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INTRODUCTION: The Abdominal aortic aneurysm (AAA) module of the Portuguese National Vascular Registry (RNPV) is a prospective, voluntary, population-based registry, that encompasses more than 90% of portuguese vascular departments. The aim of this study was to evaluate the results of the first 1000 infra-renal AAA included in the Portuguese RNPV. METHODS: Data were collected from November 2019 to December 2022 and analyzed for demographic aspects, treatment indication, aneurysm anatomic characteristics, type of intervention (EVAR and open surgical repair - OSR), outcome at 30-days and 1-year. EVAR and OSR were compared within elective and urgent settings. RESULTS: A total of 1122 patients were included in the period of study. After applying the exclusion criteria, we analyzed the first consecutive 1000 patients with infra-renal aneurysm submitted to EVAR or OSR, in elective or urgent settings. Elective procedures were perfomed in 79.2% of cases. Patients were predominantly male (91.8%), with a mean age of 74.1 ± 10.6 years. The overall 30-day mortality was 2.7% (EVAR 1.8% and OSR 5.9%; p=0.003). Pos- operative complications were more frequent in the OSR group, with significant repercussion in hospital length, reinterventions and early mortality. Baseline AAA diameter was identified as a predictor of 30-day mortality. Intra- hospital mortality was inversely related with the caseload of the center (p=0.032), mainly due to higher mortality in OSR (p=0.04). The center caseload did not impact the intra-hospital mortality in elective standard EVAR procedures. Urgent repair was performed in 205 patients with significantly larger AAA-diameter (70.5 ± 21.5 mm versus 57.5 ± 14.3 mm, p, Angiologia e Cirurgia Vascular, Vol. 19 No. 1 (2023): March

INTRODUCTION: Aortoiliac occlusive disease (AIOD) can be treated using either open surgical revascularization (OSR) or endovascular revascularization (ER). METHODS: A Medline search was performed in order to identify articles focused on the treatment of aortoiliac occlusive disease. Additional articles of scientific interest for the purpose of this non-systematic review were included by cross-referencing. RESULTS: There are a few articles reporting direct results between both techniques based on retrospective or prospective single center or multicenter studies. In the majority of studies, primary patency is generally better for surgery in comparison to ER, but at a cost of more postoperative complications, with higher rates of respiratory failure and wound infection in the open group. On the other hand, endovascular recanalization is related to higher rates of limb ischemia/thrombosis, renal dysfunction and reinterventions. In the presence of femoral artery calcified disease, the hybrid approach should be considered. CONCLUSIONS: Endovascular treatment is a suitable alternative for extensive AIOD and can be accomplished in a less invasive manner, with most midterm outcomes comparable with open reconstruction. Surgery should be reserved for multilevel calcified disease and after endovascular failure., Angiologia e Cirurgia Vascular, Vol. 18 No. 3 (2022): September

OBJECTIVE: Venous stenting of iliocaval obstructions has become a more frequent procedure over the last two decades. In-stent stenosis and thrombosis are potential complications, causing one of the main causes of symptoms recurrence and impacting quality of life. The aim of this review is to report on the impact of venous stent patency loss, as well on risk factors and management. METHODS: A systematic review was conducted according to the recommendations of the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. RESULTS: After a literature search, 12 studies (two prospective and 10 retrospective studies) were included in the analysis. A total of 1981 patients (34.1% male) and 2388 limbs (63.6% left side) were assessed. Mean age was 43.5 years (range 16-99). Indication for stenting included deep venous thrombosis (DVT) (4%), post-thrombotic syndrome (PTS) (18.8%) and non-thrombotic iliac vein lesions (NIVLs) (77.2%). Regarding treatment, most patients were submitted to angioplasty and stenting only (87%). Associated catheter directed thrombolysis or mechanical thrombectomy was performed when indicated (8.4%), and in the remaining an AVF/endophlebetomy was performed (4.6%). Primary, primary assisted and secondary patency rates at one year ranged from 68-100%, 79-90% and 85.8-100%, respectively. Reported anticoagulation duration after stenting ranged from 1-12 months. In one study involving only patients treated for NIVLs, no anticoagulation was prescribed, and antithrombotic therapy was continued for three months. Follow-up strategies included clinical and imagiological control with a mean follow-up of 19.7 months. Post-procedural stent re-stenosis was reported in 121 limbs (5.1%) and stent occlusion in 81 limbs (3.4%); the latter was distributed as follows: 11.1% after DVT, 77.8% PTS and 11.1% NIVLs. A total of 186 re-interventions were performed in symptomatic patients. The prognostic factor most consistently associated with stent failure was thrombotic inflow veins. Other reported factors were incomplete thrombolysis and age younger than 40 years. Stent placement below the inguinal ligament, type of stent and anticoagulation regimen do not seem to affect stent patency. CONCLUSION: Regarding venous lesions of the lower limbs, a selective approach and planning should focus on identification of risk factors for stent failure. It is noteworthy that most stent occlusions occur in post-thrombotic limbs. Stent failure continued after 6 months, emphasizing the importance of an extended surveillance especially on these patients., Angiologia e Cirurgia Vascular, Vol. 18 No. 3 (2022): September

Funding Information: We would like to thank Andrea Bothwell who wrote the manuscript outline and first draft on behalf of Springer Healthcare Communications. We also thank Prof. Carina Silva (ESTEsL – Escola Superior de Tecnologias de Saúde de Lisboa) who performed the preliminary statistical analysis of this study. This medical writing assistance and statistical analysis was funded by CUF Oncologia. Funding Information: Diogo Alpuim Costa has received honoraria from the Portuguese Navy, CUF Oncologia, and NTT DATA, and has served as a speaker, advisory board member, or has received research or education funding from CUF Oncologia, AstraZeneca, Hoffmann-La Roche, Merck KGaA, Novartis, Pfizer, Uriage, Daiichi Sankyo, Gilead, Merck Sharp & Dohme, Nanobiotix, Puma Biotechnology Inc., Sanofi, and Seagen Inc. Margarida Brito has participated as advisory board member for Roche, Novartis, Merck Sharp & Dohme, and Pfizer. Mário Fontes-Sousa has served as a speaker or advisory board member for Bristol Myers Squibb, Daiichi Sankyo, Gilead, Lilly, Merck Sharp & Dohme, Novartis, Pfizer, Roche, and Servier. Diogo Martins-Branco received honoraria and advisory board fees from Janssen, Pfizer, Merck Sharp & Dohme, Angelini, AstraZeneca, and Novartis, meeting and travel grants from LEO Farmacêuticos, Merck Sharp & Dohme, Ipsen, Janssen, and Roche, and institutional grants from F. Hoffmann-La Roche Ltd. José Guilherme Gonçalves Nobre, João Paulo Fernandes, Marta Vaz Batista, Ana Simas, Carolina Sales, Helena Gouveia, Leonor Abreu Ribeiro, Andreia Coelho, Mariana Inácio, André Cruz, Mónica Mariano, Joana Savva-Bordalo, Ricardo Fernandes, André Oliveira, Andreia Chaves, Mafalda Sampaio-Alves, and Noémia Afonso have nothing to declare. Publisher Copyright: © 2022, The Author(s). Introduction: Cancer care providers have faced many challenges in delivering safe care for patients during the COVID-19 pandemic. This cross-sectional survey-based study investigated the impact of the pandemic on clinical practices of Portuguese medical oncologists caring for patients with breast cancer. Methods: An anonymous online survey comprising 42 questions gathered information regarding COVID-19 testing, treatment in (neo)adjuvant and metastatic settings, and other aspects of breast cancer management. Practices before and during the pandemic were compared, and potential differences in outcomes according to respondents’ regions, case volumes, and practice type were explored. Results: Of 129 respondents, 108 worked in the public health system, giving a representative national picture of the impact of the COVID-19 pandemic on breast cancer management. Seventy-one percent of respondents reported a reduction in visits for new cases of breast cancer, and there was a shift towards increased use of telemedicine. Clinical decision-making was largely unaffected in the most aggressive indications (i.e., triple-negative, HER2-positive, visceral crisis). The use of neoadjuvant therapy increased when access to surgery was difficult, whereas dose-dense regimens decreased, and cyclin-dependent kinase 4/6 inhibitor treatment decreased for less aggressive disease and increased for more aggressive disease. The use of oral formulations and metronomic chemotherapy regimens increased, and clinical trial participation decreased. Some differences by respondents’ region and case volume were noted. Conclusion: Medical oncologists in Portugal implemented many changes during the COVID-19 pandemic, most of which were logical and reasonable responses to the current healthcare emergency; however, the true impact on patient outcomes remains unknown. publishersversion published

Rassal, C., Beckmann, L., António, N., Coelho, A., Coelho, R., & Palma, A. (2022). Sentiment analysis in all-Inclusive hotels and resorts in Portugal. Paper presented at 2nd Tourism and Hospitality Networking Conference 2022 (http://researchnet.work), na Turquia., Istanbul, Turkey. The technological advancements in the digital environment and the consequent importance that electronic word-of-mouth (eWOM) represents in the digital era highlight the need to study the opinion of consumers to increase the quality of the service provided. The research methodology is based on a literature review, analyses of 9226 online reviews extracted from the TripAdvisor platform, using Nvivo software, and the implementation of 65 questionnaires to hotel managers. The sample matches the 4- and 5-star hotels operating on all-inclusive in Portugal between 1st January 2019 and 31st October 2020. It is highlighted that TripAdvisor guest reviews represent a moderately negative to the moderately positive tone, which represents a mixed feeling, standing out as very important attributes: food, room and employees. Hotel managers, in turn, list as very important attributes: employees, food, safety, hygiene and cleanliness. In short, the hotel attributes valued as very important, both for guests and for hotel managers, are attributes related to food and employees. authorsversion published

