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

Introduction: Rupture of abdominal aortic aneurysm is still a difficult challenge for the vascular surgeon due to the high perioperative mortality. The aim of our study is to describe the characteristics of the population as well as to compare morbidity and mortality in patients undergoing open surgery or endovascular repair in our center., Methods: Database with 82 rAAA between January 2002-December 2014, studying two cohorts, open surgery and endovascular repair. Epidemiologic, clinical, surgical techniques, perioperative mortality and complications are analyzed., Results: 82 rAAA cases were operated (men: 80, women: 2). Mean age 72±9.6 years. 76.8% (63 cases) was performed by open surgery., Background: smokers 59, 7%, alcoholism 19.5%, DM 10.9%, AHT: 53.6%, dyslipidemia 30.5%. The most frequent clinical presentation was abdominal pain with lumbar irradiation: 50 cases (20.7% associating syncope). Overall hospital mortality was 58.5%. Hemodynamic shock prior to intervention was associated with increased mortality (p <.001). Anemia, leukocytosis, aneurysm size, sex and age did not show a statistically significant difference with respect to mortality (p>.05). The presence of iliac aneurysms was associated with increased mortality (p <.0045). Perioperative mortality in endovascular repair was 42%, and in open surgery was 63.5% (p>.05). Hospital stay was lower in the endovascular group (p=.3859)., Conclusions: Hemodynamic shock and the presence of concomitant iliac aneurysms have a statistically significant association with perioperative mortality in both groups. We found clinically significant differences in mortality, complications and hospital stay when comparing both groups with better results for EVAR, without statistically significant differences., (Copyright © 2016 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Chronic low back bain is a common cause of medical consultation, and is often associated with degenerative vetebral disease. Despite this, we must not forget other diseases even in those cases where the imaging tests may suggest chronic degenerative changes in the lumbar spine, including the possible presence of an abdominal aortic aneurysm with a contained rupture must be ruled out due to its prognostic and therapeutic implications. We present 5 cases of chronic low back pain associated with serious lytic lesions in the vertebral body due to chronic rupture of an abdominal aortic aneurysm., (Copyright © 2012 SECOT. Published by Elsevier Espana. All rights reserved.)

Introduction and Objectives: The aim of this work is to describe the short- and mid-term results of endovascular treatment of penetrating ulcers in the thoracic aorta., Methods: Between 1998 and 2010, 22 patients with penetrating ulcers in the thoracic aorta received endografts (mean age 69.8 years, 91% male); 50% were indicated for acute aortic syndrome (8 chest pain, 1 aortic rupture, 1 aortobronchial fistula, 1 distal embolization) and 50% for aortic or ulcer diameter. All preoperative, operative and follow-up data were recorded prospectively and met EUROSTAR criteria., Results: Technical success was 100% with no intraoperative deaths or open conversions; 6 (27.3%) required preoperative supraaortic trunk debranching and 1.3 endografts were used per patient; 27.3% developed complications in-hospital and 9.1% required reintervention prior to discharge. Mortality at 30 days was 4.5%. After a mean 52.3 month follow-up (range 0.1-122), cumulative survival free from complications and reinterventions at 100 months was 61.7% and 79.5% respectively, with 95.5% cumulative survival free from aorta- or procedure-related death. We identified no factors significantly related to poor intra- or postoperative clinical course., Conclusions: Endovascular treatment of penetrating aortic ulcers is both possible and effective despite high patient comorbidity. Although a substantial rate of complications and reinterventions can be expected-especially in-hospital-(38.3% and 20.5% respectively at 100 months), long-term mortality is low (4.5%)., (Copyright © 2011 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Endovascular stent grafting is applied for the treatment of different aortic pathologies in the current medical era. It may be lifesaving in patients with comorbidities and virtually inoperable when adopting conventional techniques. This manuscript reports on a 40-year-old patient, who was previously treated for a mycotic saccular aneurysm at the aortic arch and who presented with a descending aortic rupture at the mid-term follow-up. The descending aortic rupture was also managed successfully by endovascular measures.

