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Abstract Iron is essential for cell respiration, muscle metabolism, and oxygen transport. Recent research has shown that simulated microgravity rapidly affects iron metabolism in men. However, its impact on women remains unclear. This study aims to compare iron metabolism alterations in both sexes exposed to 5 days of dry immersion. Our findings demonstrate that women, similarly to men, experience increased systemic iron availability and elevated serum hepcidin levels, indicative of iron misdistribution after short-term exposure to simulated microgravity.

Background Therapy adherence is a key factor in the control of type 2 diabetes mellitus (T2DM). Optimal self-care requires skills in health literacy (HL). Objective This study aims to analyze the relationship between HL and adherence to therapy and to understand the possible influence of other sociodemographic and disease variables. Methods A multicenter, cross-sectional study was conducted in Portuguese in 13 different primary health care units in both rural and urban environments. A sociodemographic questionnaire and two validated instruments, “Medical Term Recognition Test” and “Summary of Diabetes Self-Care Activities,” were applied. The last value of hemoglobin A1c (HbA1c) and the number of chronic medications were collected from clinical records. Descriptive statistics and bivariate correlations were performed as well as multivariable linear regression to assess the association between HL and adherence to therapy. Key Results Participants (n = 354) were on average age 63.67 ± 10.39 years, 57.1% male and 42.9% female, 68.4% with inadequate HL and an average HbA1c of 7 ± 1.18%. Better HL was correlated with higher adherence to the total of self-care activities, nonpharmacological therapy, and foot care. In multivariable linear regression analyses, better HL (β = 0.176, p = .003), less than minimum wage (β = −0.197, p = .001) and insulin therapy (β = 0.272, p = .001) were independently associated with increased adherence to overall self-care activities. Conclusion In a representative sample of people with T2DM in Portugal, HL was a key factor for greater adherence to demanding self-care activities. [HLRP: Health Literacy Research and Practice. 2024;8(4):e194–e203.]

Abstract Astronauts in microgravity experience multi-system deconditioning, impacting their inflight efficiency and inducing dysfunctions upon return to Earth gravity. To fill the sex gap of knowledge in the health impact of spaceflights, we simulate microgravity with a 5-day dry immersion in 18 healthy women (ClinicalTrials.gov Identifier: NCT05043974). Here we show that dry immersion rapidly induces a sedentarily-like metabolism shift mimicking the beginning of a metabolic syndrome with a drop in glucose tolerance, an increase in the atherogenic index of plasma, and an impaired lipid profile. Bone remodeling markers suggest a decreased bone formation coupled with an increased bone resorption. Fluid shifts and muscular unloading participate to a marked cardiovascular and sensorimotor deconditioning with decreased orthostatic tolerance, aerobic capacity, and postural balance. Collected datasets provide a comprehensive multi-systemic assessment of dry immersion effects in women and pave the way for future sex-based evaluations of countermeasures.

Introduction: Long-term space missions trigger a prolonged neuroendocrine stress response leading to immune system dysregulation evidenced by susceptibility to infections, viral reactivation, and skin irritations. However, due to existing technical constraints, real-time functional immune assessments are not currently available to crew inflight. The in vitro cytokine release assay (CRA) has been effectively employed to study the stimulated cytokine response of immune cells in whole blood albeit limited to pre- and post-flight sessions. A novel two-valve reaction tube (RT) has been developed to enable the execution of the CRA on the International Space Station (ISS).Methods: In a comprehensive test campaign, we assessed the suitability of three materials (silicone, C-Flex, and PVC) for the RT design in terms of biochemical compatibility, chemical stability, and final data quality analysis. Furthermore, we thoroughly examined additional quality criteria such as safety, handling, and the frozen storage of antigens within the RTs. The validation of the proposed crew procedure was conducted during a parabolic flight campaign.Results: The selected material and procedure proved to be both feasible and secure yielding consistent and dependable data outcomes. This new hardware allows for the stimulation of blood samples on board the ISS, with subsequent analysis still conducted on the ground.Discussion: The resultant data promises to offer a more accurate understanding of the stress-induced neuroendocrine modulation of immunity during space travel providing valuable insights for the scientific community. Furthermore, the versatile nature of the RT suggests its potential utility as a testing platform for various other assays or sample types.

