciden-
ces range from 0.1% to 2.8%. Distal thrombosis and embo-
lization are the most frequent complications. Rupture is
observed in approximately 2% of the cases. Aneurysm
exclusion by a medial bypass or replacement of the aneu-
rysmal part with autologous venous graft are the most
commonly performed surgical procedures. Endovascular
repair is considered an alternative in selected cases.
Case Description: A 73-year-old female, with rheuma-
toid arthritis and atrial fibrillation presenting pain and
hematoma in the right calf, initiating in the previous
week was evaluated by her general practioneer.
Abstracts
Treatment for deep venous thrombosis was initiated. The
patient was refferred to our vascular surgery group as she
wasn’t doing any progress. Admissional physical examina-
tion revealed a hemodynamically stable patient with hema-
toma and pain in lower right limb (MID). The popliteal
pulse was present with no evident sign of acute ischemia.
Distal aneurysmatic dilatations of the left (4,2 cm) and
right (8 cm) femoral arteries was diagnosed in an angioto-
mography of lower limbs. A POAA with surrounding
hematoma was seen only at dupplex scan. The patient
was submitted to superficial right femoral artery bypass
athrough medial access with the use of ipsilateral reversed
Major Saphenous vein. We were forced to prematurely
interrupt surgery prior to aneurysmal sac removal, on
account of significant bleeding associated with hemody-
namic instability and requiring transfusion of 2 units of
packed red blood cells. The patient wasreferred to the
ICU. The patient evolved with pressurization and aneu-
rysm sac expansion as diagnosed by a control ultrasound.
A reintervention for aneurysm ressection and ligation of
the genicular vessels was undertaken in the 7th PO. Thel
postoperative follow-up was uneventful.
Conclusion: Physicians are not usually familiarized with
ruptured POAA and misdiagnosis is quite frequent, leading
to delay in treatment and complications. Open surgery
remains the treatment gold standard nevertheless the
endovascular approach is reported with acceptable results
when high surgical risk precludes conventional interven-
tion. Close postoperative follow-up is important specialy
when the aneurysmal sac was not removed.
SESSION 17: 19160 – ENDOVASCULAR
TREATMENT OF AN ISOLATED RIGHT
COMMON ILIAC ARTERY ANEURYSM
Cassia Yumi Yamamoto Takano,
Vitor Moron de Andrade,
Ana Letı́cia Luchiari Ferrari,
Vitor Dincão Sanches,
Northom Augusto de Jesus Perreti,
Luciana Helena Benatti,
Gabriella Pazzanese Barreira,
Giulia de Paula Vendramini Ferreira,
Guilherme Camargo Gonçalves de Abreu,
Marcia Fayad Marcondes de Abreu and
Otacilio de Camargo Junior
PUC-Campinas, Campinas, Brazil
Background: Isolated common artery aneurysms are of
rare occurence. An incidence of 1.5% has been reported.
Necropsy studies reported alower incidence rate of
approximately 0.03%. Common iliac arteries aneurysms
15
are more commonly associated to abdominal aortic aneur-
ysms. This type of aneurysm can evolve to rupture to the
pelvic retroperitoneal space or more rarely to the rectum
or sigmoid colon. Rupture is associated to high mortality
rates comparable to those of aortic aneurysms. Reported
mortality rates are 70 to 90% for the common iliac arter-
ies aneurysm and10 to 30% for the internal iliac arteries.
The external iliac artery is rarely affected. Growth rates
are lower in aneurysms smaller than 3 cm (approximately
1.1 cm/year), than in those larger than 3 cm (2.6 cm/year).
Incidence of rupture has been reported to be 33 to 50% in
these cases. Endovascular treatment is currently consid-
ered the best treatment on account of lower complication
and mortality rates.
Case Description: An 81-year-old male complaining of
lower back pain was diagnosed with an isolated right
common iliac artery aneurysm (width: 3.85 cm; extension:
6.6 cm) on an angioCT. The patient was refferred to endo-
vascular treatment with embolization of the right internal
iliac artery using either 2 8 mm or 10 mm springs. A
Zenith alpha Cook 22  70 endoprosthesis was placed in
the abdominal aorta. A leg extension of 13  77 mm was
positioned in the left iliac artery and a 11  125 mm exten-
sion in the right iliac artery. Control arteriography con-
firmed no stenosis or endoleaks. The patient is currently
on the second postoperative month and has no
complications.
Conclusion: Rupture is often the first presentation of
iliac artery aneurysms. Treatment depends on size and
association with AAA. Endovascular intervention is feasi-
ble, safe and effective.
SESSION 17: 19174 – AXILLARY
ARTERY ANEURYSM
Ana Alyra Carvalho, Carolina Martines Estrutti,
Libnah Leal Areias, Douglas Sterzza Dias,
Rafael Bernardes de Avila,
Giulianna Barreira Marcondes,
Ronald Luiz Gomes Flumignan,
Henrique Jorge Guedes Neto,
Jorge Eduardo de Amorim,
Beatriz Urbani Pessutti and
Luis Carlos Uta Nakano
UNIFESP, São Paulo, Brazil
Background: The presence of a supra or infraclavicular
pulsatile mass may raise the diagnosis of subclavian or axil-
lary artery aneurysms. Thoracic outlet syndrome in asso-
ciation to cervical rib is the main ethiologic factor.
The subclavian pulse may move upwards in the neck in
the event of a cervical rib. Poststenotic dilatation of the
16
subclavian artery beyond a mechanical thoracic outlet
obstruction or chronic soft and bony tissue damage to
the artery is seen frequently observed. Aneurysms of
the axillary artery are rare and can threaten upper
extremities vascular bed and neurologic plexus integrity.
Surgical excision and vascular grafting are the usual treat-
ments. Treating axillary artery aneurysms is of utmost
importance to prevent thromboembolism and ischemia,
which in turn can lead to gangrene and amputation of
the affected extremity. For this reason, operative manage-
ment of such cases should not be delayed.
Case Description: A 67-year-old female reporting pain
and a progressively growing mass in the left Axillary
region over the 04 months was seen at our institution.
She admits previous trauma with hyperextension of the
left upper limb. Imaging exams (doppler ultrasonography
and angiotomography) evidenced a 48  56 mm pseudoa-
neurysm of the left middle axillary artery with occlusion
of the distal segment of the axillary artery and refilling by
collaterals. Due to its mass effect we opted for open sur-
gical intervention with dissection of the pseudoaneurysm
followed by axillary-brachial artery bypass with a venous
graft. A normal postoperative three-phasic flow was
restored in the radial artery but the patient evolved with
neuropraxia and flexion limitation of the forearm muscles.
Function improvement was possible after physiotherapy.
Conclusion: Conventional surgery is an option for the
treatment of axillary aneurysms but complications such as
transitory neuropraxia are frequent.
SESSION 17: 19178 – IDIOPATHIC
INFECTED POPLITEAL ARTERY
PSEUDOANEURYSM
Josualdo Euzébio da Silva,
Ana Letı́cia Alves Barbosa, Dalila Barbosa Delfino
and Flávia Araújo de Souza Brazões
BIOCOR, Belo Horizonte, Brazil
Background: Pseudoaneuryms are usually traumatic or
iatrogenic. Idiopathic pseudoaneurysms are rare. Duplex
scan is the first choice imaging test for that disgnosis.
Popliteal aneurysms can be treated endovascularly or con-
ventionally, depending on the pseudoaneurysms features
and the patients clinical conditions.
Case Description: A 76 year-old male presenting with
phlogistic signs in the popliteal region was seen at our
outpatient clinic. Previous medical history included diabe-
tes, valvulopathy, myocardial revascularization and absence
of bilateral saphenous veins. An abscess or hematoma
accompanied by severe popliteal artery stenosis and pseu-
doaneurysm formation was diagnosed by the duplex scan
Vascular 27(1S)
US. We opted for endovascular treatment with a covered
stent implant for pseudoaneurysm exclusion, followed by
angioplasty at arterial stenosis. In addition we drained the
hematoma and initiated antibiotic therapy. The endovas-
cular treatment with the use of ViabahnVR covered stent is
a less aggressive therapeutic option that can be performed
under local anesthesia, reducing the risk of hemodynamic
instability. The patient returned for the 4-month PO visit
complaining of pain in the popliteal region. Control
duplex-scan evidenced a popliteal artery aneurysm in the
distal part of the stent. The patient was submitted to a
new endovascular procedure with implant of a new stent.
Control arteriography demonstrated total aneurysm
exclusion and patency of the peripheral artery. The patient
was discharged on the next day in good gener-
al conditions.
Conclusion: Open surgery for popliteal artery aneur-
ysms presents excellent results The multiple patients
comorbidities, his bad clinical conditions at admission as
well as the absence of both saphenous veins precluded
open surgery in this particular patient. The endovascular
approach is a minimaly invasive procedure with reduced
risk of worsening his clinical condition. Close follow-up is
of paramount importance to assess complications and/
orprospect new aneurysm formation.
SESSION 18
TL 04 – VISCERAL ANEURYSMS
BONETE ROOM 15:40 – 16:43 PM
SESSION 18: 19057 – RETROGRADE
OPEN MESENTERIC ARTERY
STENTING DURING LAPAROTOMY
FOR THE TREATMENT OF
MESENTERIC ISCHEMIA: A SINGLE
CENTER STUDY
Pedro Henrique Olivo Kronfeld, Joel Alex Longhi,
Rebeca Bosse de Jesus,
Luiz Francisco Machado Costa,
Adamastor Humberto Pereira,
Marco Aurélio Grutner, Sharbel Mahfuz Boustany,
Ricardo Bocchese Paganella,
Alexandre Araújo Pereira,
Guilherme Luis Fernandes,
Pedro Henrique Cardoso Borges and
Rebeca Bosse de Jesus
Hospital de Clı́nicas de Porto Alegre, Porto Alegre, Brazil
Background: Retrograde open mesenteric stenting
(ROMS) during laparotomy is a hybrid technique that
Abstracts
combines the advantages of open surgical and endovascu-
lar approaches. ROMS is an alternative to surgical bypass
and applies to either chronic (CMI) or acute(AMI). mes-
enteric ischemia.
Aim: To report the results of retrograde open mesenteric
stenting in a consecutive series of patients with acute mes-
enteric ischemia in a tertiary care hospital in south-
ern Brazil.
Material & Methods: All patients submitted to mesen-
teric revascularization with ROMS for the treatment of
AMI between may 2013 and may 2018 were entered in
this retrospective registry. Technical success, 30-day and
6-month mortality rates, complication rate and patency
were assessed.
Results: Nine patients with acute mesenteric ischemia
were submitted to ROMS (5 women and 4 men; median
age: 66,3 years). We revascularized only the superior mes-
enteric artery. Technical success was achieved in 8 patients
(88,8%). Primary closure of the retrograde puncture was
was done in 6 patients and patch angioplasty was used in
the remaining 3 patients. General 30-day mortality rate
was 55,5% (5/9 patients). Five early deaths occurred.
Conclusion: ROMS is a reliable alternative in the setting
of acute mesenteric ischemia. This procedure is associated
with high technical success rates, but diagnosis and treat-
ment delays are responsible for the high morbidity and
mortality rates of mesenteric ischemia. Therefore, high
suspicion index and prompt diagnosis/treatment are the
most important factors for survival.
SESSION 18: 19152 – GIANT SPLENIC
ARTERY ANEURYSM INFECTED WITH
LISTERIA MONOCYTOGENES
Marcio Luis Lucas, Nilon Erling Junior,
Eduardo Lichtenfels, Rebeca Regert,
Gabriel Azevedo Leal and Newton Roesch Aerts
Hospital Santa Casa de Misericordia – Universidade Federal de
Ciencias da Saude de Porto Alegre, Porto Alegre, Brazil
Background: Splenic aneurysms are considered the
second most common type of intraabdominal aneurysms,
yet it has a very low incidence, especially among males.
Mycotic aneurysms are more frequently located within the
abdominal or thoracic aorta and represent only 1–3% of
aortic aneurysms. Mycotic aneurysms of the splenic artery
are even rarer, and therefore represent a therapeutic chal-
lenge for the vascular surgeon.
Case Description: A 55-year-old male was admitted to
the emergency unit complaining of abdominal pain in the
last week accompanied by fever in the past three days.
Weight loss and malaise was also noted in the preceding
17
year. Initial physical examination revealed a tender pulsatile
abdominal mass on the left flank. No sign of acute blood
loss was perceived. A CT scan, performed in the emer-
gency setting, highlighted a non-ruptured splenic artery
aneurysm measuring 15-centimeter in diameter. The
patient was refferred to open surgery. Access was made
through an expanded left subcostal incision. Intense
inflammatory reaction with thick adhesions to adjacent
structures was observed. Samples of the liquified throm-
bus and of the aneurysm wall were collected for analysis.
Listeria monocytogenes was isolated from those samples
as well as from the peripheral blood samples collected at
hospital admission. Antibiotics were stepped-down to
ampicillin. Sustained elevation of systemic inflammatory
markers was noticed on the postoperative period and a
left flank collection was shown on CT scan. Open drainage
was performed and the diagnosis of pancreatic fistula was
confirmed. The patient had a good recovery and was dis-
charged on the 15th postoperative day on oral ampicillin
for extra 4 weeks. The pancreatic fistula healed after
eight weeks.
Conclusion: Listeria monocytogenes is a ubiquitous bac-
teria transmitted by food. Systemic infection is rare, even
in immunocompromised individuals. The isolation of this
pathogen in the arterial wall of a splenic aneurysm is
remarkably rare. We opted for open repair despite the
current prefference for endovascular repair in these cases.
This approach enabled us to remove the infected throm-
bus, collect tissue samples without leaving any endovascu-
lar device in the infected area.
SESSION 18: 19156 – ENDOVASCULAR
MANAGEMENT OF RUPTURED
SUPERIOR MESENTERIC
ARTERY ANEURYSM
Joaquim Placido de Freitas Alves,
Caroline Vilela Marin,
Nayara Gimenes de Melo Vieira,
Paulo Isão Sassaki Neto and
Nasser Hussein Mahfouz
Centro Universitário Várzea Grande, Cuiabá, Brazil
Background: Superior mesenteric artery aneurysms are
rare, accounting for 5.5 to 8% of cases of all visceral aneu-
rysm. Mean age ranges from 45 to 55 years. Ruptured
aneurysms present as hemorrhagic shock and mesenteric
ischemia. Rupture is associated to high morbidity and mor-
tality rates. Treatment of ruptured superior mesenteric
artery aneurysms require careful planning
The endovascular approach is associated with lower mor-
bidity and mortality rates. Chimney grafts not only restore
18
visceral arteries patency but also prevent arterial collapse
after the release of the endoprosthesis in the aorta.
Case Description: The patient was diagnosed with SMA
aneurysm in 2013. He underwent a left common iliac
artery-SMA bypass and ligation of the aneurysm. The
patient remained asymptomatic until May 2018 when an
abdominal pain started. A ruptured aneurysm proximal to
the previously treated SMA aneurysm was evidenced at an
angioCT. The patient had only the right kidney and a
patent bypass to the SMA artery, We opted for endovas-
cular repair with the use of two aortic stentgrafts associ-
ated with covered stents at the celiac trunk (sandwich
technique) and at the right renal artery (chimney tech-
nique). The patient had a fast recovery with intensive
care unit discharge after 24 hours and hospital discharge
at the third PO day.
Conclusion: Ruptured visceral aneurysm is a life-threat-
ening medical condition. Previous aortic and abdominal
operations, and unavailability of the devices necessary
for the procedure added complexity to the intervention.
SESSION 18: 19183 – CONTAINED
RUPTURE OF A GIANT SPLENIC
ARTERY ANEURYSM: A CASE REPORT
Danilo Heringer Alcure Quarto,
Moriane Barcelos Lorenzoni Zago,
Guilherme Luchine de Almeida,
Wallace Medeiros de Aguiar,
Ricardo de Souza Divino,
Ana Maria Monteiro Chagas,
Francielli Avancini Lopes, Ingrid dos Passos Silva
and Sarah Andrade de Oliveira Botelho
Hospital Maternidade São José, Colatina, Brazil
Background: Ruptured giant splenic artery aneurysm is a
rare finding. Early diagnosis and treatment are fundamen-
tal, as it represents an imminent risk for the patient’s life.
Splenic artery aneurysms correspond to 60% of all visceral
aneurysms. Size is usually around two centimeters in diam-
eter and most of them are found incidentally. Risk factors
include arterial hypertension, portal hypertension, trauma,
atherosclerosis, female gender, multiparity, alpha-1 anti-
trypsin deficiency and abdominal inflammatory processes.
We will report a case of ruptured giant aneurysm of the
splenic artery with 13.5 cm in diameter, emphasizing the
technique and the surgical tactics employed.
Case Description: A 76-year-old hypertensive female
who smoked for 30 years, sought medical attention in
the emergency room of our Institution.for precordial
pain. Cardiac causes were ruled out. Abdominal ultraso-
nography and computed tomography of the abdomen and
Vascular 27(1S)
pelvis highlighted a splenic artery aneurysm, measuring
about 13.5  10.5  10.2 cm. Additional findings included
left perirenal fluid that could correspond to a hematoma.
She was submitted to conventional surgical treatment with
a Chevron incision and retroperitoneal access by the mes-
ogastrium. We proceeded with repair and ligation of the
proximal splenic artery, partial aneurysmectomy and
removal of large thrombus from the inside. No retrograde
bleeding was observed. There were no cleavage planes for
attempting whole aneurysm excision. No signs of ischemia
and/or splenic infarction. Procedure was uneventful.
Conclusion: Despite the great development of endovas-
cular techniques, conventional open surgery remains the
gold standard for splenic artery aneurysms, particularly for
the giant ones. Postoperative complications are uncom-
mon and have not been observed in this case. The patient
was put in a close follow-up with CT or USG-Doppler.
SESSION 19
TL 05 – PERIPHERAL ARTERY
OCCLUSIVE DISEASE I
BONETE 16:50 – 18:20
SESSION 19: 19012 – CRITICAL LIMB
ISCHEMIA: TREATMENT OF THE
INTERNAL ILIAC ARTERY
Pablo Alejandro Marina, Marcelo Pettinari,
Thomas Jorge and Roberto Diaz
Sanatorio Modelo Burzaco, Argentina
Background: Percutaneous transluminal angioplasty
(PTA) is an established and effective method for the treat-
ment of critical limb ischemia. Reported technical success
for iliac occlusions range from 75 to 100% with patency
rates of 76–78% at 2-year follow-up. Vascular stents were
initially developed for managing cases with poor initial
results after PTA. Nowadays, indications have extended
to the treatment of more complex lesions, such as vascu-
lar occlusions and sub-occlusions. The technique for per-
cutaneous recanalization of iliac arterial occlusions, using
an angiographic guide followed by primary stenting, has
been described as an effective and safe therapeutic
method. Treating pain associated to critical ischemia is a
major goal.
Case description: A 65-year-old, diabetic, smoker male
was admitted for pain in the left lower extremity unre-
sponsive to vasodilators (Fontaine III, Rutherford 4). An
occlusion of left external iliac artery, a with collateral refill
at the level of the common femoral artery and severe
stenosis of the left internal iliac artery was seen at the
Abstracts
angiography performed in the emergency setting. We
opted for endovascular treatment of the left internal
iliac artery with a coronary drug eluting stent to improve
collateral circulation to the left lower extremity. A cross
over technique from the right femoral artery to left
commom iliac artery with a hydrophilic guidewire ending
at the left internal iliac. An 8fr guide-catheter was placed in
the internal iliac artery. A paclitaxel 4  13 mm drug-elut-
ing stent was deployed at the ostium of internal iliac
artery. The procedure was uneventful. The patient was
discharged after 24 hs observation with complete symp-
tom resolution.
Conclusion: Internal iliac artery revascularization for CLI
is successful only when this artery plays an important
role in the collateral circulation of the affected
lower extremity.
SESSION 19: 19017 – PHOTOGRAPHIC
CHARACTERIZATION IMAGING OF
LEG ULCERS BEFORE AND AFTER
HYPERBARIC OXYGEN TREATMENT:
LESSONS LEARNED WITH THE FIRST
10 CASES
Cristiane Antequeira Maran and
Sergio Xavier Salles Cunha
Centro de Medicina Hiperbárica do Nordeste (CMHN),
Salvador, Brazil
Background: Hyperbaric oxygen treatment (HbOT) can
improve healing of leg ulcers. HbOT effectiveness is yet to
be determined. Characterization of tissue by ultrasonog-
raphy (CATUS) is a technique used to quantitate image
brightness. It was adapted to photographic imaging of leg
ulcers (p-CATIM) in this study.
Aim: To describe the lessons learned during the first 10
cases of photographic characterization imaging of leg
ulcers before and after hyperbaric oxygen treatment.
Material & Methods: Ten diabetic patients submitted
to10-40 HbOT sessions at the Centro de Medicina
Hiperbárica do Nordeste (Vascular Surgery Division,
Hospital Geral Roberto Santos) had their leg ulcers docu-
mented by P-CATIM before and after treatment. The
color photos were transformed into gray scale with 256
brightness levels. A “black” and “white” bar sticker placed
by the ulcer was used to rescale the brightness to diminish
variability.
Results: A) reduction in open ulcer area was documented
by pixel ratio between the ulcer and the “black” square
(1 cm2 reference). B) Open ulcer brightness histograms
were wide, showing peaks associated to “necrosis” or
“granulation”. “Necrosis” had low 0–40 brightness and
19
its pixel percentages decreased with HbOT.
“Granulation” brightness varied from 40 to 150, depend-
ing on skin type. C) Skin brightness surrounding open
ulcer differed but tended to “normal” skin with HbOT.
D) “Normal” skin brightness varied individually. HbOT
decreased brightness variability and increased percentage
of pixels tending to “normal” skin. E). Technical consider-
ations: illumination, the camera-ulcer distance and angula-
tion, leg circumference effects, i.e. cylindrical leg exposed
to straight light rays, are factors that need to be optimized
and controlled during p-CATIM investigations.
Conclusion: P-CATIM quantitated leg ulcer conditions by
a) area based on number of pixels, and b) distinct tissue
brightness. Regions evaluated included a) open ulcer, b)
surrounding region, and c) “normal” skin. Brightness
levels were easily associated to “necrosis”, a low bright-
ness condition that decreased with HbOT. “Normal” skin
brightness and, more so,”granulation” may require individ-
ual definition by an expert analyzing each photo. P-CATIM
is a promising technique to quantitate HbOTeffectiveness
and timing for leg ulcer healing.
SESSION 19: 19049 – TWO-YEAR
FOLLOW-UP WITH THE DOUBLE
LAYER TECHNIQUE USING A
VIABAHN (GORE) INSIDE THE SUPERA
INTERWOVEN STENT (ABBOTT) FOR
POPLITEAL ANEURYSM REPAIR IN A
PATIENT WITH CRITICAL
LIMB ISCHEMIA
Stefany Gimenes Baptista Coutinho1,
Kyrie Eleison Proença2 and
Alexandre Inacio Moreira Coutinho1
1
Marinha do Brazil, Manaus, Brazil
2
Universidade Nilton Lins, Manaus, Brazil
Background: Acute lower limb ischemia (ALLI) with
popliteal artery aneurysm (PAA) is a challenging surgical
problem. Angiography is mandatory to study the anatomy
of the inflow and outflow vessels. Many surgical strategies
heve been proposed. Some authors recommend preoper-
ative thrombolysis, for better results with improved
runoff. Options for this treatment comprise open surgical
thromboembolectomy, catheter-directed thrombectomy
(various modalities are available including rheolytic phar-
macomechanical thrombectomy, catheter-directed throm-
bolysis and suction thrombectomy) with or without
adjunctive angioplasty and/or stenting, and bypass surgery.