Aortic rupture, independently of its location and etiology, is an extremely serious condition that leads to death rapidly. There is currently no consensus on whether endovascular treatment of the descending thoracic aortic rupture is superior to conventional surgical repair in terms of mid-or long-terms outcome. We describe our experience with 13 patients from January 2005 to January 2009 to evaluate the results in patients with descending thoracic aortic rupture undergoing endoprosthetic management., (Copyright © 2010 Elsevier España, S.L. y SEMICYUC. All rights reserved.)

Sinus of Valsalva aneurysm is a rare cardiac abnormality rupture the right sinus and if ruptured open into the right ventricle or atrium. Usually silent, may cause significant hemodynamic changes. Few cases of ruptured Valsalva sinus aneurysm have been reported in the literature, and the course of this condition during pregnancy and anesthetic management have scarcely been mentioned. We report the case of a primipara with a Valsalva sinus aneurysm that ruptured into the right ventricle. Cardiac function worsened as pregnancy progressed. A cesarean section under spinal anesthesia was scheduled.

Background: The sinus of Valsalva aneurysm (SVA) is a small dilatation caused by a separation between the aortic media and annulus fibrosus. Its origin may be either acquired or congenital. The right coronary sinus is most frequently affected, with the most common complication being rupture., Clinical Cases: We report two cases of SVA complicated with rupture to the right cavities with severe cardiac failure, which represents 0.4% of the total cardiac surgeries performed during the past year in our hospital. Case #1: We present the case of a 27-year-old male with low-effort dyspnea, nocturnal paroxysmal dyspnea, orthopnea, paroxysmal atrial fibrillation, diastolic murmur, hepatomegaly and edema of the lower extremities. Case #2: We present the case of a 33-year-old male with low-effort dyspnea, nocturnal paroxysmal dyspnea, orthopnea, diastolic murmur, severe kidney insufficiency and congestive hepatic insufficiency. Surgical resolution in both cases consisted of aneurysm resection and closure of the defect with a Dacron patch, preserving the aortic valve. Both patients survived., Conclusions: Cardiac failure and sudden auscultation changes suggest the possibility of SVA rupture. Echocardiography is sufficient to diagnose SVA, its complications, repercussions, and surgical options. SVA, even if asymptomatic, has potential risks of expansion, rupture, cardiac failure, endocarditis, embolism and sudden death. This justifies surgical correction, with a low mortality rate in both the short- and long-term.

The aortic arch aneurysm is a complex disease with a growing incidence in our population. We report a 64 year-old female with an atherosclerotic aortic arch aneurysm with a maximum diameter of 9.4 cm and evidence of contained rupture. We performed a complete aortic arch replacement in a single period of 100 minutes of circulatory arrest with deep hypothermia and brain protection with anterograde cerebral perfusion through the right axillary artery. The patient had a complete recovery without evidence of neurological damage and was extubated on the next morning. One year later, the patient is asymptomatic and the peri-aortic haematoma was completely reabsorbed.

Congenital sinus of Valsalva aneurysms are extremely rare in Spain. The lesion consists of a defect that allows the aortic media to separate from the annulus fibrosus of the aortic valve, causing it to dilate with arterial pressure. The natural course of the aneurysm involves the risk of complication due to bacterial endocarditis, with conduction blocks or myocardial ischemia. Rupture of the aneurysm, usually into a right chamber, causes a left-right shunt that leads to heart failure and death if untreated. We present the case of a previously asymptomatic 60-year-old woman who presented with a clinical picture that led to a diagnosis of hyperthyroidism, and in whom there occurred a coincident rupture of a congenital sinus of Valsalva aneurysm. We describe the anesthetic procedure and emphasize the importance of intraoperative echocardiography throughout the resection of the aneurysm.

Acute dissection of the aorta, although not common, has early and highly lethal complications. The type A dissection is treated with surgery. Patients with type B dissections are treated with surgery if they have complications like rupture, growth or visceral ischemia. Surgery, however, has complications such as spinal cord ischemia. Endovascular grafts have less mortality and complications. We report a 59 years old male patient with a type B dissection complicated with rupture. He was treated successfully with the placement of an endoluminal graft. He was discharged five days after the procedure in good conditions. After one year of follow up, the patient remains asymptomatic.