Comunicação oral por convite Background: Vascular disease is systemic in sickle cell anemia (SCA), with profound effects in organs like the brain,where stroke is the most severe end of the cerebral vasculopathy spectrum. Endothelial dysfunction is an important pathobiological mechanism in SCA systemic vasculopathy, with upregulation of adhesion molecules (e.g., VCAM-1), lower nitric oxide bioavailability, and increased oxidative stress. In previous association studies, we found positive associations between the presence of three specific VCAM1 gene promoter haplotypes and i) high blood flow velocities in the median cerebral artery, and ii) a chronic hemolysis biochemical marker. Aims: The aims of our work were: a) to investigate the functional role of those VCAM1 promoter haplotypes in endothelial cell response following endothelial activation through TNF-α stimulation; b) to assess the modulation role of proinflammatory and/or pro-oxidative stimuli on endothelial VCAM1 expression; and, finally, to evaluate how hydroxyurea (HU) treatment would affect that expression. Methods: After molecular cloning of three VCAM1 promoter haplotype constructs, using pGL4 promoterless vectors, haplotype sequence was confirmed, by Sanger sequencing, prior to transfection. Transfection experiments for each construct were performed, with or without TNF-α stimulation, using EAhy926, and HBEC as macrovascular and microvascular endothelial cell models, respectively. Differences in promoter activity were assessed by luciferase reporter assay. RNA was extracted from non-transfected EAhy926 and HBEC cell cultures stimulated or not with TNF-a and/or hemin, and with or without HU treatment. RT-qPCR was performed to analyze VCAM1 expression. HMOX1 and NOS3 were also analyzed for comparison purposes. Results: Our results showed that two VCAM1 promoter haplotypes, previously associated with pediatric cerebral vasculopathy and hemolysis in SCA, increased promoter activity in transfected and TNF-α-stimulated EA.hy926 and HBEC cells, consistent with a higher VCAM1 expression in macro and microvascular settings. In non-transfected cells, we also observed TNF-a-induced VCAM1 overexpression as well as heme-induced overexpression of HMOX1 in both cell models. Heme did not affect VCAM1 nor NOS3 expression and the latter was also not affected by TNF-a stimulus. Hydroxyurea treatment lowered TNF-a-induced VCAM1 and NOS3 expression but did not affect heme-induced HMOX1 expression. Summary/Conclusion: These data further indicate that VCAM1 haplotypes we previously associated with pediatric cerebral vasculopathy and hemolysis in SCA, induce higher VCAM1 expression potentially affecting both cerebral and systemic vasculopathy risk. The differential endothelial expression of VCAM1, NOS3, and HMOX1 after proinflammatory and/or pro-oxidative stimuli also reinforces their genetic modulation role in SCA systemic vasculopathy. N/A

Introduction: Extracorporeal membrane oxygenation (ECMO) has evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function. The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO. Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). Methods: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017). The primary outcome of this study was to investigate the prevalence of cannulation-related complications on VA ECMO and to determine its effect on patient morbimortality. Results: Eighty-two patients underwent ECMO during the period of study, 56,1% were male with a mean age of 55,8 years. The VA mode was used in 61 patients, 56 with peripheral cannulation. Femoral arterial access was established in 52 patients (73% percutaneously). Vascular complications were observed in 28,6% of the VA femoral ECMOs: 12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed limb ischemia. For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal: 8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction. There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation. Conclusions: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%). PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation., Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 26 No. 1 (2019): January - March

Patient Blood Management (PBM) �� um m��todo seguro que visa melhorar a gest��o m��dico-cir��rgica dos doentes de modo a que o seu pr��prio sangue seja conservado. Cerca de 32 a 60% dos doentes oncol��gicos t��m defici��ncia de ferro, a maioria tem anemia e, por isso, �� importante discutir estrat��gias que evitem o uso excessivo de sangue e redu����o da progress��o de tumores e recorr��ncia do cancro. Neste artigo de posicionamento, um grupo de especialistas em conjunto com a Associa����o Portuguesa para o Estudo da Anemia (AWGP) discute o programa PBM em hematologia e oncologia tendo em conta diversos fatores que s��o atualmente utilizados para aprovar os tratamentos em uso, baseados nas ��ltimas informa����es atualizadas das orienta����es internacionais do National Comprehensive Cancer Network�� (NCCN)., Revista Portuguesa de Oncologia, Vol. 3 N.�� 2 (2019): Novembro

Adventitial cystic disease (ACD) is a rare condition. It affects mostly the popliteal artery, with few cases reported affecting the radial artery. This condition is characterized by accumulation of mucinous content at the adventitious layer., Angiologia e Cirurgia Vascular, Vol 16 No 4 (2020): December

Turner syndrome (TS) is a disorder of female development with cardinal features of short stature and congenital cardiovascular defects. Congenital or acquired cardiological problems occur commonly in TS, being potentially progressive and responsible for severe complications, such as aortic dissection in young women. Accordingly, we describe a case of type A aortic dissection occurring in a woman with TS, highlighting the need to prioritize investigation in those patients to avoid a catastrophic aortic scenario., Angiologia e Cirurgia Vascular, Vol 16 No 4 (2020): December

INTRODU����O: O adenocarcinoma do p��ncreas (AP) constitui uma das mais mortais neoplasias malignas, com < 10% dos doentes vivos ao fim de um ano. M ais de 80% dos doentes com AP desenvolvem caquexia, a co-morbilidade mais marcante deste cancro. O s��ndrome caquexia-anorexia representa uma entidade sist��mica de perda de peso (PP) intencional, n��o completamente revers��vel por adequado suporte nutricional. A inflama����o sist��mica parece ser um componente-chave na sua fisiopatologia e, neste contexto, diferentes scores t��m vindo a ser validados como marcadores de progn��stico. A quimioterapia (QT) �� o tratamento standard do AP, com impacto na sobreviv��ncia. A maioria dos estudos em caquexia envolvem heterogeneidade de tumores e tratamentos, com pouca evid��ncia existente no impacto da PP no continuum da doen��a. OBJETIVOS: Este estudo pretendeu estudar a associa����o da varia����o de peso (VP) na sobreviv��ncia dos doentes com diagn��stico de AP tratados com QT, e influ��ncia do estadio de doen��a. Foram ainda avaliados potenciais biomarcadores inflamat��rios com valor preditivo e progn��stico (modified Glasgow Prognostic Score (mGPS) e r��cio neutr��filo/linf��cito (RNL)). POPULA����O E M��TODOS: Estudo de coortes retrospetivo, observacional, de 2013 a 2019, de doentes diagnosticados com AP e submetidos a QT. Par��metros demogr��ficos e de composi����o corporal foram registados ao diagn��stico e 3 meses ap��s in��cio de QT. Score mGPS e R NL foram colhidos longitudinalmente. Os doentes foram divididos em 2 coortes, de acordo com a VP ap��s QT: PP (perda de peso > 5%) e PP-ausente (PP< 5%, peso est��vel ou ganho peso). Os endpoints principais foram PP e tempo de sobreviv��ncia (TS), com estratifica����o por estadio de doen��a. An��lise estat��stica com recurso a m��todos descritivos, regress��o log��stica para testar a associa����o entre as vari��veis e outcomes e an��lise de sobreviv��ncia com modelo de cox, teste log-rank e m��todos Kaplan-M eier. Todas as an��lises foram realizadas com o software Stata 15.1. RESULTADOS: De um total de 117 doentes, 65 reuniram os crit��rios de inclus��o, com idade mediana de 69 anos (47-90), 48% mulheres. A maioria dos doentes (60%) apresentava doen��a avan��ada (localmente irressec��vel/metastizada) ao diagn��stico. Aos 3 meses ap��s in��cio de QT, 54% dos doentes tinha PP. Na an��lise multivariada de preditores de PP, doen��a avan��ada foi um preditor independente deste outcome (OR 4.66; IC 95% 1.11 to 19.6; p=0.035). Com uma mediana de tempo de seguimento desde o diagn��stico de 14.8 meses, a taxa de sobreviv��ncia aos 12 meses foi de 64.6%. O TS dos doentes com PP-ausente foi de 33.2 versus 18.5 meses para doentes com PP (HR 2.28; IC 95% 1.15 to 4.5; p=0.019; log-rank p=0.03). Na estratifica����o por estadio de doen��a, nos doentes com doen��a precoce a PP diminuiu significativamente o TS (21.9 vs 67.6 meses; HR 23.68; IC 95% 2.39-234.75; p=0.007), enquanto que PP n��o teve influ��ncia no TS dos doentes com doen��a avan��ada. Na an��lise de sobreviv��ncia, localiza����o no corpo ou cauda do p��ncreas (HR 2.34, IC 95% 1.42-3.86, p=0.001), PP (HR 1.07, IC 95% 1.01-1.12, p=0.001) e R NL elevado aos 3 meses (HR 1.09, IC 95% 1.04-1.14, p=0.001,) foram independentemente associados com menor TS. DISCUSS��O: Os resultados demonstram que a PP �� um fator independente de pior progn��stico em doentes com AP a realizar QT, com relev��ncia na doen��a em estadio precoce. Adicionalmente, o R NL surge como um biomarcador independente de progn��stico neste contexto, podendo ser um marcador surrogate do status de inflama����o sist��mica nestes doentes. CONCLUS��ES: Particularmente no AP em estadio precoce, a PP, como fator modific��vel no decurso da doen��a, dever�� ser alvo de interven����es dirigidas, que possam ter repercuss��es favor��veis no progn��stico destes doentes., Revista Portuguesa de Cirurgia, n. 49 (2020): N��mero 49 - Dezembro 2020