Case Description: A 70-year-old male with critical left
limb ischemia manifested by pain at rest, paresthesia and
sudden onset pallor (12 hours later) was seen at our
20
Vascular Clinic. Past medical history included intermitent
claudication (200 meters), arterial hypertension and pre-
vious smoking. Absence of popliteal and distal left lower
limb pulses were observed at the admissional medical
exam. A thrombosed left popliteal artery aneurysm mea-
suring 3.5 cm in greater diameter without distal runoff was
diagnosed at the Duplex ultrasound scan. Treatment strat-
egy: 1- The diagnostic angiography highlighted an acute
occlusion of the superficial femoral, popliteal, anterior
tibial, tibio-fibular trunk, posterior tibial and fibular arter-
ies with no inflow and outflow. 2-Thrombolysis with
recombinant tissue plasminogen activator (rt-PA) 5 mg
bolus and 0.05 mg/kg/h in dripping through a multiperfo-
rated microcatheter for 12 hours. 3- Evaluate runoff and
define the endovascular repair technique, after the control
angiography demonstrating restoration of flow to the left
lower extremity with preserved posterior tibial and pero-
neal runoff. 4- Identify intraluminal filling of the posterior
tibial and peroneal arteries. A tibio-fibular trunk occlusion
by atheromatosis was also identified. We undertook endo-
vascular repair with antegrade 6F access, multiple angio-
plasty of the tibio-fibular trunk and posterior tibial artery
and peroneal artery with good pre-dilation of these ves-
sels with 4/150 mm balloon, followed by the implant of the
Supera stent 4/100 mm above tibio-fibular trunk at the
popliteal artery, Relining with Supera Interwoven Nitinol
stent 5.5/150 mm and exclusion of the aneurysm with
implant Viabahn covered stent inside Supera stent with
excellent technical results.
Conclusion: Double layer technique with a Viabahn
inside a Supera stent is feasible in calcified lesions of the
popliteal artery at levels P2 and P3 with associated popli-
teal aneurysm. A 2-year patency with no signs of fracture
and good accommodation to an area of greater tortuosity
enabled the patient to recover his normal daily activities
and restore quality of life.
Vascular 27(1S)
SESSION 19: 19059 – HYBRID REPAIR
OF A DACRON GRAFT OCCLUSION
Henrique Jorge Guedes Neto, Ana Alyra Carvalho,
Wellington Gianotti Lustre,
Beatriz Périco Silveira,
Giulianna Barreira Marcondes,
Douglas Sterzza Dias,
Ronald Luiz Gomes Flumignan,
Luis Carlos Uta Nakano,
Luis Gustavo Schaefer Guedes and
Jorge Eduardo de Amorim
UNIFESP, São Paulo, Brazil
Background: Dacron grafts are widely used, specialy for
large vessels repair. A few papers reporting changes in
Dacron grafts characteristics in humans, in the long-term
have been published to date. Graft dilatation is the most
common change in the short- term. Aneurysms, occlu-
sions or kirking, have been reported in association to
this grafts. These complications can be secondary to
mechanical traumas or blood pressure variations and can
put patients life in risk. Hybrid techniques to repair graft
complications are less traumatic and therefore provide
better recovery rates. Patients with high surgical risk can
also benefit from hybrid procedures.
Case Description: A 65-year-old male with many
comorbidities (diabetes, smoker, hipercolestherolemia
and hypertension) was admitted to our Institution with
severe pain, infection and gangrene in right 4th feet toe.
Past medical hystory included a trauma in his right foot 3
months ago, an Aorto bifemoral graft 15 years ago and a
femoropoliteal bypass 8 years ago. Two years later he
begun to complain a progressive pain in his right leg.
Obstruction of right side of the aortobifemoral and fem-
oropopliteal bypass was diagnosed by the Doppler USG.
This diagnosis was confirmed by the angiotomography. We
decide to perform a non anatomic bypass (axilo deep fem-
oral artery bypass) and a limb revascularization. We made
a puncture in the prosthesis (6 mm PTFE) and inserted a
short introducer. The guide wire was advanced until the
first portion of the popliteal artery. Another guide wire
was advanced proximaly through the anterior tibial artery,
located under ultrasonography guidanc. Angioplasty was
performed with a drug coated ballon and two stents
were implanted to revascularize of the right thigh and
the leg. The patient is at the 4-follow-up month and persist
asymptomatic.
Conclusion: The hybrid approach is specially useful in
selected patients with high surgical risk and may be an
alternative for rescuing members in the acute setting.
Nevertheless there are growing reports in literature that
corroborate these impression, it is not supported by hgh-
quality scientific trials.
Abstracts
SESSION 19: 19155 – HIP
DISARTICULATION AS THE END
STAGE TREATMENT FOR PERIPHERAL
ARTERIAL DISEASE
Joao Pedro Lins Mendes de Carvalho,
Grace Carvajal Mulatti, Nelson de Luccia and
Pedro Puech-Leão
Hospital das Clı́nicas, HCFMUSP, São Paulo, Brazil
Background: Hip disarticulation is more frequently
reported in trauma or oncologic surgery. Performing hip
disarticulation to treat peripheral arterial disease is an
exception rather than the rule. Easier procedures should
be carried out first (ex: transtibial or transfemoral
amputations).
Case Description: A 47-year-old, diabetic and smoker
female with claudication of the lower extremities, (worse
in the left leg) came to our Vascular Clinic seeking a
second opinion. Her past medical history included various
failed revascularization interventions. A CT scan per-
formed In 2013 demonstrated an occlusion of the left
superficial femoral artery. At this point, she was submitted
to an angioplasty and stenting. The pain recurred one year
afterwards and a stent restenosis was diagnosed at the
new CT scan. A second angioplasty and stenting was car-
ried out this time. The patency of this revascularization
procedure lasted for only a few months and she was sub-
mitted to a femoral-popliteal bypass with synthetic graft
(dacron). She persisted asymptomatic for aproximately 3
years, but continued smoking 20 cigarettes/day.
She returned complaining of severe pain and was treated
with analgesic drugs, including opioids. She developped
opioid dependency. CTscan demonstrated the graft occlu-
sion and she underwent an iliac-femoral bypass with syn-
thetic graft (PTFE). Later on, this graft occluded too and a
transfemoral amputation was undertaken to treat her
refractory pain. She developped ischemia, infection and
wound dehiscence just a few days after sugery. The assist-
ing vascular surgeon put her in palliative care. She then
decided to seek a tertiary care hospital and was admitted
through the emergency unit of our Institution. The CT
scan highlighted complete occlusion of ther external
iliac, common femoral and profunda femoral arteries as
well as of the two grafts and the stents. The only possible
treatment at this point was hip disarticulation. This pro-
cedure was carried on after her consent and she was dis-
charged from hospital two weeks afterwards with a signif-
icant pain reduction and reduced need for analgesic drugs.
Conclusion: Only severe unsuccessful complex cases of
occlusive peripheral artery disease are refferred to hip
disarticulation, specialy when occlusion of the profunda
femoral artery is diagnosed.
21
SESSION 19: 19212 – ENDOVASCULAR
TREATMENT OF IN-STENT
RESTENOSIS IN MULTIPLE
ARTERIAL SEGMENTS
Roger André Molina Claros, Armando C. Lobato,
Camila Kolber Del Priore, Fausto Miranda Junior,
Douglas Leopoldino de Amorim,
Fernanda Federico Rezende,
Fernanda Telles Sales, Matheus Trigo Carim,
Gusthavo Tomasi Perin,
Pamela Rodrigues de Souza,
Clisse Michelle de Sá Rodrigues and
Diego Nicacio de Brito
Instituto de Cirurgia Vascular e Endovascular de São Paulo
(ICVE-SP), São Paulo, Brazil
Background: The optimal catheter-directed therapy for
femoropopliteal in-stent restenosis (ISR) remains contro-
versial. The natural history of untreated ISR is not well
established. We currently report the midterm outcomes
of a patient with asymptomatic isolated femoropopliteal
ISR who were put under strict follow-up.
Case Description: A 65-year-old smoker male with cor-
onary disease, hypertension, obesity and hystory of previ-
ous occlusive peripheral artery disease, sought medical
assistance at our Institution for pain, pallor, decreased
temperature and absence of femoral pulse in the left
lower extremity. His complaints lasted for a week at the
time of consultation. The doppler ultrasonography
revealed occlusive in-stent lesions in the left iliac femoral
segment. We antecipated technical difficulties, specially in
regards to the patient’s clinical condition. An iliac femoral
endovascular revascularization through bilateral femoral
access was planned. Operative arteriography revealed
multiple in-stent restenosis: 1. at the proximal portion of
the stent placed in the left common iliac artery, 2. a long
in-stent restenosis in the left femoral artery and 3. in the
left popliteal artery at knee level. We opted for perform-
ing a two-step intervention. The first step was performed
on the left common iliac artery, leaving the left femoropo-
pliteal segment for the second step. The first step was
accomplished using the kissing balloon technique with
8  40 balloons. An 8  50 covered stent was implanted
after the balloon dilation. The covered stent was selected
on account of the severe calcification found at the prox-
imal portion of the left common iliac artery as this finding
impairs the effectiveness of drug eluting balloons. At the
second step, we used a drug eluting balloon for the treat-
ment of the long in-stent restenosis in the femoropopliteal
segment. Control angiography confirmed patency of both
segments treated.
Conclusion: This case report illustrates the use of drug
coated balloon in the common iliac and femoral arteries.
22
SFA ISR can be safely treated by percutaneous translumi-
nal angioplasty with a DCB with reduction in recurrent
restenosis and target lesion revascularization (TLR) at
least at 1 year after POBA.
SESSION 33
TL 06 – EMBOLIZATION
KIRRA 11:10 AM – 12:15
SESSION 33: 19067 – BRONCHIAL
ARTERIES EMBOLIZATION FOR
HEMOPTYSIS: A SERIES OF 40 CASES
Ronald Luiz Gomes Flumignan,
Luis Carlos Uta Nakano,
Antonio Carlos Moura da Silva,
Douglas Sterzza Dias, Libnah Leal Areias,
Giulianna Barreira Marcondes,
Ana Victoria Pontes de Azevedo,
Carolina Dutra Queiroz Flumignan,
Gabriela Araujo Attie, Jorge Eduardo de Amorim,
Marcus Vinicius Canteras Raposo da Camara and
Henrique Jorge Guedes Neto
UNIFESP, São Paulo, Brazil
Background: Hemoptysis is a severe clinical condition
associated, in developing countries, to primary or second-
ary lung neoplasias and tuberculosis. Treatment choices
include Invasive treatments such as thoracotomy or pneu-
mectomy or bronchial artery embolization. Embolization
is a minimaly invasive procedure that is safer, less mutilat-
ing that provides effective bleeding control.
Aim: To present our casuistry and the immediate out-
comes of bronchial arteries embolization for hemopty-
sis control.
Material & Methods: A total of 40 patients with persis-
tent hemoptysis and hemodynamic instability were sub-
mitted to diagnostic arteriography at our Institution. All
procedures were performed under local anesthesia using a
2% lidocaine solution. Geofoam and microspheres were
the selected embolizing agents, and their use was at the
assisting physician discretion. The embolization procedure
was aborted whenever catheterization of the bronchial
arteries (or adequate branches) was not possible.
Results: 40 patients (30 males, 10 females, mean age:
50,37 years, age range: 21 to 74 years) were included in
the present study. Pulmonar tuberculosis and primary lung
tumors were the cause of hemoptysis in 60% and 12%,
respectively. The right lung was the source of hemoptysis
in 29 (72%) patients and the left lung in 11 (27%) cases.
Catheterism of the right bronchial arteries was possible in
Vascular 27(1S)
25/29 cases (86% success rate). Catheterism of the left
bronchial artery was possible in a 100% of the cases.
Embolization was performed in 21/25 (84%) of cases in
the right side and in 7/11 (64%) of the left side. Clinical
improvement and hemoptysis cessation was observed in
100% of the treated patients
Conclusion: The present casuistry highlights the male
predominance and tuberculosis as the main cause of
hemoptysis in our country. It also points out, that when-
ever possible, bronchial artery embolization is associated
to clinical improvement and hemoptysis cessation.
SESSION 33: 19126 – ENDOVASCULAR
EMBOLIZATION FOR HIGH-
FLOW PRIAPISM
Thamirys Guimarães Marques,
Mauricio Rocco de Oliveira,
Gustavo Bomfim dos Santos, Andre Meirelles,
Gabriel Viarengo, Adriano Angelo Cintra,
Fernanda Gohr Pinheiro Cintra and
Guilherme Vieira Meirelles
IMV-Instituto Meirelles de Cirurgia Vascular, Campinas, Brazil
Background: Priapism is a low Incidence (1.5/100 000)
prolonged involuntary erection of the penis. Laceration of
cavernosal artery or one of its branches is associated to
arteriocarvernous fistula and painless erection of the cav-
ernous bodies and of the corpus spongiosum. A few treat-
ment options have been proposed for high-flow priapism:
watchful waiting, Doppler-guided compression, endovas-
cular highly selective embolization, and surgery.
Conservative management comprises exercise (“steal syn-
drome”), warm/cold compresses, oral hydration, and ejac-
ulation with various success rates. The efficacy of these
methods lack evidence and should not delay timely med-
ical attention. If conservative management is not success-
ful, selective embolization of the cavernosal artery can be
attempted. Several embolizing agents can be used for
selective arterial embolization, including autologous
blood clot, gelatin sponge, micro-coils, polyvinyl alcohol,
and glue. Any of these embolizing agents can lead to a 75%
resolution rate.
Aim: To report our experience with endovascular man-
agement of high-flow priapism.
Material & Methods: We present two cases of high-
flow priapism after trauma and one after cocaine abuse
(3 days use) submitted to embolization with gelfoam in
our service.
Results: The patients were initialy assisted by the urolo-
gist (corporal aspiration and irrigation) without success.
Only refractory cases were referred to the vascular
Abstracts
surgeon, usualy 3 to 5 days after the event. Endovascular
embolization with gelfoam was performed with success in
all 3 cases.
Conclusion: We presented 3 cases of high-flow priapism
treated by embolization at our service. All patients were
previously submitted to unsuccessful clinical and invasive
procedures at the urology clinic. Endovascular emboliza-
tion with gelfoam is a safe, easy to perform and highly
successful method to address these cases.
SESSION 33: 19166 – TREATMENT OF A
COMPLEX POST-EVAR ENDOLEAK:
CASE REPORT
Júlio César Souza Diniz, Marco Bianco Santarosa,
Luiz Eduardo Almeida Silva,
João Victor Loureiro de Oliveira,
Carlos Diego Ribeiro Centellas,
André Luiz de Oliveira,
Milton Sérgio Bohatch Junior,
Mauricio Serra Ribeiro and
Edwaldo Edner Joviliano
Hospital das Clı́nicas de Ribeirão Preto – USP, Ribeirão Preto,
Brazil
Background: Endovascular Aneurysm Repair (EVAR)
repair is constantly evolving and is currently the preferred
treatment for most AAA cases on account of it’s more
favorable periprocedural outcomes (reduced mortality
and complications, and decreased in-hospital lenght of
stay) in comparison to Open Surgical Repair. Endoleaks
are a common complication, occurring in aproximately
20 to 25% of patients after EVAR. The type II endoleak
is the most frequent one. It usually originates from collat-
eral vessels such as the lumbar or Inferior Mesenteric
arteries and has a benign course. the Type II endoleak
may cause sac pressurization and aneurysm growth,
which ultimately leads to aortic rupture. Thefore surveil-
lance and treatment are advisable. Treatment may vary
from a simple endovascular embolization of a collateral
vessel to a combination of many different and complex
approaches. Other types of endoleak comprise type I (a
or b – proximal or distal inadequate stent seal) and type III
(a or b – leak from junctions or modular disconnections,
and leak from fabric holes). Reintervention is recom-
mended whenever these endoleaks are detected. We cur-
rently report a complex case of refractory endoleak
Case Description: JCS is a 71-year-old male submitted
to EVAR(Gore Excluder) in 2012 for a 5.7 cm AAA. A
second procedure was undertaken in 2014 to correct a
type Ia endoleak and a 2.5 cm right common iliac artery
aneurysm (the AAA was 6.0 cm at the time being), A
23
proximal cuff (Braile) and a right iliac limb extension
(Excluder) were implanted at this time. The aneurysm
grew to 6.6 cm in 2015 due to a type II endoleak originat-
ing from the lumbar arteries and the IMA (inferior mes-
enteric artery). The patient underwent two more inter-
ventions: embolization of the left internal iliac branch with
Onyx (2015) and of the IMA with Onyx/coil (2017). A
progressive aneurysm enlargement up to 7.4 cm was diag-
nosed in 2019 and caused by persistent type II endoleak
from the lumbar arteries. Direct aneurysm sac catheteri-
zation and embolization (Onyx/coils) via a translumbar
aortic puncture was carried out. A significant endoleak
reduction was observed in the control imaging tests.
Conclusion: Endoleaks remain a concern and a cause for
post EVAR reintervention. This can be burdensome to the
patients and costly to the Health System. Translumbar
aortic puncture remains a treatment option when other
embolic pathways fail or are not feasible.
SESSION 33: 19167 – EMBOLIZATION
OF A RENAL ARTERY
PSEUDOANEURISM: CASE REPORT
Otacilio de Camargo Junior,
Gabriella Pazzanese Barreira,
Vitor Moron de Andrade,
Ana Letı́cia Luchiari Ferrari,
Northom Augusto de Jesus Perreti,
Luciana Helena Benatti, Vitor Dincão Sanches,
Guilherme Camargo Gonçalves de Abreu,
Marcia Fayad Marcondes de Abreu,
Giulia de Paula Vendramini Ferreira and
Cassia Yumi Yamamoto Takano
PUC-Campinas, Campinas, Brazil
Background: Minimally invasive methods, such as endo-
vascular interventions have become more, effective and
easy to perform. Embolotherapy for the treatment of
tumors and hemorrhage is an example. The diagnosis
and location of the injury is usually achieved by non-inva-
sive imaging methods. Renal angiography should be carried
out only when injury location was not possible or when-
ever embolization is antecipated. Refractory hemorrhage
as well as other complications can be addressed by
embolotherapy.
Case Description: A 50-year-old male with acute renal
failure of undetermined cause was reffered to our hospital
from a neighbouring city hospital. Previous medical hys-
tory included bariatric surgery, hypertension and diabetes
mellitus. The nephrology team scheduled a renal biopsy
after the patients serum glucose level and blood pressure
were under control. After the procedure, the patient
24
complained of lower back pain and was submitted to a CT.
A 2 cm peri-renal hematoma with active bleeding was diag-
nosed at the left side where the renal biopsy was per-
formed. Arteriography of the left renal artery was under-
taken and bleeding from a branch located in the lower
pole was evidenced. Catheterization and embolization
with 1.5  2, 2  4, 3  4, 3  6 micromoles was per-
formed. Control angiography revealed a late blush.
Postoperative follow-up was uneventful. The patient was
discharged on the third PO without complaints.
Conclusion: Embolization has proved to be an excellent
treatment for refractory hemorrhage particularly in diffi-
cult access sites. Open surgery may not be feasible or
associated to complications in this cases.
SESSION 34
TL 07 – DISEASE OF THE SUPRA-
AORTIC TRUNKS 1
KIRRA ROOM 14:30 – 15:36
SESSION 34: 19053 – INFECTION AFTER
CAROTID ENDARTERECOMY
Henrique Jorge Guedes Neto,
Rafael Bernardes de Avila,
Rebeca Mangabeira Correia,
Antonio Carlos Moura da Silva, Ettore Cavalieri,
Vladimir Tonello de Vasconcelos,
Jorge Eduardo de Amorim,
Ronald Luiz Gomes Flumignan,
Luis Gustavo Schaefer Guedes and
Luis Carlos Uta Nakano
UNIFESP, São Paulo, Brazil
Background: Infection after any type of vascular surgery
is associated to significant morbidity and mortality. It can
often lead to failure of the vascular reconstruction, reop-
eration and prolonged hospital stay. Infectious complica-
tions of carotid surgery can be disastrous. A 12-year sys-
tematic review on infection after carotid endarterectomy
with Dacron revealed an overall incidence rate of 0.25% to
0.50%. The most common presentation include swelling in
the cervical region and pseudoaneurysm formation.
Diagnosis can extend up to 3 years after the operation.
Case Description: A 67-year-old caucasian male with
hypertension, hypercholesterolemia and smoking sought
medical assistance at our Institution within two hours of
a transient ischemic attack (TIA). Previous medical hystory
included leukemia 20 years ago, currently in remission. A
complex plaque causing more than 70% stenosis of the left
internal carotid artery as well as a less than 50% stenosis
Vascular 27(1S)
of the right internal carotid artery was diagnosed at the
US Doppler scan. Theses findings were confirmed by
angiotomography. An endarterectomy of the left internal
carotid artery without intra-arterial shunt using bovine
pericardium patch was undertaken. Control US Doppler
scan performed 3 months afterwards revealed progression
of the right internal carotid artery stenosis (70%). the US
doppler scan findings of an unstable plaque with 70% ste-
nosis was confirmed by angio CT. Surgery was carried out
with good immediate results. Twenty one days later the
patient started complaining of pain and a lump at the left
side of the neck. Angiotomography revealed a pseudoa-
neurism of the left internal carotid artery. We opted for a
SUPRA AORTIC TRUNKS I implant inside the common
and the internal carotid arteries followed by coil emboli-
zation of the left external carotid artery. The neck abcess
was drained three days later. Propionibacterium acnes
grew in the abcess culture but not in the blood cultures.
We interpreted this as a biofilm infection with a sessil
bacteria. The patient is assymptomatic and will use long-
term antibiotics for at least an year.
Conclusion: Infectious complications of carotid surgery
can be of delayed onset. Physicians must be aware and
prompt treatment should be undertaken to avoid disas-
trous outcomes.
SESSION 34: 19091 – CAROTID ARTERY
ANEURYSM – CASE REPORT AND
LITERATURE REVIEW
Flávia Moreira, Victor Bilman, Alberto Vescovi,
Bernardo Massière, Daniel Leal, Paula Vivas,
Bruno Demier, Lucas Hashimoto and
Arno Von Ristow
CENTERVASC/PUC-RIO, Rio de Janeiro, Brazil
Background: Extracranial carotid artery aneurysm
(AACE) is rare but associated to high morbidity and mor-
tality. Early diagnosis and timely treatment are therefore
mandatory to avoid undesired outcomes. This case report
aims at discussing a case of symptomatic distal internal
carotid aneurysm.
Case Description: A 72-year-old hypertensive and dys-
lipidemic male, was admitted to the emergency depart-
ment complaining of non-disabling left hemiparesis in the
last 12 hours. He also reported a similar episode, in the
previous week. At admission, only a slight weakness was
perceived in the left side. A non-obstructive kinking and
ectasia of the medial-proximal third associated to vascular
tortuosity of the right internal carotid artery was diag-
nosed at the carotid and vertebral arteries duplex scan.
An aneurysmal dilatation of aproximately 18 mm in
Abstracts
diameter was reported in the right internal carotid artery,
extending for 31 mm to the carotid foramen, with a sig-
nificant thrombosed area inside at the angio CT scan. A
diffusion MRI highlighted small areas of infarction in the
right hemisphere, confirming the hypothesis of microem-
bolization. Unfractionated heparin was administered in a
continuous infusion pump. Double antiaggregation was
also provided prior to the endovascular treatment. A
large floating thrombus inside the aneurysmal sac was
diagnosed in the arteriography performed on the fourth
hospitalization day. We opted for endovascular aneurysm
repair with implant two flow modulating stents
(4.75  35 mm; 5.00  35 mm, Pipeline) to guarantee lam-
inar flow. No cerebral protection devices were used and
no distal embolizations were observed. The patient
remained hemodynamically stable, without any neurologi-
cal deficit. The patient was discharged on the third post-
operative day and is currently asymptomatic and pursuing
a follow-up protocol at our Institution outpatient clinic.
