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INTRODUCTION: Percutaneous endovenous treatment is the first-line therapy for chronic nonmalignant iliocaval venous obstruction (ICVO) due to low morbidity and suitable medium and long-term results. Open surgical procedures are only used as a last resort therapy. However, there is a lack of updated data regarding surgical techniques and outcomes. We present two cases of surgical venous reconstructions to treat ICVO using expanded polytetrafluoroethylene (ePTFE) grafts and discuss the evidence regarding technical aspects to improve long-term patency. CASE REPORTS: The first case concerns a 69-year-old male with chronic edema and venous ulceration associated with ICVO secondary to iliocaval stent thrombosis. After an unsuccessful endovascular treatment attempt, we performed a surgical iliocaval bypass using a 10mm ringed ePTFE graft. After three months, complete ulcer healing was observed. The other patient was a 63-year-old female with disabling chronic edema of the right lower limb and venous claudication consequent to the ligation of the right common femoral vein to correct an iatrogenic vascular injury during orthopedic surgery. The patient underwent venous bypass between the deep femoral vein and the ipsilateral common iliac vein using a 12mm ringed ePTFE graft. A marked improvement in clinical symptoms was observed after treatment. A venous stent was used later to treat an anastomotic stenosis. CONCLUSION: Our experience supports open venous reconstruction as a viable option for patients with benign ICVO and debilitating symptoms not amenable to endovascular treatment. Important technical aspects such as adequate inflow vein, the choice of the prosthetic graft, long-term anticoagulation, and the creation of a distal arteriovenous fistula should be considered to improve patency., Angiologia e Cirurgia Vascular, Vol. 18 No. 4 (2022): December

INTRODUCTION: Light induced amaurosis refers to a transient monocular or binocular vision loss triggered by bright lights. Like amaurosis fugax, light induced amaurosis is associated with carotid artery stenosis but they differ from each other in presentation and pathophysiology. It is thought to be an impairment in the regeneration of retinal visual pigments caused by the inability of carotid circulation to sustain the increased metabolic activity occurring when the retina is exposed to bright lights. With this report we aim to present a case of light induced amaurosis and its management. CASE REPORT: We describe a 74-year-old man with the isolated complaint of monocular visual loss from his left eye when exposed to bright lights. These episodes were self-limited and lasted for several minutes. His vision was reportedly good between episodes. He also complained of headache and dizziness. There were no other focal neurological deficits present. The patient had a history of peripheral artery disease, chronic heart failure, hypertension, dyslipidaemia, permanent atrial fibrillation and had a history of heavy smoking in the past. Chronic medical therapy included anticoagulation with rivaroxaban, antiplatelet therapy with acetylsalicylic acid and atorvastatin. Imaging studies (doppler ultrasonography and Computed tomography angiography) revealed a significant morphologic stenosis of the left common carotid artery, left internal carotid artery with sub occlusive disease and right internal carotid artery with 70-75% stenosis (North American Symptomatic Carotid Endarterectomy Trial - NASCET). The vertebral arteries study did not reveal significant morphologic disease. The patient was submitted to left common and internal carotid artery endarterectomy and Dacron patch angioplasty. The visual symptoms progressively improved after surgical treatment. The dizziness and headache were completely gone. CONCLUSION: Light induced amaurosis is a rare and less known symptom associated with severe carotid artery stenosis. Its timely recognition is important to not deprive patients of timely treatment., Angiologia e Cirurgia Vascular, Vol. 18 No. 3 (2022): September

INTRODUCTION: Ectopic kidneys with concomitant aortoiliac aneurysmal disease have been previously reported in the literature, however its exact prevalence is unknown. The objective of this review is to summarize current knowledge on the treatment this special group of patients. METHODS: A non-systematic literature research was performed on the treatment of aortoiliac aneurysmal disease in patients with ectopic kidneys. RESULTS: Literature on the management of patients with aorto-iliac aneurysms and concomitant ectopic kidneys is limited to case reports and very small series. Treatment modalities which include open, endovascular or hybrid techniques, should preserve the variable vasculature of the ectopic kidney. Several different surgical solutions have been proposed, highlighting the uncertainty on the optimal management strategy. However, a growing number of reports suggest safety and efficacy with adapted endovascular techniques. CONCLUSION: In parallel to the general trend in the management of abdominal aortic aneurysm, it is expected that a growing number of patients will concomitant aorto-iliac aneurysm and ectopic kidneys will be treated with endovascular techniques., Angiologia e Cirurgia Vascular, Vol. 18 No. 2 (2022): June

INTRODUÇÃO: O fenómeno de nutcracker refere-se à compressão da veia renal esquerda (VRE), habitualmente entre a aorta e a artéria mesentérica superior. Quando sintomático, designa-se síndrome de nutcracker. Os sintomas/sinais estão relacionados com o desenvolvimento de hipertensão venosa renal e o diagnostico depende da conjugação da clínica e alterações laboratoriais na presença de critérios imagiológicos. Habitualmente a indicação terapêutica depende da severidade dos sintomas. Existem várias opções terapêuticas: transposição/ pontagem da VRE para uma implantação mais distal na veia cava inferior, transposição da veia gonadal, auto- transplante renal, e tratamento endovascular. CASO CLÍNICO: Doente de 40 anos, sexo feminino, observada em consulta de cirurgia vascular por varizes pélvicas e vulvares recidivadas. Por suspeita de síndrome de congestão pélvica, realizou estudo complementar com venoTAC que revelou fenómeno de nutcracker com dilatação importante da veia ovárica (VO) e varizes pélvicas. O exame sumário de urina revelou hematúria. Foram ponderadas várias opções de tratamento, tendo sido decidido fazer uma transposição da VO para a veia ilíaca comum (VIC). Através de uma pequena incisão paramediana esquerda (com cerca de 5cm) foi realizada uma abordagem retroperitoneal dos vasos. Procedeu-se à identificação e isolamento da VO (sinalizada com fio guia colocado pela veia femoral comum direita no início do procedimento). Localizada posteriormente à VO, isolou-se a VIC. Procedeu-se à secção transversal da VO e anastomose em termino-lateral da VO à VIC. O tratamento foi complementado com esclerose com espuma de varizes vulvares por via endovascular. A doente teve alta no primeiro dia de pós-operatório. Ao 6o mês de pós- operatório mantem-se sem recidiva das varizes e sem hematúria. DISCUSSÃO: O Síndrome de nutcracker pode implicar uma morbilidade importante, com risco de trombose da VRE e perda da função renal. O melhor tratamento ainda não está definido e a seleção da melhor opção é dificultada pelo reduzido número de casos, ausência de estudos prospetivos randomizados, e pela ausência de follow-up a longo prazo de algumas das opções terapêuticas. A transposição da VRE é o procedimento mais habitual, seguido pelo auto-transplante renal. O nosso serviço tem vasta experiência na transplantação renal e o auto-transplante tem tido bons resultados; no entanto, não deixa de ser uma intervenção complexa, com riscos potenciais não desprezíveis, com uma convalescença prolongada e um impacto estético importante, sobretudo se aferido à idade jovem dos doentes. Corroborado pelo resultado do caso clínico apresentado, os autores consideram que a transposição da VO é uma alternativa terapêutica menos invasiva a ser considerada., Angiologia e Cirurgia Vascular, Vol. 18 No. 2 (2022): June