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Endovascular aneurysm sealing (EVAS) using the Nellix system is an alternative method for abdominal aortic aneurysm (AAA) repair. Type 1 endoleaks are not an uncommon complication following conventional endovascular aortic aneurysm repair (EVAR), occurring in up to 10 % of cases. The incidence of these endoleaks following Nellix EVAS was determined to be up to 3,1% in short-term follow-up. Early detection and classification of this issue is crucial to avoid the potential of sac rupture, previously described. As so, we report a successful endovascular treatment of type 1a endoleak, twenty-four months after a Nellix EVAS implantation. An 82 year-old male underwent a Nellix endovascular repair for a 55 mm infra-renal aortic aneurysm in 2014. Final angiography showed successful aneurysm exclusion with no endoleaks. Regular follow-up using computed tomography angiography (CTA) showed a relatively satisfying good stentgraft positioning, no signs of endoleaks and shrinkage of the aneurysm sac. CTA of 2016 showed a new type 1a endoleak associated wit a significant growth of the aneurysm sac. The authors performed prompt embolization of the endoleak with 0,018��� detachable coils and Onyx 34. Final angiography showed patency of the endografts with satisfactory exclusion of the endoleak. The incidence and significance of type 1 endoleaks following Nellix EVAS was previously studied in literature, with some cases reported and the natural history of untreated type 1 endoleak after EVAS might lead to sac rupture and death. The embolization of the endoleak with coils and Onyx appears to be a safe and effective management choice to achieve technical and clinical success in the treatment of these cases., Angiologia e Cirurgia Vascular, Vol 16 No 3 (2020): September

Introduction: Anemia is associated with increased adverse outcomes during the early postoperative period because of high physiologic stress and increased cardiac demand. The aim of this study was to assess the relationship between pre-operative anemia and morbi-mortality outcomes in patients undergoing elective carotid endarterectomy (CEA), open aortic repair (OAR) or endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) and infrainguinal bypass surgery in chronic limb-threatening ischemia. Methods: Retrospective analysis of all elective patients between 2016-2018, who underwent: CEA, OAR, EVAR and infrainguinal bypass surgery in chronic limb-threatening ischemia. Emergency procedures and transfusion of more than 4 units of red blood cells (RBC) were excluded. Hemoglobin levels were categorized according to the WHO definition for anemia: severe (< 8 g/dL), moderate (8-10.9 g/dL), mild (11-11.9 g/dL in women and 11-12.9 g/dL in men) and no anemia (���12 g/dL in women and ���13 g/dL in men). Results: Our study population comprised 257 patients, of which 74 (28%) underwent EVAR, 26 (10.1%) OAR, 67 (26.1%) CEA and 90 (35%) infrainguinal bypass. Pre-operative anemia was identified in 37.4% (n = 96) of the patients. Of those, 67.7% (n = 65) had mild anemia and 32.3% (n = 31) had moderate-severe anemia. Anemic patients have longer length of stay when compared with non-anemic patients (16.61��16.5; 7.68��4.92, respectively) (p = 0.022) and also longer stay in the post-operative care unite in comparison with patients with hemoglobin within the normal range (average 2.08 days �� 1.12; 1.77 days �� 1.01, respectively) (p, Angiologia e Cirurgia Vascular, Vol 16 No 3 (2020): September

Angiologia e Cirurgia Vascular, Vol 16 No 2 (2020): June

Introduction: Endograft limb kinking remains one of the major causes of secondary interventions and rehospitalisation after Endovascular aneurysm repair (EVAR). However, the importance of improving limb patency has received little focus. Endograft limb kinking also remains ill-defined, with considerable variability in the literature concerning its clinical presentation and natural history. The purpose of this paper is to search for an appropriate definition for limb graft kinking as well as intra-operative and follow-up approaches for a timely diagnosis. Methods: A literature review was performed in the MEDLINE database. Results: Several imaging methods have been reviewed, and they all present advantages and drawbacks. Completion Angiography (CA) is routinely performed after removal of stiff guidewires, but it is considered an inadequate means of determining high-risk limb grafts. Cone Beam Computed Tomography (CBCT) has been shown to be feasible both in EVAR planning and as completion imaging to detect complications missed by CA. Duplex Ultrasound, pressure measurement and intravascular ultrasound have also been proposed as adjuncts for intraoperative evaluation of limb grafts. Discussion: Standardizing criteria for hemodynamically significant kinking diagnosis is necessary in order to define patients that may benefit from re-interventions to reduce the risk of limb occlusion. Further studies are necessary in order to raise awareness for this complication which can lead to limb graft thrombosis and limb loss and in order to establish an appropriate diagnosis and follow up protocol., Angiologia e Cirurgia Vascular, Vol 16 No 2 (2020): June

Sickle cell anemia (SCA) is a multifactorial-like monogenic disease that results from homozygosity for the HBB:c.20A>T mutation. Children with SCA usually present a systemic vascular disease with profound effects in organs like the brain, with stroke being the most severe end of the cerebral vasculopathy spectrum. Endothelial dysfunction plays a major role in vasculopathy and several adhesion molecules, such as vascular cell adhesion molecule 1 (VCAM-1), are produced by a cytokine-activated endothelium. In previous genotype/phenotype association studies, we found positive associations of specific VCAM1 gene promoter variants and haplotypes to high blood flow velocities in the median cerebral artery, and to chronic hemolysis biochemical markers. Our aims in this study were to: (i) assess the role of those variants, together with imaging, serological and hematological parameters as potential biomarkers of cerebral vasculopathy in SCA children, and (ii) evaluate the functional effects of the VCAM1 promoter haplotypes on endothelial cell response following endothelial activation by TNF-alpha stimulation. We investigated seventy children with SCA of sub-Saharan ancestry, with focussing on cerebral vasculopathy, as well as on stroke risk (as measured by transcranial Doppler ultrasound). PCR and Sanger sequencing were used for genotyping VCAM-1 gene. Statistical analyses were performed using SPSS (v.25.0) software. When statistical significance was identified for specific haplotypes, plasmid constructs were created by molecular cloning using a promoterless pGL4.10[luc2] vector. Haplotype sequence of each construct was confirmed by Sanger sequencing prior to transfection to EAhy926 and HBEC (macrovascular and microvascular endothelial cell models, respectively) with and without TNF-alpha stimulation. Differences in promoter activity were then assessed by luciferase reporter assays. We analysed 6 VCAM1 promoter variants and 7 haplotypes with potential modulating effect. The rs1409419_T allele and haplotype 7 (Hap7) were positively associated with stroke, stroke risk, and high levels of LDH. On the other hand, haplotype 1 (Hap1) was negatively associated with stroke. Luciferase reporter assays showed differences in promoter activity, in both endothelial cell models, as a result of Hap1 and Hap7 transfection. Hap1 endothelial cell transfection led to a decrease, while Hap7 transfection led to an increase in promoter activity. These results are consistent with: (i) lower VCAM1 expression, hence a protective effect, due to Hap1 and (ii) higher expression due to Hap7 and consequently, increased vasculopathy risk, in a pro-inflammatory milieu. The association between specific haplotypes and endothelial cell response further enhances the modifier effect of VCAM1 not only on macro- and microvascular endothelial dysfunction but also on systemic SCA vasculopathy. Furthermore, we suggest that those haplotypes, together with the imaging, biochemical and hematological parameters, may be used to design a sensitive and specific biomarker panel for SCA vasculopathy risk, severity and prognosis. info:eu-repo/semantics/publishedVersion

Introduction: Over the past decade, endovascular treatment (EVT) is taking over visceral arterial aneurysms treatment considering its effectiveness, safety and minimal invasiveness. Methods: We retrospectively evaluated our department experience in visceral arterial aneurysms endovascular approach from 2009 to 2019. Results: From 2009 to 2019, nineteen visceral artery aneurysms were submitted to EVT (mean age 62,5 years, 53% women). The addressed arterial segments were: the splenic artery (52%, n=10) followed by the renal artery (21%, n = 4), the hepatic artery (11%, n = 2), the superior mesenteric artery (11%, n = 2) and the celiac arrtery (5%, n = 1). Average diameter was 26,9 �� 5,4 mm [range 21���39 mm]. The majority were asymptomatic incidental findings (74%). Concomitant aneurysms were found in 3 patients (15,8%). EVT included: stent-graft exclusion (n = 9), aneurysm-sac coil embolization (n = 6), stent-assisted coil embolization (n=2) and segmental artery exclusion (n=2). Median radiological follow-up was 46,8 months [range 1,1���128 months]. Early SMA occlusion was reported in one case after stent-assisted coil embolization, however without ischemic symptoms. End-organ loss was reported in one case (renal artery coil embolization, without overall renal function worsening). Conclusion: Nowadays, endovascular approach is the first-line intervention for most visceral arterial aneurysms. Although still limited, the reported results are favourable and are in line with the current literature., Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

Treatment of aortic pathologies involving the aortic arch represents a great challenge for vascular surgeons. Endografting techniques, comparing to open surgery, are less invasive approaches. However, an adequate proximal landing zone remains a challenge and, regarding this issue, parallel graft techniques represent a viable endovascular treatment option in patients with challenging aortic arch pathology by extending the proximal landing zone while maintaining aortic side branches perfusion. Parallel graft techniques required a thorough planning and the clinical and imagiological follow-up are mandatory. They appear to be a safe and minimally invasive alternative techniques in selected fragile patients. The authors report three clinical cases that required the use for parallel grafts to treat complex pathology of aortic arch., Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

Resumo O aneurisma da veia ��zigos �� uma entidade cl��nica rara, descrita num n��mero reduzido de case reports na literatura. Neste artigo, descreve-se o caso de um aneurisma da veia ��zigos, diagnosticado acidentalmente numa angio-tomografia computorizada (AngioTC) durante a investiga����o cl��nica de um quadro de hemoptises, numa doente do sexo feminino de 82 anos hipocoagulada com varfarina. Foi diagnosticada uma traqueobronquite e repetiu-se AngioTC ap��s resolu����o do quadro agudo, que revelou trombose completa do aneurisma. Decidiu-se tratamento conservador da doente, com follow-up imagiol��gico seriado., Angiologia e Cirurgia Vascular, Vol 13 No 3 (2017): September

Treatment of aortic pathologies involving the aortic arch represents a great challenge for vascular surgeons. Endografting techniques, comparing to open surgery, are less invasive approaches. However, an adequate proximal landing zone remains a challenge and, regarding this issue, parallel graft techniques represent a viable endovascular treatment option in patients with challenging aortic arch pathology by extending the proximal landing zone while maintaining aortic side branches perfusion. Parallel graft techniques required a thorough planning and the clinical and imagiological follow-up are mandatory. They appear to be a safe and minimally invasive alternative techniques in selected fragile patients. The authors report three clinical cases that required the use for parallel grafts to treat complex pathology of aortic arch. O tratamento das patologias que envolvem o arco aórtico representam um enorme desafio para os cirurgiões vasculares. As técnicas de reparação endovascular, em comparação com a cirurgia aberta, são menos invasivas. Contudo, obter uma zona de selagem proximal ideal pode ser complexo. Relativamente a este tópico, as parallel graft techniques representam uma opção viável em doentes com patologia complexa do arco aórtico, ao permitir a extensão da zona de selagem proximal, mantendo a perfusão dos troncos supra-aórticos. As parallel graft techniques requerem um planeamento apropriado, assim como um follow-up clínico e imagiológico adequados. São técnicas aparentemente seguras e minimamente invasivas, consideradas como alternativas válidas em doentes selecionados. Os autores têm como objectivo reportar três casos clínicos em que as parallel graft techniques foram utilizadas para tratar patologia complexa do arco aórtico.