Background: Mortality of traumatic aortic lesions is over 80%. A group of those who survive, develop a chronic pseudo aneurism, usually asymptomatic, that is detected during imaging studies. Since conventional surgical treatment of traumatic aortic lesions has a great mortality, endovascular treatment has been used as an alternative treatment in the last decade., Aim: To report our experience with endovascular treatment of traumatic aortic lesions., Patients and Methods: Report of seven patients aged 22 to 65 years, with traumatic aortic lesions. Under general anesthesia an endovascular prosthesis was inserted through the femoral artery., Results: No complications were observed in the postoperative period, and after a follow up ranging from 4 to 40 months, no endoleaks or other complications have been detected., Conclusions: Endovascular treatment of traumatic aortic lesions has good immediate and midterm results.

Traumatic rupture of the aorta has a near 80% mortality. Most patients die on the site of the accident. Conventional surgical repair of these lesions has a high morbidity and mortality, generally associated to the severity of associated lesions. Over the last decade, endovascular treatment has become an effective therapeutic alternative. We report a 40 years old male, that suffered a traumatic rupture of the descending thoracic aorta in a car accident. A successful endovascular repair was performed, installing an endoprothesis on the site of the lesion, using a femoral artery approach. The patient had a good postoperative evolution and was discharged from the hospital once complete rehabilitation of his associated lesions was obtained.

A 62-year-old man with grade III ischemia of the legs and occlusion of an aortofemoral shunt underwent axillofemoral bypass and bilateral profundoplasty. During surgery, an aneurysm in the aortic origin of the right common iliac artery ruptured, requiring ligation of the inferior vena cava, the iliac veins and the right common iliac artery. Upon transfer of the patient to the recovery unit, the sigmoid intramucosal pH (pHi) was 6.83 (arterial pH 7.35), the regional CO2 pressure (PrCO2) was 100 mmHg (arterial PCO2 35.2 mmHg), and the lactic acid concentration was 3.6 mmol/L. Ischemic colitis was suspected and colonoscopy confirmed the presence of severe rectal and moderate sigmoid inflammation. An extended sigmoidectomy was performed with colostomy. The patient died from multiorgan failure 48 hours after surgery. Ischemic colitis is a severe complication of aortic surgery. Sigmoid pHi monitoring is non-invasive and highly useful for the early diagnosis of ischemic colitis.

In 1991, a technique to exclude aortic aneurysms from circulation inserting an endoluminal graft through the femoral artery, was described. This procedure, usually used for elective abdominal aneurysms, can also be used in the thoracic aorta. We report a 41 years old male with a Marfan syndrome, presenting with a descending aorta aneurysm that ruptured to the mediastinum and pleural cavity. He was compensated hemodynamically and an endovascular stent-graft was deployed at the ruptured zone, through the femoral artery. The postoperative evolution of the patient was uneventful. This technique will allow a less invasive treatment of ruptured aortic aneurysms.

Congenital aneurysms of the sinus of Valsalva are relatively rare, tending to be most frequent in adults. Untreated, there is a substantial risk of complication due to bacterial endocarditis and, if rupture occurs, rapid and progressive cardiac insufficiency is fatal at short term. We report the case of a 53-year-old male with a ruptured right sinus of Valsalva aneurysm, resulting in an anomalous right atrium fistula. Symptoms presented, clinical diagnosis and, above all, transesophageal echocardiography were crucial in the final diagnosis leading to an early and satisfactory surgical intervention. Catheterization and angiography were not definitive. Echocardiographic data are described and a bibliography of relevant research articles is provided.

We report a 26 years old male that suffered a motorcycle accident resulting in a traumatic aortic rupture and splenic laceration. He was subjected to a surgical repair of the aortic lesion under complete heparinization. The splenic rupture was non operatively managed successfully.