The 1-month-control angiotomography revealed regres-
sion of the aneurysm and stent patency.
Conclusion: Nevertheless open repair is considered the
preferred approach in these cases, limitations of this
approach require alternative treatment. Endovascular
therapy has been increasingly employed in selected cases
with low complication rates and encouraging outcomes.
SESSION 34: 19113 – TRANSCAROTID
ARTERY REVASCULARIZATION
(TCAR) FOR SYMPTOMATIC SEVERE
CAROTID STENOSIS COMBINED WITH
AORTIC ARCH ANATOMIC
VARIATION: CASE REPORT
Marcelo Sembenelli, Rodrigo Gibin Jaldin,
Marcone Lima Sobreira,
Rafael Elias Farres Pimenta,
Regina Moura Ceranto, Matheus Bertanha,
Jamil Victor de Oliveira Mariúba,
Mariana Tais Silva Secondo and
Winston Bonetti Yoshida
Universidade Estadual Paulista UNESP, Botucatu, Brazil
Background: Transcarotid access was described as a
technical alternative to avoid manipulation of endovascular
devices in the aortic arch. As a consequence, it can help
prevent distal embolization of debris and avoid complica-
tions related to the transfemoral approach. We currently
report the use of direct transcarotid access for angioplasty
in a patient with high surgical risk for endarterectomy and
an anatomical variation of the aortic arch that limits the
use of transfemoral access.
25
Case Description: An 83-year-old male with hyperten-
sion, hypothyroidism and impaired functional status was
admitted at our Institution, complaining of paresis of the
lower right limb extending to the superior right limb over
the past two days. The CT scan diagnosed an ischemic
area in left median cerebral artery territory. The
angioCT demonstrated a left internal carotid occlusion
at the bifurcation and major stenosis of right internal
carotid artery. A stop in transition M1-M2 of left
Meedial cerebral artery (MCA). A hypoplastic left verte-
bral artery as well as both common carotid arteries
emerging directly from the ascending aorta were also
reported. Transcarotid approach was undertaken with
exposure of the anterior wall of the right common carotid
arery for puncture under direct visualization. A 6Fr bride
tip sheath was used and the right carotid lesion was trans-
posed with a 0.014 “Stabilizer XS guidewire. Cerebral pro-
tection was provided by a Spider FX 5  190 filter located
in the petrous segment. Angioplasty and stenting (Protegé
EV3, 6  40  135), extending from the bulb to the inter-
nal the carotid artery was carried out. Balloon accommo-
dation (6  20  145 Simpass endo14) to follow. Control
arteriography demonstrated absence of residual stenosis,
areas of dissection and/or distal embolization. The paten
was discharged in the 2nd PO.
Conclusion: Multicentric analysis reports comparable
results for brain injury as well as early and late mortality
rates for both transcarotid artery revascularization and
carotid endarterectomy. Technical advantages are also
reported for this approach in comparison to femoral
artery access. We report the use of transcarotid tech-
nique with dissection of the anterior wall only as a feasible
and safe method to perform CAS in patients with a hostile
aortic arch.
SESSION 34: 19130 – CAROTID ARTERY
STENTING: 5-YEAR SINGLE
CENTER EXPERIENCE
Mauricio Rocco de Oliveira, Matheus Trigo Carim,
José Tadeu Melo, Gustavo Santos,
Gabriel Viarengo, Thamirys Guimarães Marques
and Guilherme Vieira Meirelles
IMV -Instituto Meirelles de Cirurgia Vascular, Campinas, Brazil
Background: Carotid artery stenting (CAS) is considered
an acceptable alternative to carotid endarterectomy (CEA),
particularly in high-risk patients. Half a decade have passed
since the publication of the Carotid Revascularization
Endarterectomy vs Stenting Trial (CREST) paper but the
incidence of periprocedural stroke in the course of CAS
with embolic protection devices (EPDs) remains largely
26
unchanged, in particular in high-risk groups including
patients with symptomatic carotid stenosis and septuage-
narians. The CREST study showed no significant differences
between stent and endarterectomy in terms of the risk of
stroke or death over its 10-year follow-up.
Aim: Evaluate the peroperatory morbidity of carotid
stenting in our service.
Material & Methods: This is a single center non-ran-
domized retrospective study of 137 patients submitted to
CAS with EPD flow cessation – MO.MA Proximal
Cerebral Protection Device (Medtronic, Santa Rosa, CA)
and filter-protected Emboshield (Abbott Vascular)
between January 2014 and February 2019. Eligible patients
presented symptomatic internal carotid artery (ICA) ste-
nosis greater than 60% and asymptomatic ICA stenosis
greater than 70% as measured by angiotomography
according to the NASCET criterium. A symptomatic ste-
nosis was defined as an ipsilateral stroke, transient ische-
mic attack or amaurosis fugax occurring within 6 months
of the index procedure. Durability and patency were
assessed by Doppler ultrasound.
Results: The primary composite end point (any ipsilateral
stroke, transient ischemic attack or amaurosis fugax at the
periprocedural period) occurred in 5 cases (3,64%): 2
cases of stroke (without major sequelae) using filter and
2 cases of transient ischemic attack and 1 case of amau-
rosis fugax using MOMA. Mean age was 71,7 years, 58%
and 42% were previously symptomatic or asymptomatic
respectively. The MO.MA Proximal Cerebral Protection
Device was used in 43,8% of the cases and the filter-pro-
tected Emboshield in 56,2%. The use of an EPD was pro-
tective against major complications.
Conclusion: The present series of CAS procedures per-
formed in our Service, using embolic protection devices
(EPDs) demonstrated a very low incidence of adverse
events at 30 days. The follow-up results of our study val-
idate CAS as a safe and durable procedure to prevent
ipsilateral stroke, with an acceptable rate of restenosis,
recurrence and mortality.
SESSION 34: 19138 – ENDOVASCULAR
MANAGEMENT OF A MYCOTIC
ANEURYSM OF THE INNOMINATE
ARTERY: A CASE REPORT
Priscilla Matos, Andre Estenssoro,
Lais da Cunha Gamba and Marina Farjallat
Hospital Sı́rio Libanês, São Paulo, Brazil
Background: Innominate artery aneurysms represent 3%
of all supra-aortic aneurysms. Only 1% is of mycotic etiology.
Distal embolization with upper limb ischemia, thrombosi or
Vascular 27(1S)
compression of mediastinal structures are the major pre-
sentations. Rupture is the worse scenario and can occur in
almost 11% of the cases. Despite refinement of the endo-
vascular technique, most cases are still treated by conven-
tional surgery (sternotomy, aneurysm resection and inter-
position grafting). We present a case of innominate artery
aneurysm encompassing the origin of the right common
carotid artery, combined with a descending aortic aneurysm
submitted to endovascular repair in the same procedure.
Case Description: A 69-year-old male was admitted to
the emergency room of the Hospital Sirio Libanês with
fever, abdominal pain in the left iliac fossa and loss of
8 kilos in the last month. Past medical history included
hypertension and a past smoking habit. The CT-scan diag-
nosed an innominate artery aneurysm combined with a
descending aortic aneurysm. The innominate artery aneu-
rysm included the origin of the left common carotid artery.
There was no dilation of the abdominal aorta. We opted for
endovascular repair, with implant of an iliac branch in the
innominate and subclavian arteries and one stent-graft in the
common carotid artery, with braquial access through the left
arm. The descending aortic aneurysm was treated with
aortic endoprosthesis placed in the thoracic aorta, above
the celiac trunk. This case report highlights the successful
outcome of advanced endovascular skills in treating a mycot-
ic innominate artery aneurysm. No limb ischemia or neuro-
logic sequelae were detected in the nine months follow-up.
Post-operative CT-scan showed no signs of endoleak.
Conclusion: We believe endovascular repair is a viable
and minimaly invasive treatment option to the convention-
al repair, especially in patients with high cardiologic risks
or in the emergency setting.
SESSION 35
TL 08 – VASCULAR ACCESS FOR
HEMODIALYSIS
KIRRA ROOM 15:40 – 16:40
SESSION 35: 19002 – RISK FACTORS
FOR HEMODIALYSIS ARTERIOVENOUS
FISTULA FAILURE: THE ROLE OF
DOPPLER ULTRASOUND
Jocefabia Reika Alves Lopes1,
João Antonio Corrêa1 and
Ana Lı́gia de Barros Marques2
1
FMABC, Santo Andre, Brazil
2
UFMA, Imperatriz, Brazil
Background: The increasing prevalence of chronic
kidney disease with age has enhanced the demand for
arteriovenous fistula (AVF) creation. Proper patient
Abstracts
selection is the key for a functional AVF. Doppler ultra-
sound is said to help reduce the incidence of AVF
dysfunction.
Aim: To analyze the relationship between risk factors for
AVF failures and preoperative Doppler ultrasound results.
Material & Methods: This is a prospective study con-
ducted at the Renal Disease Clinic and the Imperatriz-
Maranhão Nephrology Clinic from October 2016 to
September 2018. The study comprised two hundred and
twenty eight patients with chronic renal failure undergoing
AVF creation for hemodialysis in one of the two
Institutions. The patients were assigned to one of the fol-
lowing trial arms: to perform Doppler ultrasound in the
preoperative period (50%), or not (50%). Patients were
followed-up for 6 months.
Results: Overall a total of 53 AVF failures (23.2%) were
observed. Comparisons between failures and associated
risk factors in the global sample revealed significant asso-
ciation between an ipsilateral central venous catheter
(P ¼ 0.04, Odds ratio 1.24) and obesity (P ¼ 0.05, Odds
ratio 1.36), which was not repeated in the Doppler ultra-
sound group alone. There was no statistical difference
between the number of hospitalization days prior to the
procedure among the groups (AVF failure or not)
(p ¼ 0.29; Wilcoxon-Mann-Whitney non-parametric U
test). In addition, there was no statistical difference
between the number of hospitalization days prior to the
procedure (p ¼ 0.052) among patients performing the
Doppler US and those who did not (Wilcoxon-Mann-
Whitney’s non-parametric U test).
Conclusion: We concluded obesity and the presence of
central venous catheter were the risk factors for AVF
failure in our study. We noted that both physical exam
and Doppler ultrasound were able to eliminate unsuitable
veins before AVF creation. Additionaly, we were not able
to demonstrate a relationship between the number of
hospitalization days prior to the vascular access and AVF
failure. We anticipate a benefit for perioperative Doppler
ultrasound to help reduce AVF failures in obese patients
and in those with central venous catheters.
27
SESSION 35: 19064 – DEVELOPMENT
OF A SIMULATOR FOR TRAINING
HEMODIALYSIS AVF
Luis Carlos Uta Nakano,
Vinicius Bignatto Carvalho,
Henrique Jorge Guedes Neto,
Carolina Martines Estrutti, Gabriela Araujo Attie,
Rafael Bernardes de Avila, Artur Naddeo Junior,
Vladimir Tonello de Vasconcelos,
Wellington Gianotti Lustre,
Jorge Eduardo de Amorim,
Marcus Vinicius Canteras Raposo da Camara and
Ronald Luiz Gomes Flumignan
UNIFESP, São Paulo, Brazil
Background: The application of realistic or virtual simu-
lators for healthcare training is a global tendency. Several
simulators for vascular surgery training are available in the
market, but the high-cost prevent their use in third world
countries. Training with the use of simulators helps resi-
dents develop medical technical skills before executing
procedures on real patients. Simulators are also routinely
used in medical exams to help evaluate candidates from
both theoretical and practical points of view. The devel-
opment of low-cost, easy to assemble and user-friendly
simulators can popularize their use as a teaching/training
method with great benefit to the patients.
Aim: To develop a realistic simulator for training hemo-
dialysis fistula creation
Material & Methods: A low cost simulator in the format
of the superior limb was assembled using a foam mold
covered with a thin layer of silicone-mimicking skin and
silicone tubes inside, representing either the radial artery
(pulsatile liquid) or the cephalic vein. The foam molds and
the silicone vessels are disposable and can be used only
once. The silicone mold and the pumping mechanism can
be used several times.
Results: The assembled simulator proved useful for train-
ing residents to perform patent and non-leaking AV anas-
tomosis. Training consisted of making the skin incision,
dissection and clamping of the vessel, performing the anas-
tomosis with a 5.0 prolene suture with continuous or
separate stitches.
Conclusion: The assemble of a low-cost, user-friendly
reproducible simulator for training residents to perform
AV anastomosis proved feasible, effective and of great ben-
efit patient wise.
28
SESSION 35: 19110 – HEMODIALYSIS
ACCESS IN A COMPLICATED PATIENT
USING THE HeROVR GRAFT: A
CASE REPORT
Gustavo Bomfim dos Santos,
Mauricio Rocco de Oliveira,
Thamirys Guimarães Marques,
Luiz Fernando Nascimento, Daniel Simões Castro,
Aline Meira Martins and
Guilherme Vieira Meirelles
IMV -Instituto Meirelles de Cirurgia Vascular, Campinas, Brazil
Background: Occlusions and central vein stenosis are
common issues of end stages dialytic patients. The
HeROVR graft (Hemodialysis Reliable Outflow-HeROVR ) is
considered the last alternative to those patients who have
exhausted other access options and provides a definitive
access solution. The HeROVR graft bypasses occlusion and
traverses stenosis with outflow directly into the central
venous circulation. This technique allows more hemodial-
ysis maintenance. The HeROVR graft includes a PTFE com-
ponent of 6 mm inner diameter that is anastomosed to the
braquial artery and a 53 cm long catheter with a connector
to be implanted in the atrium through a percutaneous
access. The hemodialysis is performed by PTFE graft punc-
tion that is attached to the venous outflow component. To
maintain adequate flow through the graft, the ejection
fraction should be over 20% and the systolic blood pres-
sure should be at least 100 mmHg. The device became first
available in the United States in 2008 after the FDA clear-
ance for use in catheter-dependent patients with central
venous stenosis and/or occlusion. To our knowledge, the
present case reportcorresponds tp the first case of
Hemodialysis Reliable Outflow (HeROVR ) Graft device
implant in Brazil.
Case Description: HeROVR grafts were placed in two
end stage dialytic patients, with primary success. Both
had previously bilateral fistulas failure and none superior
access option. They had at least 3 attempt of arteriove-
nous fistula before the HeROVR graft placement. Patency
rates at the 6-month imaging control was 100%. One
patient died of a non-related cause and the AVF was
occluded at the end. The other patient experienced initial
hand flow steal during hemodialysis. This manifestation
improved when a left-behind contralateral dialyses cathe-
ter (permicathVR ) was removed
Conclusion: International literature review reports a sig-
nificantly lower rate of bacteraemia episodes with the
HeROVR device in comparison with other catheters. The
HeROVR graft has proved useful for clinic applicability in
hemodialysis patients with central vein occlusion or no
other option for AV fistula creation in a few countries.
Vascular 27(1S)
Our experience with the device is limited and should be
extended before we can make our own conclusions.
SESSION 35: 19169 – THE BENEFIT OF
DOPPLER ULTRASONOGRAPHY IN
THE PLANNING AND FOLLOW-UP OF
ENDOVASCULAR RESCUE OF
ARTERIOVENOUS FISTULA:
CASE REPORT
Lissa Severo Sakugawa, Alexandre Rocha Dietrich,
Alexandre Petnys, Edgar Rabboni,
Milton Alves das Neves Junior,
Ricardo Carrelo da Costa,
Thiago Mattiazzo de Vieira Castro and
Maria Lúcia Sayuri Iwasaki
Hospital do Servidor Publico Municipal São Paulo, São Paulo,
Brazil
Background: Arteriovenous fistula (AVF) is the preferen-
cial hemodialysis access, despite the risk of developing com-
plications such as stenosis, aneurysmal dilatation, pseudoa-
neurysms formation and thrombosis compromising its
long-term patency. AVF stenosis may compromise its func-
tionality, predisposing to thrombosis and access loss.
Stenosis can now be treated by the endovascular tech-
nique, allowing for greater AVFpatency. Doppler ultraso-
nography is a low-cost and easily available examination that
contribute not only to early diagnosis of complications but
also of a dysfunctional AVF. In addition, It can facilitate plan-
ning of the endovascular treatment, help select the device
to be used, reduce the need for contrast media during the
exam and provide potoerative hemodynamic evaluation.
Case Description: A 78-year-old female with hiperten-
sion, type II diabetes mellitus, hepatitis C and pre-dialytic
chronic kidney disease was submitted to a left brachioce-
phalic AVF. No maturation of the AVF was observed up to
the 60th PO day. Hemodialysis could not be performed
through this vascular access. An AVF stenosis, 2.5 cm
above the elbow line, close to the anastomosis, with no
maturation (flow: 212.3ml/min) and inadequate develop-
ment of the proximal cephalic vein was diagnosed on the
Doppler US. The phlebography confirmed the perianasto-
motic stenosis and demonstrated central veins patency
and absence of proximal stenosis. An angioplasty was
undertaken to rescue the AVF access, as follows. An ultra-
sonography-guided retrograde puncture of the cephalic
vein, 10 cm above the stenosis, with a 6f introducer was
carried out. A 0.035’’ hydrophilic guide wire was advanced
and transposed the stenosis allowing to perform angio-
plasty with a non-pharmacological 7  60 mm balloon
(Biotronik). Angiographic control revealed resolution of
Abstracts
the stenosis and flow restoration. The doppler US control
calculated an AVF flow of 2146.9 ml/min. In addition, no
stenosis were detected.
Conclusion: Doppler ultrasonography is an important
diagnostic as well as a non-invasive postoperative follow-
up tool in the AVF armamentarium.
SESSION 36
TL 09 – COMPLEX AORTIC
ANEURYSM 2
KIRRA ROOM 16:50 – 18:15
SESSION 36: 19127 – RUPTURED
AORTOILIAC ANEURYSM DUE TO A
TYPE II ENDOLEAK: A CASE REPORT
Elpidio Ribeiro da Silva Filho,
Carolina Lourenço Gomes Eccard,
Júlio César Souza Diniz,
João Victor Loureiro de Oliveira,
André Luiz de Oliveira,
João Vinicius Fernandes Beata Teixeira,
Luiz Eduardo Almeida Silva,
Tercio Ferreira Oliveira, Mauricio Serra Ribeiro
and Edwaldo Edner Joviliano
Hospital das Clı́nicas d Ribeirão Preto – Univeridade de São
Paulo (USP), Ribeirão Preto, Brazil
Background: Type II endoleak occurs in up to 30% of
endovascular aneurysm repair (EVAR). Its long-term sig-
nificance continues to be one of the most controversial
topics. Their natural history is mostly benign but they can
occasionaly lead to aneurysm sac expnsion and eventual
rupture. The purpose of the endovascular treatment is to
achieve a complete exclusion of the aneurysmal sac by
means of intraluminal prosthetic grafts placement.
However, a frequent and feared complication is the per-
sistence of blood flow in the aneurysmal sac after the
endovascular repair (endoleak).
Case Description: An 83-year-old male was admitted to
the emergency room with severe fast-onset pelvic pain
starting only a few hours before. Previous medical history
included endovascular repair of an aortoiliac aneurysm
with Zbis endograft in 2015 with loss to follow-up, con-
trolled systemic hypertension, no smoking and/or previ-
ous cardiovascular events. At physical examination, the
patient was conscious and oriented, presented normal
blood pressure (98  62 mmHg) and a regular heart rate
of 105 bpm. The abdomen was painful and a pulsatile mass
was papable in the hypogastrium. An aortoiliac aneurysm
rupture was reported at the angio CT. Endovascular repair
29
was undertaken with Endurant II aortic endograft and
embolization of arterial branches of the left internal iliac
artery. Intraoperative aortography revealed a type II endo-
leak of the Internal iliac artery branches. A new type II
endoleak of the inferior mesenteric artery branches was
evidenced in a control follow-up CT. The patient was
submitted to a new embolization procedure with ethyl-
ene-vinyl alcohol and is currently asymptomatic with no
further complications.
Conclusion: The natural history of type II endoleak as
well as the approach itself remains uncertain except in the
case of persistent type II endoleak (>6-month duration)
and aneurysm sac expansion. Spontaneous resolution can
occur in up to 50% of the cases.
SESSION 36: 19025 – ENDOVASCULAR
REPAIR OF JUXTARENAL ABDOMINAL
AORTIC ANEURYSM WITH A
FENESTRATED STENTGRAFT TO THE
FOUR VISCERAL ARTERIES AND
FEMOROFEMORAL BYPASS FOR
AORTOILIAC OCCLUSIVE DISEASE
Claudia Guimarães Agle2,
César Amorim Pacheco Neves1,
orea Carneiro1 and
Flávia D
Dejean Amorim Sampaio Filho1
1
CEAVE – Centro de Excelência em Angiologia, Cirurgia Vascular
e Endovascular, Salvador, Brazil
2
FTC – Faculdade de Tecnologia e Ciências, Salvador, Brazil
Background: Abdominal aortic aneurysm (AAA) involv-
ing the renal arteries (juxtarenal and pararenal) or with a
proximal neck smaller than 10 mm, represents a challenge
for conventional surgical treatment. The first endovascular
treatment of complex aortic aneurysms was published in
1999. Nowadays various endovascular treatment options
(BEVAR, FEVAR; EVAR with physician-modified stentgrafts
or parallel stents techniques such as Chimney, Snorkel,
Sandwich and Periscope) as well as hybrid techniques
have been proposed, validated and are currently in use
to address complex aortic aneuryms. The assisting inter-
ventionist can choose the technique according to the
aneurysm classification, his personal experience and avail-
ability of the necessary devices. We currently describe the
endovascular rpair of a juxtarenal abdominal aortic aneu-
rysm using a fenestrated stentgraft to the four visceral
arteries and a femorofemoral bypass for an aortoiliac
occlusive disease.
Case Description: A 61-year-old male with a mutation in
the JAK2 gene, sought medical attention for intermittent
claudication in the left lower limb (LLL), a juxtarenal
30
abdominal aortic aneurysm and a left iliofemoral obstruc-
tive arterial disease. Physical examination revealed absence
of pulses in LLL and normal pulses in right lower limb (RLL).
The arterial duplex of lower limbs demonstrated normal
flow in the RLL, refilling of the superficial femoral artery in
the LLL, that was kept patent to the foot. A 6,1 cm juxtare-
nal fusiform aneurysm with left aortoiliac occlusion was
diagnosed at the Angio-CT. The endovascular repair was
carried out under general anesthesia. Four vascular
accesses were necessary to perform the procedure (dis-
section of bilateral common femoral arteries, right axillary
and left subclavian arteries accesses). The fenestrated
stent-graft body (COOK) was introduced through the
right femoral artery. The bridges to the visceral arteries
(Advanta balloon expandable stent) were implanted
through the upper limbs accesses. The device’s distal exten-
sion was then implanted with a monoiliac stentgraft. Finally,
a femorofemoral bypass with ringed PTFE prosthesis was
performed. The procedure was uneventfull and the patient
was discharged on the second postoperative day.
Conclusion: Complex AAA treatment with fenestrated
stentgraft is an excellent immediate and short-term ther-
apeutic option. Endoprosthesis preparation time is a
potential disadvantage, especially in the emergency setting.
SESSION 36: 19101 – LATE POST EVAR
TYPE III ENDOLEAK MANAGED BY
THE ENDOVASCULAR APPROACH
Antonio Jose Nascimento,
Leonardo Augusto D’avila Gonçalves,
Hudson Cruz Reis Carvalho,
Vinicius de Oliveira Godoy,
Eduardo Pereira Nascimento,
Marcelle Souza Alves da Silva,
Marcelo Guedes Cysne,
Luiz Ronaldo Godinho Pereira and
Roberto Luiz Pereira Ribeiro
Hospital Marcio Cunha, Ipatinga, Brazil
Background: Late complications such as type III endo-
leaks are frequently overlooked during follow-up. They
can often be mistaken for a type II endoleak or can be
missed altogether. Disconnection and distortion are usu-
ally more notable signs of type III endoleaks, and the diag-
nosis is usually confirmed only during intervention.