Introdução: Ao longo da última década, a abordagem endovascular tem assumido um papel preponderante no tratamento dos aneurismas das artérias viscerais (AAVs). Esta mudança de paradigma tem em conta a eficácia, a segurança e o facto de o tratamento endovascular ser menos invasivo quando comparada com a cirurgia clássica. Reportamos a experiência do nosso centro no tratamento endovascular de AAVs. Métodos: Revimos retrospectivamente os casos de AAVs tratados no nosso centro de 2009 a 2019. Resultados: De 2009 a 2019, foram tratados dezanove aneurismas viscerais (idade média 62,5 anos, 53% do sexo feminino). Os segmentos arteriais afetados foram: a artéria esplénica (52%, n = 10), a artéria renal (21%, n = 4), a artéria hepática (11%, n = 2), a artéria mesentérica superior (11%, n = 2) e o tronco celíaco (5%, n = 1). O diâmetro aneurismático médio foi de 26,9 ± 5,4 mm [intervalo de 21 a 39 mm]. A maioria dos AAVs corresponderam a achados assintomáticos (74%). Foram encontrados aneurismas concomitantes em 15,8% dos casos. As técnicas endovasculares utilizadas foram as seguintes: exclusão do aneurisma com recurso a stent recoberto (n = 9), embolização do saco aneurismático com coils (n = 6), embolização assistida por stent (n = 2), exclusão segmentar da artéria (n = 2). O tempo médio de follow-up foi de 46,8 meses [intervalo 1,1-128 meses]. Foi constatada oclusão precoce da artéria mesentérica superior em um caso (após embolização assistida por stent), sem sintomatologia de isquemia intestinal. Foi também constatada uma trombose renal após embolização de aneurisma renal com coils, sem agravamento da função renal. Conclusão: Atualmente, a abordagem endovascular é considerada como tratamento de primeira linha no contexto dos aneurismas viscerais. Ainda que limitada, esta série demonstra resultados favoráveis e em linha com o reportado na literatura. Introduction: Over the past decade, endovascular treatment (EVT) is taking over visceral arterial aneurysms treatment considering its effectiveness, safety and minimal invasiveness. Methods: We retrospectively evaluated our department experience in visceral arterial aneurysms endovascular approach from 2009 to 2019. Results: From 2009 to 2019, nineteen visceral artery aneurysms were submitted to EVT (mean age 62,5 years, 53% women). The addressed arterial segments were: the splenic artery (52%, n=10) followed by the renal artery (21%, n = 4), the hepatic artery (11%, n = 2), the superior mesenteric artery (11%, n = 2) and the celiac arrtery (5%, n = 1). Average diameter was 26,9 ± 5,4 mm [range 21-39 mm]. The majority were asymptomatic incidental findings (74%). Concomitant aneurysms were found in 3 patients (15,8%). EVT included: stent-graft exclusion (n = 9), aneurysm-sac coil embolization (n = 6), stent-assisted coil embolization (n=2) and segmental artery exclusion (n=2). Median radiological follow-up was 46,8 months [range 1,1-128 months]. Early SMA occlusion was reported in one case after stent-assisted coil embolization, however without ischemic symptoms. End-organ loss was reported in one case (renal artery coil embolization, without overall renal function worsening). Conclusion: Nowadays, endovascular approach is the first-line intervention for most visceral arterial aneurysms. Although still limited, the reported results are favourable and are in line with the current literature.

Introduction: Endovascular techniques have been revolutionizing the revascularization of patients with chronic limb threatening ischemia (CLTI), showing consistently high limb salvage rates. However, endovascular recanalization of infrapopliteal occlusive disease can be technically demanding and the failure rate for these types of lesions is about 20%. In that case, an alternative vascular access may be required. We report our experience concerning CLTI patients who underwent retrograde access and recanalization of chronic occlusions after failure of anterograde attempts. Methods: Retrospective institutional review of consecutive patients requiring retrograde punctures to obtain endovascular revascularization (2013���2018) ��� 51 limbs in 50 patients. The primary outcome was to evaluate the technical success and the limb salvage - major-amputation free survival. The secondary outcomes were the rate of major and minor amputation, the global survival of this population and the characterization of the population and the endovascular procedures performed. Results and conclusion: The technical success was achieved in 76,5% of the procedures. The major amputation free-survival rate was 81,4% at 6 months. The femoro-popliteal and distal territories were concomitantly treated in 63,3% of the procedures and isolated distal territory was treated in 32,7%. Femoral approach was always initially performed (90,2% anterograde). Direct revascularization according to the angiosome concept was obtained in 64,6% of the cases. Anterior tibial artery was punctured in 33,3% of cases followed by pedal artery (27,5%), peroneal artery (19,6%), common plantar artery (7,8%), posterial tibial artery above the ankle (3,9%), supra-articular popliteal artery (3,9%), lateral plantar artery (2%) and metatarsal artery (2%). Percutaneous transluminal angioplasty (PTA) was performed in 69,4% of the procedures (2% with Drug Elluting Balloons) and PTA and stenting in 28,6%. During follow-up 19,4% of patients were submitted to major amputation and 29,4% to minor amputation. The rate of healing at 6 months was 43,3%. The results of the retrograde access and recanalization of chronic occlusions are comparable to data reported in the literature, confirming it as a valuable alternative. As so, the retrograde access approach for revascularization of CLTI patients appears to be a safe and effective alternative that expands revascularization options after the failure of a conventional endovascular anterograde approach, allowing the salvaging a greater number of limbs, particularly in patients with significant co-morbidities., Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

Introduction: Type B aortic intramural hematoma (B-IMH) has a complex and variable natural history: it can remain stable and resolve spontaneously or progress to dissection, aneurysm, ulcer or even rupture. The possibility of disease progression, frequently with mild or no symptomatology, poses a significant treatment dilemma. Clinical Case: We report a case of a 60 year-old-female diagnosed with an acute B-IMH, initially treated medically. However, 1-month control CTA revealed disease progression (increased B-IMH thickness and evolution to an ulcer-like-projection with 20 mm diameter and 11 mm depth). She was submitted to a left carotid-subclavian bypass followed by TEVAR and left-subclavian ostial embolization. During follow-up (5 months) patient remain asymptomatic, demonstrating favorable aortic remodeling. Conclusion: Type B-IMH is a dynamic pathology. From presentation to late follow-up, patients remain at high risk for abrupt catastrophic complications. As reported, TEVAR seems to be a safe and effective approach in the event of unfavorable evolution., Angiologia e Cirurgia Vascular, Vol 15 No 4 (2019): December

Introduction: Diagnosis of chronic iliac venous outflow obstruction is challenging, and no ideal imaging method has yet been defined. Even with imaging with superb detail, common iliac vein disappearance as occurs in Post-Thrombotic Syndrome (PTS) may be missed even by the most experienced radiologist. This scanning error occurs due to psychophysiological factors of human visual perception. The purpose of this paper is to report on the ���obturator hook sign���, evidencing obturator vein engorgement as a collateral pathway and hence a marker for hemodynamically significant chronic iliac venous outflow lesion, supporting this diagnosis. Methods: Retrospective review of Indirect and Direct Computed Tomography Venography (CTV) and Magnetic Resonance Venography (MRV) imaging of the obturator hook sign and comprehensive literature review regarding iliac vein outflow obstruction diagnosis focusing on collateral vein development. Results : The obturator hook sign is identified in Direct CTV, Indirect CTV and MRV of patients with chronic iliac venous outflow obstruction. The sign was never identified in imaging studies with no chronic iliac obstruction, suggesting high specificity. Discussion: Venous collateralization is poorly understood, but it has been shown that when the main venous path is stenosed or occluded and the venous pressure rises, flow is side-tracked through alternative pathways. When the main venous path lesion is stented, flow once again takes the lower resistance pathway and the collaterals withdraw. The obturator hook sign can be easily recognisable in CTV and MRV due to its peculiar anatomy and immediately points us towards hemodynamically significant chronic iliac venous outflow obstruction., Angiologia e Cirurgia Vascular, Vol 15 No 3 (2019): September