Objective: To describe complications and mortality in patients diagnosed of Stanford's type A (Daily) dissection of the ascending aorta requiring circulatory arrest for emergency placement of an aortic graft., Patients and Methods: Retrospective study of 21 patients treated between December 1992 and November 1997., Results: Hypertension was the disease most often associated with the diagnosis (in 8 of the 21 patients). Preoperative mortality was 9.5% (2 of the 21 patients), no deaths occurred in the operating room and postoperative mortality was 15.8% (3 of the 19 patients who underwent surgery). Durations in mean time (SD) in minutes were as follows: anesthesia-surgery 437.9 (92), extracorporeal circulation 192.5 (47), aortic clamping 82.6 (20), circulatory arrest 30.5 (8). Retrograde cerebral circulation was carried out during circulatory arrest in all cases. Mean temperature during this period was 14.9 degrees C. During the postoperative period we recorded three permanent neurological complications, six cases of acute renal failure and seven respiratory complications, specifically one instance of adult respiratory distress syndrome and six of pneumonia, the most common. Consumption of blood products was high, with great interindividual variation., Conclusion: Anesthesia for and recovery from surgery for acute aortic dissection is complex and associated with a high rate of postoperative complication and high consumption of blood products.

Postoperative paraplegia caused by ischemic injury of the spinal cord is the most disabling complication of thoracoabdominal surgery, particularly when repair of the descending thoracic aorta is involved. We describe the case of a 59-year-old man who underwent emergency surgery for placement of a Dacron prosthesis to repair a ruptured descending thoracic aorta aneurysm, using an aortic cross-clamping technique plus aortic-femoral partial bypass with normothermia and an ischemic time of 165 minutes. The early postoperative course included complete spinal syndrome with motor and sensory loss below T5, with consequent respiratory insufficiency of neuromuscular origin. The result was a difficult postoperative course including prolonged mechanical ventilation and recurrent respiratory infections. Possible causes include prolonged time of ischemia, inadequate monitoring of distal aortic pressure and inappropriate surgical technique related to the absence of angiographic data on spinal vascularization. We conclude that ischemic time should be kept to under 30 minutes whenever possible. In cases of prolonged ischemia, bypass techniques with outflow to the distal aortic segment are more effective whenever mean blood pressure at this point rises to 60 mmHg or more. Vasodilator use should be reserved for cases of severe arterial hypertension and left ventricular failure and/or life-threatening increases in aortic wall stress even if not leading to dangerous decreases in distal aortic pressure. Finally, angiographic study to obtain anatomical details of spinal blood flow is advisable.

We report the case of a patient with a congenital aneurysm of the sinus of Valsalva ruptured in the right ventricle, aortic valvular regurgitation and ventricular septal defect that remained asymptomatic for many years and presented clinically with severe volume overload of the heart and congestive heart failure. We describe the anatomic, echocardiographic and angiographic findings of this unusual entity with a review of the literature.

A patient presented to our emergency department from another hospital diagnosed with pelvic fracture after a motor vehicle accident. In the ensuing 12 hours, chest pain developed, and a widened mediastinum on chest radiography was found. Posterior aortography showed aortic arch rupture. During surgery, we found a complete circumferential disruption of the arch between the brachiocephalic trunk and the carotid artery. Even though thoracic aortic injuries rarely occur in motor vehicle accidents, thoracic arch ruptures are extremely uncommon. This injury should be suspected after high-speed motor vehicle accidents, when accompanied with chest pain or widened mediastinum.

We present three cases of communication between the false channel of an ascending aortic dissection and a right cardiac chamber in three patients that had previously been operated on for aortic valve replacement. In two cases there already was a degree of aortic dissection at the moment of surgery. Diagnosis was confirmed by transesophageal echocardiography and/or aortography. Two patients developed severe cardiac failure and underwent surgery, while the other one is surviving with medical treatment.

Objective: To analyze morbidity and mortality in patients undergoing surgery for aneurysm of the abdominal aorta, in order to identify risk factors., Patients and Methods: We conducted a retrospective study of 143 patients with aortic aneurysm undergoing surgery between January 1986 and April 1993. One hundred twenty-seven aneurysms were infrarenal and 16 were adjacent to the kidney., Results: Surgery was scheduled in 67.1% of the cases, emergency in 27.2% and deferred in 5.59%. The mortality for each of these groups was 8.3%, 33.3% and 62.5%, respectively. Exitus took place within the first 24 hours after admission. Secondary diseases, usually ischemic cardiopathy, were present in 68.5%. The most frequently observed postoperative complications were cardiovascular, followed by renal, respiratory and digestive problems. The most frequent cause of death was acute myocardial infarction, followed by hypovolemic shock in emergency patients. Factors representing significant risk of mortality were age over 80 years (p < 0.001), aneurysmatic rupture (p < 0.001) and blood loss requiring transfusion of more than 4 units of packed red cells during surgery (p < 0.001)., Conclusions: The increase in the number of elective procedures (including scheduled resection of small aneurysms), early diagnosis and treatment of ruptures and aggressive hemodynamic management in the perioperative period--with special attention to cardiovascular status in the first 24 hours after surgery--are all factors that can contribute to better outcome.