Structural failure of the endoprosthesis, fracture, or dis-
connection of modular components of the endoprosthesis
are the major causes. Attention should be paid to the
aneurysm sac as pressurization and endotension
may supervene.
Vascular 27(1S)
Case Description: 64-year-old asymptomatic ex-smoker
male with hypertension, diabetes mellitus, dyslipidemia
and hyperuricemia presenting with a late post EVAR
(2005) type III endoleak was referred to our Vascular
Clinic. The angio CT revealed a type III endoleak with
complete disconnection of endoprosthesis parts (proximal
CAF and main body). Endovascular interposition of two
ENDURANT 28 X 28 X 70 endoprosthesis by US-guided
bilateral common femoral arteries access with proglide,
led to complete sealing of the endoleak. Hospital length
of stay was three days. The patient was discharged with
antiplatelet therapy and was followed up accordingly to
our protocol with imaging control at t, 6 and 12
months in the first year and yearly thereafter.
Conclusion: This abstract reinforces the need for close
follow-up after EVAR for early detection of complications
and timely and effective care.
SESSION 36: 19131 – PROPHYLACTIC
ENDOANCHOR USE IN EVAR WITH
HOSTILE PROXIMAL NECK: TWO
CASES REPORT
Júlio César Souza Diniz,
João Victor Loureiro de Oliveira,
Edwaldo Edner Joviliano, Mauricio Serra Ribeiro,
Carolina Lourenço Gomes Eccard,
João Vinicius Fernandes Beata Teixeira,
Andre Luiz de Oliveira,
Elpidio Ribeiro da Silva Filho,
Marco Bianco Santarosa and
Luiz Eduardo Almeida Silva
Hospital das Clı́nicas USP – RP, Ribeirão Preto, Brazil
Background: Type Ia endoleak and graft migration are
some of the endovascular aneurysm repair (EVAR) com-
plications that can be addressed by EndoAnchors. These
are small helical devices, which lock the endograft to the
aorta to obtain secure transmural fixation and prevent
proximal aortic neck complications, such as graft migra-
tion and type IA endoleaks. In addition, it seems beneficial
in the treatment of complex aortic neck disease, with
challenging anatomy and difficult landing zones, such as
short, wide, conical or hyperangulated necks. The use of
EndoAnchors helps obtain an adequate proximal seal in a
subset of patients that would otherwise have required
open surgical repair or more advanced endovascular tech-
niques, such as branched or fenestrated repairs.
Case Description: Two patients with AAA and hostile
neck, were treated with prophylactic EndoAnchor
implants at our Service. FAPC is an 84-year-old male
with a 5,7 cm AAA and a conical short neck (11 mm),
submitted to EVAR with Endurant II endoprosthesis
(Medtronic). Five EndoAnchors were prophylactically
Abstracts
implanted on the proximal neck, without complications.
Control imaging tests demonstrated adequate endopros-
thesis and EndoAnchors placement and absence of type IA
endoleak. The second patient is GSC, an 82-year-old
female with a 5,1 cm AAA and short neck (10 mm). Four
EndoAnchors were applied to the proximal neck after
EVAR with Endurant II endoprosthesis (Medtronic), with-
out complications. Control imaging tests confirmed endo-
prosthesis and EndoAnchors position and the absence of
type IA endoleak.
Conclusion: Aortic neck complications remain a chal-
lenge for endovascular aneurysm repair. Type Ia endoleak
and endoprothesis migration continue to occur despite
the new devices and the technological progress.
Prophylactic use of EndoAnchors to prevent type Ia endo-
leak and endoprosthesis migration in EVAR with challeng-
ing neck was applied to the two reported cases without
complications. The patients are asymptomatic and
approaching the 6-month follow-up visit.
SESSION 36: 19135 – POSTOPERATIVE
AORTIC NECK AND COMMON ILIAC
ARTERIES DILATION: LONG-TERM
FOLLOW-UP
Fábio Hüsemann Menezes, Ana Clara Alves Costa,
Bruno Pagnin Schmid and
Laura Lane Menezes Polsin
Universidade Estadual de Campinas, Campinas, Brazil
Background: Aortic dilatation is of multifactorial etiolo-
gy, including genetic and environmental factors. The activ-
ity of metalloproteinases in the aortic wall results in deg-
radation of elastic and collagen fibers and the regenerative
process results in a fibrotic tissue that do not present the
same properties of the healthy wall, leading to weakness
and progressive dilatation. Smoking history, high blood
pressure and the presence of obstructive pulmonary dis-
ease are well known accelerating contributors. The aim of
the operative procedure is to prevent rupture by replacing
the most diseased segment of the aorta with open repair
(OR) or excluding this segment from the blood stream
with the interposition of an endograft (EVAR). Literature
reviews on postoperative neck dilation reports a 10–
36% incidence.
Aim: To ascertain enlargement of infrarenal aortic neck
(>2.5 cm in diameter) and common iliac vessels (>1.5 cm)
in our series of patients.
Material & Methods: The data was retrieved from a
prospective follow-up registry of all patients submitted
to open repair of AAA at the University hospital. This
trial was approved by the Institutional IRB.
31
Results: A total of 203 patients submitted to OR
between 1989 and 2013 and under active follow-up (min-
imum 12 months, up to 24 years) at our Service were
identified in our database. Annual imaging tests (duplex
ultrasound or computed tomography) with detailed
assessment of aortic and iliac arteries diameter was avail-
able for only 155 patients. Therefore, the study population
comprised 155 patients (84% males, 91% Caucasians,
mean age: 68.3y). Comorbidities included smoking (89%)
hypertension (76%) and diabetes mellitus (13%). Life-table
analysis demonstrated a 95.5% chance of being free from
aortic dilatation at 10 years, dropping to 73.3% at 15 years
of follow-up. Dilation of an arterial segment was present in
16.8% of the patients. The incidence of dilatation for the
aortic neck, visceral aorta and iliac arteries were respec-
tively: 10.5%, 0%, 10.5% in up to five years follow-up.
These numbers increased to 14%, 8.8% and 10.5%
between 5 and 10 years follow-up and to 24.1%, 6.9%
and 24.1% between 10 and 15 years follow-up. For the
patients with more than 15 years follow-up, these num-
bers raised to 41.7%, 8.3% and 50% dilatation for the
aortic neck, visceral aorta and iliac arteries respectively.
Anastomotic pseudoaneurysms were rare with one case
at the proximal aortic anastomosis.
Conclusion: Our findings are similar to the ones
reported in the international literature and suggests this
is a continuum disease that cannot be interrupted by OR
or EVAR alone. Continuous surveillance is warranted
to monitor disease progression and provide
timely treatment.
SESSION 36: 19145 –
THORACOABDOMINAL AORTIC
ANEURYSM REPAIR WITH BRANCHED
ENDOPROSTHESIS COMBINED WITH
CHIMNEY TECHNIQUE
Thamirys Guimarães Marques1,
Mauricio Rocco de Oliveira1,
Gustavo Bomfim dos Santos1,
Aline Meira Martins1, José Reginaldo Simão2,
Armando C. Lobato2 and
Guilherme Vieira Meirelles1
1
IMV – Instituto Meirelles de Cirurgia Vascular, Campinas, Brazil
2
ICVE – Instituto de Cirurgia Vascular e Endovascular de São
Paulo, São Paulo, Brazil
Background: Thoracoabdominal aortic aneurysm
remains one of the most challenging aortic pathologies.
Conventional open repair requires an experienced multi-
disciplinary team as well as a high-end medical care in a
high volume hospital. Thoracic endovascular aortic repair
32
(TEVAR) is a less invasive approach with reduced periop-
erative mortality and morbidity rates. Complication rate is
estimated to be as higher as 38%. Secondary reinterven-
tions may be necessary in 19–24% of the cases. Endoleak is
one of the major causes for reintervention.
Case Description: An asymptomatic 70-year-old male
with thoracoabdominal aortic aneurysm involving the
renal arteries (5 cm) sought medical attention at our
Outpatient Clinic. A custom-made endoprosthesis with
proximal branches for the celiac and mesenteric arteries
and distal branches for both renal arteries was ordered.
We realized, at the very beginning of the procedure, that it
would be very difficult to catheterize the renal arteries
with the branched endograft and opted for chimney
grafts. A control angiotomography demonstrated a type
IB endoleak at the left renal graft. This was treated in a
new procedure with a viabahn interposition.
The treatment was successful and the patient remained
asymptomatic without aneurysm expansion.
Conclusion: The management of endoleaks remains an
inherent challenge to TEVAR, particularly as evolving tech-
niques and devices have allowed treatment of increasingly
complex aneurysm anatomy.
SESSION 36: 19209 – SANDWICH
TECHNIQUE TO MANAGE
COMPLICATIONS OF PREVIOUS
ENDOVASCULAR ANEURYSM
REPAIR (EVAR)
Fernanda Federico Rezende,
Matheus Trigo Carim, Roger André Molina Claros,
Pamela Rodrigues de Souza,
Clisse Michelle de Sá Rodrigues,
Diego Nicacio de Brito, Gusthavo Tomasi Perin,
Fernanda Telles Sales,
Douglas Leopoldino de Amorim,
Fausto Miranda Junior, Camila Kolber Del Priore
and Armando C. Lobato
ICVE- SP, São Paulo, Brazil
Background: The sandwich technique (ST) was first
introduced in 2008 to treat aortoiliac aneurysms extend-
ing to the hypogastric arteries and has rapidly improved to
address all four types of complex aortic aneurysms. The
concept of this technique was based on the trihedron
feasibility, immediate availability and cost-effectiveness.
This technique was primarily developed to overcome ana-
tomical and device constraints that limited endovascular
approach in either elective or urgent settings. We current-
ly report the use of ST to address complications of a
previous EVAR.
Vascular 27(1S)
Case Description: A 72-year-old obese, hypertensive,
dyslipidemic male was reffered to our Vascular Clinic in
2015 for an abdominal aortoiliac aneurysm. Past medical
history included hyperuricemia, polycystic kidney and
chronic non-dialytic renal disease. A large asymptomatic
pulsatile mass was palpable in the abdomen and a large
infrarenal abdominal aortoiliac aneurysm (10 cm aortic,
6 cm left common iliac artery and 1.8 cm right common
artery) was diagnosed on a computerized angiotomogra-
phy (CT). He was submitted to a one-step-only endovas-
cular procedure including EVAR with a bifurcated sten-
tgraft of infrarenal fixation, left hypogastric artery coil
embolization and Bell Bottom technique (iliac limb
20 mm in diameter) in the right common iliac artery
(RCIA). A complete aneurysm exclusion was confirmed
at the control angiography as well as on the follow-up
angio-CTs performed at one, six and twelve months.
In 2017 the patient returned complaining of pain and an
abdominal mass. The angio-CT revealed a type IB endoleak
due to proximal migration of the right iliac limb (Bell
Bottom 20 mm) and distal migration of the proximal
graft fixation. No type IA endoleak was observed. An
infrarenal aortic cuff (36 mm) was implanted to fix the
proximal neck graft migration. The sandwich technique
was used to repair type IB endoleak caused by the hypo-
gastric backflow. Three different vascular accesses were
used: a left brachial punction to introduce two self-
expandable cover stent (7  100 cm and 7  150 cm)
through the right hypogastric artery; a right percutaneous
femoral access to introduce the iliac limb extension
(12  120 cm and 10  120 cm) and a left femoral punction
to perform angiography. The final control angiogram
revealed a complete aneurysm sac exclusion and patency
of the right hypogastric artery. The patient returned only
to the one-year follow-up visit complaining of abdominal
pain at palpation. Another type Ib endoleak owing to a
right hypogastric artery dilation was detected in a control
angioCT. The patient underwent a third procedure
through a left branchial punction to introduce a self-
expandable cover stent (8  100 cm with 5 cm overlap-
ping) through the right upper gluteal artery to seal the
type Ib endoleak. Completion angiography as well as
24-hours postoperative angioCT demonstrated complete
aneurysm sac exclusion and patency of the right upper
gluteal artery.
Conclusion: Sandwich technique has proved to be an
important tool in endovascular armamentarium to solve
anatomical adversities not feasible with the standard endo-
vascular and/or with conventional vascular techniques.
Abstracts
SESSION 36: 19124 – INTRAOPERATIVE
NEUROPHYSIOLOGICAL
MONITORING IN ENDOVASCULAR
AORTIC DISSECTION REPAIR
Juliana Gonçalves1, Laı́s Miller Reis Rodrigues2,
Marcello Romiti1, Ricardo Jr. Ferreira2,
Francisco Cardoso Brochado Neto1,
Asdrubal Marquez Tomaz1 and
Euclides Padilla Hernandez1
1
ANGIOCORPORE, Santos, Brazil
2
Clı́nica Dr. Ricardo Ferreira, Monitorização Neurofisiol
ogica
Intraoperatoria Ltda, Brazil
Background: Prevention of transient or permanent neu-
rological injuries, especially paraplegia, during endovascu-
lar repair of aortic aneurysms and/or dissections repre-
sent a substantial challenge. Intraoperative
neurophysiological monitoring (IOM) allows for early
identification of intraoperative spinal cord ischemia and
to guide treatment to reduce the risk of paraplegia.
Blood supply to the spinal cord originates from the verte-
bral arteries and is fed by two to eight radicular arteries
arising from the subclavian and intercostal arteries and
from the lateral sacral and iliac areries. The arteria radi-
cularis magna, also called Adamkiewicz artery plays a
major role in this process. During EVAR one or more
radicularis arteries can be occluded by the stentgraft, lead-
ing to different degrees of spinal cord ischemia severity.
Case Description: We will present two cases of neuro-
physiologic monitoring during EVAR. The first patient was
a 65-years-old hypertensive male with a dissected thoracic
aortic aneurysm (Stanford B, DeBakey III). A left carotid-
left subclavian artery bypass followed by aortic stentgraft
deployment covering the left subclavian artery and
extending to a large area of thoracic aorta (thoracoabdo-
minal transition) was undertaken in order to treat the
aneurysm and cover the primary entry of the dissection.
The second patient was an 81-year-old hypertensive, dys-
lipidemic, diabetic male with a thoracic aortic aneurysm
that developed a post TEVAR type IB endoleak. Stentgraft
coverage was extended to the thoracoabdominal transi-
tion. We decided to perform IOM in these patients as
both stentgrafts were implanted very close to the emer-
gence of the Adamkiewicz artery. Motor and somatosen-
sory evoked potential parameters were monitored.
Conclusion: Multimodal intraoperative neurophysiologi-
cal monitoring (IOM) is a noninvasive technique that con-
tributes for early identification of spinal cord ischemia
during aortic endovascular repair, allowing for timely
treatment institution to prevent paraplegia.
33
SESSION 37
TL 10–PERIPHERAL ARTERY
OCCLUSIVE DISEASE 2
BONETE ROOM 09:00 – 10:09 AM
SESSION 37: 19016 –
FEMOROPOPLITEAL DOPPLER
VELOCITIES IN HYPERBARIC OXYGEN
TREATMENT OF DIABETIC PATIENTS
WITH LEG ULCERS
Cristiane Antequeira Maran and
Sergio Xavier Salles Cunha
CMHN, Salvador, Brazil
Background: Hyperbaric oxygen treatment (HbOT)
improves healing of leg ulcers. Treatment effectiveness is
yet to be established. Doppler measurement of peak sys-
tolic velocity (PSV) is a simple technique to ascertain
blood flow changes. HbOT is vasoconstrictive, as
increased oxygen content reduces blood flow. In contrast,
leg ulcers are associated to vasodilatation.
Aim: To ascertain the pre and post HbOT femoropopli-
teal PSV
Material & Methods: 30 patients (32 legs presenting leg
ulcers), mean age 61 years12 (SD) (range 29–85y)
undergoing oxigen hyperbaric treatment at the Centro
de Medicina Hiperbárica do Nordeste, (Vascular Surgery
Division, Hospital Geral Roberto Santos) were submitted
to PSV measurement of the Common femoral and popli-
teal arteries by Doppler ultrasound. Comorbidities includ-
ed diabetes mellitus (100%, 23% insulin-dependent) and
hypertension (97%). Prevalence of increased (10%),
unchanged (within 10%) or decreased (10%) PSV were
determined. Absolute values of specific subgroups were
compared by t-test statistics.
Results: Common femoral or popliteal arteries PSV were
increased in 11 legs (34%), unchanged in 8 (25%) and
decreased in 13 (41%) extremities. Subgroups identified
included: I) decreased velocities (n ¼ 12, 37.5%), II) con-
tradictory femoropopliteal differences with increased/
decreased velocities (n ¼ 10, 31%), III) increased velocities
(n ¼ 6, 19%), and IV) unchanged velocities (n ¼ 4, 12.5%).
Pre HbOT Common femoral artery PSV were similar in
subgroups I and III (12337 vs 11619 cm/s (p ¼ .66)),
changing to 10426 and 14429 cm/s (p ¼ .01) post
HbOT. In general, popliteal artery PSV either decreased
(d) or increased (i) from 7922(d)-5919(i) cm/s
(p ¼ .02) to 5818(d)-82/20 (i) cm/sec (p ¼ .004).
Conclusion: Doppler PSV is a simple technique to pin-
point HbOT blood flow responses. Post HbOT vasocon-
striction have occurred in most extremities (69%, 22/32)
as shown by decreased PSV values, these results may
34
suggest a return to normal physiological behavior.
Complex PSV responses, however, predominated: e.g.
popliteal PSV being affected by femoral stenosis. The pre-
sent data warrants future research to monitor PSV behav-
ior during HbOT treatment. Vasoconstriction in response
to HbOT may predict a subgroup of patients with more
effective and faster ulcer healing rates.
SESSION 37: 19020 – TECHNICAL
SUCCESS IN LONG SUPERFICIAL
FEMORAL ARTERY OCCLUSIONS
TREATED WITH VIABAHN
Pablo Alejandro Marina, Marcelo Pettinari,
Armando Aldassoro, Thomas Jorge and
Roberto Diaz
Sanatorio Modelo Burzaco, Argentina
Background: Chronic total occlusions are always a chal-
lenge for vascular revascularization. Long-term patency
largely depends on the endoprosthesis used. The selected
endoprosthesis should be prepared to stand movements
of flexion, torsion and shortening of the treated artery, as
well as severe calcification.
Aim: To ascertain revascularization outcomes of a series
of long occlusions of the superficial femoral artery submit-
ted to viabahn implant.
Material & Methods: 21(16–25 cm long and 5–15 cm
long) viabahn with heparin coating were implanted in 20
patients. It was not possible to cross the occlusion in 4
patients. The primary technical success rate was 85.7%.
Failure to cross the total occlusion was associated to: 1)
The selected vascular access (50%). 2) Severe calcification
(50%). Vascular access in the successful cases was ante-
grate in 14 patients, contralateral in 3 patients and popli-
teal in 3 patients. Contraleteral or popliteal accesses were
tried whenever the antegrade access failed.
Results: The total average length of the lesion was
21.85 cm. Predilatation was carried out with peripheral
balloon 1–1 the diameter of the vessel. Crossing techni-
ques included: 1. Use of a 0.035 hydrophilic guide wire in 9
patients, 2. Push the loop with a hydrophilic guide wire in
8 patients, 3. Plain drill with a straight guide wire in the
remaining patients.
Conclusion: Recanalization of long occlusions of the
superficial femoral artery can be performed with relatively
high success rates. Expertise with different vascular
accesses and crossing techniques are required
Vascular 27(1S)
SESSION 37: 19052 – LASER
ENDARTERECTOMY
Jorge Eduardo de Amorim,
Caio Augusto de Souza, Juliana Pagotto Trevizo,
Daniel Hachul Moreno,
Luis Gustavo Schaefer Guedes,
Ronald Luiz Gomes Flumignan,
Henrique Jorge Guedes Neto,
Giulianna Barreira Marcondes,
Vinicius Bignatto Carvalho, Kenji Nakahara Rocha,
Arthur Cristiano Baston and
Luis Carlos Uta Nakano
UNIFESP, São Paulo, Brazil
Background: Peripheral artery disease (PAD) is a highly
prevalent pathology with approximately 200 million
people affected worldwide. Prevalence rates are estimated
in more than 10% among high-income countries and more
than 20% in low to mid-income countries. It ends up as a
chronic inflammatory disease, with atheriosclerosis and
atheroma plaque formation as the pathophysiological
basis. Besides the occlusion itself and the consequent
reduction in blow flow/ischemia, it also plays a risk
factor in emboli formation. Lethal consequences may
occur when emboli end up in the coronary, pulmonary
and/or brain arteries. Preventing the formation of these
plaques and developing techniques for effective plaque
removal are essential. Endarterectomy, arterectomy,
angioplasty and stenting are the major treatment options.
The use of laser in vascular procedures was first described
in 1980’s. In 1985, Dr. John Eugene, from the University of
California, proposed the use of argon ion laser radiation
to dissecate the arteriosclerotic plaque in association with
open endarterectomy technique. Later on, in 1990, he
published an initial trial, with 16 patients, on the use of
his open laser endarterectomy technique. Nowadays, the
excimer laser with XeCl is currently considered the best
laser option for arterial disease. This is a pulsative cold
laser, with low-risk of thrombous formation and damage
to the arterial wall.
Case Description: A 75-year-old male with bilateral
peripheral arterial disease and a trofic lesion in the left
foot was seen at our Outpatient Vascular Unit. The
patient was submitted to endolaser endarterectomy
(Excimer Laser System, Spectranetics) in the femoropopli-
teal segment with good results.
Conclusion: Excimer laser endarterectomy is a treat-
ment option in selected cases of chronic limb ischemia.
Abstracts
SESSION 37: 19108 – LOWER LIMB
ANGIOPLASTY WITH THE SAFARI
TECHNIQUE: THE EXPERIENCE OF A
HIGH COMPLEXITY CENTER
Moriane Barcelos Lorenzoni Zago,
Wallace Medeiros de Aguiar and
Danilo Heringer Alcure Quarto
Hospital e Maternidade São José, Colatina, Brazil
Background: Percutaneous transluminal angioplasty
(PTA) has proved useful in the treatment of atheroscle-
rotic disease of the lower limbs with short and long term
results comparable to surgical treatment. Retrograde
angioplasty can be undertaken whenever the antegrade
approach is unsuccessful. The SAFARI technique (subinti-
mal arterial flossing with antegrade-retrograde interven-
tion for subintimal recanalization) has been proposed as a
last resource for complex cases.
Aim: To ascertain limb salvage rates for angioplasty with
the safari technique.
Material & Methods: This retrospective descriptive
study with quantitative data analysis was conducted in a
specialized center for endovascular treatment in the city
of Colatina-ES. All patients undergoing angioplasty with
the SAFARI technique from 2015 to 2019, were included
Results: A total of 52 interventions were performed in 52
patients (31 (59.6%) males, mean age: 72.25 years (range:
43–88). All patients had a Ruttherford score of 4.5-6 and
extensive lesions, according to the TASC C and D
Classification. The distal vascular access sites were: fibular
artery in 24 cases, anterior tibial artery in 17 cases, pos-
terior tibial artery in 9 cases, popliteal and superficial fem-
oral (intra Stent) arteries in only one case, each. Primary
success was obtained in 42 (80.7%) cases. In 2 (3.8%) cases
there was primary success. There was no success in
8 (15.3%) of the cases.
Conclusion: The SAFARI angioplasty is associated with
high technical success as well as low morbidity and mor-
tality rates. These results were supported by the present
series. This technique is therefore a safe and effective tool
in the critical limb ischemia armamentarium.