Introduction: Type B aortic intramural hematoma (B-IMH) has a complex and variable natural history: it can remain stable and resolve spontaneously or progress to dissection, aneurysm, ulcer or even rupture. The possibility of disease progression, frequently with mild or no symptomatology, poses a significant treatment dilemma. Clinical Case: We report a case of a 60 year-old-female diagnosed with an acute B-IMH, initially treated medically. However, 1-month control CTA revealed disease progression (increased B-IMH thickness and evolution to an ulcer-like-projection with 20 mm diameter and 11 mm depth). She was submitted to a left carotid-subclavian bypass followed by TEVAR and left-subclavian ostial embolization. During follow-up (5 months) patient remain asymptomatic, demonstrating favorable aortic remodeling. Conclusion: Type B-IMH is a dynamic pathology. From presentation to late follow-up, patients remain at high risk for abrupt catastrophic complications. As reported, TEVAR seems to be a safe and effective approach in the event of unfavorable evolution. Introdução: O hematoma intramural da aorta tipo B (HIM-B) tem uma história natural complexa e variável: pode permanecer estável e resolver espontaneamente ou evoluir para disseção aórtica, degenerescência aneurismática, úlcera penetrante ou mesmo rotura. Esta possibilidade de progressão da doença, frequentemente associada a sintomatologia frustre, torna a abordagem e tratamento do HIM-B complexos. Caso clínico: Doente de 60 anos, do sexo feminino, com diagnóstico de HIM-B após recorrer ao serviço de urgência por dor torácica, inicialmente sujeita a tratamento médico. No angioTC de controlo, ao 1º mês, foi identificada uma ulceração da parede da aorta (20 mm de diâmetro e 11 de profundidade). Foi então submetida a um bypass carótido-subclávio esquerdo seguido de TEVAR e embolização ostial da artéria subclávia esquerda. Durante o follow-up (5 meses) a doente permanece assintomática verificando-se remodeling aórtico favorável. Conclusion: O HIM-B é uma patologia dinâmica. Desde a apresentação inicial até uma fase avançada do follow-up pode cursar com complicações catastróficas. O tratamento endovascular parece ser uma opção segura e com bons resultados em caso de evolução desfavorável, tal como reportado neste caso.

Dissertação de Mestrado em Ensino de Educação Física nos Ensinos Básico e Secundário

Sickle cell anemia (SCA) is a highly heterogeneous and multifactorial-like monogenic disease that arises from homozygosity for the c.20A>T mutation in the HBB gene. Vascular disease is systemic in SCA, with profound effects in organs like the brain, where stroke is the most severe end of the cerebral vasculopathy (CVA) spectrum. Endothelial dysfunction plays a major role in vasculopathy with several adhesion molecules, such as VCAM1, being produced by the endothelium altered as a response to inflammatory cytokine (e.g., TNF-α) signalling. In previous association studies, we found positive associations between the presence of four specific VCAM1 gene promoter haplotypes and i) high blood flow velocities in the median cerebral artery, and ii) a chronic hemolysis biochemical marker. In this study, we aimed to assess the functional role of those VCAM1 promoter haplotypes in endothelial cell response following endothelial activation through TNF-α stimulation. After molecular cloning of 3 haplotype constructs, using a pGL4 promoterless vector, haplotype sequence was confirmed, by Sanger sequencing, prior to transfection. We used EAhy926, HUVEC and HBEC as different endothelial cell models, and performed transfection experiments for each construct, with and without TNF-α stimulation. Differences in promoter activity were assessed by luciferase reporter assay. All haplotypes showed differences in promoter activity, after TNF-α stimulation, in all cell models. Haplotype 1 showed decreased promoter activity, while haplotypes 7 and 8 showed increased activity after TNF-α stimulation, in all cell models. These results are consistent with lower VCAM1 expression due to haplotype 1, and therefore a protective effect. Conversely, a higher expression due to haplotypes 7 and 8, suggests an increased vasculopathy risk, in a pro-inflammatory milieu. The association between specific haplotypes and endothelial cell response further enhances the modifier effect of VCAM1 on endothelial dysfunction and its impact in SCA pathophysiology, as well as its potential role as a biomarker of SCA vasculopathy risk, severity and prognosis. This work was partially supported by INSA_202DGH720 project. info:eu-repo/semantics/publishedVersion

Introduction: Splenic artery pseudoaneurysms (SAP) represent a rare clinical entity typically caused by sequelae of pancreatitis or abdominal trauma. Unprovoked, spontaneous SAP are exceedingly rare, with only two other case reports in the literature up to date. In this paper we pretend to present a case of a ruptured idiopathic SAP successfully treated endovascularly. Methods: Relevant medical data were collected from hospital database. Results: The patient is a 75-year-old male with no past history of pancreatitis, abdominal trauma or abdominal surgery. He was admitted in the emergency department with thoracalgia with interscapular irradiation with few hours of evolution. He referred food intolerance with vomiting for approximately 7 days. In the diagnostic work-up, a computed tomography angiogram (CTA) was performed and revealed a previously unknown voluminous hiatus hernia and a ruptured 25 mm SAP with active bleeding into a 104x98 mm perigastric collection in the left hypochondrium extending to the thorax, a 34 mm peri-pancreatic and a 35 mm pararenal collection. Urgent treatment was planned in the angiography suite, and after selective catheterization of the splenic artery, pseudoaneurysm origin was identified and embolized both proximally and distally with coils. The end result angiogram was apparently successful. CTA was repeated and revealed complete embolization of the pseudoaneurysm, with no evidence of bleeding. Peri-aneurysmatic collections remained unchanged in size and splenic infarction was evident in 50% of parenchyma. He was discharged 10 days after the initial procedure. Conclusions: Endovascular surgery seems a good option for SAP even in rupture, with good short-term results. In this case, it was admitted that it could be a bridge to open surgery with aneurysmectomy and splenectomy. However, given the good clinical recovery post-embolization, no further surgery was considered. Nowadays there is little consensus on follow-up, and long term results are largely unknown., Angiologia e Cirurgia Vascular, Vol 15 No 1 (2019): March

Introduction: Kawasaki Disease (KD) is a self-limited, unknown-cause febrile vasculitis that predominantly addresses medium-sized arteries and most patients are under 5-years-old. In addition to life-threatening coronary artery involvement, aneurysms may develop in almost any medium-sized vessel, however systemic artery aneurysms (SAA) are described in only 2% of cases. The objective of this study was to identify cases of KD associated SAA and to analyze their frequency, anatomical distribution, treatment and outcomes. Methods: systematic literature review, performed using MEDLINE database. Results: Literature review retrieved a total of 9 reports corresponding to 38 patients and a total of 134 KD-SAA. The most affected arteries were the brachial artery (29.8%), the internal iliac artery (18,6%), the common iliac artery (16,4%) and the subclavian artery (11,2%) with bilateral involvement being a common feature. History of concomitant coronary involvement was present in almost every patients. Only 5 SAA (3,7%) required intervention. Medical therapy was associated with SAA regression in approximately half of the patients, with better results when initiated promptly after diagnosis. Worst outcomes were found in younger patients, showing higher rates of morbimortality. The underlying coronary sequelae dictated the prognosis. Conclusions: Considering their rarity, only multicenter collaboration and literature research can provide more insight about KD-SAA treatment and outcomes, defining the potential role of KD as a primary cause of late vascular lesion. Late presentation KD-SAA may present some diagnostic and therapeutic challenges in view of a more likely need for intervention once the benefit of medical treatment has been outweighed., Angiologia e Cirurgia Vascular, Vol 15 No 2 (2019): June

Introduction: Unfractionated heparin (UFH) has been used for decades to prevent thrombotic events during vascular surgery. Although it is known that UFH has a complex and nonlinear pharmacokinetics, with great individual variability, anticoagulation monitorization in vascular surgery is not routine and a standard empirical dose is often used. Activated clotting time (ACT) has been shown to be a simple, reliable and inexpensive way to monitor UFH anticoagulant effect, being routinely used during cardiac surgery. However, heparinisation remains a dilemma in vascular surgery and few studies emphasized the role of anticoagulation monitoring in this setting. Objectives: To investigate whether a fixed heparin dose of 5000 IU in arterial vascular surgery results in adequate and homogeneous heparinisation in all patients. Secondary endpoints: to identify preoperative factors for heparin response, intraoperative events and outcomes. Methods: This observational prospective pilot study included 30 consecutive patients undergoing arterial vascular surgery. ACT monitoring was performed before clamping and at 3, 30 and 60 minutes after 5000 IU UFH bolus. Preoperative and intraoperative data were also accessed. A target ACT of ��� 200 s was set, taking in account of the lowest ACT value admitted by vascular surgery recommendations. Results: The average ACT value increased to 210.20 �� 28.82 s (1.61 �� 0.25 times vs baseline) 3 minutes after bolus, then declined to 191.60 �� 21.86 s and 173.4 �� 21.37 s after 30 and 60 minutes, respectively. Three minutes after UFH bolus, 53% patients had ACT ��� 200 s, decreasing to one third and 7% at 30 and 60 minutes, respectively. Even when weight-based, a correlation between heparin dose per kilogram and ACT change was not found (r = 0.187; p = 0.322). There was also no correlation between ACT values and preoperative hemoglobin, platelet count, creatinine clearance or INR. There was a positive correlation between preoperative aPTT and intraoperative ACT measurements (r = 0.432; p = 0.017). There was no difference between ACT values and previous antithrombotic/anticoagulant therapy and between intraoperative ACT and intraoperative blood loss. Conclusions: This study confirms that administrating a fixed or even a weight-based heparinisation is insufficient to provide consistent anticoagulation levels in all patients. Perioperative anticoagulation should be monitored and ACT-based. Larger clinical RCT's are warranted., Angiologia e Cirurgia Vascular, Vol 14 No 4 (2018): December