The purpose of this paper is to present the case of a patient with traumatic rupture of the aorta, that was diagnosed and treated successfully. We describe the clinical data and diagnostic procedures of this case and we analyze the diagnostic and treatment aspects in accordance to the review of the literature. If, as in this case, the lesion does not extend through the adventitia and the entity is suspected based on the mechanism of the traumatism, a successful surgical treatment is feasible. This can be done by only clamping the aorta and doing the repair without an atrium to aorta by-pass, as was done in this case with no complications, or with the use of such a by-pass with a centrifugal pump with which it might be possible to prevent, in some cases, the paraplegia that can be associated with the clamping of the aorta. We conclude that a high degree of suspicion and a precise surgical technique are mandatory for a successful treatment of a traumatic rupture of the aorta.

Aortocaval fistula is a rare complication of abdominal aortic aneurysms that occurs with a frequency of 1% of operative cases or less. In this report we present a case of aortocaval fistula associated with ruptured and inflammatory aortic aneurysm that became apparent after evacuation of the thrombus. The inferior cava was ligated. We discuss the clinical syndrome and the management of patients with aortocaval fistula secondary to an abdominal aortic aneurysm and the results of surgical repair.

We present a rare postoperative complication after surgical procedures for rupture of abdominal aortic aneurysms. The disease, a pseudomembranous colitis, was early recognized (by evidence of clostridium difficile after a coprocultive) and satisfactorily treated with vancomycin. From the literature review we found only a similar case but results were absolutely different from our case.

Between 1986 and 1992, 133 patients with abdominal aneurysms presented to our Department of Vascular Surgery. Of these, 97 (73%) were elective cases and 36 (27%) had ruptured. In all these patients resections were undertaken. Postoperative complications occurred in 28 patients (28%) for elective resection and in 17 patients (47%) for ruptured aneurysms (p < 0.05), with mortality rates of 46 and 94%, respectively (p < 0.005). The postoperative mortality for elective resection was 13% and for rupture 44% (p < 0.001).

Primary aortoduodenal fistula is an uncommon complication of abdominal aortic aneurysm and is a rare cause of gastrointestinal bleeding. A case of primary arterioenteric fistula due to the rupture of an abdominal aortic aneurysm into the third portion of the duodenum is presented. Aneurysmectomy, duodenal repair, and extra-anatomic revascularization of the legs was performed. Diagnosis of primary aortoenteric fistula is difficult. The usual explorations are not demonstrative, and exploratory laparotomy is often mandatory.

Traumatic section of descendent aorta, severe complication of a thoracic traumatism, requires an early recognition and restoration because its high mortality rate. Between 1988 and 1990, three patients underwent surgical approach, by direct aortic clamping [correction of clamplaje], at our Service. In two cases, a heart stoppage appeared during the clamping/unclamping [correction of clampaje/desclampaje] maneuvers. One of them had previously electrocardiographic abnormalities, suggestive of heart contusion. Two patients died, one of them during surgical procedure because an irreversible heart stoppage, and the second patient died after 7 days because of a brain hemorrhage. One case presented postoperative paraplegia. Respective rates and literature about the main factors implicated in the diagnosis and treatment of such pathology are reviewed.

We present a case of a sinus of Valsalva aneurysm ruptured into right atrium secondary to aortic endocarditis. Early surgical procedure was indicated bases on transthoracic echocardiography. This technique demonstrated a abscess image enlarged into the right atrium and color Doppler showed a turbulent flow from aortic valve to right atrium. Cardiac surgery was performed with transesophageal echocardiography monitoring. This technique allowed anatomical and functional aortic valve evaluation and the abscess location and extension. This case shows the value of transthoracic and transesophageal color Doppler echocardiography in the diagnosis and management of patients with complications secondary to infective endocarditis.