35
SESSION 37: 19144 – HYBRID
ENDOVASCULAR APPROACH TO
TREAT INFECTED PTFE
FEMOROPOPLITEAL BYPASS IN
CRITICAL LIMB ISCHEMIA
Eduardo Lichtenfels, Nilon Erling Junior,
Thiago Graziotin Bombardelli,
Andre Reitz Silvestri da Costa, Rebeca Regert and
Newton Roesch Aerts
Hospital Santa Casa de Misericordia – Universidade Federal de
Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
Background: Open surgery is currently considered the
last resource for critical limb ischemia (CLI) revasculariza-
tion after failed endovascular interventions.
Case Description: We report a case of a 76-year-old
male presenting with an infected ischemic ulcer on the left
ankle. Preoperative exams showed heavily calcified arter-
ies and a long-segment occlusion of the superficial femoral
artery (SFA) and distal arteries. The peroneal artery was
the single vessel runoff. Initial attempt for endovascular
revascularization was unsuccessful. An above the knee
femoropopliteal bypass with expandable polytetrafluoro-
ethylene (PTFE) graft was accomplished with the use of a
Fogarty embolectomy catheter for arterial occlusion due
to circumferential calcified arteries unsuitable for usual
arterial clamping. Infection of the inguinal incision was
noted on the 5th postoperative day. Systemic antibiotics
(vancomycin and piperacillin-tazobactam) were adminis-
tered but were unable to prevent dehiscence of the ingui-
nal incision and and abscess formation. A hybrid revascu-
larization procedure was undertaken on the 13th
postoperative day. Open access was granted through the
popliteal and femoral arteries with simultaneous retro-
grade and antegrade recanalization of the long-segment
heavily calcified SFA occlusion. The infected PTFE graft
was removed and arterial closure was performed with a
collateral vein patch angioplasty. The SFA angioplasty was
completed with the deployment of an interwoven nitinol
wire stent from the popliteal artery to proximal SFA, and a
standard nitinol stent close to the ostium of the deep
femoral artery. The distal flow was still poor and the
severe stenosis of the single vessel runoff was also treated
with plain balloon angioplasty. The patient was discharged
on the 8th postoperative day.
Conclusion: Endovascular strategies can be used in com-
bination with open surgical techniques after the failure of a
conventional bypass in complex cases of critical
limb ischemia.
36
SESSION 37: 19210 –
PSEUDOANEURYSM OF THE
COMMON FEMORAL ARTERY IN AN
AMPUTATED PATIENT
Sthefano Atique Gabriel, Augusto da Silva,
Claudia Helena Spir Sant Anna and
Camila Bauman Beteli
UNILAGO, São José do Rio Preto, Brazil
Background: Lower limb revascularization with the use
of prosthetic grafts can be associated with late, anasto-
motic pseudoaneurysm formation in up to 7% of cases.
Complications include hemorrhage, distal ischemia, rup-
ture and death. Patients with anastomotic pseudoaneur-
ysms are at higher risk for emergency surgery and there-
fore present lower survival rates. Amputation is
associated to 50% cardiovascular mortality. We will
report a case of anastomotic pseudoaneurysm of the
common femoral artery in an amputated patient.
Case Description: An 86-year-old male submitted to
suprapatellar amputation of the right lower limb due to
peripheral arterial disease 6 years ago sought medical care
complaining of pain and a pulsatile mass in the right ingui-
nal region. Past medical history included a difficult to con-
trol hypertension and a femoro-popliteal graft with PTFE
prosthesis in the right lower extremity. The Doppler ultra-
sound identified the pseudoaneurysm (diameter:
4.2  7.3 cm; neck: 1.56 cm) in the common femoral
artery with mural thrombus and a non-functioning pros-
thetic graft. The pseudoaneurysm was catheterized
through a left axillary access and excluded with the use
of FluencyVR Plus 9  120 mm covered stent. Control angi-
ography demonstrated pseudoaneurysm exclusion and
preservation of the deep femoral artery branches.
Conclusion: Ultrasound surveillance of prosthetic grafts
anastomosis is advisable for the early diagnosis of pseu-
doaneurysms. Endovascular approach with covered stent
implant is a safe and effective treatment option in these
cases. Open surgical repair is not recommended on
account of the high risk of iatrogenic lesions in association
to surgical manipulation
Vascular 27(1S)
SESSION 38
TL 11 – VENOUS DISEASE 1
BONETE ROOM 10:10 – 11:15
SESSION 38: 19068 – VENA CAVA
FILTER COMPLICATION
Jorge Eduardo de Amorim,
Ronald Luiz Gomes Flumignan,
Carlos Alberto Castro Teixera Junior,
Carolina Martines Estrutti, Ana Alyra Carvalho,
Brena Costa dos Santos,
Rafael Bernardes de Avila,
Henrique Jorge Guedes Neto and
Luis Carlos Uta Nakano
UNIFESP, São Paulo, Brazil
Background: Deep vein thrombosis (DVT) is a highly
prevalent disease worldwide. The estimated prevalence in
Brazil is 60 new cases per 100,000 inhabitants per year.
This value escalates to 500 new cases per 100,000 inhab-
itants per year in the elderly population. Treatment pur-
poses are to prevent recurrence and avoid the onset of
complications such as pulmonary thromboembolism.
Anticoagulation is the mainstay therapy for DVT. Vena
cava filter placement is an alternative prophylaxis against
pulmonary thromboembolism. Indications include absolute
contraindication for anticoagulation, complications due to
anticoagulant use, thromboembolism recurrence despite
adequate anticoagulation therapy, or indication for throm-
bolytic therapy, or low cardiovascular reserve. Vena cava
filter placement can be accomplished, through femoral and
jugular access (depending on whether the procedure will
be performed in the superior vena cava or inferior vena
cava) under ultrasound guidanceThis technique is associat-
ed to low morbidity and mortality rates. Complications
may include hematoma, infection or inadvertent arterial
puncture at the access site or filter fracture, migration or
embolization. Vena cava lesions or deep venous thrombosis
and pulmonary embolism itself are also described.
Case Description: An asympyomatic 78-year-old male
reporting recurrent episodes of DVT with one episode
of pulmonary embolism with vena cava filter implant 5
years ago was seen at our outpatient clinic. He was also
diagnosed with abdominal aortic aneurysm in a routine
imaging test. Perforation of the aneurysm cover by the
vena cava filter stem was observed at the
Angiotomography. The patient had no clinical condition
for any invasive procedure and was put on close clinical
follow-up. He has reached three years of follow-up and
persists asymptomatic.
Conclusion: Conservative treatment for vena cava filter
complication may be an option in cases not fit for surgery.
Abstracts
SESSION 38: 19072 – VENA CAVA
FILTER INDICATIONS
Luis Carlos Uta Nakano,
Rafael Bernardes de Avila,
Antonio Carlos Moura da Silva,
Clara Cardoso Franco Avancini,
Gabriela Araujo Attie, Fabio Akio Takihi,
Thais Rodrigues de Freitas, Pamelli Lopez Kamel,
Carolina Martines Estrutti,
Beatriz Urbani Pessutti, Natália Borges Cardin,
Caio Augusto de Souza, Juliana Pagotto Trevizo,
Camila Bento Soares, Jorge Eduardo de Amorim,
Ronald Luiz Gomes Flumignan and
Henrique Jorge Guedes Neto
UNIFESP, São Paulo, Brazil
Background: Venous thromboembolism (VTE) is one of
the most common circulatory diseases. VTE is an impor-
tant cause of mortality and morbidity in hospitalized
patientsand is rated the third most common vascular dis-
ease, after myocardial infarction and stroke. Prophylactic
management include systemic anticoagulation drugs such
as unfractionated (UFH) and low-molecular-weight hepa-
rin (LMWH) However, in the setting of complications,
failure or contraindications to anticoagulation, vena cava
filter placement is recognized as an effective preventive
measure for pulmonary embolism (PE). The filter is a
mechanic alternative for pharmacological prophylaxis.
Two types of filters are currrently available in the maket:
permanent and retrievable. Permanent filters have been
used since 1970 in patients with long-term need for
mechanical prophylaxis. Potential complications include
migration, occlusion and thrombosis at the access site.
Retrievable filters very introduced in 1990s for temporary
PE risk. It can be removed after PE risk mitigation or after
the resolution of the anticoagulation containdication.
Trauma with bone fractures, head and spinal injuries, dis-
eases requiring long term bed rest, contraindications for
systemic anticoagulation are the main target for this type
of filter.
Aim: To ascertain vena cava filter indications in an univer-
sity hospital setting
Material & Methods: The Medical records of all patients
submitted to vena cava filter implant at UNIFESP were
reviewed for gender, age, the indication that motivated
the vena cava filter implant and the vascular access site.
Results: 131 patients (71 females and 60 males, mean age
51.78 years, range: 4–89 y) were submitted to vena cava
filter implant at our Institution. Contraindication for anti-
coagulation was the major indication (76.8%), followed by
pulmonary thromboembolism in the presence of adequate
anticoagulation (24.8%). The right femoral vein was the
37
vascular access in 52% of the cases, followed by the left
femoral vein im 27% and the right jugular in 21%.
Conclusion: The results of this retrospective study are
similar to the ones reported in the international literature.
SESSION 38: 19151 – PERCUTANEOUS
PHARMACOMECHANIC
THROMBECTOMY FOR EXTENSIVE
VENA CAVA THROMBOSIS
Lais da Cunha Gamba, Andre Estenssoro,
Priscilla Matos and Marina Farjallat
Hospital Sı́rio Libanês, São Paulo, Brazil
Background: Vena cava thrombosis is a rare but severe
medical condition associated with high mortality and mor-
bidity rates. Symptomatology usually include bilateral
edema and pain of the lower extremities. Phlegmasia or
superior vena cava syndrome are also reported.
Case Description: We present a series of three cases of
vena cava thrombosis admitted to Sirio Libanês Hospital
from January 2014 to December 2018. The first one was a
37-year-old female with acute vena cava thrombosis
extending to both iliac veins. She underwent pharmaco-
mechanic thrombectomy with AngioJet. The next day the
patient complained of acute pain and edema of the lower
limbs and a venography demonstrated vena cava occlusion.
She was submitted to a revised pharmacomechanical
thrombectomy with AngioJet, with good results. The
second patient was a 73-year-old female with an abdominal
neoplasia involving the vena cava and the renal veins. She
was submitted to tumor resection and vena cava recon-
struction with a Dacron bypass. Thrombosis of the vena
cava prosthesis was diagnosis on the 11th PO. A successful
pharmacomechanical thrombectomy of the vena cava was
carried out with AngioJet. The third patient was a 55-
years-old female with chronic kidney failure due to type
1 diabetes mellitus. She had multiple hemodialysis accesses
along her lifetime, including catheters in both Jugular and
subclavian veins. She presented an acute superior vena
cava thrombosis with superior vena cava syndrome. She
was submitted to pharmacomecchanical thrombectomy of
the superior vena cava with AngioJet device and implant of
new permcath catheter without complications. The cath-
eter is functional her symptoms improved.
Conclusion: Vena cava thrombosis remains a challenge
for vascular surgeons. Pharmacomechanical thrombec-
tomy with AngioJet device is a safe and effective treatment
option in these cases.
38
SESSION 38: 19159 – FOAM
SCLEROTHERAPY AND
COMPRESSION FOR VENOUS
LEG ULCERS.
Eduardo Toledo de Aguiar and
Paula Casals do Nascimento
Spaço Vascular, São Paulo, Brazil
Background: Venous leg ulcer is estimated to occur in
approximately 1.5% of the Brazilian population. Healing
times are long and recurrence is frequent. Reports in lit-
erature suggests associating therapy for venous insufficien-
cy with compression therapy may lead to reduced healing
times and recurrence risks. Clinical evidence though,
is poor.
Aim: To ascertain the outcomes of echoguided foam
sclerotherapy combined to compression therapy in
regards to healing times and recurrence of venous ulcers.
Material & Methods: A clinical, observational, retro-
spective study was conducted by revision of the medical
records of all patients submitted to echoguided foam
sclerotherapy and compression therapy at our Clinic
from September 2004 to December 2014. Inclusion crite-
ria comprised the presence of open lower limb wound in
association with primary chronic venous disease (C6 Ep
As, p Pr). Exclusion criteria included secondary chronic
venous disease. Analyzed variables were described by
mean  standard deviation and the recurrence rate was
presented in a survival curve. Statistical tests were applied
when appropriate and statistical significance was consid-
ered when p < 0.05%. The esclerotherapy foam was pre-
pared by the Tessari method by mixing 1 ml of 3% polido-
canol to 4 ml of air
Results: A total of 171 wounds in 147 patients (77.6%
female, mean age 61.7  12.8) were analyzed.
Hypertension was the most common associated morbidity
(57.1%) and 29.3% of the patients had previous varicose
veins surgery. The volume of foam injected ranged from 10
to 15 ml per limb. The mean number of sessions was 2.02
 1.08. Wound healing was observed in 79.5% of the
patients; 79.4% healed in up to 6 months. Recurrence
rate was observed in 19.4% of the patients and was
higher in men. Survival curve estimates indicate that 49%
of treated limbs should e free of injury within 48 months.
Conclusion: Despite the combined treatment approach,
healing process is slow and the recurrence rate is high in
the 48-month follow-up period.
Vascular 27(1S)
SESSION 38: 19172 – TREATMENT OF
FACIAL VENOUS MALFORMATIONS
Ana Alyra Carvalho, João Manoel Silveira Lara,
Brena Costa dos Santos,
Jorge Eduardo de Amorim,
Ronald Luiz Gomes Flumignan,
Henrique Jorge Guedes Neto,
Vladimir Tonello de Vasconcelos and
Luis Carlos Uta Nakano
UNIFESP, São Paulo, Brazil
Background: Arteriovenous malformations are rare,
accounting for only 1.5% of all vascular anomalies. Fifty
percent of these malformations occur in the oral or max-
illofacial regions. They usually result from vascular disrup-
tion in association to birth defects. Treatment options
include endovascular, conventional surgery or sclerother-
apy approaches. Sclerotherapy is reserved for slow-flow
venous and/or lymphatic malformations. Absolute alcohol
is the most used sclerosing agent. Major potential risks of
alcohol injection include nerve damage, cardiovascular
toxicity and skin necrosis. Careful planning and medical
expertise is required for that task. Various ultrasound
guided needles are employed for the access and sclerosing
agent injection.
Case Description: A 21-year-old female with a bulging
malformation located at the right hemi-face since the age
of 08 months sought medical care at our Vascular
Outpatient Unit. A right hemi-face vascular tumor of of
7  6 cm with no frits or murmurs was reported at phys-
ical examination. Doppler ultrasound described the lesion
as a poorly defined parenchyma with homogeneous echo-
genicity and sparse calcifications with some hypodense and
flow-free areas measuring around 5 mm. Compressible
vessels were identified in the muscle and subcutaneous
layers. No signs of arteriovenous fistula were reported.
We opted for sclerotherapy sessions with absolute alco-
hol. Serial sessions were performed with Ultrasound
guided puncture of the arteriovenous malformation. The
patient evolved satisfactorily with significant reduction of
the malformation dimensions at the 3-month follow-up.
The patient was very satisfied with the result.
Conclusion: Sclerotherapy with absolute alcohol is a
good option to treat facial venous malformations.
Abstracts
SESSION 39
TL 12 – DISEASE OF THE SUPRA-
AORTIC TRUNKS 2
BONETE ROOM 11:20 AM – 12:32
SESSION 39: 19075 – TRACHEO-
INNOMINATE ARTERY FISTULA (TIF)
WITH MASSIVE BLEEDING
CONTROLLED BY DOUBLE AND
PARALLEL COVERED STENT
INSERTION: a CASE REPORT.
Calogero Presti, Ivan Benaducci Casella and
Marcelo Fernando Matielo
Hospital Sirio-Libanês, São Paulo, Brazil
Background: Tracheo-innominate artery fistula (TIF) is a
life-threatening complication of tracheostomy. Bleeding
results from vessel erosion, caused either by the pressure
exerced by the tip of the tracheal cannula or by an over-
inflated cuff over the innominate artery. TIF is a surgical
emergency requring immediate resuscitative and tampo-
nating measures. Mortality rates approach 100% when left
untreated. Survival rates may reach up to 80% when prop-
erly managed. Scarce data support the use of endovascular
repair as the first-line treatment.
Case Description: We describe the case of a 63-year-
old woman with a rare malignant thyroid cancer and a
chronic definitive tracheostomy. She was admitted on
account of a pulmonary infection and presented massive
bleeding through the tracheostomy, followed by cardiac
arrest, on her first day in the hospital. Bleeding was
caused by TIF and was controlled with a Criss-Cross
endovascular technique with covered stents inserted by
the left femoral access (10  100 mm heparin-bonded
Viabahn beginning in the innominate artery and ending in
the right common carotid artery) and by the right brachial
access (11  100 mm heparin-bonded Viabahn beginning in
the subclavian artery an ending in the innominate artery)
covering the TIF orifice and restoring the blood flow on
the carotid and subclavian arteries. The reconstructon of
the tracheostomy inferior wall and coverage of the innom-
inate artery was undertaken seven days later with a skin
flap. Despite all our efforts, the patient presented hemo-
dynamic instability and septic shock on day 16 and died on
day 20 due to massive stroke caused by carotid artery
obstruction by the implanted stents
Conclusion: The endovascular repair is feasible and can
be lifesaving but special attention shoud be paid to avoid
compression of the supra-aortic trunk vessels, as hap-
pened in the present case.
39
SESSION 39: 19132 – SLING RING: IS IT
NECESSARY TO RESECT A
SUBCLAVIAN KOMMERELL
DIVERTICULUM?
Guilherme Vieira Meirelles,
Thamirys Guimarães Marques,
Douglas Alexandre R. Pereira, Gustavo Santos,
Mauricio Rocco de Oliveira, Julio C. Toledo and
Luis Fernando Nascimento
IMV -Instituto Meirelles de Cirurgia Vascular, Campinas, Brazil
Background: Vascular rings are congenital abnormalities
of the aortic arch that result in compression of the tra-
cheobronchial tree and/or the esophagus, leading to respi-
ratory and gastrointestinal symptoms. They can be classi-
fied as complete or incomplete according to the degree of
encirclement of this end organs.
Case Description: We present two 50-year-old males
with progressive dysphagia and weight lost, diagnosed with
Kommerell diverticulum on a angio CT scan. Additional
findings included a right side aortic arch, anomalous posi-
tion of the right subclavian artery and the aberrant origin
of the left subclavian artery in the descending aorta. The
Kommerell diverticulum was of the incomplete type,
encircling only the esophagus. We opted to exclude the
Kommerell diverticulum and revascularize the subclavian
artery. The diverticulum was excluded by placing an aortic
endograft, followed by embolization of the proximal seg-
ment of the subclavian artery. A carotid–subclavian bypass
with PTFE was performed in the same procedure. The
patients are doing well and are under follow-up in our
outpatient unit.
Conclusion: Sling ring with right aortic rotation can pro-
duce extrinsic esophageal compression by the left subcla-
vian artery and by the Kommerell diverticulum.
Esophageal compression can be alleviated by endovascular
exclusion of th diverticulum alone. Endovascular approach
is feasible and can abbreviate thoracotomy and subclavian
artery resection.
40
SESSION 39: 19153 – TREATMENT
APPROACH FOR A PARAGANGLIOMA
TUMOR GROWING TO THE BASE OF
THE SKULL
Matheus Trigo Carim,
Douglas Alexandre R. Pereira, Gustavo Santos,
Mauricio Rocco de Oliveira,
Thamirys Guimarães Marques,
Daniel Simões Castro and
Guilherme Vieira Meirelles
IMV -Instituto Meirelles de Cirurgia Vascular, Campinas, Brazil
Background: Paragangliomas are rare neuroendocrine
tumors that arise from the extra-adrenal autonomic para-
ganglia. Estimated incidence is 1 new case per 30,000
inhabitants per year. These tumors are benign in most
cases but malignant clinical behaviour have been described
in 5–30% of cases. They usually occur in adults between 30
and 60 years, but early onset paragangliomas have been
reported in association to genetic inheritance. They are
space-occupying tumors. Symptomatology can be related
either to compression of adjacent anatomical structures
or by cathecolamine secretion, resembling a pheochromo-
cytoma. The most common clinical presentation is a pain-
less mass located in the lateral cervical region. Surgical
excision is the only treatment option for complete erad-
ication, provided malignancy is excluded by
histopathology.
Case Description: We report a 32-year-old female seen
at our outpatient unit for a painless, left cervical mass with
progressive growth over the past seven months. On phys-
ical examination, a pulsatile, fibroelastic, painful mass was
observed in the left cervical region, below the angle of the
mandible. An audible systolic murmur was also noted.
Cranial nerves were spared. Routine laboratory tests
were unremarkable. A hypoechoic, heterogeneous,
highly vascularized lesion was diagnosed by the Doppler
ultrasound close to left carotid bifurcation topography. An
angio MRI of the cervical region revealed the presence of a
mass occupying the jugulo-carotid space and extending to
the base of the skull without cleavage planes with the
carotid artery, suggesting a carotid glomus tumor. The
cerebral-cervical angiography with contralateral carotid
compression demonstrated no perfusion of the contralat-
eral side of the brain. Tumor embolization with onyx car-
ried out. The procedure was uneventful and the patient is
doing well.
Conclusion: Embolization was effective to reduce the
tumor size but it is still too risky to undertake any surgical
resection. Close tumor monitoring is advisable as the clin-
ical course is unpredictable.
Vascular 27(1S)
SESSION 39: 19177 – CAROTID-
COVERED STENT FOR ADVANCED
SUBMANDIBULAR GLAND TUMOR
Ana Letı́cia Alves Barbosa, Dalila Barbosa Delfino,
Flávia Araújo de Souza Brazões and
Josualdo Euzébio da Silva
BIOCOR, Belo Horizonte, Brazil
Background: Most tumor of the head and neck arise
from mucosal surfaces of the aerodigestive tract. This
medical condition is ranked sixth in disease frequency
throughout the world. Carotid artery rupture is an atyp-
ical complication to occur in patients with tumor of the
head and neck. Treatment for this complication should be
well planned, extremely careful and performed in the less
aggressive way. Surgical or endovascular approaches
are described.
Case Description: A 66-year-old male, with adenocarci-
noma of the submandibular gland and severe episodes of
acute onset hemorrhage was submitted to sessions of
hemostatic radiotherapy. Past medical history included
resection of a tumor located in the right cervical region
with early recurrence on the 40th postoperative day.
Chemotherapy and radiotherapy were administered for
tumor reduction. An orocervical fistula was diagnosed
after these adjuvant therapy. At admission, the patient
presented high-volume bleeding from the orocervical fis-
tula with a 4 points hemoglobin drop. Bleeding was tem-
porarily controlled with compressive dressing while the
patient underwent imaging tests. A type II carotid rupture
without indication of resection tumor was diagnosed. The
head and neck team contraindicated carotid arery ligation.
Therefore, a covered stent (viabahnVR ) with exclusion of
the external carotid artery was implanted with coverage
of the tear in the carotid bulb. The patient was discharged
after 48 hours, without any neurological sequelae.
Conclusion: This case report illustrates the use of endo-
vascular stent implantation to stop bleeding from carotid
rupture in a head and neck tumor patient in a safe and
effective way.
Abstracts
SESSION 39: 19203 – ENDOVASCULAR
REPAIR OF STENT COMPLICATIONS
IN THE LEFT SUBCLAVIAN ARTERY
Pamela Rodrigues de Souza,
Roger André Molina Claros,
Diego Nicacio de Brito,
Clisse Michelle de Sá Rodrigues,
Armando C. Lobato, Camila Kolber Del Priore,
Fausto Miranda Junior, Fernanda Telles Sales,
Fernanda Federico Rezende,
Douglas Leopoldino de Amorim,
Gusthavo Tomasi Perin and Matheus Trigo Carim
ICVE-SP – Instituto de Cirurgia Vascular e Endovascular de São
Paulo, São Paulo, Brazil
Background: Stent dislodgment, migration, fractures,
stroke and thrombosis are some of the possible compli-
cations associated to stenting at the subclavian arteries.