Introduction: Acute carotid stent thrombosis (ACST), defined according to the Academic Research Consortium as occurring in the first 24 hours after the procedure, is described as an exceedingly rare complication of CAS but it can lead to catastrophic neurologic consequences. The European Society for Vascular Surgery updated guidelines state thrombolysis and intravenous abciximab may be effective, but provide no specific recommendations. Given the lack of data concerning the optimal management, the purpose of this review was to evaluate the current literature and report on ACST aetiology and management strategies. Methods: Literature review was performed in the MEDLINE database. Results: No data on ACST is evident in large randomized controlled trials. ACST incidence rate ranges from 0.5-0.8%, reaching as high as 33% in acute-setting. Considering aetiology, it can be subdivided into 2 main groups: systemic causes and technical complications. In the first antiplatelet non-compliance/resistance were the most reported while in the latter carotid artery dissection and plaque protrusion were the most common causes. Also, dual layer stents were associated with greater risk for ACST There are three main approaches for ACST: pharmacologic, endovascular and surgical. Pharmacologic management included anticoagulation, thrombolysis and facilitated thrombolysis. A role for thrombolysis and facilitated thrombolysis is still to be determined. Endovascular treatment was the most common approach to intraprocedural ACST: mechanical thrombectomy with or without concomitant facilitated thrombolysis. Surgical options included carotid endarterectomy with stent explantation which was a bail-out after failed endovascular treatment with excellent recanalization rates. In asymptomatic ACST conservative management with anticoagulation was unanimous. Discussion: As a conclusion, ACST is probably an underestimated clinical entity associated with multiple risk factors. Decision on the best approach depends if ACST occurs intraprocedural or afterwards, on the development of neurologic status deterioration and on centre��s experience. Additional studies must be undertaken to better define optimal management., Angiologia e Cirurgia Vascular, Vol 14 No 4 (2018): December

Sickle cell anaemia (SCA) is an autosomal recessive genetic disease that leads to the synthesis of haemoglobin S (HbS). The pathophysiology of the disease is centred on HbS polymerization inside the red blood cells, which become sickle-shaped (SSRBCs), rigid, viscous and adherent-prone to the vascular endothelium, favouring the occurrence of chronic haemolysis and vaso-occlusion. The main vascular problems of SCA arise from several pathways including endothelial dysfunction and nitric oxide (NO) metabolism. Children with SCA have a much higher risk (11% by age 20 years) of developing stroke or silent cerebral infarcts (up to 37%) than the general paediatric population. Abnormal interactions between SSRBCs and the cerebral arterial endothelium lead to endothelial injury, vaso-occlusion and tissue ischemia and result in cerebral vasculopathy (CVA) through a yet unknown pathophysiological mechanism. Current risk screening strategies rely mainly on imaging techniques (transcranial Doppler ultrasonography and magnetic resonance imaging) and children with altered results undergo regular blood transfusion and/or hydroxyurea therapy to reduce stroke risk/recurrence. However, we need more specific/sensitive biomarkers for stroke prediction/prognosis. Genetic modulators may be paramount in SCA pathophysiology and in CVA severity. They include variants in VCAM1 (endothelial dysfunction), ITGA4 (cell-cell adhesion), and NOS3 (nitric oxide metabolism. The main goals of this work are: a) improve the knowledge on the genetic architecture of paediatric cerebral vasculopathy in SCA; b) assessing the consequences of those genetic variants on gene expression/protein function; c) identify genotypic/phenotypic markers of SCA sub-phenotypes; and d) analyse their potential as genetic modulators of disease severity. This would be crucial in assessing potential pharmacological targets specifically aimed to the vascular system and instrumental for the design of novel preventive, prophylactic or therapeutic strategies. INSA_202DGH72 and ISAMB N/A

Introduction: Splenic artery pseudoaneurysms (SAP) represent a rare clinical entity typically caused by sequelae of pancreatitis or abdominal trauma. Unprovoked, spontaneous SAP are exceedingly rare, with only two other case reports in the literature up to date. In this paper we pretend to present a case of a ruptured idiopathic SAP successfully treated endovascularly. Methods: Relevant medical data were collected from hospital database. Results: The patient is a 75-year-old male with no past history of pancreatitis, abdominal trauma or abdominal surgery. He was admitted in the emergency department with thoracalgia with interscapular irradiation with few hours of evolution. He referred food intolerance with vomiting for approximately 7 days. In the diagnostic work-up, a computed tomography angiogram (CTA) was performed and revealed a previously unknown voluminous hiatus hernia and a ruptured 25 mm SAP with active bleeding into a 104x98 mm perigastric collection in the left hypochondrium extending to the thorax, a 34 mm peri-pancreatic and a 35 mm pararenal collection. Urgent treatment was planned in the angiography suite, and after selective catheterization of the splenic artery, pseudoaneurysm origin was identified and embolized both proximally and distally with coils. The end result angiogram was apparently successful. CTA was repeated and revealed complete embolization of the pseudoaneurysm, with no evidence of bleeding. Peri-aneurysmatic collections remained unchanged in size and splenic infarction was evident in 50% of parenchyma. He was discharged 10 days after the initial procedure. Conclusions: Endovascular surgery seems a good option for SAP even in rupture, with good short-term results. In this case, it was admitted that it could be a bridge to open surgery with aneurysmectomy and splenectomy. However, given the good clinical recovery post-embolization, no further surgery was considered. Nowadays there is little consensus on follow-up, and long term results are largely unknown. Introdução: Pseudo-aneurisma da artéria esplénica representa uma entidade clínica rara, sendo as etiologia mais frequentes as complicações de pancreatite (aguda ou crónica) ou de trauma abdominal. O Pseuso-aneurisma idiopático é excecionalmente raro, com apenas dois casos descritos na literatura. O objetivo deste artigo é apresentar um caso de rotura de pseudoaneurisma da artéria esplénica, tratado com sucesso por cirurgia endovascular. Métodos: Foi realizada a seleção de dados clínicos relevantes da base de dados hospitalar e foi realizada uma pesquisa bibliográfica. Resultados: O doente é um homem de 75 anos de idade sem história prévia de pancreatite, trauma ou cirurgia abdominal. Foi admitido no serviço de urgência com um quadro de toracalgia com irradiação interescapular com poucas horas de evolução. Ele referia também um quadro de intolerância alimentar com vómitos com 7 dias de evolução. Na avaliação diagnóstica, uma angiotomografia computadorizada (AngioTC) foi realizada e revelou uma volumosa hérnia de hiato desconhecida e a ruptura um pseudoaneurisma da artéria esplénica com 25 mm de diâmetro com hemorragia ativa e várias coleções perianeurismáticas na sua dependência. O doente foi encaminhado para a Angiosuite e após cateterização seletiva da artéria esplênica, a origem do pseudoaneurisma foi identificada, procedendo-se à embolização proximal e distal à sua origem com coils. O resultado final foi satisfatório com aparente embolização completa do pseudoaneurisma. A angioTC foi repetido 8 dias após o procedimento, revelando embolização completa do pseudoaneurisma, sem evidência de hemorragia. As coleções peri-aneurismáticas permaneceram inalteradas em tamanho e identificaram-se àreas de enfarte esplénico a ocupar cerca de 50% do baço. O doente teve alta ao 10.º dia pós-operatório. Conclusões: A cirurgia endovascular parece ser uma boa opção para o tratamento de pseudoaneurismas da artéria esplénica mesmo em rotura, com bons resultados em curto prazo. Neste caso, admitiu-se que o tratamento endovascular poderia ser uma ponte para cirurgia convencional com aneurismectomia e esplenectomia. No entanto, dada a boa evolução clínica pós-procedimento não se realizou mais nenhum procedimento. Atualmente, existe pouco consenso relativo a follow-up e os resultados a longo prazo são em grande parte desconhecidos.

Introduction: Infectious celiac artery aneurysm (ICAA) is an extremely rare diagnosis, and only a few cases have been reported in the literature to date. We aimed to review this rare clinical entity, focusing on diagnosis and treatment strategies. Methods: A systematic literature review was performed using MEDLINE database according to the PRISMA guidelines. Results: A total of 11 cases of ICAA were identified in the literature to date. Treatment options were extremely variable and included both open and endovascular surgery. Open surgery included aneurysm ligation or aneurysmectomy with or without revascularization with bypass. Endovascular options are increasingly used and include embolization of the aneurysm and collaterals, stentgraft exclusion of the ICAA and in one case report, Chimney technique was used to exclude the aneurysm maintaining celiac trunk patency. Unsurprisingly, antibiotherapy was consistently an essential part of the treatment strategy. Conclusions: Due to the rarity of ICAA, natural history is unclear. Still, surgical treatment is unanimous regardless of aneurysm size. Short term results of endovascular treatment are encouraging, but endovascular implantation of prosthetic material in an infected environment is a concern, so lifelong antibiotherapy and close monitoring are advisable., Angiologia e Cirurgia Vascular, Vol 15 No 1 (2019): March

Sickle cell anaemia (SCA) arises from homozygosity for the mutation c.20A>T in the HBB gene. However, it shows a multifactorial-like behaviour with high heterogeneity of clinical features. Cerebral vasculopathy (CVA), namely paediatric ischemic stroke, is one of its most devastating consequences. The risk of CVA development, specifically stroke or silent cerebral infarction, may be modulated by underlying genetic modifiers, for example those affecting vascular homeostasis. In this study, we aimed to investigate the impact of variants in genes related with endothelial adhesion (VCAM1 and ITGA4) and nitric oxide metabolism (NOS3) on CVA in a group of 70 SCA children well characterized according to their CVA degree. In addition, the effect of the same genetic variants on biochemical/haematological biomarkers of chronic haemolysis was also analysed. Moreover, we also evaluated the putative additional modulating role of variants previously identified as stroke risk factors by genome-wide associated studies: GOLGB1 Y1212C, ENPP1 K173Q and PON1 Q192R. Molecular analysis was performed using PCR, PCR-RFLP, next-generation sequencing and Sanger sequencing. SPSS software was used for statistical analyses and association studies. One of the seven VCAM1 promoter haplotypes found and the VCAM1 promoter rs1409419_T showed association with moderate to high time-averaged mean of maximum velocity in the middle cerebral artery. The same association was observed for the variant ENPP1 K173Q. On the other hand, we observed that ITGA4 variants rs113276800_A and rs3770138_T were associated with stroke events. As for NOS3, one of the six haplotypes and the intron 4 VNTR_4b allele (5 repeats) were associated with lower risk of silent cerebral infarction. Chronic haemolysis biomarker levels also seemed to be influenced by genetic variants. LDH levels was higher in the presence of VCAM1 promoter rs1409419_T and one VCAM1 haplotype but lower in patients with one of the two ITGA4 haplotypes found. Genetic modulation also occurred in total bilirubin levels, which were higher in association with VCAM1 rs3783613_C allele. Our results, namely the association between specific variants with certain cerebral vasculopathy predictors further enhances their putative modulating effect on SCA paediatric stroke risk, severity and prognosis. These findings provide additional clues on the SCA pathophysiology and uncover features in these genes that may prove to be crucial as potential therapeutic targets. INSA_202DGH720 and ISAMB info:eu-repo/semantics/publishedVersion