Introduction: Renal artery aneurysms are rare clinical entities whose treatment criteria are not fully established. Endovascular treatment has gained acceptance in the case of renal artery trunk aneurysms. However, in the case of aneurysms of the renal artery branches, such procedures are often impossible due to high morbidity, so the question remains about the best treatment modality. We present a clinical case of multiple bilateral aneurysms of the renal artery branches in a young patient adequately treated with ex-vivo reconstruction and renal autotransplantation. Case-presentation: A 35-year-old woman was diagnosed with bilateral renal artery aneurysms during an investigation of secondary arterial hypertension (AHT). The patient underwent surgical treatment with renal autotransplantation, and the right kidney was initially treated. Transperitoneal laparoscopic nephrectomy was performed. She underwent ex vivo repair of aneurysms, on the bench, with aneurysmectomy and aneurysmorrhaphy. The graft was implanted in the right iliac fossa with anastomoses to the external iliac artery and vein. After three months, an identical procedure was performed on the left. Upon inspection, a large aneurysm was observed in the renal artery bifurcation and another small aneurysm in one of the branches; both corrected with aneurysmec- tomy and aneurysmorrhaphy. Ex-vivo angiographic control ensured the preservation of graft arteries patency without evidence of residual aneurysms. The kidney was implanted in the left external iliac vessels uneventfully. A study with renal scintigraphy confirmed the adequate function of both kidneys. The patient is asymptomatic at nine months of follow-up with serum creatinine and glomerular filtration rate within normal values. Conclusion: Renal autotransplantation with ex vivo arterial repair seems to be a good solution in treating aneurysms of the renal artery, particularly in complex cases with multiple aneurysms., Angiologia e Cirurgia Vascular, Vol. 17 No. 4 (2021): December

INTRODUCTION: In situ lesser saphenous vein (LSV) graft has been advocated in cases of lower limb revascularization where target arteries are confined to the lower leg and the greater saphenous vein (GSV) is neither available nor suitable. This often occurs in diabetic or end-stage renal diseased patients, whose occlusive disease pattern typically affects the tibioperoneal vessels, sparing the femoropopliteal segment. In situ technique offers the potential advantages of decreased surgical trauma to the vein, better size-matching and improved hemodynamics. The posterior approach simplifies the surgical procedure; it achieves similar graft patency and limb salvage rates compared to standard procedures. CASE REPORT: We report a case of an 89 years-old male diabetic patient with previous attempts of endovascular revascularization of the posterior tibial and peroneal arteries; he presents with a nonhealing ulcer of the first toe of the right foot. Ultrasonographic vein mapping revealed varicose GSV in both limbs and a linear, ~3mm diameter, LSV in the right leg. The patient underwent right limb retrogeniculate popliteal to distal posterior tibial artery bypass with in situ LSV through a posterior approach. Post-operative bypass thrombosis occurred after seven days; it was resolved with surgical thrombectomy, vein angioplasty and arteriovenous shunt ligation. During follow-up at the outpatient clinic, the bypass remains patent and skin lesions healing without complications. CONCLUSION: In situ LSV is a safe and viable option conduit for popliteal to distal arteries bypasses. Vascular surgeons should be aware of the posterior approach, which simplifies and comfortably exposes the anatomic structures required for this surgery., Angiologia e Cirurgia Vascular, Vol 17 No 3 (2021): September

Introduction: The development of aneurysms in iliac arteries excluded from high-pressure direct flow from the aorta is very uncommon. We report a case of successful treatment of bilateral metachronous iliac artery aneurysms (MIA), found 10 years after an aortobifemoral bypass, with perfusion only by retrograde flow from the common femoral arteries (CFA). Case Report: A 76-year-old man came for consultation after incidental finding of bilateral MIAs, 10-years after aorto- bifemoral bypass for treatment of an aortic abdominal aneurysm (AAA). Computed tomography angiography (CTA) showed a right internal iliac artery (IIA) aneurysm of 43-mm diameter and a left common iliac artery (CIA) aneurysm of 45-mm diameter that were not present 10-years before. Exclusion of the left CIA aneurysm was achieved with a left IIA to external iliac artery (EIA) endograft using two covered stents (���banana��� technique). The right IIA aneurysm was excluded with embolization of the distal internal iliac branches and aneurysm sac with coils and occlusion of the proximal EIA with an occluder. There were no postoperative complications. A CTA two months after surgery showed total exclusion of the left CIA aneurysm and normal filling of the left IIA, as well as complete occlusion of the right IIA aneurysm. Conclusion: This case highlights that aneurysmal degeneration of iliac arteries can be generated by retrograde blood flow after treatment of AAAs with aortobifemoral grafts. An endovascular approach using the ���banana��� technique proved to be effective in treating MIAs while maintaining patency of one IIA., Angiologia e Cirurgia Vascular, Vol 17 No 3 (2021): September

Introdu����o: O kinking da art��ria renal p��s-transplante �� uma complica����o rara, geralmente associada �� disfun����o precoce do enxerto. M��todos: Apresentamos um caso cl��nico de um kinking da art��ria renal p��s-transplante com uma apresenta����o cl��nica incomum. Foi realizada uma revis��o dos registos cl��nicos com o consentimento do doente. Resultados: Homem de 52 anos com doen��a renal terminal secund��ria a nefropatia por IgA foi submetido a transplante renal de doador cadav��rico. O doente apresentou boa fun����o renal no p��s-operat��rio, no entanto, ap��s tr��s meses iniciou uma redu����o gradual da diurese e agravamento da fun����o renal a necessitar de permanecer em "posi����o de c��coras" 5 horas por dia para manter um d��bito urin��rio adequado. Foi realizada uma pontagem entre a art��ria il��aca externa esquerda e a art��ria renal do enxerto com veia grande safena aut��loga para corre����o de um kinking da art��ria renal com recupera����o da fun����o do enxerto. Conclus��o: A tor����o da art��ria renal comumente manifestada como disfun����o do enxerto renal pode-se apresentar de forma singular. A interven����o precoce �� essencial para preservar a viabilidade do enxerto., Angiologia e Cirurgia Vascular, Vol 17 No 2 (2021): June