Data on stent fracture at the subclavian artery are scarce.
A recent Chinese study of 6555 patients undergoing cor-
onary percutaneous intervention reported a 22% inci-
dence of stent fractures. Incidence increased along time.
Predisposing factors included overlapping stents, longer
stents, drug eluting stents, post-dilation with larger non-
compliant balloons and pre-dilation. No gender differen-
ces or association with emergency setting was reported.
Forty one percent of these patients had in-stent resteno-
sis, 5,8% occlusion, 4,6% thrombosis. Target lesion revas-
cularization was necessary in 24,8% of the patients.
Case Description: A 54-year-old, female was referred to
our outpatient clinic in March 2018, complaining of severe
headache, syncope, paresthesis and motor/sensory impair-
ment of the upper left limb (ULL). Symptoms started in
the previous month and subsided at rest. No pulse was felt
at the left radial and brachial arteries and the ULL was
pale. Imaging exams, including angiotomography of the
supra-aortic trunk, aortic arch and intracranial vessels
demonstrated an 80% stenosis of the left subclavian
artery (LSA) and a 60% stenosis of left internal carotid
artery, stent fracture at the proximal end of the LSA,
stent migration to the aortic arch, LSA occlusion and
thrombosis. The patient informed she had been submitted
in 2016 to a percutaneous transluminal angioplasty (PTA)
of the left subclavian artery (LSA) with balloon-expandable
stent, in another service. We opted for endovascular
treatment through the left brachial access. Arteriography
confirmed the LSA occlusion, the stent fracture at the
proximal part of LSA, the stent dislodgment into the
aortic arch. Endovascular revascularization with a self-
expandable stent (9  40 mm) was undertaken. Control
arteriography evidenced persistence of the stenosis. A bal-
loon angioplasty (9X40 mm) was carried out. Again, per-
sistence of proximal and distal stent closure with stenosis
41
required ballooning with a 7  40 mm armed balloon.
Accomplishment angiogram demonstrated complete LSA
patency. Radial and brachial pulses were palpable and
strong, perfusion and temperature were restored in the
left superior extremity.
Conclusion: Subclavian stent complications are a rare
severe medical condition. Endovascular intervention
proved safe and effective to address stent complications
in this location.
SESSION 40
TL 13 – VASCULAR TRAUMA 1
BONETE ROOM 14:30 – 15:33
SESSION 40: 19071 – ENDOVASCULAR
REPAIR OF AORTOILIAC
ARTERIOVENOUS FISTULA
Ronald Luiz Gomes Flumignan,
Jorge Eduardo de Amorim,
Henrique Jorge Guedes Neto,
Giulianna Barreira Marcondes,
Rafael Bernardes de Avila,
Jean Felipe Pedrozo da Silva, Douglas Sterzza Dias
and Luis Carlos Uta Nakano
UNIFESP, São Paulo, Brazil
Background: Arteriovenous fistulas (AVF) are a congen-
ital or acquired abnormal communication between an
artery and a vein, occurring in any point of the vascular
system. Symptomatology varies according to size and loca-
tion. Large AVF can ultimately lead to cardiac decompen-
sation and death. Other presentations include the steal
syndrome. Symptoms decur from hypoflow and encom-
pass extremity cooling, pain, pallor, decrease or absence of
distal pulses, distal cyanosis and muscle fatigue. Imaging
tests can confirm the diagnosis, establish the size and loca-
tion and assist in therapeutic planning. Conventional sur-
gery usually incurs in higher morbidity and mortality rates.
Endovascular approach is considered the treatment of
choice for AVF. Endoprosthesis implant, embolization
and occluders are some of the options available that can
be used alone or in combination.
Case Description: A 77-year-old male with severe steal
syndrome, was admitted for endovascular repair of an
aortoiliac aortoarteriovenous fistula. The fistula orifice
was covered by an endoprosthesis implant with symptom
improvement
Conclusion: Endovascular repair is a safe and effective
treatment alternative for aortoiliac arteriovenous fistula.
42
SESSION 40: 19077 – PERIOPERATIVE
AND MIDTERM OUTCOMES OF
PATIENTS WITH BLUNT AORTIC
INJURY ADMITTED TO A TERTIARY
UNIVERSITY HOSPITAL.
Lais da Cunha Gamba, Nicole Inforsato,
Inez Ohashi Torres, Tatiane Carneiro Gratão,
Erasmo Simão da Silva, Nelson de Luccia and
Pedro Puech-Leão
HCFMUSP-Hospital das Clı́nicas, Faculdade de Medicina da
Universidade de São Paulo, São Paulo, Brazil
Background: Blunt aortic injury is the leading cause of
death in victims of blunt polytrauma. Pre-hospital mortal-
ity rates approach 85%. Subsequent mortality in non-oper-
ated survivors of 1% per hour for the first 48 hours
is reported.
Aim: To ascertain in hospital and midterm outcomes of
patients with blunt aortic injury admitted to a tertiary
university hospital.
Material & Methods: A retrospective, single center
study emcompassing all blunt aortic trauma patients admit-
ted to HCFMUSP from January 2001 to March 2018 was
conducted. Patientscharts were reviewed for age, gender,
type of trauma, aortic lesion classification (grade I: intimal
tear, grade II: intramural hematoma, grade III: pseudoaneur-
ysm, grade IV: rupture), treatment approach (conservative,
open repair or endovascular repair), associated lesions, in-
hospital outcome (good recover, death, sequels) and
follow-up duration. Trauma and Injury Severity Score
(TRISS), Injury Severity Score (ISS) and Revised Trauma
Score (RTS) were also analyzed. Chest computed tomog-
raphy (CT) scans were reviewed and statistical analysis was
performed using the Fisher Exact test
Results: A total of 63 (92% male, mean age: 34y) patients
were admitted to HCFMUSP for a traumatic aortic injury
during the study time span. The leading cause of injury was
motor vehicle collisions. Median TRISS was 49% (IQR 9–
87%), median RTS was 7.84 (IQR 6.3-7.8). All patients had
ISS over 15 (median 43 IQR 31.5-55.5). The majority
(92%) of patients had associated lesions such as fractures
(77%). Most of the aortic lesions were grade III (54.7%),
1.56% were grade I, 11% were grade II and 32,8% were
grade IV. Most patients underwent endovascular repair
(90%), 8% underwent open repair and 2% conservative
treatment. The median in hospital stay was 11 days (IQR
7–29.5). Mean Intensive care unit stay was 8 days (IQR 3–
23). In hospital motality rate was 15%; deaths were not
correlated with the lesion type or the selected treatment
but with associated injuries. Sixty three percent of the
patients were discharged in good clinical conditions, 14%
had sequels. Paraplegia (28%) was the most common one.
Median follow-up time was 4 years (IQR1-7 years).
Vascular 27(1S)
During the follow-up period, 56% of the patients had
good quality of life, 12% had important sequels and
11,6% died. Most (94,7%) control angioCT scans were
normal. A type Ia endoleak was seen in only one patient.
Conclusion: Patients with blunt thoracic injury are crit-
ical. Endovascular repair proved safe and beneficial in mid-
term follow-up.
SESSION 40: 19149 – ENDOVASCULAR
APPROACH TO RECURRENT UPPER
GASTROINTESTINAL BLEEDING
SECONDARY TO ARTERIO- PORTAL
FISTULA SYNDROME AFTER
PENETRATING ABDOMINAL TRAUMA
Ana Carolina Brito Pavan, Felipe Damascena,
Marcone Lima Sobreira, Carlos Antonio Calamori,
Leonardo Pelafsky, Regina Moura Ceranto,
Winston Bonetti Yoshida,
Karise Naves de Rezende, Arthur Curtarelli,
Rodrigo Gibin Jaldin and Matheus Bertanha
UNESP Botucatu, Botucatu, Brazil
Background: Arterio-portal fistula syndrome (APFS) is a
rare and reversible cause of portal hypertension caused by
communication between a visceral artery and the portal
venous system. Iatrogenic lesions, perforating traumas,
aneurysms and congenital malformations are the most
commom ethiologies. Clinical presentation depends on
the diameter, topography and fistula flow. The majority
of patients is asymptomatic. The most common symptoms
are gastrointestinal bleeding (33%), ascites (26%), conges-
tive heart failure (4.5%) and diarrhea (4.5%). Endovascular
correction is the treatment of choice for symptomat-
ic patients.
Case Description: A 40-year-old skinny male was admit-
ted for recurrent upper gastrointestinal bleeding (UGB),
hyporexia and weight loss. Past medical history included
previous endoscopic treatments for UGB, TIPS implant for
portal hypertension, a penetrating abdominal trauma
(knife) 20 years ago and a left nephrectomy. Physical exam-
ination revealed paleness, tachycardia and a normal blood
pressure. The abdomen was innocent with no signs of liver
disease. He denied alcoholism and had negative serologies
for hepatitis. Abdominal ultrasound demonstrated dis-
crete signs of hepatopathy, a portal vein of increased
dimensions with augmented splenic flow suggestive of
APFS to left renal artery. The APFS was confirmed by
Tomographic Angiography. Upper gastrointestinal endos-
copy diagnosed a hypertensive gastropathy and excluded
bleeding from an active peptic ulcer. The arteriography
also confirmed the hypothesis of APFS and identified the
Abstracts
bleeding site. We opted for endovascular approach with
fistula occlusion with a 14 mm  10 mm vascular plug
system (Lifetech Scientific) inserted in the left renal
artery and embolization of the posterior splenic artery
with two free release coils (14 cmx10 mm, Nester, Cook
Medical). A complete occlusion of the A-P fistula was
achieved and the patient presented symptom improve-
ment with appetite recovery, weight gain and no new epi-
sodes of HDA.
Conclusion: Symptomatic or refractory patients should
undergo interventional treatment Asymptomatic patients
should also undergo treatment to avoid future complica-
tions. The endovascular approach is the treatment of
choice in all cases, including those with high flow APF or
when splenic vessels are involved. Fistula flow and diame-
ter are important for device choice to ensure adequate
A-P communication closure and avoid embolization of
non-target vessels. Small and low flow APF may be treated
with thrombotic or sclerosing agents
SESSION 40: 19162 – ENDOVASCULAR
TREATMENT FOR CHRONIC
TRAUMATIC CAROTID
PSEUDOANEURYSM
Franciele Tibola, Guilherme Gobbi Neto,
José Valério Librelotto Stefanello Ii,
Michelly de Souza Moraes Costa,
Juliana Libman Luft, Lyssa Moretti,
Mauricio de Barros Jafar, Mauri Luiz Comparin and
Isabela Ribeiro Siqueira
Santa Casa de Campo Grande, Campo Grande, Brazil
Background: Carotid pseudoaneurysms are rare and
potentially lethal. Blunt or penetrating trauma, infection,
vasculitis and iatrogeny are the main causes of carotid
pseudoaneurysms. Signs and symptoms include a pulsatile
cervical mass, compression of adjacent structures, bleed-
ing or neurological deficits. Open surgery used to be the
first choice treatment, but has been replaced by the endo-
vascular approach on account of reduced morbidity and
mortality rates associated to this minimally inva-
sive procedure.
Case Description: A 39-year-old single black male was
victim of penetrating trauma at the left cervical region
nineteen years ago. Over the years, he noticed increased
volume of his left cervical region and the appearance of a
pulsatile mass. A pseudoaneurysm of the left common
carotid artery was diagnosed by angiotomography of the
neck and thorax. We opted for endovascular treatment
with Viabahn covered stent (8 mmx5 cm). The procedure
43
was uneventful with complete involution of the cervi-
cal mass.
Conclusion: Treatment of carotid pseudoaneurysms is
always warranted in order to prevent rupture or neuro-
logic sequelae. This case illustrate the use of endovascular
intervention to address carotid pseudoaneurysm in a safe
and user-friendly way.
SESSION 41
TL 14 – VASCULAR TRAUMA 2
BONETE ROOM 15:40 – 16:40
SESSION 41: 19107 –
UNCONVENTIONAL USE OF
ARTERIAL ENDOPROSTHESIS TO
REPAIR ARTERIOVENOUS FISTULA
CAUSED BY FIREARM INJURY TO THE
LOWER EXTREMITY: CASE REPORT
Stela Karine Braun, Lailana Suéling Cavalheiro,
Cristina de Oliveira, Alcides André Dezordi Vogel,
Vinicius Matos Menegola,
João Victor Guimaraes Almeida,
Gustavo Cardena Monteiro,
Gabriela Pereira de Moura,
André dos Santos Cleto and
Luis Guilherme Toledo da Silva
Hospital Universitário de Santa Maria, Santa Maria, Brazil
Background: Arteriovenous fistula (AVF) is an abnormal
communication between an artery and a vein., Penetrating
injuries are the main cause of traumatic arteriovenous
fistula. The endovascular approach is superior to conven-
tional surgery in these cases. Besides being more flexible
and encompassing both diagnostic and therapeutic capa-
bilities, it is associated to lower morbidity and mortality
rates, even in difficult to access areas. Embolization agents
include autologous clots, gelfoam sponges, microfibrillar
collagen, polyvinyl alcohol sponge, springs, detachable
and non-detachable balloons and cyanoacrylate.
Case Description: A 30-year-old male was seen at our
outpatient clinic for edema and persistent pain upon left
lower limb extention Past medical history included a fire-
arm injury to his left lower extremity and an unsuccessful
attempt to correct it 4 years afterwards. A medial malleo-
lus ulcer and skin pigmentation was noted on physical
examination. Computed tomography angiography evi-
denced: 1. diffuse dilation of the external iliac, common
and superficial femoral arteries; 2.arteriovenous fistula of
the superficial femoral vein and artery at the adductor
canal level; 3. dilation of the external iliac and superficial
44
femoral veins near the fistula; 4. diffuse dilation of the deep
and superficial venous systems of the left lower extremity,
5. volumetric enlargement of the left lower limb. The arte-
riography revealed AVF between the femoral artery, the
superficial femoral vein at the adductor canal level and the
proximal the segment of the superficial femoral artery
with increased caliber (estimated diameter between 13
and 14 mm). The left superficial femoral artery was dis-
sected just below the inguinal fold followed by implanta-
tion of 2 iliac extensions (Aorfix – 12  82 mm and
14  82 mm) covering the entire extension of the AVF.
The patient presented complete symptom resolution
and healing of the lower left limb ulcer.
Conclusion: Endovascular approach was fundamental for
the resolution of this case in a safe and user-friendly way.
The use of arterial endoprosthesis was necessary due to
arterial dilatation.
SESSION 41: 19168 –
PSEUDOANEURYSM OF A FEMORAL
ARTERY BRANCH: CASE REPORT
Gabriella Pazzanese Barreira,
Antonio Claudio Guedes Chrispin,
Giulia de Paula Vendramini Ferreira,
Luciana Helena Benatti, Juliana Zavarize,
Amalia Favero, Rafael Caivano and
Otacilio de Camargo Junior
PUC-Campinas, Campinas, Brazil
Background: The significant advance of interventional
medicine over the past decades was accompanied by the
increase in diagnostic and therapeutic procedure options
with complication rates varying from 0.7% to 9%. The esca-
lonating number of interventional procedures was followed
by a raise in the number of complications such as pseudoa-
neurysms, arteriovenous fistulas, hemorrhage, arterial
thrombosis, arterial dissection, nerve and venous compres-
sions. Pseudoaneurysms are the most frequent complication
of interventional procedures. The common femoral artery is
the most commonly affected vessel after diagnostic or ther-
apeutic procedures They can progressively expand to cause
compression of surrounding structures or even rupture.
Pseudoaneurysms more often result from direct, blunt or
penetrating trauma or iatrogenic punctions. Diagnostic
workup include the finding of a pulsatile tumor mass on
physical examination and appropriate signs on imaging
tests. Treatment varies according to symptomatology and
the pseudoaneurysm features ranging from compression
to injection of sclerosing agents and surgical intervention.
Case Description: A 69-year-old female underwent car-
diac catheterization for chest pain and hypertensive crisis.
Vascular 27(1S)
Two hours after the procedure the patient complained of
pain and noted an abdominal mass. Contained extravasa-
tion of contrast media not far from the vascular access
was demonstrated at the angio CT scan and raised the
suspicion of an iatrogenic pseudoaneurysm formation.
We opted for open surgery to be able to identify the
lesion site. Bleeding was noted on a branch of the external
iliac artery and immediate vessel interruption
was undertaken.
Conclusion: The current case illustrates the increase in
iatrogenic complications in association to the increased
number of interventional procedures and highlights the
need for conventional surgery in some cases.
SESSION 41: 19194 – COMPARISON OF
ENDOVASCULAR AND SURGICAL
OUTCOMES FOR TRAUMATIC
INJURIES OF THE
SUBCLAVIAN ARTERY
Vitor Moron de Andrade, Flavio Henrique Simeão,
Rebecca Marcelino Ribeiro,
Barbara Cozaro Valentini, Rafael Caivano,
Mariana Greccho Nunes,
Gabriella Pazzanese Barreira,
Giulia de Paula Vendramini Ferreira,
Glauber Rielli, Juliana Zavarize,
Vitor Dincão Sanches, Marina Trino de Moraes,
Gabriel Viarengo and Otacilio de Camargo Junior
PUC-Campinas, Campinas, Brazil
Background: Traumatic injuries of the subclavian artery
represent a diagnostic challenge on account of the occult
nature of the lesion. A high index of suspicion is required
for prompt diagnosis and timely treatment. Diagnostic and
treatment delay corroborate the high mortality rates
reported in these cases. Treatment choices include open
surgery or endovascular procedures.
Case Description: Five patients underwent surgical
treatment for subclavian artery trauma. Two of them,
underwent conventional surgery, one with saphenous
vein replacement due to loss of an arterial segment and
the other due to resection of the part of the artery injured
by gunshot. Three patients were submitted to endovascu-
lar surgery. Case 1: A 76-year-old male presented an acute
left upper limb occlusion following a pharyngolaryngoeso-
phagectomy. A successful embolectomy of the left upper
extremity was carried out. A pulsatile mass was observed
on the territory of the left subclavian artery, three days
afterwards. Thoracic angiotomography confirmed a pseu-
doaneurysm (3.9  1.3 cm). The patient underwent endo-
vascular treatment with stent implant (VIABAHNVR ,
Abstracts
11 mmx50 mm, WL GORE) with complete resolution of
the lesion. Case 2: A 44-year-old male who fell off from a
six-meter-high platform was admitted to the Emergency
Unit for a right hemothorax and exposed humerus frac-
ture. Pulses were symmetrical at admission but left upper
limb ischemia was noted 24 hours later. Doppler ultraso-
nography evidenced absence of flow in left subclavian and
distal arteries. Occlusion of left subclavian artery, without
contrast leakage was demonstrated at arteriography. The
endovascular repair with stenting was uneventful with
complete patient recover. Case 3: A 46-year-old male
was submitted to a thyroidectomy for a neoplastic lesion
surrounding the right subclavian artery (RSA). This artery
was injured in two different spots, 5 mm distant from each
other, during surgery. He underwent revascularization
with end-to-end anastomosis. On the first postoperative
day his right arm was pulseless with signs of ischemia.
Arteriography revealed oclusion of the RSA. A distal
access was attempted through brachial catheterization
without success. Neck incision was reopened and the
guidewire advanced through the lesion by direct view
and fluoroscopy. A 100  8 mm VIABAHNVR endoprosthe-
sis (WL GORE) was successfully placed on the RSA.
Conclusion: The five patients had satisfactory results,
with return of the distal pulses. Endovascular repair is a
less invasive procedure in comparison to conventional sur-
gery and promotes faster postoperative recovery, reduc-
ing patient hospitalization time. The endovascular treat-
ment of subclavian artery lesions can be safely performed,
representing in a valid alternative to open surgery.
SESSION 42
TL 15 – PERIPHERAL ANEURYSMS 2
BONETE ROOM 16:50 – 17:50
SESSION 42: 19060 – CORRECTION OF
RUPTURED FEMORAL ARTERY
PSEUDOANEURYSM
Ronald Luiz Gomes Flumignan,
Luis Carlos Uta Nakano,
Jorge Eduardo de Amorim,
Vladimir Tonello de Vasconcelos,
Gabriel Cambraia Pereira,
Antonio Carlos Moura da Silva,
Brena Costa dos Santos, Daniel Hachul Moreno
and Henrique Jorge Guedes Neto
UNIFESP, São Paulo, Brazil
Background: Vascular surgeons are progressively opting
for the endovascular approach because of its advantages
45
(shorter hospitalization time, reduced postoperative pain
and use of local anesthesia, to list only a few) over the
conventional approach. Therefore, the increased number
of minimally invasive procedures has contributed to raise
vascular complications such as false aneurysms. A pseu-
doaneurysm is a pulsating hematoma that is limited by the
vessel adventitia or by the tissue surrounding the artery, a
communication with the vessel lumen is maintained
through the arterial wall. It is most commonly found as
a complication of percutaneous femoral artery access
during endovascular procedures. The incidence of femoral
artery pseudoaneurysm nears 1% after angiograms and
may reach up to 8% after therapeutic endovascular pro-
cedures. It occurs more frequently after complex and
longer procedures with aggressive anticoagulation therapy
or coagulopathy. Doppler Ultrasonography is the method
of choice for diagnosing this medical condition. It also
keeps good accuracy in the evaluation of the related com-
plications (anemia, compressive neuropathy, venous
thrombosis, critical limb ischemia, skin necrosis, infection
and rupture).
Case Description: An 81-year-old female complaining of
right thigh enlargement was diagnosed with a pseudoa-
neurysm of the right femoral artery by ultrasonography.
After a failed attempt for endovascular repair, we opted
for conventional surgery with ligature of the femoral
artery without compromising the limb perfusion. Cardiac
surgery and systemic heparinization was performed
because of a pedicled thrombus in the aortic arch. The
patient had a hemorrhagic stroke but is stable from the
vascular standpoint of view
Conclusion: Prompt surgical approach for femoral artery
pseudoaneurysm rupture is mandatory for limb
preservation.
SESSION 42: 19140 – ENDOVASCULAR
MANAGEMENT OF INTERNAL ILIAC
ARTERY ANEURYSM WITH
PRESERVATION OF THE BOTH
INTERNAL AND EXTERNAL ILIAC
ARTERIES: CASE REPORT
Lais da Cunha Gamba, Andre Estenssoro,
Priscilla Matos and Marina Farjallat
Hospital Sı́rio Libanês, São Paulo, Brazil
Background: Isolated aneurysms of the internal iliac
artery are a rare variant of aorto-iliac aneurysm disease.
Seventy percent of the iliac aneurysms occur in the
commom iliac artery, while 20 and 10% are found in the
internal and external iliac arteries respectively. Two thirds
have involvement of more than one segment of the iliac
46
tree and one third are bilateral. Rupture occurs in up to
38% at initial presentation with a 58% mortality rate. The
endovascular technique represents a minimally invasive
option for elective corrections, with low mortality and
morbidity rates. Anatomic challenges and device limita-
tions are some drawbacks of this technique. We present
the case of an internal iliac aneurysm with artery dissec-
tion treated with endovascular technique with a bifurcated
iliac device and preservation of both external and internal
iliac arteries.
Case Description: A 59-year-old asymptomatic male
was diagnosed with a common iliac artery aneurysm in
routine imaging exams. Past medical history included pre-
vious smoking and a family history of infrarenal abdominal
aortic aneurysm. CT-scan evidenced a 25 mm right
common iliac artery and a dissected 30 mm left common
iliac artery. internal and external left iliac arteries were
16 mm in diameter. We chose to treat only the left iliac
artery because of the size and the dissection. A bifurcated
iliac device was inserted through ipsilateral and contralat-
eral accesses with preservation of both internal and exter-
nal left iliac arteries and supported in the left common iliac
artery. We opted not to extend it to the infrarenal abdom-
inal aorta. The procedure was uneventful and the patient
discharged without complaints. Follow-up one-month CT-
scan at showed the correct placement of the endopros-
thesis and no sign of endoleak.