Aim: Carotid blowout syndrome is a rare but devastating complication of head and neck malignancy, and is associated with a reported mortality and neurologic morbidity of 40% and 60% respectively. The aim of this case report is to present our experience with a single case of massive haemorrhage from the internal carotid artery (ICA) in a previously irradiated neck treated with a stentgraft, hence maintaining carotid artery patency. Methods: Relevant medical data were collected and literature review was performed. Results: The patient is a 61-year-old male with a previous history of head and neck cancer submitted to radical surgery and chemo and radiotherapy. Seven years later, the patient was diagnosed with osteoradionecrosis of the mandibula and submitted to surgery. Hospital stay was prolonged due to local infection and suture dehiscence with carotid artery exposure. No previous episodes of sentinel bleeding were registered. Life-threatening haemorrhage from the surgical wound started acutely. Under manual compression, the patient was rushed to the angiography suite and the diagnostic angiography ascertained active bleeding from the ICA. A stentgraft Atrium Advanta V12 (Maquet Getinge group, Hudson, NH, USA) was deployed maintaining ICA patency. The patient was subsequently submitted to surgical reconstruction and had an uneventful recovery. Discussion: Management of acute carotid blow syndrome is critical, often requiring a multidisciplinary approach. Stentgraft placement is a highly feasible and effective approach with lower morbimortality rates when compared to surgical repair/ ligation or endovascular embolization. However long term results with patency rates are currently lacking., Angiologia e Cirurgia Vascular, Vol 14 No 3 (2018): September

Introduction: Iliac artery dissection without aortic involvement is a rare entity, with most cases associated with predisposing factors such as trauma, atherosclerosis, connective tissue disorders or vigorous exercise. The best treatment is not unanimous, and depends on the acuteness and severity of symptoms. Criteria for intervention include prevention of aneurysmatic degeneration, acute limb ischemia, inguinal pain and aneurysm rupture. Recent results using endovascular technique showed comparability with open repair, but there is paucity of data concerning long term results. Methods: Relevant medical data were collected from hospital database. Results: The patient is a 65 years old male, referred to the emergency department for abdominal pain in the left lower quadrant with inguinal irradiation. No signs or symptoms of acute limb ischemia were present. He had no previous history of connective tissue disease, cardiovascular risk factors, trauma or vigorous exercise. A CTA was performed, which identified an acute common left iliac artery dissection, with no evidence of vascular compromise of the ipsilateral limb He was submitted to surgical left femoral approach and percutaneous right femoral approach and dissection exclusion with two stentgrafts. Resolution of abdominal pain occurred immediately. Imagiologic follow-up with CTA was performed 12 and 24 months later with no signs of dissection or residual stenosis. Conclusion: In this case, an hybrid procedure with femoral surgical approach was performed for access site control. The use of bilateral femoral access was useful to identify the true lumen more accurately and to accommodate a more precise stent placement assuring adequate sealing. At 24 months follow-up, the patient maintains asymptomatic with no evidence of complications in the imagiologic follow-up. No signs or symptoms suggestive of connective tissue disease developed., Angiologia e Cirurgia Vascular, Vol 14 No 3 (2018): September

Introdu����o: A Isquemia Mesent��rica Aguda (IMA) e Colite Isqu��mica (CI) s��o duas entidades cl��nicas indissoci��veis que podem aparecer no mesmo doente, simultaneamente ou em per��odos temporais distintos. No entanto, a maioria dos doentes com CI n��o apresentam causa vascular obstrutiva major identific��vel, por oposi����o �� IMA. Segundo o American College of Gastroenterology (ACG), a exclus��o de IMA por angio-tomografia computorizada deve ser realizada em todos os doentes com crit��rios de CI severa. Este estudo teve como objetivos determinar se existe uma associa����o entre a gravidade da CI e a presen��a de IMA e identificar preditores de IMA na CI severa. M��todos: Foram selecionados todos os doentes admitidos com o diagn��stico de CI, no per��odo de 2010 a 2014. Resultados: Durante o per��odo estudado foram selecionados 241 doentes, 213 com CI isolada e 28 com CI+IMA. A gravidade da CI foi estratificada de acordo com os crit��rios do ACG, n��o se identificando casos de IMA concomitante na CI ligeira, enquanto 1,5% dos doentes com CI moderada e 56,8% dos doentes com CI severa apresentaram IMA concomitante. O grupo CI severa foi comparado com o grupo IMA+CI severa. A presen��a de hematoqu��zias foi mais frequente no grupo CI isolada (p, Angiologia e Cirurgia Vascular, Vol 14 No 3 (2018): September

Introduction: Currently, the prevalence of Diabetes Mellitus (DM) in Portugal is 13,3% in adult population. Patients with DM have a 15-25% lifetime risk of developing a foot ulcer. Additionally, diabetic angiopathy is a unique vascular disease that has predilection for below-the-knee arteries. Meanwhile, endovascular techniques have been revolutionizing the revascularization of neuroischemic diabetic foot (NIDF) patients, showing consistently higher limb salvage rates. The survival of NIDF patients reaches 50% at 5 years after revascularization and limb salvage, but decreases to 50% at 2 years after a major amputation. With this study, the authors intend to describe their experience on endovascular revascularization for the treatment of NIDF patients. Methods: Retrospective institutional review of consecutive patients requiring endodistal revascularization (January 2010 - December 2017) - 464 limbs in 326 patients. We evaluated demographics and co-morbidities data and performed statistic analysis to determine factors and outcomes as limb salvage, major and minor amputation rates. The primary outcome was to evaluate the technical success, the limb salvage, the rate of major and minor amputation and the global survival of this population. The secondary outcomes were to characterize the population, the endovascular procedures performed and the evolution over the last years. Operative reports were reviewed to analyze the endovascular procedures and techniques. Results and conclusions: The technical success was achieved in 85% of the procedures. The iliac sector was only treated in 0,7% of the procedures and femoro-popliteal sector in 63,2%. Antegrade femoral approach, was obtained in 91, 3% of the procedures. A complementary retrograde distal approach was performed in 7,6% of procedures. Direct angiossomic revascularization was obtained in 60,9% of the cases. In the femoral and popliteal arteries, PTA was performed in 56,3% of the procedures and recanalization, PTA and stenting in 42,4%. During FU, 14,1% of patients was submitted to major amputation and 36,4% to minor amputation. The major amputation free-survival rate was 80,1% at 12 mo and the rate of healing at 12 mo was 63,2%. The 12 mo global survival was 79,8%. Direct angiossomic revascularization (p=0,014) and the number of tibial arteries recanalized (p=0,01) were both associated with a higher limb salvage rate and a faster healing of the ulcer. In the opposite side, there was an association between the increasing of renal dysfunction and poor healing (p=0,04). The endovascular reintervention rate was 20,4%. The results of the author���s study on endodistal revascularization, highlights the need to prioritize investigation and revascularization in NIDF patients to improve the outcome of foot ulcer, giving the possibility of salvaging a greater number of limbs., Angiologia e Cirurgia Vascular, Vol 14 No 4 (2018): December

Aim: Carotid blowout syndrome is a rare but devastating complication of head and neck malignancy, and is associated with a reported mortality and neurologic morbidity of 40% and 60% respectively. The aim of this case report is to present our experience with a single case of massive haemorrhage from the internal carotid artery (ICA) in a previously irradiated neck treated with a stentgraft, hence maintaining carotid artery patency. Methods: Relevant medical data were collected and literature review was performed. Results: The patient is a 61-year-old male with a previous history of head and neck cancer submitted to radical surgery and chemo and radiotherapy. Seven years later, the patient was diagnosed with osteoradionecrosis of the mandibula and submitted to surgery. Hospital stay was prolonged due to local infection and suture dehiscence with carotid artery exposure. No previous episodes of sentinel bleeding were registered. Life-threatening haemorrhage from the surgical wound started acutely. Under manual compression, the patient was rushed to the angiography suite and the diagnostic angiography ascertained active bleeding from the ICA. A stentgraft Atrium Advanta V12 (Maquet Getinge group, Hudson, NH, USA) was deployed maintaining ICA patency. The patient was subsequently submitted to surgical reconstruction and had an uneventful recovery. Discussion: Management of acute carotid blow syndrome is critical, often requiring a multidisciplinary approach. Stentgraft placement is a highly feasible and effective approach with lower morbimortality rates when compared to surgical repair/ ligation or endovascular embolization. However long term results with patency rates are currently lacking. Objetivo: A síndrome de blowout carotídeo é uma complicação rara mas potencialmente catastrófica, da neoplasia de cabeça e pescoço, e está associada a uma mortalidade e morbidade neurológica reportadas de 40% e 60%, respetivamente. Pretende-se apresentar a nossa experiência com um caso de blowout carotídeo com hemorragia maciça com origem na artéria carótida interna (ACI) num doente com história prévia de radioterapia cervical e osteorradionecrose da mandíbula, tratado por via endovascular com colocação de um stent recoberto mantendo, assim, a permeabilidade carotídea. Métodos: Realizou-se revisão dos dados clínicos relevantes bem como revisão da literatura existente. Resultados: Trata-se de um doente do sexo masculino de 61 anos, com história prévia de neoplasia da cabeça e pescoço, submetido a cirurgia radical e quimio e radioterapia. Sete anos depois, o paciente foi diagnosticado com osteorradionecrose da mandíbula e submetido a cirurgia reconstrutiva. A estadia hospitalar pós-operatória foi prolongada por infeção local e deiscência da ferida cirúrgica com exposição carotídea. Não houve registo de episódios prévios de hemorragia sentinela, no entanto o doente apresentou início súbito de hemorragia major com origem na ferida cirúrgica. Sob compressão manual, o doente foi admitido na suite angiográfica tendo-se constatado hemorragia ativa da ACI. Posteriormente implantou-se um stent recoberto Atrium Advanta V12 (Maquet Getinge, Hudson, NH, EUA) mantendo-se a permeabilidade da ACI. Numa segunda fase, após estabilização do doente em unidade de cuidados intensivos, o doente foi submetido a reconstrução cirúrgica, sem intercorrências. Discussão: O tratamento da síndrome de blowout carotídeo agudo é emergente, exigindo muitas vezes uma abordagem multidisciplinar. A colocação de um stent recoberto é uma abordagem exequível e eficaz em contexto agudo, com menores taxas de morbimortalidade associadas, quando comparado ao tratamento/laqueação cirúrgica ou embolização endovascular. No entanto, desconhece-se os resultados a longo prazo, em particular taxas de permeabilidade.