Background: The surge of the COVID-19 pandemic in Portugal and the implemented public health measures were accompanied with a noticeable decrease in patients��� attendance to the Emergency Department (ED). Objectives: This study aims to evaluate the impact of COVID-19 pandemic on Vascular Surgery ED admissions, by comparing clinical and demographic characteristics of patients visiting the ED during the pandemic and the homologous period of 2019. Methods: We retrospectively collected data from patients admitted to the ED of a Portuguese tertiary hospital centre between March 4th and April 1st, 2020 ��� two weeks before and two weeks after the governmental implementation of the state of emergency in our country due to the COVID-19 pandemic ��� and the homologous period of 2019. Individual medical records were revised to obtain patients demographics and characteristics, clinical severity under the Manchester Triage System (MTS), final diagnosis, need for hospitalization or emergent/urgent surgery, in-hospital length of stay and mortality within 30 days of hospital discharge. Results: A total of 119 and 210 patients visited the Vascular Surgery ED during the pandemic and the homologous period of 2019, respectively. Males comprised the majority of patients in both years and the proportion of women visiting the ED was lower in 2020 compared to 2019 (P=0.015). The MTS attributed a lower number of high-priority levels (yellow and orange) to patients visiting the ED in 2020 (P=0.048). A higher proportion of patients required in-hospital treatment or emergent/ urgent surgery (P, Angiologia e Cirurgia Vascular, Vol 17 No 1 (2021): March

Chronic periaortitis and retroperitoneal fibrosis are related entities that develop with periaortic inflammation and deposition of fibroinflammatory tissue in the retroperitoneal space. This pathological fibroinflammatory process may be associated with endovascular treatment of abdominal aortic aneurysms (EVAR) as well as the treatment of aortoiliac arterial occlusive disease with stent/stent-graft implantation. We performed a systematic review of the literature in the MEDLINE database of original articles that documented the development of periaortitis after endovascular aortoiliac treatment for occlusive and aneurysmatic arterial disease. We included a total of 12 articles describing 14 cases of this complication. Most of the reported cases are related to the development of periaortitis after EVAR in the treatment of abdominal aortic aneurysms (AAA). The majority of patients are male, with ages ranging from 45 to 78 years. This complication was verified with the use of different devices that included nitinol or stainless-steel stents. In the case of stent-grafts this complication occurred with both polyester and polytetrafluoroethylene (PTFE) coverings. The severity of the clinical picture was also highly variable, with some cases presenting with hydronephrosis resulting from urethral obstruction. Treatment with corticotherapy, tamoxifen, or a combination of the two was effective in all cases. Periaortitis is an extremely rare complication of aortoiliac endovascular treatment. Similar to idiopathic retroperitoneal fibrosis, corticosteroid therapy appears to be highly effective and early treatment seems to be essential to avoid complications., Angiologia e Cirurgia Vascular, Vol 16 No 4 (2020): December

Angiologia e Cirurgia Vascular, Vol 16 No 4 (2020): December

Introduction: Subclavian arterial puncture is a relatively frequent complication of attempted placement of central venous catheters (CVC). The placement of a CVC in the artery is rarer, but with potential serious complications especially in its withdrawal. Anticipating these complications, control of potential bleeding in catheter withdrawal is usually performed by surgical or endovascular approach with endoprosthesis release. Our goal is to present the treatment with a percutaneous arterial closure device. Materials / Methods: Presentation of a clinical case of a CVC placed in the subclavian artery treated with a percutaneous arterial closure device. Results: A 51-year-old man hospitalized for acute myocardial infarction. On the first day of hospitalization, the introduction of a CVC into the right subclavian vein was attempted. In view of the suspected intraarterial position, CT angiography scan demonstrated that the CVC had been introduced into the subclavian artery with a point of entry proximal to the passage under the clavicle and with a path to the brachiocephalic trunk. Hypocoagulation with UFH was initiated given the risk of pericateter thrombosis and embolization. The use of percutaneous closure device ProGlide�� was planned using the CVC pathway. As predictable difficulties for this option was the long CVC path to the arterial entry point, raising questions about the extent of the suture mechanism of the device and the progression of nodes in this path. Under fluoroscopic control, an angioplasty balloon was progressed until the CVC point of entrance for temporary bleeding control in case of ProGlide�� failure; in which case the procedure would be completed with a covered endoprosthesis; the subclavian artery had a diameter of 12 mm and was ipsilateral to a brachiocephalic fistula. It was decided to retrograde puncture the fistula and progress the balloon to the subclavian artery. The rigid guide wire was then placed through the CVC and the CVC removed. Two Proglide�� closure devices (positioned at 10 p.m. and 2 p.m.) were released. The complete resolution of clinical and imaging hemorrhage was verified. Discussion/Conclusions: Placement of CVC in the subclavian artery is a potentially serious complication since its removal can be complicated with severe haemorrhage. Depending on the point of entry, there may be additional complexities due to the proximity of the vertebral and carotid arteries. In this case we left open several hypotheses (endovascular and ultimately surgical), but our preference was ad initium the percutaneous introduction of closure device given the feasibility, simplicity, less aggressiveness, non-interference with the vertebral ostium, and lower cost compared to a covered endoprosthesis., Angiologia e Cirurgia Vascular, Vol 16 No 3 (2020): September

Introdu����o: A t��cnica criss-cross combina acesso vascular anter��grado e retr��grado da veia popl��tea, de modo a obter recanaliza����o venosa em doentes com trombose venosa profunda (TVP) ileofemoral associada a trombose das veias popl��tea e gemelares. Caso cl��nico: Doente do sexo feminino de 57 anos, com antecedentes de histerectomia radical e linfadenectomia de n��dulos linf��ticos p��lvicos em 2013, devido a neoplasia uterina, com consequente linfedema cr��nico do membro inferior direito. Admitida na urg��ncia por edema grave do membro inferior direito, com 7 dias de evolu����o. �� observa����o, a paciente apresentava edema da coxa e perna, cianose da perna, dor gemelar, extremidades quentes e pulsos distais palp��veis. Estudo com ecodoppler a objetivar trombose dos eixos venosos do membro inferior direito. Estudo com TC contrastado excluiu extens��o proximal do trombo para a veia il��aca comum direita ou veia cava; excluiu tromboembolismo pulmonar e evidenciou clips cir��rgicos em proximidade com a veia il��aca externa direita, causando uma respetiva redu����o luminal superior a 50%. A doente foi submetida a trombectomia e fibrin��lise dirigida por cateter. Obteve-se acesso vascular atrav��s de pun����o ecoguiada da veia popl��tea. Ap��s coloca����o de introdutores em sentido retr��grado e anter��grado, realizou-se trombectomia das veias gemelares at�� �� veia femoral comum, com recurso a aspira����o por cateter. Instituiu-se perfus��o de alteplase e heparina n��o fracionada por via perif��rica, mantidas durante 72 horas, com controlo angiogr��fico a cada 24h. Ap��s recanaliza����o satisfat��ria, realizou-se angioplastia com bal��o 14x40mm, seguida de stent 14x80mm na veia il��aca externa. N��o ocorreram complica����es hemorr��gicas major. O tratamento invasivo foi complementado com drenagem postural e meia el��stica compressiva, permitindo melhoria cl��nica imediata e progressiva. Ap��s dois dias, a doente recebeu alta medicada com heparina de baixo peso molecular. Em consulta de follow-up ap��s um m��s, constatou-se melhoria cl��nica progressiva e alterada hipocoagula����o para rivaroxabano ad aeternum. Conclus��o: A t��cnica de criss-cross permite recanaliza����o do inflow e outflow, restaurando pat��ncia venosa e mantendo a fun����o valvular, aspetos com eventual papel cr��tico nos resultados ap��s TVP ileofemoral extensa., Angiologia e Cirurgia Vascular, Vol 16 No 3 (2020): September