Conclusion: We believe preservation of the internal iliac
arteries should always be attempted. The current proce-
dure allow for other endovascular procedures should the
contralateral internal iliac aneurysm grow or a new aortic
aneurysm appear.
SESSION 42: 19202 – EVAR FOR
ISOLATED COMMON ILIAC ARTERY
ANEURYSM WITH BRANCHED
DEVICE (IBD)
Gusthavo Tomasi Perin, Fausto Miranda Junior,
Camila Kolber Del Priore,
Fernanda Federico Rezende,
Fernanda Telles Sales, Pamela Rodrigues de Souza,
Clisse Michelle de Sá Rodrigues,
Roger André Molina Claros,
Diego Nicacio de Brito,
Douglas Leopoldino de Amorim,
Matheus Trigo Carim and Armando C. Lobato
ICVE-SP – Instituto de Cirurgia Vascular e Endovascular de São
Paulo, Brazil
Background: Isolated aneurysms of the iliac arteries are
a rare occurence. A degenerative process of the vascular
Vascular 27(1S)
wall is the cause in the majority cases. Patients are usually
asymptomatic and diagnosed during routine imaging tests.
Symptoms include pain, compression of neighboring
organs, thrombosis and distal embolization. Elective surgi-
cal approach is the treatment of choice. It is indicated for
symptomatic patients and for those with common iliac
artery aneurysms larger than 2.5 cm or with rapid
growth (5 mm in six months). The large aneurysm size
at diagnosis, the deep location in the pelvis are associated
to high risks of bleeding, injury of adjacent vessels and of
the urinary tract during open surgery. Higher mortality
rates are reported for surgery in the urgent setting.
Case Description: A 54 year-old male, diagnosed with
left common iliac artery aneurysm, was under follow-up at
our Vascular Clinic. He complained of diffuse abdominal
pain over the previous week that subsided with simple
oral analgesia. Twenty-four hours later, he developed
worsening pain and sought medical attention at the emer-
gency department. Intravenous analgesia did not help. The
angiotomography demonstrated a 5 mm growth in the
past 4 months. He was admitted to the Intensive Care
Unit for analgesia optimization and careful treatment plan-
ning. An iliac branch device was placed in the left internal
iliac artery. The procedure was uneventful. The six-month
control angiotomography revealed the aneurysm exclu-
sion and a patent hypogastric artery.
Conclusion: This report aims to show that endovascular
treatment of common iliac artery aneurysms with IBD is
safe, feasible and effective.
SESSION 42: 19205 – ENDOVASCULAR
REPAIR OF ISOLATED COMMON ILIAC
ARTERY ANEURYSM BY THE
CHIMNEY TECHNIQUE
José Reginaldo Simão, Silvia Elena Ferreira and
Mario Luiz Simonetto Pereira
Hospital Albert Sabin, Bragança Paulista, Brazil
Background: Isolated common iliac artery aneurysm
correspond to only 7% of all intra-abdominal aneurysms.
Rupture is the major complication, occuring in up to 38%
of the cases at the initial presentation. Mortality rate is as
high as 58% in these cases. Surgery is indicated when aneu-
rysm diameter reaches 2,5 to 3.0 cm. Intraoperative injury
of the iliac veins an/or the ureters are complications of
surgical intervention. Endovascular solutions for isolated
common iliac aneurysm are associated to good results,
lower mobidity and mortality rates. The sandwich tech-
nique introduced by Lobato et cols in 2008, has the advan-
tage of preserving the internal iliac artery flow, avoiding
colonic ischemia, buttock claudication and impotence.
Abstracts
Case Description: A 51-year-old male in good health
and a 27 mm asymptomatic common iliac artery aneu-
rysm, diagnosed in a routine CT for lumbar pain investi-
gation, was seen at our vascular clinic. The angio CT
measures were: CIA length – 4,5 cm, a proximal neck
length of 2,0 cm and diameter: 11 mm in; IIA diameter –
6,3 mm; EIA diameter -10,8 mm. The patient was treated
using endovascular chimney technique. We used a viabahn
endoprosthesis in the internal iliac artery and a viabahn
iliac branch device to cover the common end external iliac
arteries. The access for the internal iliac artery was
through the left brachial artery using a 0,35 mm hydrophil-
ic super stiff amplatz guide wire and destination sheath.
For the common iliac artery, we opted for dissection of
the common femoral artery, using an 11 cm introducer
sheat, terumo stiff guide wire, centimeter pigtail catheter
and amplatz super stiff guide wire. The result was the
complete revascularization of CIA, EIA and IIA without
endoleak. Ballooning was not necessary. The patient was
maintained using double antiplatelet therapy with aspirin
and clopidogrel. The patient is currently at the six-month
follow-up visit and the CT scan demonstrates patent iliac
arteries, no endoleak or stenosis.
Conclusion: We understood a proximal neck of 2 cm
was able to support the anchorage of two endoprothesis.
The parallel stent technique can be used for the treatment
of iliac artery aneurysms in an easy and cost wise way.
SESSION 56
TL 16 – MISCELLANIA
KIRRA ROOM 09:30 – 10:37 AM
SESSION 56: 19040 – MEDIAL
CALCINOSIS IN A NON-DIABETIC
PATIENT WITH NO CHRONIC
KIDNEY DISEASE
Otacı́lio Figueiredo da Silva Júnior1,
Ana Beatriz Paraguay Figueiredo2 and
Antônio Carlos de Araújo Neto1
1
Universidade Federal da Paraı́ba, João Pessoa, Brazil
2
Faculdade de Ciências Médicas da Paraı́ba, Cabedelo, Brazil
Background: Medial Calcinosis is caused by hydroxyap-
atite deposit in the tunica media layer of peripheral and
visceral arteries. Medial calcinosis is more frequent in
Chronic Kidney Disease (CKD) or in Diabetes Mellitus
patients. Pathophysiology is not fully elucidated.
Activation of Runx2 gene and Bone Morphogenetic
Protein expression associated with the Gla Protein
Deficiency of the Matrix are the most common triggers.
47
Case Description: A 57-year-old non-diabetic male,
with preserved renal function, underwent an x-ray in
2006 to investigate a possible fracture of the right ankle.
Abnormal radiopaque vessels were detected, suggesting
high vascular calcification. Family history elicited 1st to
3rd grade relatives with bone disease. The patient was
reffered to our Vascular Clinic and the following exams
were request: Computed Tomography (CT) of Chest with
Calcium Score, of the Neck, Upper Abdomen, Pelvis and
Lower Limbs, Color Doppler of the Carotid and Vertebral
Arteries and laboratory tests. The calcium Scoring Chest
CT showed a score of 451.13 (high risk according to the
Agatston Protocol) deposited in the arterial smooth
muscle. Idiopathic Medial Calcinosis was diagnosed. The
patient looked for a second opinion at the nephrologist,
endocrinologist and cardiologst. He was put on a restrict-
ed diet and medication to treat dyslipidemia. Imaging tests
were repeated several times during the follow-up visits
without significant changes in vessel lumen diameters.
Last calcium score though, was 1,227.14.
Conclusion: This abstract reports a rare presentation of
medial calcinosis, not accompanied by diabetes mellitus or
chronic kidney disease and the evolution along the years.
Family history of bone disease may indicate a possible
genetic transmission of calcium deposition in the
vascular bed.
SESSION 56: 19042 – HEMOSTASIS BY
COMPRESSION FOR PERCUTANEOUS
PROCEDURES OF VALVULAR AND
ENDOPROSTHESIS IMPLANTS
Pablo Alejandro Marina, Marcelo Pettinari,
Roberto Diaz, Miguel Segovia and Thomas Jorge
Sanatorio Modelo Burzaco, Argentina
Background: Opening of the femoral camera and use of
percutaneous vascular closure systems for valvular and
endoprosthesis endovascular procedures are associated
to higher morbidity rates. Wound care and infection are
of great concern.
Aim: To describe a technique of hemostasis by compres-
sion to be used for endovascular procedures for valvular
and endoprosthesis implant.
Material & Methods: Eight cases of percutaneous aortic
valve and endoprosthesis performed without opening of
the femoral camera and without the use of percutaneous
closure systems, carried out in our center, are described.
The technique include puncture and progressive dilatation
of the femoral artery and adjacent tissues with dilatators
of 8, 12, 14 and 17 french. This allows for aortic valve or
endoprosthesis implant without complications.
48
The patient is followed-up at an intensive care unit and the
16 or 17F introducer is exchanged for a 14 F with com-
pressive bandage. After an hour the 14F introducer is
removed. The patient is left in observation for 24–72 hs,
depending on his clinical evolution. The patient is seen
after a week and a detailed doppler USG of the femoral
camera is performed at 30 days of the procedure
Results: No complications were observed at the punc-
ture site during hospital stay, or at the 1-week and the
one-month follow-up visits.
Conclusion: Percutaneous implantation of aortic valve
and endoprosthesis can be safely performed with the tech-
nique described, without the need for dissection of the
femoral access or usage of expensive vascular closure sys-
tems. Further research is warranted to validate the pro-
posed technique.
SESSION 56: 19051 – EVALUATION OF
THE TEACHING METHODS FOR
BLOOD GASOMETRY COLLECTION
DURING MEDICAL COURSE
Luis Carlos Uta Nakano, Osias Martins Prestes,
Vinicius Bignatto Carvalho,
Henrique Jorge Guedes Neto,
Ronald Luiz Gomes Flumignan,
Wellington Gianotti Lustre,
Luiz Gustavo Perez Vasquez,
Vladimir Tonello de Vasconcelos,
Ana Alyra Carvalho,
Matheus Giovanni Medina Molina and
Jorge Eduardo de Amorim
UNIFESP, São Paulo, Brazil
Background: The growing number of medical schools in
the country is a concern in terms of the quality of the
egress. The Ministry of Education under the supervision of
the Federal Medical Council and the Scientific Council of
the Brazilian Medical Association are in charge of moni-
toring the educational activities of all medical training insti-
tutions in the country. The continental dimensions of our
country though, is of great concern in this regards. One of
the forms to control medical graduate skills is to perform
periodic skills tests. At UNIFESP, the skills tests are applied
to 4th and 5th grade medical students. We test for medical
skills that are mandatory for all generalist physicians.
Aim: To ascertain the need for testing medical skills
during medical course.
Material & Methods: The skill test applied consisted of
collecting an arterial blood sample for gas analysis. The
test was applied to 5th grade medical students. A simula-
tor for arterial blood sample collection at the radial artery
Vascular 27(1S)
was used. An actor played the role of a patient. Medical
student were tested not only for their posture in relation
to the “patient” but also for their medical skills in arterial
blood sampling. The analyzed parameters included: 1.
Ethics: presentation and application of authorization to
perform the procedure, 2. Technical parameters: device
choice, technique and safety issues
Results: A total of 110 5th grade medical students (56
males and 54 females, mean age: 26 years (range:24-28
years) were enrolled. Regarding the ethical parameters,
97% of the students responded to all checklist items (pre-
sented, asked the patient’s name, explained the procedure
and asked for authorization to perform the procedure).
Regarding the appropriate device choice, 85% chose the
appropriate items for the procedure (syringe, needle, hep-
arin). In regads to safety issues, only 43% of the medical
students remembered the Allen’s maneuver or performed
it correctly. Regarding the collection technique, 75% were
able to correctly collect the sample for the test.
Conclusion: The skills test results point out flaws in the
teaching methods for blood gas sampling in our Institution.
Confirmation of palmar arch patency (Allen’s maneuver)
prior to sampling was not performed by the majority of
the participants. This data led to the reformulation of the
teaching methods for arterial blood gas sampling
at UNIFESP.
SESSION 56: 19065 – COMPARISON OF
CENTRAL VENOUS PUNCTURE
TECHNIQUES: ULTRASOUND-
GUIDED  ANATOMIC LANDMARK
Luis Carlos Uta Nakano,
Antonio Carlos Moura da Silva,
Beatriz Urbani Pessutti,
Patrick Israel Fligelman Kanas,
Vinicius Bignatto Carvalho,
Rebeca Mangabeira Correia,
Brena Costa dos Santos,
Ronald Luiz Gomes Flumignan,
Jorge Eduardo de Amorim and
Henrique Jorge Guedes Neto
UNIFESP, São Paulo, Brazil
Background: Central venous access is one of the most
frequently performed procedures in the emergency
departments and intensive care units. All physicians
should be familiarized with the available techniques for
the sake of patient’s safety. The internal jugular vein
access is the most commonly used of all central vein
accesses. Many techniques have been described, varying
from direct puncture to surgery. Direct puncture can be
Abstracts
guided by ultrasound or by anatomic landmarks. Recent
trials recommend the use of ultrasound guidance for all
central venous access to reduce complication rates.
Aim: This study aims to compare ultrasound-guided cen-
tral venous puncture versus non-guided technique (ana-
tomic landmark)
Material & Methods: One hundred medical students
were randomized to ultrasound-guided  anatomic land-
mark technique for central venous access at the internal
jugular vein. All of them attended the exposure class and
the practical training using simulators. The number of
attempts to achieve central vessel access was the primary
endpoint.
Results: A total of 100 6th grade medical students (56
men and 44 women, mean age: 27 years (range: 25 to 31
years) were enrolled in this study. Eight students had
already performed the procedure in patients and were
excluded from the analysis. Randomization was applied.
Forty five 6th graders first performed the ultrasound-
guided technique and then the anatomic landmarks tech-
nique while the remaining 47 medical students first per-
formed the anatomic landmarks technique and then the
ultrasound-guided technique. The number of attempts to
achieve the vessel puncture was remarkably different
among the two techniques. A mean of 1.3 attempts
(range 1 – 3) for the ultrasound-guided technique and of
5.2 attempts (range 2 – 8) for the anatomic land-
marks technique.
Conclusion: The use of ultrasound guidance for central
venous access significantly reduced the number of
attempts necessary for a successful access. This will cer-
tainly enhance patients safety and contribute to reduce
associated morbidity and mortality rates.
SESSION 56: 19129 – SURGICAL
TREATMENT FOR POSTOPERATIVE
LYMPHOCELE REFRACTORY TO
ULTRASOUND-GUIDED
POLIDOCANOL FOAM INJECTION
Régis Fernando Angnes,
Luciano Amaral Domingues,
Charles Andre Berres and Francelle Miletho Silva
Blanc Hospital, Porto Alegre, Brazil
Background: Postoperative lymphocele is a rare and
potentially serious complication. The extravasated lymph
is initially contained by neighboring tissues. The generated
inflammatory process causes the formation of a capsule
around it, giving rise to a lymphocele. An increase in lym-
phatic pressure, followed by inflammation and eventually
infection can lead to progressive volume increase.
49
Treatmet is imperative at this point. No consensus have
been reach regarding the preffered approach to lympho-
cele. Treatment ranges from compressive therapy alone or
combined with injection of sclerosing agents or glues to
surgical resection.
Case Description: A 43-year-old female with a history
of bariatric surgery 6 years ago, underwent a series of
plastic surgeries (abdominoplasty, mammoplasty with
breast implant and medial thighplasty) 6 months ago. A
revision medial thighplasty with external drainage for 30
days was undertaken to treat a recurrent “seroma”
formed in the distal portion of the right thigh. Lymph
was identified at the drainage flask. Needle aspiration
combined to inelastic compression therapy, manual lym-
phatic drainage and myolymphokinetic activities was insti-
tuted for about 10 days. A significant bulging appeared in
the distal medial part of the right thigh and was diagnosed
as a lymphocele. Four attempts for lymphocele occlusion
were made by the the injection of 20 ml of microfoam
made of 1% polidocanol in the first procedure and 3% of
polidocanol in the last 3 procedures. These attempts were
combined with inelastic compressive therapy, manual lym-
phatic drainage and myolymphokinetic activities with no
improvement. A guided surgical intervention with intra-
operative lymphochromia was undertaken. Three ml of
toluidine blue at 11% was injected in the first interdigital
space of the right foot, followed by direct lymphocele
incision. Dye leakage was identified through numerous
subdermal lymphatic vessels during the procedure.
These vessels were sutured. On the second postoperative
day, leakage of a small volume of a bluish fluid was identi-
fied on the surgical incision and a new suture was per-
formed. Lymphorrhea decreased until ceasing on the
tenth postoperative day with inelastic compres-
sive treatment.
Conclusion: Surgical treatment combined to inelastic
compression may be the last resource in refractory
cases. This treatment proved efficient in the
reported case.
50
SESSION 57
TL 17 – VENOUS DISEASE 2
KIRRA ROOM 10:40 – 11:52 AM
SESSION 57: 19200 – ILIOFEMORAL
RECANALIZATION
Fausto Miranda Junior,
Clisse Michelle de Sá Rodrigues,
Armando C. Lobato, Roger André Molina Claros,
Pamela Rodrigues de Souza,
Diego Nicacio de Brito, Matheus Trigo Carim,
Gusthavo Tomasi Perin,
Douglas Leopoldino de Amorim,
Fernanda Federico Rezende, Fernanda Telles Sales
and Camila Kolber Del Priore
ICVE – Instituto de Cirurgia Vascular e Endovascular de São
Paulo, São Paulo, Brazil
Background: Deep venous thrombosis (DVT) occurs at
an annual incidence rate of 1 per 1000 adults. This rate
increases sharply after the age of 45 years, reaching
5–6 per 1000 adults by the age of 80. Chronic venous
insufficiency (post-thrombotic syndrome) and pulmonary
embolism are the most common complications of this dis-
ease. Treatment goals are to prevent recurrences and
avoid complications. Pharmacological as well as non-phar-
macological treatment options are available, including
early thrombus removal with different percutane-
ous techniques.
Case Description: A 40-year-old male was admitted to
the emergency room complaining of pain and edema in his
right lower limb (RLL), developing after blunt trauma.
Acute venous thrombosis of the common femoral and
femoral veins as well as of the popliteal vein above and
below the knee was diagnosed at a Doppler ultrasound.
Pharmacological treatment with low molecular weight
heparin and oral warfarin was initiated in another hospital.
The patient presented pulmonary thromboembolism two
days afterwards, but the assisting physician decided for
maintenance of conservative treatment. After hospital dis-
charge, the patient looked for a second opinion at our
institution. Pain and edema was noted in his right lower
limb. Thrombosis extending from the external iliac to the
popliteal vein was shown in a Doppler ultrasound.
Pharmacomechanical thrombectomy of the entire throm-
bosed segment was performed through the saphenous
vein. Control venography revealed complete recanaliza-
tion of the treated venous segments with functioning
valves. We opted not to release a venous stent in the
treated area. Immediate regression of edema and pain
(12 hours) was observed. Hospital discharge occurred in
the 5th PO day with INR of 3.5. Follow-up control
Doppler ultrasonography was performed at 30 and 120
Vascular 27(1S)
days revealing complete patency of the iliofemoral and
popliteal segments.
Conclusion: We report a case of deep venous thrombo-
sis of the iliofemoropopliteal segments submitted to phar-
macomecanical thrombectomy, without the use of venous
stent. Early treatment institution is the key for successful
venous recanalization and maintenance of valvu-
lar function.
SESSION 57: 19195 – CLINICAL
MANIFESTATIONS AND TREATMENT
OUTCOMES OF RETROPERITONEAL
VENOUS STENOSIS (RVS): A SINGLE
CENTER PROSPECTIVE STUDY
Paulino Gomes de Souza Neto
Clı́nica Privada, São Paulo, Brazil
Background: The Chronic Venous Insufficiency (CVI) is a
cosmopolitan high prevalent disease. Reported recurrence
rates after varicose veins surgery vary from 1,8% to 60% in
5 years. Some of those patients were initially diagnosed as
CVI secondary to left common iliac vein compression.
Treating patients with acute deep venous thrombosis or
CVI is associated to improvement of pelvic symptoms. My
personal observation is that symptoms coincide with the
location of collateral circulation
Aim: To answer the following questions: 1. Are those
collaterals associated to the symptoms or is it just a coin-
cidence? 2. Can I downsize the pelvic symptoms just by
performing the Iliac Vein angioplasty alone, without the
need of pelvic varices embolization?
Material & Methods: This single center prospective trial
was conducted in our Vascular Clinic from January 2007 to
December 2018. A total of 193 patients with Iliac Vein
Stenosis and indication for angioplasty due to CVI C3 to
C6 or DVT were enrolled. Angiography was performed
before and after stenting Patients were questioned about
pelvic symptoms (neurologic, orthopedic, gynecologic, uri-
nary and venous) before and at least 30 days after vein
stenting. Statistical analysis included previous symptoms,
collateral circulation and relief of symptoms. Allergic
patients were excluded.
Results: Lumbar symptoms were the most prevalent
symptom, occurring in 65,03% of the patients, followed
by gynecological in 53,99%, urinary in 17,18% and neuro-
logical in 7,98%. The presence of gynecological symptoms
predicted uterine varices in 80% and sacral varices in
62.14%. Urinary symptoms predicted Uterine varices in
73.68% and vesical varices in 36.84% of the cases.
Lumbar symptoms predicted pre-sacral varices in 69,81%
and uterine varices in 48.11%. Neurologic symptoms
Abstracts
predicted medullary varices in 53,85% and uterine varices
in 46,15%. I addition, they predicted the absence of
ascending lumbar vein in 97.33% of the patients.
Conclusion: RVS develop signs and symptoms related to
other medical specialties. Their manifestations, although
pleomorphic, are predictable and can be related to the
topography of the developed collateral circulation
Treatment of the stenosis alone without varices emboliza-
tion is enough to control the symptoms except in May-
Thurner Syndrome.
SESSION 57: 19201 – PORTAL VEIN
THROMBOSIS AND INTERVENTIONAL
THERAPY WITH ANGIOJETVR
João Antonio Corrêa,
Leonardo Cardoso Bringel de Olinda,
Marcel Gutierrez, Gustavo Lamy,
Rafaella Elias Bosco and Rafaella Elias Bosco
FMABC, Brazil
Background: Incidence of Portal Vein Thrombosis (PVT)
is higher in patients with cirrhosis, hepatobiliary cancer
and abdominal infection. PVT is a rare medical condition
otherwise. This case report describes PVT in a patient
without any risk factors as well as the selected treatment
approach.
Case Description: A 69-year old male was admitted to
the emergency department with severe abdominal pain in
right upper quadrant, tachypnea and dyspnea and edema of
the lower limbs. No signs of deep venous thrombosis
were detected. The patient denied smoking and alcohol-
ism. Past medical history included: advanced prostate
cancer and chronic atrial fibrillation. Portal vein thrombo-
sis was diagnosed at MRI and Doppler USG of the abdo-
men. Laboratory tests were indicative of liver damage.
Anticoagulation with clexaneVR and antibiotic therapy for
the treatment of nosocomial pneumonia were adminis-
tered. A mechanical thrombectomy with Angiojet device
and thrombolytic therapy was introduced because of
worsening of the hepatic function. Intraoperative improve-
ment of the portal circulation and significant thrombus
dissolution was achjeved but the patient evolved to hem-
orrhagic shock and death.
Conclusion: Thrombosis is the second cause of death in
cancer patients. Prostate cancer is not a serious risk factor
for this type of thrombotic condition Local infusion of
thrombolytic agents provides resolution of thrombi with
a low risk of bleeding. AngioJet is one of the most com-
monly used pharmacomechanical thrombectomy devices.