INTRODUCTION: The concept of the Nellix endoprosthesis is based on endovascular aneurysm sealing with endobags and was launched in the market for endovascular abdominal aortic aneurysm repair (EVAR). The manufacturer recently issued a hazard alert due to higher rates of endoleaks, migration and aneurysm enlargement. CASE REPORT: The authors present a clinical case of a seventy year-old man previously submitted to EVAR with a Nellix device in another country. The patient presented with an asymptomatic Type Ia endoleak and proximal aortic neck aneurysmatic degeneration. The anatomy was considered unfavourable for further endovascular management. After multidisciplinary discussion and workup, open surgical conversion was selected. Complete endoprosthesis explantation and in-situ reconstruction were performed. The post-operative course was uneventful. CONCLUSION: Once presented with a patient considered fit for open surgical conversion and with aneurysm morphology unfavourable for endovascular, the authors believe that open conversion may constitute a very acceptable method of repair and should be offered.

Os médicos de família (MF) têm desempenhado um papel crucial na gestão da pandemia COVID-19 em todo o mundo. A partilha da experiência e das metodologias de trabalho desenvolvidas neste contexto têm sido fundamentais para garantir cuidados de saúde adequados à comunidade. Neste trabalho, são descritas as estratégias organizacionais e ferramentas desenvolvidas em Portugal para dar resposta à pandemia, particularmente as metodologias desenvolvidas numa unidade de saúde familiar na área metropolitana de Lisboa. Estas permitiram garantir o seguimento dos doentes de COVID-19, mantendo-se paralelamente a atividade assistencial aos restantes grupos vulneráveis. As competências basilares dos MF, como a proximidade e o conhecimento das comunidades, associadas a uma enorme capacidade de adaptação e reorganização de equipa, são determinantes-chave para que esta crise sanitária seja ultrapassada.

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.

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.

Purpose: Early positron emission tomography–derived metrics post–oligometastasis radioablation may predict impending local relapses (LRs), providing a basis for a timely ablation. Methods and Materials: Positron emission tomography data of 623 lesions treated with either 24 Gy single-dose radiation therapy (SDRT) (n = 475) or 3 × 9 Gy stereotactic body radiation therapy (SBRT) (n = 148) were analyzed in a training data set (n = 246) to obtain optimal cutoffs for pretreatment maximum standardized uptake value (SUVmax) and its 3-month posttreatment decline (ΔSUVmax) in predicting LR risk, validated in a data set unseen to testing (n = 377). Results: At a median of 21.7 months, 91 lesions developed LRs: 39 of 475 (8.2%) after SDRT and 52 of 148 (35.1%) after SBRT. The optimal cutoff values were 12 for SUVmax and –75% for ΔSUVmax. Bivariate SUVmax/ΔSUVmax permutations rendered a 3-tiered LR risk stratification of dual-favorable (low risk), 1 adverse (intermediate risk) and dual-adverse (high risk). Actuarial 5-year local relapse-free survival rates were 93.9% versus 89.6% versus 57.1% (P < .0001) and 76.1% versus 48.3% versus 8.2% (P < .0001) for SDRT and SBRT, respectively. The SBRT area under the ROC curve was 0.71 (95% CI, 0.61-0.79) and the high-risk subgroup yielded a 76.5% true positive LR prediction rate. Conclusions: The SBRT dual-adverse SUVmax/ΔSUVmax category LR prediction power provides a basis for prospective studies testing whether a timely ablation of impending LRs affects oligometastasis outcomes.

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.