Aortoenteric fistula (AEF) is a rare cause of gastrointestinal (GI) bleeding. There are two types of AEF: primary and secondary. Primary AEF usually occurs in association with abdominal aortic aneurysm (AAA). Secondary AEF are associated to aortic grafts, normally in relation to graft infection, and represent the most common type. A high level of suspicion is essential to a prompt diagnosis. If not promptly diagnosed and treated the associated mortality is very high. The role of endovascular treatment is not yet defined. Our aim is to perform a non-systematic review of the available literature concerning etiology, clinical presentation, diagnosis and treatment of AEF., Angiologia e Cirurgia Vascular, Vol 16 No 2 (2020): June

Introdu����o: O diagn��stico de aneurismas venosos viscerais �� tipicamente incidental. Apesar do uso disseminado de m��todos de imagem precisos a identifica����o destas les��es continua a ser extremamente rara. Dentro destes, os aneurismas da veia renal s��o o subgrupo menos frequente correspondendo a uma pequena percentagem. M��todos: Apresentamos um caso-cl��nico de uma doente de 52 anos com um aneurisma gigante da veia do transplante renal associado a uma f��stula arteriovenosa. Adicionalmente foi realizada uma revis��o da literatura na base de dados MEDLINE. Resultados: Doente de sexo feminino com antecedentes de transplante renal de dador vivo com o enxerto localizado na fossa il��aca esquerda, recorre ao servi��o de urg��ncia com dor no local do enxerto renal e febre. �� observa����o do enxerto com ecografia observa-se uma les��o de grandes dimens��es no bacinete com fluxo identificado ao Doppler. Realizou angiotomografia computadorizada que revelou presen��a de uma f��stula arteriovenosa entre art��ria e a veia renal, com um volumoso aneurisma da veia renal a ocupar praticamente todo o seio renal, de aproximadamente 5.6cm de maior di��metro. Numa primeira fase foi realizada emboliza����o da f��stula arteriovenosa renal com coils. Pela manuten����o do quadro s��tico com disfun����o do enxerto foi posteriormente submetida a nefrectomia do enxerto. Conclus��o: Os aneurismas da veia renal s��o les��es extremamente raras com apenas alguns casos publicados na literatura. Estes aneurismas s��o pass��veis de tratamento por via endovascular ou cir��rgica, no entanto, tendo em conta a escassez de dados publicados desconhecem-se os resultados a longo prazo., Angiologia e Cirurgia Vascular, Vol 16 No 2 (2020): June

Introdu����o: O linfedema dos membros inferiores �� uma patologia relativamente comum que condiciona um marcado impacto na qualidade de vida do doente. Pode ocorrer primariamente ou ser secund��rio a um fator externo. O seu tratamento na maioria dos casos �� conservador atrav��s de massagem de drenagem linf��tica e medidas de compress��o externa. No entanto, a cirurgia reconstrutiva do sistema linf��tico tem vindo a ganhar popularidade. Adicionalmente, nos casos mais graves pode ser necess��rio a realiza����o de procedimentos cir��rgicos de redu����o de membro na corre����o de dismorfias associadas ao linfedema cr��nico. M��todos: Foi feita a revis��o de um caso cl��nico grave de linfedema do membro inferior que foi tratado com recurso a um procedimento cir��rgico de redu����o de membro. Posteriormente procedeu-se a uma revis��o da literatura utilizando a base de dados MEDLINE. Resultados : Doente de 46 anos com antecedentes de obesidade m��rbida seguido por linfedema precoce do membro inferior direito que surgiu na segunda d��cada de vida. O doente foi observado em consulta de cirurgia vascular com queixas de linforragia tendo sido institu��do tratamento conservador com terapia compressiva. Apesar da melhoria inicial o linfedema progrediu com agravamento das queixas e recidiva de linforragia na coxa. Foi submetido a cirurgia de redu����o de membro com evolu����o favor��vel e marcada melhoria cl��nica no p��s-operat��rio. Conclus��o: O linfedema dos membros inferiores �� uma entidade pouco reconhecida que condiciona um marcado impacto na qualidade de vida dos doentes. Atualmente n��o existe tratamento curativo e os resultados do tratamento conservador s��o limitados. O tratamento cir��rgico, nomeadamente com cirurgia de redu����o do membro visa solucionar os casos mais graves nomeadamente complica����es associadas �� cronicidade do linfedema., Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

Resumo A fibrose retroperitoneal (FR) �� uma doen��a rara, caracterizada por inflama����o e fibrose na periferia da aorta abdominal com dissemina����o ao longo do espa��o retroperitoneal, invadindo estruturas contiguas. Em cerca de dois ter��os dos casos esta condi����o �� idiop��tica apresentando uma causa secund��ria nos restantes. Mais frequentemente as formas secund��rias est��o associadas a f��rmacos e neoplasias, no entanto outras situa����es podem levar ao desenvolvimento da doen��a. Na ��ltima d��cada tem surgido alguma evid��ncia de que a FR est�� associada �� angioplastia, stenting ou implanta����o de endopr��tese nos eixos aortoil��acos, no entanto a literatura publicada �� muito escassa. Apresentamos a nossa experi��ncia com dois doentes com arteriopatia grau IIb, um com estenose pr��-oclusiva da art��ria il��aca comum esquerda tendo sido submetido angioplastia e stenting da les��o, outro com estenose morfologicamente significativa da aorta abdominal infrarrenal tendo sido submetido a angioplastia e coloca����o de duas endopr��teses cobertas aortoil��acos sob a forma de kissing stent. Ambos os doentes desenvolveram dor lombar marcada tendo sido visualizado em angio-TC um processo inflamat��rio peria��rtico sugestivo de fibrose retroperitoneal que posteriormente evoluiu para aneurisma da aorta abdominal inflamat��rio. O mecanismo fisiopatol��gico desta altera����o n��o se encontra descrito, no entanto, poderemos supor que a angioplastia e stenting poder�� levar a rotura da integridade da placa ateroscler��tica com exposi����o de antig��nios contidos no seu interior desencadeando uma resposta inflamat��ria local. Por outro lado, poder�� existir uma rea����o imunol��gica diretamente contra o stent. �� importante pensar nesta poss��vel complica����o, uma vez que existe uma not��vel resposta �� corticoterapia e pela possibilidade de desenvolvimento de aneurisma da aorta inflamat��rio., Angiologia e Cirurgia Vascular, Vol 13 No 4 (2017): December