51
SESSION 57: 19206 – RECANALIZATION
OF OCCLUDED COMMON ILIAC VEIN
STENT IN COCKETT’S SYNDROME
Fernanda Telles Sales,
Fernanda Federico Rezende,
Gusthavo Tomasi Perin,
Douglas Leopoldino de Amorim,
Matheus Trigo Carim, Pamela Rodrigues de Souza,
Roger André Molina Claros,
Diego Nicacio de Brito,
Clisse Michelle de Sá Rodrigues,
Camila Kolber Del Priore, Fausto Miranda Junior
and Armando C. Lobato
ICVE – Instituto de Cirurgia Vascular e Endovascular de São
Paulo, São Paulo, Brazil
Background: Iliac vein compression syndrome, also
known as May-Thurner or Cockett’s syndromes, consists
of extrinsic obstruction of the left common iliac vein
(LCIV) by the overlapping right common iliac artery at
the bifurcation, resulting in various clinical manifestations,
including extensive deep vein thrombosis of the ipsilateral
lower limb.
Case Description: A 36 year-old female presented with
past episode of left iliofemoral deep vein thrombosis
(DVT) five years ago, receiving treatment with low-molec-
ular-weigh heparin with good clinical outcome. Imaging
control exams showed vein recanalization. After 4
months, the patient presented with a new episode of
DVT during anticoagulation left therapy. A left commom
iliac vein compression was diagnosed. The patient denied
endovascular treatment at the time being. Fourteen
months ago she was submitted, in another center, to
baloon angioplasty/stent of the left iliofemoral segment
with self-expandable stent 16  140 mm. In December/
2018, she came to our institution complaining of relapsing
symptoms of pain and edema of the left lower extremity.
The initial duplex ultrasound revealed iliofemoral deep
vein thrombosis along with stent occlusion in left
common iliac vein. Phlebography was conducted by a con-
tralateral right common femoral vein approach and an
infrarenal vena cava filter was implanted. Phlebography
showed total occlusion of the previous stent, with its
proximal segment completely collapsed. A pharmacome-
chanical thrombectomy was performed by ipsilateral
approach of the left common femoral vein. A new phle-
bography evidenced stent patency and the collapse of its
proximal extremity. A new proximal stent (12  60 mm)
was placed up to the external iliac vein and another distal
stent (16  80 mm) was implanted 1 cm cranially to the
iliac bifurcation, in the inferior vena cava and below the
previous stent. A control phlebography was performed
after post-ballooning showing the stent patency with no
52
residual stenosis. Patient had complete resolution of pain
and edema 12 hours after the procedure. She maintained
asymptomatic during follow-up, in anticoagulation therapy
with Xarelto (TM). Postoperative angioCT at one-month
revealed no thrombosis or stenosis of the stent and of the
left lower extremity venous system.
Conclusion: The iliac vein stent collapse is an infrequent
complication, which can result in stent thrombosis.
However, its recanalization and pharmacomechanical
thrombectomy is possible, with realignment by endovas-
cular technique. Key-words: iliac vein, thrombosis, endo-
vascular approach, Cockett syndrome.
SESSION 57: 19207 – A NEW PARALLEL
STENT TECHNIQUE FOR
RECANALIZATION OF LOWER
VENACAVA FILTER THROMBOSIS
Douglas Leopoldino de Amorim,
Fernanda Federico Rezende,
Fernanda Telles Sales, Gusthavo Tomasi Perin,
Matheus Trigo Carim, Diego Nicacio de Brito,
Pamela Rodrigues de Souza,
Roger André Molina Claros,
Camila Kolber Del Priore, Fausto Miranda Junior
and Armando C. Lobato
ICVE – Instituto de Cirurgia Vascular e Endovascular de São
Paulo, São Paulo, Brazil
Background: Pulmonary embolism is the most feared
complication of deep venous thrombosis (DVT). The
vena cava filter (VCF) is indicated when anticoagulation
is not feasible. VCF complications can have important
impact on patient’s health requiring prompt intervention.
Case Description: A 58-year-old female was admitted to
the Emergency Unit, complaining of pain and edema of the
lower limbs. Her past medical history included right iliofe-
moral DVT and pulmonary embolism treated with VCF
implant 3 years ago. Anticoagulation was contraindicated
on account of previous resection of a sella turcica tumor.
Extensive bilateral iliofemoral DVT was diagnosed at the
Duplex Scan. Thrombosis of the inferior VCF extending to
the common femoral veins was also confirmed at phlebog-
raphy. A suprarenal inferior vena cava filter was implanted
through a right internal jugular vein access. After a failed
attempt to cross the thrombosis by bilateral femoral
approach, we opted to performed the through-and-
through technique using a guidewire introduced through
a right jugular access, crossing the VC filter and external-
ized through the right common femoral vein. This proce-
dure was repeated for the left common femoral vein.
Pharmacomechanical thrombectomy was employed with
Vascular 27(1S)
successful thrombus removal except for the ones located
in the upper third of the VCF. A pre-dilatation of the VCF
was also conducted without success. Therefore, we opted
for deploying two venous stents starting two centimeters
above the upper portion of the infrarenal VCF and extend-
ing to the bilateral femoral region. Bilateral post-balloon-
ing by the kissing-balloon technique was undertaken in
sequence. Complete patency of both stents was con-
firmed at the control phlebography and migration of the
suprarenal VCF to the superior vena cava, was detected.
The VCF was then successfully withdrawn. Immediate pain
and edema regression were observed in the first postop-
erative hours.
Conclusion: We currently report a new technique to
recanalize previous thrombosis of vena cava filter by com-
bining several endovascular techniques with extensive
pharmacomechanical thrombectomy of inferior vena cava
filter occlusion. Key words: vena cava filter, endovascular,
thrombectomy, venous stent
SESSION 57: 19211 – ENDOVASCULAR
TREATMENT OF MAY THURNER AND
NUTCRACKER SYNDROMES
Augusto da Silva, Claudia Helena Spir Sant Anna,
Sthefano Atique Gabriel and
Camila Bauman Beteli
UNILAGO, São José do Rio Preto, Brazil
Background: Nutcracker syndrome is a medical condi-
tion caused by extrinsic compression of the left renal vein
by the superior mesenteric artery. Clinical manifestations
include back pain, hematuria and pelvic congestion. May
Thurner syndrome, also known as Iliac vein compression
syndrome is a medical condition caused by extrinsic com-
pression of the left common iliac vein by the right
common iliac artery. Discomfort, swelling, pain or signs
of left iliofemoral vein thrombosis are the most common
clinical presentation forms The presence of both syn-
dromes in the same patient is extremely rare.
Case Description: A 27-year-old female was reffered to
our Vasculat Clinic for pain and swelling in her left thigh as
wel as dispareunia and varices in the pubic region over the
past three years. Doppler ultrasound suggested iliac vein
compression. Multislice computed angiotomography, on
its turn, demonstrated compression of the left iliac vein
by the right common iliac artery and compression of the
left renal vein by the superior mesenteric artery. This
imaging test confirmed the suspicion of combined May-
Thurner and Nutcracke syndromes Endovascular
approach with stenting of the iliac and the renal veins
was carried out.
Abstracts
Conclusion: May-Thurner syndrome is caused by com-
pression of the left common iliac vein by the right
common iliac artery. It is not an infrequent source of
venous abnormalities in the left lower extremity. The
overlying artery appears to induce a partial obstruction
of the vein in two ways: by its anatomic orientation with
subsequent physical entrapment of the left common iliac
vein, and by extensive intimal hypertrophy of the vein
resulting from the chronic pulsatile force of the right
53
common iliac artery. This condition has been estimated
to occur in 2–5% of patients who undergo evaluation for
lower extremity venous disorders. When associated to
Nutcracker syndrome the treatment became a challenge
to the endovascular surgeon. In recent years, treatment
with endovascular techniques has been described for both
venous compressions and excellent short-term results
with venous stent placement have been reported either
in case reports and in small series
54
Author Index
A Artur Naddeo Junior; 27
Adamastor Humberto Pereira; 7, 8,
9, 16
Adriano Angelo Cintra; 22
Alberto Vescovi; 24
Alcides André Dezordi Vogel; 43
Alexandre Petnys; 28
Alexandre Araújo Pereira; 7, 8,
9, 16
Alexandre de A. Melo; 11
Alexandre Inacio Moreira
Coutinho; 19
Alexandre Petnys; 28
Alexandre Rocha Dietrich; 28
Aline Meira Martins; 28, 31
Amalia Favero; 44
Ana Alyra Carvalho; 12, 15, 20, 36,
38, 48
Ana Beatriz Paraguay
Figueiredo; 47
Ana Carolina Brito Pavan; 42
Ana Clara Alves Costa; 31
Ana Lı́gia de Barros Marques; 26
Ana Letı́cia Alves Barbosa; 16, 40
Ana Letı́cia Luchiari Ferrari; 15, 23
Ana Lı́gia de Barros Marques; 26
Ana Maria Monteiro Chagas; 18
Ana Victoria Pontes de
Azevedo; 22
André Luiz de Oliveira; 23, 29
Andre dos Santos Cleto, 22
Andre Estenssoro; 13, 26, 37, 45
André M. Chacon; 11
André Luiz de Oliveira; 23, 29
Andre Meirelles; 22
Andre Reitz Silvestri da Costa; 35
Anna Paula W. Baptista; 11
Antônio Carlos de Araújo Neto; 47
Antonio Carlos Moura da Silva;
12, 22, 24, 37, 45, 48
Antonio Claudio Guedes
Chrispin; 44
Antonio Jose Nascimento; 30
Armando Aldassoro; 34
Armando C. Lobato; 3, 21, 31, 32,
41, 46, 50, 51, 52
Arno Von Ristow; 24
Arthur Cristiano Baston; 12, 34
Arthur Curtarelli; 42
Asdrubal Marquez Tomaz; 33
Augusto da Silva; 36, 52
B
Barbara Cozaro Valentini; 44
Beatriz Périco Silveira; 20
Beatriz Urbani Pessutti; 4, 5, 12,
15, 37, 48
Bernardo Massière; 24
Bianca Giannetti Moraes; 12
Brena Costa dos Santos; 36, 38,
45, 48
Bruno Demier; 24
Bruno Pagnin Schmid; 6, 31
C
Caio Augusto de Souza; 34, 37
Caio Cesar Bovo Delfino; 12
Calogero Presti; 5, 39
Camila Bauman Beteli; 36, 52
Camila Bento Soares; 37
Camila Kolber Del Priore; 21, 32,
41, 46, 50, 51, 52
Camila M. Sartori; 5
Carlos Alberto Castro Teixera
Junior; 36
Carlos Antonio Calamori; 42
Carlos Diego Ribeiro Centellas; 23
Carlos Eduardo Zanoni
Consolo; 13
Carlos Sassi; 14
Carolina B. Faustino; 5
Carolina Dutra Queiroz
Flumignan; 8, 22
Carolina Lourenço Gomes Eccard;
29, 30
Carolina Mardegan; 11
Carolina Martines Estrutti; 4, 5, 15,
27, 36, 37
Caroline Vilela Marin; 17
Cassia Yumi Yamamoto Takano;
15, 23
César Amorim Pacheco Neves; 29
Charles Andre Berres; 49
Clara Cardoso Franco Avancini; 37
Claudia Guimarães Agle; 29
Claudia Helena Spir Sant Anna;
36, 52
Cledicyon Eloy da Costa; 9
Vascular 27(1S)
Clisse Michelle de Sá Rodrigues;
21, 32, 41, 46, 50, 51
Cristiane Antequeira Maran; 19, 33
Cristina de Oliveira; 43
D
Dalila Barbosa Delfino; 16, 40
Daniel Barreto Gomes; 10
Daniel Einstoss Korman; 14
Daniel Hachul Moreno; 12, 34, 45
Daniel Leal; 24
Daniel Simões Castro; 28, 40
Danilo Heringer Alcure Quarto;
11, 18, 35
Dejean Amorim Sampaio Filho; 29
Diego Nicacio de Brito; 21, 32, 41,
46, 50, 51, 52
Douglas Alexandre R. Pereira;
39, 40
Douglas Leopoldino de Amorim;
21, 32, 41, 46, 50, 51, 52
Douglas Sterzza Dias; 15, 20, 22, 41
Driely de Amorim Beligoli; 14
E
Edgar Rabboni; 28
Eduardo Lichtenfels; 17, 35
Eduardo Pereira Nascimento; 30
Eduardo Toledo de Aguiar; 38
Edwaldo Edner Joviliano; 23, 29, 30
Elpidio Ribeiro da Silva Filho;
29, 30
Erasmo Simão da Silva; 6, 42
Ettore Cavalieri; 24
Euclides Padilla Hernandez; 33
F
Fabio Akio Takihi; 37
Fábio Hüsemann Menezes; 6, 31
Fabrı́cio Neto Ladeira; 14
Fausto Miranda Junior; 21, 32, 41,
46, 50, 51, 52
Felipe Damascena; 42
Fernanda Federico Rezende; 21,
32, 41, 46, 50, 51, 52
Fernanda Gohr Pinheiro Cintra; 22
Fernanda Telles Sales; 21, 32, 41,
46, 50, 51, 52
Flávia Araújo de Souza Brazões;
14, 16, 40
Abstracts
Flávia D
orea Carneiro; 29
Flávia Moreira; 24
Flavio Henrique Simeão; 44
Flávio Nigri; 3
Francelle Miletho Silva; 49
Franciele Tibola; 43
Francielli Avancini Lopes; 18
Francisco Cardoso Brochado
Neto; 33
Francisco Cialdine Frota Junior; 12
Francisco Dias; 9
G
Gabriel Azevedo Leal; 17
Gabriel Cambraia Pereira; 5, 45
Gabriel Viarengo; 22, 25, 44
Gabriela Araujo Attie; 4, 12, 22,
27, 37
Gabriela Gomes Prates; 8
Gabriela Pereira de Moura; 43
Gabriella Lucas Richards; 11
Gabriella Pazzanese Barreira; 15,
23, 44
Giovani Jose Dal Poggetto
Molinari; 6
Giulia de Paula Vendramini
Ferreira; 15, 23, 44
Giulianna Barreira Marcondes; 5,
15, 20, 22, 34, 41
Glauber Rielli; 44
Grace Carvajal Mulatti; 21
Guilherme Camargo Gonçalves de
Abreu; 15, 23
Guilherme Gobbi Neto; 43
Guilherme Luchine de Almeida;
11, 18
Guilherme Luis Fernandes; 7, 8,
9, 16
Guilherme Vieira Meirelles; 9, 22,
28, 31, 39
Gustavo Bomfim dos Santos; 22,
28, 31
Gustavo Calado de Aguiar
Ribeiro; 9
Gustavo Cardena Monteiro; 43
Gustavo Júlio Dreher; 7, 8, 9
Gustavo Lamy; 51
Gustavo Santos; 25, 39, 40
Gusthavo Tomasi Perin; 21, 32, 41,
46, 50, 51, 52
H
Henrique Jorge Guedes Neto; 4, 5,
8, 12, 15, 20, 22, 24, 27, 34, 36,
37, 38, 41, 45, 48
Heytor Jose de Oliveira Cabral; 13
Hudson Cruz Reis Carvalho; 30
I
Igor Rafael Sincos; 11
Inez Ohashi Torres; 42
Ingrid dos Passos Silva; 18
Isabela Ribeiro Siqueira; 43
Ivan Benaducci Casella; 5, 39
Ivana Sá Brito; 7
J Leonardo Pelafsky; 42
Jamil Victor de Oliveira
Mariúba; 25
Jean Felipe Pedrozo da Silva; 41
Jean Marc Vinagre Prado de
Olivera; 9
João Antonio Corrêa; 26, 51
João Felipe Pinheiro Sales; 14
João Manoel Silveira Lara; 5, 8, 38
Joao Pedro Lins Mendes de
Carvalho; 21
João Victor Guimaraes
Almeida; 43
João Victor Loureiro de Oliveira;
23, 29, 30
João Vinicius Fernandes Beata
Teixeira; 29, 30
Joaquim Placido de Freitas
Alves; 17
Jocefabia Reika Alves Lopes; 26
Joel Alex Longhi; 7, 8, 9, 16
Jorge Eduardo de Amorim; 4, 5, 8,
12, 15, 20, 22, 24, 27, 34, 36, 37,
38, 41, 45, 48
Jose Dalmo de Araujo Filho; 14
José Reginaldo Simão; 31, 46
José Tadeu Melo; 25
José Valério Librelotto Stefanello
Ii; 13, 43
Josualdo Euzébio da Silva; 16, 40
Juliana Gonçalves; 33
Juliana Libman Luft; 43
Juliana Pagotto Trevizo; 34, 37
Juliana Zavarize; 44
Juliano de Oliveira Barbosa
Guedes; 14
Julio C. Toledo; 39
Júlio César Souza Diniz; 23, 29, 30
K Marcelo Pettinari; 18, 34, 47
Karise Naves de Rezende; 42
Kelston Paulo Felice de Sales; 3
Kenji Nakahara Rocha; 34
Kyrie Eleison Proença; 19
55
L
Lailana Suéling Cavalheiro; 43
Lais da Cunha Gamba; 13, 26, 37,
42, 45
Laı́s Miller Reis Rodrigues; 33
Laura Lane Menezes Polsin; 31
Leonardo Augusto D’avila
Gonçalves; 30
Leonardo Cardoso Bringel de
Olinda; 51
Lethicia M. Valladão; 5
Leticia do Espirito Santo Dias; 13
Libnah Leal Areias; 5, 15, 22
Lilia Kazumi Miyahira; 13
Lissa Severo Sakugawa; 28
Lucas Hashimoto; 24
Luciana Helena Benatti; 15, 23, 44
Luciano Amaral Domingues; 49
Luis Carlos Uta Nakano; 4, 5, 8,
12, 15, 20, 22, 24, 27, 34, 36, 36,
37, 37, 38, 41, 45, 48
Luis Eduardo Maiorquin; 10
Luis Fernando Nascimento; 39
Luis Guilherme Toledo da Silva; 43
Luis Gustavo Schaefer Guedes; 8,
12, 20, 24, 34
Luis Marcelo Aielo Viarengo; 14
Luiz Antônio de Azevedo
Accioly; 10
Luiz Eduardo Almeida Silva; 23,
29, 30
Luiz Fernando Nascimento; 28
Luiz Francisco Machado Costa; 7,
8, 9, 16
Luiz Gustavo Perez Vasquez; 48
Luiz Ronaldo Godinho Pereira; 30
Lyssa Moretti; 43
M
Manoel Lobato; 11
Marcel Gutierrez; 51
Marcelle Naomi Oshiro
Shinzato; 13
Marcelle Souza Alves da Silva; 30
Marcello Romiti; 33
Marcelo Cury; 3
Marcelo Fernando Matielo; 39
Marcelo Guedes Cysne; 30
Marcelo Sembenelli; 25
Marcia Fayad Marcondes de
Abreu; 15, 23
Marcio Luis Lucas; 17
56
Marco Aurelio Grudtner; 7, 8, 9, 16
Marco Bianco Santarosa; 23, 30
Marcone Lima Sobreira; 25, 42
Marcos Rogério Couvre; 13
Marcus Vinicius Canteras Raposo
da Camara; 12, 22, 27
Maria Lúcia Sayuri Iwasaki; 28
Maria P. Mariz; 5
Mariana Greccho Nunes; 44
Mariana Tais Silva Secondo; 25
Marina Farjallat; 26, 37, 45
Marina Trino de Moraes; 44
Mario Luiz Simonetto Pereira; 46
Marlon Madson Bonfim Oliveira; 14
Matheus Bertanha; 25, 42
Matheus Giovanni Medina
Molina; 48
Matheus Leme de Marchi; 5
Matheus Trigo Carim; 21, 25, 32,
40, 41, 46, 50, 51, 52
Mauri Luiz Comparin; 43
Mauricio de Barros Jafar; 13, 43
Mauricio Rocco de Oliveira; 9, 14,
22, 25, 28, 31, 39, 40
Mauricio Serra Ribeiro; 23, 29, 30
Michelly de Souza Moraes Costa; 43
Miguel Segovia; 47
Milena Nakase Takayassu; 13
Milton Alves das Neves Junior; 28
Milton Sérgio Bohatch Junior; 23
Ml Raghavan; 6
Moriane Barcelos Lorenzoni Zago;
11, 18, 35
N
Nasser Hussein Mahfouz; 14, 17
Natália Borges Cardin; 37
Nayara Gimenes de Melo
Vieira; 17
Nelson de Luccia; 5, 13, 21, 42
Newton Roesch Aerts; 17, 35
Nicole Inforsato; 42
Nilon Erling Junior; 17, 35
Northom Augusto de Jesus Perreti;
15, 23
O 32, 41, 46, 50, 51, 52
Osias Martins Prestes; 48
Otacilio de Camargo Junior; 15,
23, 44
Otacı́lio Figueiredo da Silva
Júnior; 47
P
Pablo Alejandro Marina; 18, 34, 47
Pamela Rodrigues de Souza; 21, 32,
41, 46, 50, 51, 52
Pamelli Lopez Kamel; 37
Patrick Israel Fligelman Kanas; 48
Paula Vivas; 24
Paula Casals do Nascimento; 38
Paula Vivas; 24
Paulino Gomes de Souza Neto; 50
Pedro Puech-Leão; 5, 13, 21, 42
Pedro Puech-Leão; 5
Pedro Henrique Cardoso Borges; 7,
8, 9, 16
Pedro Henrique Olivo Kronfeld; 7,
8, 9, 16
Paulo Isaõ Sassaki Neto; 17
Priscilla Matos; 13, 26, 37, 45
R
Rafael Caivano; 44
Rafael Bernardes de Avila; 4, 5, 15,
24, 27, 36, 37, 41
Rafael Caivano; 44
Rafael Elias Farres Pimenta; 25
Rafaella Elias Bosco; 51
Rebeca Bosse de Jesus; 7, 8, 9, 16
Rebeca Mangabeira Correia; 5, 8,
24, 48
Rebeca Regert; 17, 35
Rebecca Marcelino Ribeiro; 44
Regina Moura Ceranto; 25, 42
Régis Fernando Angnes; 49
Ricardo de Souza Divino; 11, 18
Ricardo Bocchese Paganella; 7, 8,
9, 16
Ricardo Carrelo da Costa; 28
Ricardo de Souza Divino; 11, 18
Ricardo Jr. Ferreira; 33
Roberto Diaz; 18, 34, 47
Roberto Luiz Pereira Ribeiro; 30
Rodrigo Gibin Jaldin; 25, 42
Roger André Molina Claros; 21,
Ronald Luiz Gomes Flumignan; 4,
5, 8, 12, 15, 20, 22, 24, 27, 34, 36,
37, 38, 41, 45, 48
Vascular 27(1S)
S
Sarah Andrade de Oliveira
Botelho; 18
Sebastião Barreto de Brito Filho; 3
Sergio Xavier Salles Cunha; 19, 33
Sharbel Mahfuz Boustany; 7, 8,
9, 16
Silvia Elena Ferreira; 46
Stefany Gimenes Baptista
Coutinho; 19
Stela Karine Braun; 43
Sthefano Atique Gabriel; 36, 52
T
Tatiane Carneiro Gratão; 42
Tercio Ferreira Oliveira; 29
Thais Rodrigues de Freitas; 37
Thamirys Guimarães Marques; 22,
25, 28, 31, 39, 40
Thiago Graziotin Bombardelli; 35
Thiago Mattiazzo de Vieira
Castro; 28
Thomas Jorge; 18, 34, 47
V
Victor Bilman; 24
Vinicius Bertoldi; 11
Vinicius Bignatto Carvalho; 8, 27,
34, 48
Vinicius Brazil Correa da
Cunha; 10
Vinicius de Oliveira Godoy; 30
Vinicius Matos Menegola; 43
Vitor C. Gornati; 11
Vitor Dincão Sanches; 15, 23, 44
Vitor Moron de Andrade; 15,
23, 44
Vladimir Tonello de Vasconcelos;
4, 8, 24, 27, 38, 45, 48
W
Wallace Medeiros de Aguiar; 11,
18, 35
Walter Campos Jr.; 11
Wellington Gianotti Lustre; 4, 8,
20, 27, 48
Winston Bonetti Yoshida; 25, 42