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Introduction: Severe ilio-femoral occlusive disease can limit the endovascular treatment of aorto-iliac aneurysms. In high surgical risk patients, inventive and staged hybrid interventions can be the answer to achieve definitive treatment. Clinical Case: A 68-year-old male, with multiple comorbidities, presented with simultaneous occurrence of bilateral common iliac aneurysms and severe ilio-femoral occlusive disease associated with right critical limb-threatening ischemia. In order to exclude the iliac aneurysms, preserve pelvic flow and revascularize the threatened limb we decided for a three-staged hybrid intervention. First, we began with a right external iliac angioplasty with femoral endarterectomy to create adequate arterial access. In a second intervention, we implanted a bifurcated aortoiliac endograft through this access. In order to prevent pelvic ischemia, contralateral leg outflow was directed to the left internal iliac artery with a combination of self-expandable and balloon-expandable covered stents. Finally, a right femoro-posterior tibial artery bypass completed the revascularization. At 1,5-year follow-up, no complications are reported and the patient is asymptomatic. Conclusion: In patients with poor medical condition and complex aorto-iliac aneurysmal and occlusive disease, a staged hybrid approach like the one described in this case-report can be feasible and associated with durable midterm patency and excellent clinical outcome.

Pseudoaneurysms after gastro-intestinal tract surgery are rare. Most of them occur after biliary tract and pancreatic surgery. They can lead to potentially serious consequences, such as rupture, hemorrhage and death. For these reasons, pseudoaneurysms should be diagnosed and treated as soon as possible.

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.

Introduction: Post-implantation syndrome (PIS) is the clinical and biochemical expression of an inflammatory response following endovascular repair of an aortic aneurysm (EVAR). The reported incidence in literature varies from 14-60%. Recentently, a study has demonstrated that red blood cell distribution width (RDW) is an independent biomarker predictor of the PIS in patients submitted to EVAR in the early postoperative period. Methods: Retrospective institutional review of consecutive patients submitted to elective EVAR (January 2015- April 2020). The primary outcome was to evaluate the incidence of PIS, defined as fever (>38ºC) and leukocytosis (>12000/μL), excluding infection complication. The secondary outcomes were to identify the potential role of clinical and biomarker parameters to predict the risk of developing PIS after EVAR. Results and conclusion: According to the inclusion criteria, 107 patients were identified. The median age was 75 years old (93.5% men). Comorbidities presented: hypertension (75%), smoking (66%), hypercholesterolemia (59%), coronary artery disease (32%), chronic kidney disease (30%), and diabetes mellitus (DM) (18%). The incidence of PIS was 10,2%. Age, gender and cardiovascular risk factors were found to be similar in both groups (P>0.05). Regarding the procedure approach, the majority of patients were treated with percutaneous access (72%) (P=0,49). In both groups (PIS vs. no PIS), the hemoglobin values significantly decreased (P=0,04) after surgery by approximately 14%. The same trend was observed for mean corpuscular volume (MCV) (P=0.032), which reflected the increasing of the RDW although not reaching statistical significance. Although delta variation of hemoglobin and delta RDW did not reach statistical significance comparing both groups (P=0,53 and P= 0,07 respectively), delta MCV was found to be significantly lower in the group with PIS (P=0.012). The importance of having a biomarker which measurement allows the prediction of patients who have more risk to develop PIS, may help with the early management of this condition.

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.

Introduction: In many areas of Medicine, biomarkers have been proving their value in disease management. The inclusion of inflammatory biomarkers in acute limb ischemia (ALI) decision-making remains debatable due to the scarce literature evidence. Nevertheless, much attention has been held towards the prognostic value of these simple, readily available and low-cost biomarkers might have. Therefore, this review aimed to identify studies that support the utility of preoperative inflammatory markers, such as the neutrophil-lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR), for predicting ALI outcome. Methods: A comprehensive systematic search was applied to Medline database to identify all the cohort studies that specifically investigated and compared the outcomes of ALI patients in relation to their preoperative inflammatory biomarkers. Results: Four cohort studies were included in the review: two published citations, one research letter and one unpublished paper from the same authors of this review. In all studies, the primary outcomes were amputation and/or survival. All studies reported that higher NLR values were independently associated with adverse outcomes after treatment. One study stated that NLR ≥ 5.2 was found to have an 83% sensitivity and 63% specificity for predicting amputation within 30 days (Area Under Curve (AUC) 0.8) while other found that NLR ≥ 5.4 demonstrated to have a 90.5% sensitivity and 73.6% specificity for predicting 30-day amputation or death (AUC 0.86). Higher preoperative RDW, MPV, PLR and C-reactive protein were also reported as predictors of amputation in acute arterial thromboembolism patients in another study. Conclusion: This review demonstrates that although limited literature exists, inflammatory biomarkers like NLR and PLR appear to have a role in ALI preoperative risk stratification. Definition of levels and trends of inflammatory biomarkers and their relationship with treatment outcome could be established through multicentric studies, influencing timing and intervention selection and leading to potential improvements in ALI morbimortality.

Introduction: Guidewire fracture is a rare complication of percutaneous coronary intervention (PCI). Retained fragments can cause thrombosis, dissection, perforation of the vessel or embolize. When is impossible to withdraw or to trap the fragment during the procedure, management is debatable between surgical removal or conservative approach. When choosing to leave the fragment in place, the patient remains at risk for all of the aforementioned complications. Clinical Case: 65-year-old male patient submitted to PCI with stenting of distal right coronary artery in 2017. A proximal optimization technique was performed, with a guidewire placed in the posterior descending artery (PDA). After stenting, the protection guidewire became entrapped and after several retrieval attempts, it fractured. Wire fragment remained within the RCA and ascending aorta with a free mobile distal part in the beginning of the innominate artery. Multiple attempts went in vain for wire retrieval and a conservative approach was adopted. Two and a half years later, the patient felt a sudden chest pain and then collapsed. He was transferred to our Hospital for emergent surgery due to cardiac tamponade. Intra-operatively, cardiac surgeons found the guidewire perforating the posterior descending artery. When trying to pull it out, the guidewire fractured again. Post-intervention CTA revealed migration of the fragmented guidewire now it was entrapped in a tortuous initial portion of the right internal carotid artery and a small pseudoaneurysm was visible at the distal portion of the wire. Surgical approach was performed revealing the presence of the wire within the carotid medial wall, in a subintimal plane. The 7 cm fragment was successfully withdrawn, through a common carotid transverse incision. Pseudoaneurismectomy was performed and carotid artery bifurcation reconstruction with internal carotid artery re-implantation into the bifurcation, end-to-end anastomosis. The patient had an uneventful postoperative course. Conclusion: Although leaving the wire in place remains an option, coronary guidewire fractured fragments can be associated not only with immediate complications but also with potential adverse events in the long run.

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

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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.

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.

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.

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.

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.

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.

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.