Introduction/Objectives: Type A aortic dissection (AD) usually requires urgent surgical treatment and aortic segment replacement remains the gold standard. However, it is a very aggressive procedure and some patients are considered too frail for this treatment. Nowadays, endovascular repair represents an alternative treatment but still without precise indications. Our objective is to present a case of hybrid treatment of a type A AD with resource a transapical cardiac access. Material/Methods: Clinical case and literature review. Results: A 65-year-old man with history of chronic pulmonary obstructive disease, atrial fibrillation and hypertension came to the emergency department with abdominal pain. He underwent angio-CT that revealed type A AD with an PAU in the ascending aorta (AA). After evaluation by cardiac surgery, he was considered too frail for conventional surgery. Angio-CT was repeated after two weeks of medical treatment and revealed false aneurysm growth, with imminent risk of rupture. We thought about endovascular treatment and different options were considered, the final decision was to propose the patient for an hybrid treatment. The procedure was started with a femoro-rigth axilar bypass and embolization of the brachyocephalic trunk. Then an endoprosthesis (Valiant��) was delivered below the left subclavian artery and two periscopes (Viabahn��) were progressed form left carotid and axillar arteries and the second endoprosthesis (Valiant��) was released into the aorta, inside the first, with coverage of the left common carotid and subclavian, and the Viabahn�� were released. After multiple attempts, it was not possible to progress the third endoprosthesis AA because of lack of support and hemodynamic instability whenever the guidewire was progressed for the left ventricle and the procedure was interrupted. Subsequently performed angio-CT revealed permeable AA dissection and untreated false aneurysm. We discussed other options and an anterograde (transapical) approach was considered to progress a guidewire on through-and-through to achieve the support we need to progress the endoprothesis. With the support of the cardiac surgery the cardiac apex was punctured and using the through-and-through technique the guide wire was progressed to femoral artery which allowed advancement of the endoprosthesis (Valiant��) through the retrograde pathway and release under rapid-pacing in the AA with good final result. Discussion/Conclusions: Endovascular treatment is an alternative in patients of high clinical risk and adequate anatomical characteristics, yet technically challenging. When the retrograde progression of the endoprosthesis is not achieved, the transapical cardiac approach is an alternative to be considered., Angiologia e Cirurgia Vascular, Vol 13 No 3 (2017): September

The number of patients treated with abdominal aortic aneurysm (AAA) increased considerably in the last decades. Even though open surgery remains the gold standard for AAA treatment, endovascular techniques like Chimney grafts (CGs) showed to be reliable to treat patients with contraindications for conventional surgery and hostile neck aneurysms. CGs are off-the-shelf stents which are accessible and useful for urgent/emergent cases. This work reports a case of a 67 years-old caucasian male with a symptomatic infrarenal aortic aneurysm having a 2.5mm short neck and a maximum diameter of 67 mm. Due to patient comorbidities and after ruling out other causes for the pain, he was treated in urgency with chimney technique to prevent rupture., Angiologia e Cirurgia Vascular, Vol 15 No 4 (2019): December

Homem de 65 anos observado em consulta externa de cirurgia vascular por apresentar edema assim��trico do membro inferior esquerdo ap��s acidente de trabalho que lhe ter�� condicionado imobiliza����o prolongada. Pela suspeita de trombose venosa profunda, o doente realizou ecodoppler venoso dos membros inferiores que con!rmou ao diagn��stico de trombose venosa profunda iliofemoral tendo concomitantemente sido identi!cada a presen��a de "uxos arterializados na veia popl��tea, levantando a suspeita de uma f��stula arteriovenosa de localiza����o infra-popl��tea. Procedeu-se �� realiza����o de angiografia que revelou a presen��a de uma f��stula arteriovenosa (FAV) entre a art��ria tibial posterior e veia hom��nima. Ap��s 6 meses de anticoagula����o, o doente foi proposto para tratamento endovascular da FAV tendo realizado a implanta����o de um stent recoberto de ePTFE GraftMaster�� 3.5��26mm (Abbott Vascular, Santa Clara, CA) com resolu����o imagiol��gica da FAV (!gura 3). �� data de alta, o ecodoppler de controlo revelou total permeabilidade luminal do stent colocado na art��ria tibial posterior esquerda, na qual se detetaram "uxos de morfologia trif��sica, sem evid��ncia de "uxos arterializados na veia popl��tea. Com um ano de seguimento o doente mant��m a art��ira tibial posterior perme��vel., Angiologia e Cirurgia Vascular, Vol 15 No 4 (2019): December

Introduction: Between 14���20% of patients with critical lower-limb ischemia (CLI) are not candidates for revascularization due to extensive occlusions in crural/pedal vessels. Frequently these patients are young and functionally active. In these cases, the concept of shunting blood through veins to get this reversed flow to reach the nutritive tissue capillary bed becomes attractive. Our aim is to report our very recent experience in venous arterialization. Material/Methods: We retrospectively reviewed the cases of venous arterialization performed in our institution between April 2018���2019. Results: Four patients were treated: 3 males/1 female with mean age of 58.5 years. All patients had PAD stage 4. All patients were studied with arteriography and ultrasound and were considerate no revascularizable (2 of them after an attempt of endovascular/surgical treatment). In one patient a trial with endovenous prostaglandin was performed, without clinical response. In all cases, the patients were facing a major amputation. Arterialization was performed as a last attempt to save the limb. Regarding the surgical procedures, the donor inflow artery was the infragenicular popliteal artery in 2 cases, distal femoral artery in 1 case and anterior tibial artery in 1 case. In 3 cases the bypass used the great saphenous vein (GSV) in situ to arterialize the medial marginal vein; in 1 case was used an inverted GSV bypass with the distal anastomosis at the posterior tibial vein. The venous valves were destroyed by combination of Fogarty catheter (proximally) and angioplasty balloon (distally). Collaterals were ligated to focalize the blood flow. In all patients marked improvement in foot perfusion was achieved. Two of them had excellent evolution in the postoperative period and healed foot lesions. One patient was amputated with permeable bypass. One patient presented good initial evolution but later had bypass thrombosis (presum- ably due to inadequate arterial inflow from the anterior tibial artery) and undergone major amputation. Discussion/Conclusions: Despite advances in surgical and endovascular techniques, an important number of patients with CLI are not candidates to arterial revascularization and most patients with inoperable CLI will face a major amputation. In that setting, venous arterialization should be considered but not all patients are candidates to this procedure and a careful preoperative evaluation is required. Our preliminary experience is encouraging: the procedure was relatively straightforward, the resulting improve in foot perfusion was surprisingly good, the patency rate and limb salvage rate was 75 and 50%. In our opinion the major issues are selection of inflow artery and outflow vein and the learning curve in interpretation of the angiographic result to guide optimal focalization of the blood flow., Angiologia e Cirurgia Vascular, Vol 15 No 4 (2019): December