Introdução: A Isquemia Mesentérica Aguda (IMA) e Colite Isquémica (CI) são duas entidades clínicas indissociáveis que podem aparecer no mesmo doente, simultaneamente ou em períodos temporais distintos. No entanto, a maioria dos doentes com CI não apresentam causa vascular obstrutiva major identificável, por oposição à IMA. Segundo o American College of Gastroenterology (ACG), a exclusão de IMA por angio-tomografia computorizada deve ser realizada em todos os doentes com critérios de CI severa. Este estudo teve como objetivos determinar se existe uma associação entre a gravidade da CI e a presença de IMA e identificar preditores de IMA na CI severa. Métodos: Foram selecionados todos os doentes admitidos com o diagnóstico de CI, no período de 2010 a 2014. Resultados: Durante o período estudado foram selecionados 241 doentes, 213 com CI isolada e 28 com CI+IMA. A gravidade da CI foi estratificada de acordo com os critérios do ACG, não se identificando casos de IMA concomitante na CI ligeira, enquanto 1,5% dos doentes com CI moderada e 56,8% dos doentes com CI severa apresentaram IMA concomitante. O grupo CI severa foi comparado com o grupo IMA+CI severa. A presença de hematoquézias foi mais frequente no grupo CI isolada (p

Introdu����o: A democratiza����o da repara����o a��rtica endovascular (EVAR) alterou significativamente a estrat��gia terap��utica do aneurisma da aorta abdominal (AAA), devido ao seu car��cter minimamente invasivo e �� menor morbi-mortalidade perioperat��ria associada. No entanto, complica����es espec��ficas, como o endoleak tipo 1a (T1aE) e o endoleak tipo 2 persistente (pT2E), foram associadas a outcomes adversos, sendo o mais grave a rotura aneurism��tica. Apresentamos um caso de rotura de AAA p��s EVAR devido a T1aE e pT2E tratado na nossa institui����o. Caso Cl��nico: Trata-se de um doente do sexo masculino, de 73 anos, submetido a EVAR noutra institui����o por AAA infrarrenal sem intercorr��ncias. Cerca de 7 anos ap��s-EVAR, o doente �� observado no Servi��o de Urg��ncia da nossa institui����o por quadro de dor abdominal e s��ncope com recupera����o espont��nea. Um AngioTC foi realizado e revelou crescimento do saco aneurism��tico, hiperdensidade espont��nea do trombo, elevada densidade da gordura retroperitoneal direita e um pT2E com origem em art��rias lombares. Foi decidida interven����o cir��rgica aberta mas intra-operat��riamente, ap��s a abertura do saco aneurism��tico, foram detetados tanto pT2E quanto T1aE. Foi ent��o submetido a aneurismectomia parcial, laquea����o dos ��stios das art��rias lombares, preenchimento do saco anerism��tico com produtos pr��-tromb��ticos a selar o colo proximal e encerramento do saco de aneurisma com ajuste do colo proximal. O doente teve alta cl��nica 15 dias ap��s o procedimento. A AngioTC realizado 1 m��s ap��s o procedimento revelou aus��ncia de endoleaks e estabilidade do tamanho do saco aneurism��tico preenchido com produtos pr��-tromb��ticos. No follow-up a 2 anos, o doente manteve-se assintom��tico e os achados da AngioTC permaneceram inalterados. Discuss��o: A rotura p��s-EVAR �� um desafio terap��utico significativo para cirurgi��es vasculares. Neste caso, os achados pr��-operat��rios da AngioTC levaram �� decis��o terap��utica de endoaneurismorrafia de colaterais. O achado intra-operat��rio de T1aE no contexto da rotura aneurism��tica e instabilidade hemodin��mica, for��ou-nos a uma solu����o inventiva com o objetivo de recuperar a selagem adequada do colo proximal. Esta foi essencialmente uma variante do banding proximal previamente descrito para T1aE. A explanta����o da endopr��tese foi considerada demasiado time-consuming e agressiva num doente j�� inst��vel. Resultados do follow-up a 2 anos s��o encorajadores., Angiologia e Cirurgia Vascular, Vol 14 No 1 (2018): March

Introdução: A democratização da reparação aórtica endovascular (EVAR) alterou significativamente a estratégia terapêutica do aneurisma da aorta abdominal (AAA), devido ao seu carácter minimamente invasivo e à menor morbi-mortalidade perioperatória associada. No entanto, complicações específicas, como o endoleak tipo 1a (T1aE) e o endoleak tipo 2 persistente (pT2E), foram associadas a outcomes adversos, sendo o mais grave a rotura aneurismática. Apresentamos um caso de rotura de AAA pós EVAR devido a T1aE e pT2E tratado na nossa instituição. Caso Clínico: Trata-se de um doente do sexo masculino, de 73 anos, submetido a EVAR noutra instituição por AAA infrarrenal sem intercorrências. Cerca de 7 anos após-EVAR, o doente é observado no Serviço de Urgência da nossa instituição por quadro de dor abdominal e síncope com recuperação espontânea. Um AngioTC foi realizado e revelou crescimento do saco aneurismático, hiperdensidade espontânea do trombo, elevada densidade da gordura retroperitoneal direita e um pT2E com origem em artérias lombares. Foi decidida intervenção cirúrgica aberta mas intra-operatóriamente, após a abertura do saco aneurismático, foram detetados tanto pT2E quanto T1aE. Foi então submetido a aneurismectomia parcial, laqueação dos óstios das artérias lombares, preenchimento do saco anerismático com produtos pró-trombóticos a selar o colo proximal e encerramento do saco de aneurisma com ajuste do colo proximal. O doente teve alta clínica 15 dias após o procedimento. A AngioTC realizado 1 mês após o procedimento revelou ausência de endoleaks e estabilidade do tamanho do saco aneurismático preenchido com produtos pró-trombóticos. No follow-up a 2 anos, o doente manteve-se assintomático e os achados da AngioTC permaneceram inalterados. Discussão: A rotura pós-EVAR é um desafio terapêutico significativo para cirurgiões vasculares. Neste caso, os achados pré-operatórios da AngioTC levaram à decisão terapêutica de endoaneurismorrafia de colaterais. O achado intra-operatório de T1aE no contexto da rotura aneurismática e instabilidade hemodinâmica, forçou-nos a uma solução inventiva com o objetivo de recuperar a selagem adequada do colo proximal. Esta foi essencialmente uma variante do banding proximal previamente descrito para T1aE. A explantação da endoprótese foi considerada demasiado time-consuming e agressiva num doente já instável. Resultados do follow-up a 2 anos são encorajadores Introduction: Endovascular aortic repair (EVAR) has significantly altered the therapeutic strategy for abdominal aortic aneurysm (AAA), due to less invasiveness and lower perioperative morbi-mortality. However, specific complications such as type 1a endoleak (T1aE) and persistent type 2 endoleak (pT2E) have been associated with adverse outcomes including aneurismal rupture. We present a case of AAA rupture due to both T1aE and pT2E treated in our institution. Case Report: The patient is a 73-year-old male, submitted to EVAR at another institution for infra-renal AAA with no apparent complications. He was admitted in the emergency department, 7 years post-EVAR, with abdominal pain and loss of consciousness with spontaneous recovery. A CTA was performed and revealed aneurysmal sac growth, spontaneous hiperdensity of the thrombus, high density in the fat in the right retroperitoneum and a pT2E. Intra-operatively, after opening the aneurysmal sac, both pT2E and T1E were detected. He was submitted to partial aneurismectomy, suture of the ostia of the lumbar arteries, filling of the aneurysm sac with prothrombotic products and closure of the aneurysm sac with adjustment of the proximal sealing zone. The patient was discharged 15 days post-procedure. CTA performed 1 month after the procedure revealed no endoleak, aneurismal sac stability filled with prothrombotic products. At 2-year follow-up the patient remained asymptomatic and the CTA findings remained unchanged. Discussion: Rupture post-EVAR is a significant therapeutic challenge for vascular surgeons. In this case, pre-operative CTA findings lead to plan an open surgery with endoaneurismorrhaphy of collaterals. Intra-operative finding of T1aE in the context of aneurismal rupture and hemodynamic instability, forced us into an inventive solution aiming to regain proximal sealing. This was essentially a variant of previously described proximal banding for T1aE. Endoprosthesis explantation was considered too time-consuming and aggressive in an already unstable patient. Results at 2-year follow-up were encouraging.