Introduction: Chronic Mesenteric Ischemia (CMI) resulting from an impaired blood flow of the splanchnic organs is characterized by an insidious clinical course and is often an underestimated and undertreated disease. The natural history is progressive, caused by atherosclerosis progression in a polymorbidity and aging society. Due to collateralization, diffuse stenotic lesions can remain asymptomatic for a long time and usually manifests when an acute medical or surgical event occurs. In those cases, the clinical suspicion is crucial to reach the diagnosis promptly, allowing to preserve the patients’ quality of life and, above all, the patients’ life. Clinical case 1: A 48-year-old woman with a history of smoking goes to the emergency department for hypogastric abdominal pain, nausea, and vomiting. A study was performed by computed tomography angiography (CTA) that demonstrated occlusion of the superior mesenteric artery (SMA) and significant stenosis of the celiac trunk associated with thickening of small bowel suggestive of ischemia. A thrombectomy of the superior mesenteric artery and retrograde stenting of the artery ostium was performed, followed by extensive enterectomy on 24-hour laparotomy. After hospital discharge, the patient had new abdominal complaints, and stent occlusion was documented in the SMA. She underwent an iliohepatic bypass with good results. Clinical case 2: A 76-year-old man previously submitted to a right axillofemoral and femoropopliteal sequential bypass to treat chronic limb-threatening ischemia (CLTI), went to the emergency department with complaints of abdominal pain, vomiting, and constipation. The diagnosis of a subocclusive intestinal syndrome was made, having performed a computed tomography (CT) scan where it was observed the Ileum adhered to the cecum, which was thickened; the celiac trunk and SMA had subocclusive stenosis. The patient underwent primary celiac trunk stenting with a balloon-expandable stent. After celiac artery revascularization, a right colectomy was performed with two segmental enterectomies. Conclusion: Mesenteric ischemia is a severe condition that is often underdiagnosed due to the lack of awareness of most physicians and nonspecific symptoms. The vascular intervention aims to prevent intestinal necrosis, which can lead to the patient’s death. Timely diagnosis is therefore essential, and revascularization must be performed before or at the same time as intestinal surgery. The close collaboration between the general and vascular surgery teams is essential to the success of these cases.

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

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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.

Introdução: A técnica criss-cross combina acesso vascular anterógrado e retrógrado da veia poplítea, de modo a obter recanalização venosa em doentes com trombose venosa profunda (TVP) ileofemoral associada a trombose das veias poplítea e gemelares. Caso clínico: Doente do sexo feminino de 57 anos, com antecedentes de histerectomia radical e linfadenectomia de nódulos linfáticos pélvicos em 2013, devido a neoplasia uterina, com consequente linfedema crónico do membro inferior direito. Admitida na urgência por edema grave do membro inferior direito, com 7 dias de evolução. À observação, a paciente apresentava edema da coxa e perna, cianose da perna, dor gemelar, extremidades quentes e pulsos distais palpáveis. Estudo com ecodoppler a objetivar trombose dos eixos venosos do membro inferior direito. Estudo com TC contrastado excluiu extensão proximal do trombo para a veia ilíaca comum direita ou veia cava; excluiu tromboembolismo pulmonar e evidenciou clips cirúrgicos em proximidade com a veia ilíaca externa direita, causando uma respetiva redução luminal superior a 50%. A doente foi submetida a trombectomia e fibrinólise dirigida por cateter. Obteve-se acesso vascular através de punção ecoguiada da veia poplítea. Após colocação de introdutores em sentido retrógrado e anterógrado, realizou-se trombectomia das veias gemelares até à veia femoral comum, com recurso a aspiração por cateter. Instituiu-se perfusão de alteplase e heparina não fracionada por via periférica, mantidas durante 72 horas, com controlo angiográfico a cada 24h. Após recanalização satisfatória, realizou-se angioplastia com balão 14x40mm, seguida de stent 14x80mm na veia ilíaca externa. Não ocorreram complicações hemorrágicas major. O tratamento invasivo foi complementado com drenagem postural e meia elástica compressiva, permitindo melhoria clínica imediata e progressiva. Após dois dias, a doente recebeu alta medicada com heparina de baixo peso molecular. Em consulta de follow-up após um mês, constatou-se melhoria clínica progressiva e alterada hipocoagulação para rivaroxabano ad aeternum. Conclusão: A técnica de criss-cross permite recanalização do inflow e outflow, restaurando patência venosa e mantendo a função valvular, aspetos com eventual papel crítico nos resultados após TVP ileofemoral extensa.