Introduc��a��o: O stress ergono��mico associado a�� execuc��a��o procedimentos endovasculares leva o cirurgia��o vascular a assumir frequentemente um conjunto de posturas e movimentos para controlo imagiolo��gico do procedimento. Isto condiciona um aumento do risco a longo termo de desenvolvimento de patologia mu��sculo-esquele��tica. A utilizac��a��o de smart glasses (o��culos inteligentes) podera�� ter um papel na reduc��a��o deste risco, permitindo ao profissional controlar o procedimento sem necessidade de reposicionamento constante. Atrave��s da aplicac��a��o do questiona��rio Quick Exposure Check (QEC), compa- ramos o risco ergono��mico durante a realizac��a��o de procedimentos endovasculares com e sem a utilizac��a��o de smart glasses. Me��todos: O QEC foi aplicado por um observador externo durante a realizac��a��o de procedimentos endovasculares com e sem a utilizac��a��o de smart glasses Epson Moverio BT-35E��. Os dois grupos de procedimentos foram comparados relativamente ao score total no QEC e aos scores parciais que avaliam o risco relativo a diferentes segmentos anato��micos (coluna cervical, coluna lombar, ombro/brac��o e punho/ma��o). Os scores parciais de auto-percepc��a��o de stress e de ritmo de trabalho, avaliados pelo profissional, foram tambe��m comparados. Resultados: O QEC foi aplicado a um total de 12 procedimentos. Os procedimentos com utilizac��a��o de smart glasses (n=6) obtiveram um score total me��dio significativamente mais baixo no QEC (83.7 ��� risco ergono��mico baixo), comparativamente aos procedimentos sem utilizac��a��o de smart glasses (108.3 ��� risco ergono��mico moderado; p=0.009). Os scores parciais me��dios relativos a�� coluna cervical e lombar foram tambe��m significativamente mais baixos neste grupo (lombar: 11.3 vs 18; p=0.002) (cervical: 18 vs 26.7; p=0.002). Na��o se encontraram diferenc��as estatisticamente significativas para os scores parciais me��dios relativos ao ombro/brac��o e punho/ma��o, nem para os scores parciais me��dios de auto-percepc��a��o de stress e de ritmo de trabalho. Conclusa��o: A utilizac��a��o de smart glasses durante a cirurgia endovascular mostrou reduzir o risco ergono��mico, avaliado pela escala QEC, de moderado para baixo. Esta reduc��a��o traduz-se principalmente numa diminuic��a��o do risco de patologia mu��sculo-esquele��tica a ni��vel da coluna e do pescoc��o., Angiologia e Cirurgia Vascular, Vol 15 No 3 (2019): September

Introduction: Above-knee stump ischemia is a serious condition. If left untreated usually courses with progression to irreversible ischemia. Without treatment the path from here usually leads to hip disarticulation and death. Our aim is to present our most recent experience in stump revascularization. Material/Methods: We retrospectively reviewed all patients with above-knee stump ischemia treated in our institution between July 2018 to March 2019. Results: We present four clinical cases treated in our institution in the last nine months. Two of them presented with non-acute stump ischemia with pain and skin lesions developed after minor trauma several months after surgery and stump healing. In both cases the computed tomography angiography (CTA) showed occlusion of the common femoral artery (CFA) and was inconclusive regarding the status and quality of the deep femoral artery (DFA). Despite this, ischemia severity deemed obligatory an attempt to revascularization, DFA was surgically exposed and proved to be an adequate target run off to a bypass. In the other two, the ischemia of the stump was acute. In one patient it was after surgical treatment of an ipsilateral false aneurism of the CFA (with ligation of the EIA) treated with a bypass from the EIA to both the superficial and DFA. The other was a patient admitted with aortic bifurcation occlusion and irreversible right leg ischemia that was submitted to primary above-knee amputation. In the next postoperative days, the patient developed severe stump ischemia. An axillo femoral bypass and proximal re-amputation was performed. Three patients resolved the stump ischemia and fared well, the last one died in the postoperative period. Discussion/Conclusions: Above-knee stump ischemia usually leads to progressive stump degradation/necrosis/infection, eventually leading to death. When the common/deep femoral arteries are occluded, re-amputation is usually insufficient and progression of ischemia can dictate the need for a hip disarticulation, a very aggressive and mutilating procedure with high rate of morbidity and mortality that do not prevent progression to pelvic ischemia and death. Revascularization of above-knee amputation stump, based on DFA or hypogastric revascularization, is the best therapeutic alternative and should be attempted even in frail patients. We believe that our small series reinforces the idea that stump revascularization is possible and can save both: stump and life., Angiologia e Cirurgia Vascular, Vol 15 No 2 (2019): June

Angiologia e Cirurgia Vascular, Vol 15 No 2 (2019): June

Introduction: A number of guidelines for the management of carotid disease are available to help clinicians in therapeutic decision and provide useful guidance for the best care of the patients. They stated that carotid endarterectomy (CEA) has some benefit in symptomatic patients with carotid stenosis of 50-69% and is highly beneficial in stenosis of 70-99%, with mortality/ stroke rate less than 6%. The maximum benefit is observed when surgery is performed within two weeks after the cerebrovascular event. CEA in asymptomatic patients should be offered to patients with life expectancy higher than 5 years, stenosis of >70%, and perioperative complications should be less than 3%. The aim of this study is to analyse our clinical practice, review treated patients and referral times and compare the outcomes of our institutional practice with published guidelines. Material and methods: Retrospective study of patients undergoing carotid endarterectomy at Centro Hospitalar Universit��rio do Porto between 2010 and 2015. Results: Between 2010 and 2015, 404 patients underwent CEA, 76% men, and mean age 69 years for both sexes. The degree of stenosis was usually evaluated by ultrasound. The use of complementary study with angio-CT was required in 20% and angiography in 2.2% of the cases. The majority of patients (54.2%) were symptomatic (stroke/ TIA, Angiologia e Cirurgia Vascular, Vol 15 No 2 (2019): June

Introdu����o: Os resultados a longo prazo do EVAR dependem da fixa����o proximal da endopr��tese de forma a evitar migra����o da mesma e o desenvolvimento de endoleak tipo Ia. As caracter��sticas anat��micas do colo aneurism��tico, nomeadamente a presen��a de trombo, podem influenciar os resultados do EVAR. Objetivos: Estudar a rela����o entre o trombo do colo aneurism��tico e o tipo de endopr��tese utilizada e o desenvolvimento de endoleak Ia. Materiais/M��todos: An��lise retrospetiva da base de dados de doentes com AAA tratados por EVAR na nossa institui����o entre dezembro 2001-2013. Procedemos �� revis��o de todos os angioTACs pr��-operat��rios dispon��veis (total de 164) e dividimos os doentes em dois grupos: com trombo significativo no colo aneurism��tico (>25% da circunfer��ncia do colo) versus sem trombo significativo. Estudamos ainda o tipo de endopr��tese (fixa����o supra versus infra-renal) utilizada. Posteriormente, avaliamos o follow-up e o desenvolvimento de endoleak tipo Ia. Resultados: Dos 164 doentes, 38 doentes apresentavam trombo > 25% da circunfer��ncia a��rtica (versus 126 com trombo, Angiologia e Cirurgia Vascular, Vol 15 No 1 (2019): March