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.

Introdução: O diagnóstico de aneurismas venosos viscerais é tipicamente incidental. Apesar do uso disseminado de métodos de imagem precisos a identificação destas lesões continua a ser extremamente rara. Dentro destes, os aneurismas da veia renal são o subgrupo menos frequente correspondendo a uma pequena percentagem. Métodos: Apresentamos um caso-clínico de uma doente de 52 anos com um aneurisma gigante da veia do transplante renal associado a uma fístula arteriovenosa. Adicionalmente foi realizada uma revisão 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 ilíaca esquerda, recorre ao serviço de urgência com dor no local do enxerto renal e febre. À observação do enxerto com ecografia observa-se uma lesão de grandes dimensões no bacinete com fluxo identificado ao Doppler. Realizou angiotomografia computadorizada que revelou presença de uma fístula arteriovenosa entre artéria e a veia renal, com um volumoso aneurisma da veia renal a ocupar praticamente todo o seio renal, de aproximadamente 5.6cm de maior diâmetro. Numa primeira fase foi realizada embolização da fístula arteriovenosa renal com coils. Pela manutenção do quadro sético com disfunção do enxerto foi posteriormente submetida a nefrectomia do enxerto. Conclusão: Os aneurismas da veia renal são lesões extremamente raras com apenas alguns casos publicados na literatura. Estes aneurismas são passíveis de tratamento por via endovascular ou cirúrgica, no entanto, tendo em conta a escassez de dados publicados desconhecem-se os resultados a longo prazo.

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.

Introdução: O linfedema dos membros inferiores é uma patologia relativamente comum que condiciona um marcado impacto na qualidade de vida do doente. Pode ocorrer primariamente ou ser secundário a um fator externo. O seu tratamento na maioria dos casos é conservador através de massagem de drenagem linfática e medidas de compressão externa. No entanto, a cirurgia reconstrutiva do sistema linfático tem vindo a ganhar popularidade. Adicionalmente, nos casos mais graves pode ser necessário a realização de procedimentos cirúrgicos de redução de membro na correção de dismorfias associadas ao linfedema crónico. Métodos: Foi feita a revisão de um caso clínico grave de linfedema do membro inferior que foi tratado com recurso a um procedimento cirúrgico de redução de membro. Posteriormente procedeu-se a uma revisão da literatura utilizando a base de dados MEDLINE. Resultados : Doente de 46 anos com antecedentes de obesidade mórbida seguido por linfedema precoce do membro inferior direito que surgiu na segunda década de vida. O doente foi observado em consulta de cirurgia vascular com queixas de linforragia tendo sido instituído 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 redução de membro com evolução favorável e marcada melhoria clínica no pós-operatório. Conclusão: O linfedema dos membros inferiores é uma entidade pouco reconhecida que condiciona um marcado impacto na qualidade de vida dos doentes. Atualmente não existe tratamento curativo e os resultados do tratamento conservador são limitados. O tratamento cirúrgico, nomeadamente com cirurgia de redução do membro visa solucionar os casos mais graves nomeadamente complicações associadas à cronicidade do linfedema.