A hemorragia major �� uma complica����o conhecida da bi��psia renal percut��nea, com uma taxa aproximada de 2,2%. A emboliza����o arterial selectiva �� um procedimento seguro, eficaz e pouco invasivo, com aplica����o importante na gest��o de hemorragias ativas, como por exemplo nas les��es iatrog��nicas ap��s bi��psia renal. Caso cl��nico de doente do sexo feminino, 52 anos. No contexto do diagn��stico imagiol��gico de neoplasia renal metastizada, submetida a biopsia renal percut��nea. Admitida na sala de emerg��ncia, 3 horas ap��s a bi��psia renal, por choque hemorr��gico, com angio-TC a evidenciar volumoso hematoma retroperitoneal com sinais de hemorragia ativa na depend��ncia da neoplasia renal. Por aus��ncia de condi����es para interven����o cir��rgica, foi realizada angiografia com inten����o de controlo da hemorragia. Procedeu-se a emboliza����o selectiva do foco hemorr��gico com micropart��culas PVA (��lcool polivin��lico). Ap��s realiza����o do procedimento, a doente evoluiu favoravelmente do ponto de vista hemodin��mico, com resolu����o do choque hemorr��gico., Angiologia e Cirurgia Vascular, Vol 15 No 1 (2019): March

Introdu����o: As caracter��sticas do colo aneurism��tico, em particular a presen��a de trombo, podem limitar o tratamento por EVAR. Objetivos: Estudar se a presen��a de trombo no colo aneurism��tico e o tipo de endopr��tese utilizada (fixa����o supra ou infra-renal) t��m impacto na fun����o renal dos doentes tratados por EVAR na nossa institui����o. Materiais/M��todos: An��lise retrospectiva da base de dados de doentes com AAA tratados por EVAR na nossa institui����o entre dezembro/2001 e dezembro/2013. Para cada doente avaliamos o valor de creatinina e clearence nos pr�� e p��s-operat��rio. Dos doentes com agravamento da fun����o renal, selecionamos aqueles que tiveram les��o renal aguda (LRA) pelos crit��rios de RIFLE modificados, e estudamos a rela����o entre LRA e trombo do colo aneurism��tico e tipo de endopr��tese utilizado. Da base de dados de 241 doentes foram exclu��dos os doentes IRC em hemodi��lise �� data do procedimento e aqueles em que n��o disp��nhamos de an��lises com fun����o renal no pr�� e p��s-operat��rio. Relativamente ao estudo da rela����o endopr��tese utilizada e fun����o renal: 127 foram tratados com endopr��teses de fixa����o supra-renal, 74 com endoproteses de fixa����o infra-renal e 27 foram exclu��dos da an��lise por terem sido tratados com endopr��teses tor��cicas ou n��o dispormos dessa informa����o. Relativamente ao estudo do trombo do colo aneurism��tico, conseguimos esse dado para 190 doentes. Resultados: relativamente ao impacto do trombo do colo aneurism��tico na fun����o renal verificamos que dos 190 doentes estudados, 21 (11%) desenvolveram LRA no p��s-operat��rio e a presen��a de trombo no colo em >25% e >50% da circunfer��ncia do colo, apresentou rela����o estatisticamente significativa com o desenvolvimento de LRA (p=0,045 e p=0,010, respetivamente). Relativamente ao estudo das endopr��teses utilizadas, 14.2% dos doentes tratados com endopr��teses de fixa����o supra-renal e 5.4% dos tratados com endopr��teses de fixa����o infra-renal desenvolveram LRA no pos-operat��rio, no entanto esta diferen��a n��o se mostrou estatisticamente significativa (p=0,052). Discuss��o/conclus��es: Na nossa experi��ncia a presen��a de trombo do colo aneurism��tico teve rela����o com o desenvolvimento de LRA no p��s-operat��rio imediato mas n��o parece ter impacto na fun����o renal aos 6 e 12 meses. Os doentes tratados com endopr��teses de fixa����o supra-renal desenvolveram mais LRA no p��s-operat��rio mas esta diferen��a n��o se mostrou estatisticamente significativa., Angiologia e Cirurgia Vascular, Vol 14 No 1 (2018): March

Introdu����o: Ap��s revasculariza����o cir��rgica do membro inferior �� habitualmente prescrito antiagregantes plaquet��rios e a anticoagula����o �� considerada em casos de risco aumentado de trombose. Realizamos uma revis��o sistem��tica da literatura da evid��ncia existente sobre o uso prolongado de anticoagulantes no p��s-operat��rio de pontagens do membro inferior. Material e m��todos: Revis��o sistem��tica da literatura dispon��vel na base de dados Pubmed. Resultados: Os estudos selecionados para a revis��o final consistiam em: 6 estudos aleatorizados controlados (e 4 an��lises post-hoc), 1 estudo prospectivo com controlos hist��ricos e 3 estudos retrospectivos. Conclus��o: A efic��cia da hipocoagula����o depende do conducto utilizado e factores intr��nsecos da pontagem. Existe benef��cio de hipocoagula����o nas pontagens com o conduto venoso aut��logo mas o n��vel de INR e os factores de risco para trombose poder��o influenciar os resultados. Nas pontagens poder�� haver benef��cio naquelas com calibre diminu��do e baixa velocidade m��dia. A incid��ncia de hemorragia major �� significativa, sendo essencial a cuidadosa avalia����o do risco beneficio na prescri����o de hipocoagula����o cr��nica., Angiologia e Cirurgia Vascular, Vol 14 No 1 (2018): March