Resumo A fibrose retroperitoneal (FR) é uma doença rara, caracterizada por inflamação e fibrose na periferia da aorta abdominal com disseminação ao longo do espaço retroperitoneal, invadindo estruturas contiguas. Em cerca de dois terços dos casos esta condição é idiopática apresentando uma causa secundária nos restantes. Mais frequentemente as formas secundárias estão associadas a fármacos e neoplasias, no entanto outras situações podem levar ao desenvolvimento da doença. Na última década tem surgido alguma evidência de que a FR está associada à angioplastia, stenting ou implantação de endoprótese nos eixos aortoilíacos, no entanto a literatura publicada é muito escassa. Apresentamos a nossa experiência com dois doentes com arteriopatia grau IIb, um com estenose pré-oclusiva da artéria ilíaca comum esquerda tendo sido submetido angioplastia e stenting da lesão, outro com estenose morfologicamente significativa da aorta abdominal infrarrenal tendo sido submetido a angioplastia e colocação de duas endopróteses cobertas aortoilíacos sob a forma de kissing stent. Ambos os doentes desenvolveram dor lombar marcada tendo sido visualizado em angio-TC um processo inflamatório periaórtico sugestivo de fibrose retroperitoneal que posteriormente evoluiu para aneurisma da aorta abdominal inflamatório. O mecanismo fisiopatológico desta alteração não se encontra descrito, no entanto, poderemos supor que a angioplastia e stenting poderá levar a rotura da integridade da placa aterosclerótica com exposição de antigénios contidos no seu interior desencadeando uma resposta inflamatória local. Por outro lado, poderá existir uma reação imunológica diretamente contra o stent. É importante pensar nesta possível complicação, uma vez que existe uma notável resposta à corticoterapia e pela possibilidade de desenvolvimento de aneurisma da aorta inflamatório.

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.

Homem de 65 anos observado em consulta externa de cirurgia vascular por apresentar edema assimétrico do membro inferior esquerdo após acidente de trabalho que lhe terá condicionado imobilização prolongada. Pela suspeita de trombose venosa profunda, o doente realizou ecodoppler venoso dos membros inferiores que con!rmou ao diagnóstico de trombose venosa profunda iliofemoral tendo concomitantemente sido identi!cada a presença de "uxos arterializados na veia poplítea, levantando a suspeita de uma fístula arteriovenosa de localização infra-poplítea. Procedeu-se à realização de angiografia que revelou a presença de uma fístula arteriovenosa (FAV) entre a artéria tibial posterior e veia homónima. Após 6 meses de anticoagulação, o doente foi proposto para tratamento endovascular da FAV tendo realizado a implantação de um stent recoberto de ePTFE GraftMaster® 3.5×26mm (Abbott Vascular, Santa Clara, CA) com resolução imagiológica da FAV (!gura 3). À data de alta, o ecodoppler de controlo revelou total permeabilidade luminal do stent colocado na artéria tibial posterior esquerda, na qual se detetaram "uxos de morfologia trifásica, sem evidência de "uxos arterializados na veia poplítea. Com um ano de seguimento o doente mantém a artéira tibial posterior permeável.

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.

Superficial femoral artery (SFA) aneurysms are rare clinical disorders, with few case reports and small series published concerning atherosclerotic aneurysms. We report a clinical case a giant aneurysm of the SFA, in a patient previously submitted to extensive SFA endarterectomy and vein angioplasty. A 73-year-old man presented at a routine vascular surgery consultation. The patient had been submitted to a right SFA endartectomy and vein patch angioplasty, sixteen years ago, for intermittent claudication. Physical examination demon- strated a large pulsatile mass of the right thigh. His right pedal pulse was palpable. Ultrasound and computed tomography scan confirmed a 78x71x240mm aneurysm of the right superficial femoral artery. He was proposed to aneurysmectomy and femoro-popliteal bypass. During operative intervention, proximal and distal control was obtained and the aneurysm opened. A large amount of thrombus was removed and a femoro-popliteal bypass was performed using the ipsilateral great saphenous vein. The postoperative period was uneventful, as was the patient recovery. In our report, the aneurysmal area matched precisely to the endarterectomised area and no other aneurysms were found. So we are facing an uncommon case of a SFA degeneration into a giant aneurysm after extensive endarterectomy and vein angioplasty.

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 Universitário 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

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.