Introduction/Aims: Horseshoe kidney (HSK) is a renal malformation that results from the kidney's fusion in midline. It is an unusual entity that rarely coexists with Abdominal Aortic Aneurysm (AAA). Because of the anatomical characteristics (intimate relationship between kidney and aorta, variability in the renal arteries, veins and collecting systems emergency) conventional surgery can be technically difficult. Endovascular treatment has emerged as a therapeutic alternative in some cases of congenital renal malformations. We report a case of endovascular aneurysm repair (EVAR) in a patient with coexistent AAA and HSK. Material / Methods: We review a case of a patient with coexistent AAA and HSK treated by EVAR in our institution with description of diagnosis, treatment, outcome and complications. Results: A 74-year-old man was referred to our center with an assymptomatic AAA. He had medical history of ischemic heart disease, congestive heart failure and smoking. CT angiography revealed an infrarenal AAA, with 57mm diameter and HSK. After studying anatomical features, the patient was proposed for EVAR. Under general anesthesia both femoral arteries were exposed. An Endurant�� II endoprosthesis was deployed immediately distal to an accessory renal artery and two iliac extenders were deployed in the left and one in the right side. Control angiography found an image compatible with endoleak type1 so a new dilatation of the proximal colon with Reliant�� balloon was performed. In the final control angiography there was still some reflux into the aneurysmal sac which was interpreted as probable endoleak type 2. Postoperatively angioCT revealed endoleak type 1 which led to reintervention with implantation of an aortic extender Endurant��, with good result. In control angioCT there was no evidence of endoleak and all renal arteries were patent. Conclusions: EVAR has clear advantages in cases of coexistent AAA and HSK, anatomically complex for conventional surgery. Although renal vasculature in these patients is very variable, sometimes with accessory arteries responsible for vascularization of considerable percentages of parenchyma. Thus, preoperative planning is essential to assess the need to exclude accessory renal arteries and consider, individually, the risk / benefit ratio., Angiologia e Cirurgia Vascular, Vol 14 No 1 (2018): March

A calcifica����o vascular est�� associada a um agravamento das categorias de isquemia nos doentes com doen��a arterial perif��rica de forma independente e representa um enorme desafio quer no tratamento endovascular quer na cirurgia de revasculariza����o. Apresentamos um caso cl��nico de um doente com m��ltiplos fatores de risco cardiovasculares e com fatores de risco para calcifica����o (diabetes e a doen��a renal cr��nica), com isquemia cr��tica, adequadamente tratada com um bypass popl��teo-pedioso., Angiologia e Cirurgia Vascular, Vol 14 No 2 (2018): June

A fibrose retroperitoneal (FR) �� uma doen��a rara, caracterizada por inflama����o e fibrose na periferia da aorta abdominal com dissemina����o ao longo do espa��o retroperitoneal, invadindo estruturas cont��guas. Em cerca de dois ter��os dos casos esta condi����o �� idiop��tica havendo uma etiologia definida nos restantes. Mais frequentemente as formas secund��rias est��o associadas a f��rmacos e neoplasias, no entanto outras situa����es podem levar ao desenvolvimento da doen��a. Na ��ltima d��cada tem surgido alguma evid��ncia de que a FR est�� associada �� angioplastia, stenting ou implanta����o de endopr��tese nos eixos aortoil��acos, no entanto a literatura publicada �� muito escassa. Apresentamos a nossa experi��ncia com dois doentes com isquemia grau IIb, um com estenose pr��-oclusiva da art��ria il��aca comum esquerda tendo sido submetido angioplastia e stenting da les��o, outro com estenose morfologicamente significativa da aorta abdominal infrarrenal tendo sido submetido a angioplastia e coloca����o de dois stents cobertas aortoil��acos sob a forma de kissing stent. Ambos os doentes desenvolveram dor lombar marcada tendo sido visualizado em angio-TC um processo inflamat��rio peria��rtico sugestivo de fibrose retroperitoneal que posteriormente evoluiu para aneurisma inflamat��rio da aorta abdominal. O mecanismo fisiopatol��gico desta altera����o n��o se encontra descrito, no entanto, poderemos supor que a angioplastia e stenting poder�� levar a rotura da integridade da placa ateroscler��tica com exposi����o de antig��nios contidos no seu interior desencadeando uma resposta inflamat��ria local. Por outro lado, poder�� existir uma rea����o imunol��gica diretamente contra o stent. �� importante pensar nesta poss��vel complica����o, uma vez que existe uma not��vel resposta �� corticoterapia e pela possibilidade de desenvolvimento de aneurisma da aorta inflamat��rio., Angiologia e Cirurgia Vascular, Vol 13 No 3 (2017): September

Introdu����o/Objetivos: A dissec����o a��rtica tipo A (AD) geralmente requer tratamento cir��rgico urgente e a substitui����o do segmento a��rtico continua o gold standard. No entanto, �� um procedimento muito agressivo e alguns doentes s��o exclu��dos do tratamento pelas suas comorbilidades. Atualmente, o tratamento endovascular representa uma alternativa, ainda sem indica����es precisas. O nosso objetivo �� apresentar um caso de tratamento h��brido de uma AD tipo A com recurso a um acesso vascular card��aco transapical. Material/M��todos: revis��o de um caso cl��nico e literatura. Resultados: Homem de 65 anos com antecedentes de doen��a pulmonar obstrutiva cr��nica, fibrila����o auricular e hipertens��o arterial; recorreu ao servi��o de urg��ncia por dor abdominal. Realizou angio-TAC que revelou uma AD tipo A e uma ��lcera (PAU) na aorta ascendente (AA). Ap��s a avalia����o por cirurgia card��aca, foi considerado n��o candidato para cirurgia convencional. A angio-TAC foi repetida ap��s duas semanas de tratamento m��dico e revelou crescimento do falso aneurisma, com risco iminente de rutura. Ponderamos o tratamento endovascular e diferentes op����es foram consideradas, a decis��o final foi propor um tratamento h��brido. O procedimento foi iniciado com um bypass femoro-axilar direito e emboliza����o do tronco braquiocef��lico. Em seguida, uma endopr��tese (Valiant��) foi libertada abaixo da art��ria subcl��via esquerda e dois perisc��pios (Viabahn��) foram progredidos das art��rias axilar e car��tida esquerdas e a segunda endopr��tese (Valiant��) foi libertada, dentro da primeira, com cobertura da car��tida e subcl��via esquerdas. Ap��s v��rias tentativas, n��o foi poss��vel progredir a terceira endopr��tese para a Aorta Ascendente por falta de suporte e instabilidade hemodin��mica e o procedimento foi interrompido. Posteriormente, a angio-TAC foi repetida e revelou dissec����o da AA perme��vel e o falso aneurisma n��o tratado. Foram discutidas outras op����es e foi ponderado um acesso vascular anter��grado (transapical) com o objetivo de conseguir o suporte para progredir a endopr��tese. Com o apoio de um cirurgi��o card��aco, o ��pice card��aco foi abordado e puncionado e um fio guia r��gido foi avan��ado, criando um throught-and-through, do ap��x card��aco at�� �� art��ria femoral, o que permitiu o avan��o da endopr��tese (Valiant��) por via retr��grada e a sua liberta����o em rapid pacing sem intercorr��ncias e com bom resultado final. Discuss��o/Conclus��es: o tratamento endovascular AD tipo A �� uma alternativa em doentes de alto risco cl��nico e caracter��sticas anat��micas adequadas, ainda que tecnicamente possa ser desafiante. Quando a progress��o da endopr��tese por acesso vascular retr��grado n��o �� conseguida, a abordagem card��aca transapical �� uma alternativa a ser considerada., Angiologia e Cirurgia Vascular, Vol 13 No 3 (2017): September