A hemorragia major é uma complicação conhecida da biópsia renal percutânea, com uma taxa aproximada de 2,2%. A embolização arterial selectiva é um procedimento seguro, eficaz e pouco invasivo, com aplicação importante na gestão de hemorragias ativas, como por exemplo nas lesões iatrogénicas após biópsia renal. Caso clínico de doente do sexo feminino, 52 anos. No contexto do diagnóstico imagiológico de neoplasia renal metastizada, submetida a biopsia renal percutânea. Admitida na sala de emergência, 3 horas após a biópsia renal, por choque hemorrágico, com angio-TC a evidenciar volumoso hematoma retroperitoneal com sinais de hemorragia ativa na dependência da neoplasia renal. Por ausência de condições para intervenção cirúrgica, foi realizada angiografia com intenção de controlo da hemorragia. Procedeu-se a embolização selectiva do foco hemorrágico com micropartículas PVA (álcool polivinílico). Após realização do procedimento, a doente evoluiu favoravelmente do ponto de vista hemodinâmico, com resolução do choque hemorrágico.

Introdução: Os resultados a longo prazo do EVAR dependem da fixação proximal da endoprótese de forma a evitar migração da mesma e o desenvolvimento de endoleak tipo Ia. As características anatómicas do colo aneurismático, nomeadamente a presença de trombo, podem influenciar os resultados do EVAR. Objetivos: Estudar a relação entre o trombo do colo aneurismático e o tipo de endoprótese utilizada e o desenvolvimento de endoleak Ia. Materiais/Métodos: Análise retrospetiva da base de dados de doentes com AAA tratados por EVAR na nossa instituição entre dezembro 2001-2013. Procedemos à revisão de todos os angioTACs pré-operatórios disponíveis (total de 164) e dividimos os doentes em dois grupos: com trombo significativo no colo aneurismático (>25% da circunferência do colo) versus sem trombo significativo. Estudamos ainda o tipo de endoprótese (fixação 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 circunferência aórtica (versus 126 com trombo

Introdução: As características do colo aneurismático, em particular a presença de trombo, podem limitar o tratamento por EVAR. Objetivos: Estudar se a presença de trombo no colo aneurismático e o tipo de endoprótese utilizada (fixação supra ou infra-renal) têm impacto na função renal dos doentes tratados por EVAR na nossa instituição. Materiais/Métodos: Análise retrospectiva da base de dados de doentes com AAA tratados por EVAR na nossa instituição entre dezembro/2001 e dezembro/2013. Para cada doente avaliamos o valor de creatinina e clearence nos pré e pós-operatório. Dos doentes com agravamento da função renal, selecionamos aqueles que tiveram lesão renal aguda (LRA) pelos critérios de RIFLE modificados, e estudamos a relação entre LRA e trombo do colo aneurismático e tipo de endoprótese utilizado. Da base de dados de 241 doentes foram excluídos os doentes IRC em hemodiálise à data do procedimento e aqueles em que não dispúnhamos de análises com função renal no pré e pós-operatório. Relativamente ao estudo da relação endoprótese utilizada e função renal: 127 foram tratados com endopróteses de fixação supra-renal, 74 com endoproteses de fixação infra-renal e 27 foram excluídos da análise por terem sido tratados com endopróteses torácicas ou não dispormos dessa informação. Relativamente ao estudo do trombo do colo aneurismático, conseguimos esse dado para 190 doentes. Resultados: relativamente ao impacto do trombo do colo aneurismático na função renal verificamos que dos 190 doentes estudados, 21 (11%) desenvolveram LRA no pós-operatório e a presença de trombo no colo em >25% e >50% da circunferência do colo, apresentou relação estatisticamente significativa com o desenvolvimento de LRA (p=0,045 e p=0,010, respetivamente). Relativamente ao estudo das endopróteses utilizadas, 14.2% dos doentes tratados com endopróteses de fixação supra-renal e 5.4% dos tratados com endopróteses de fixação infra-renal desenvolveram LRA no pos-operatório, no entanto esta diferença não se mostrou estatisticamente significativa (p=0,052). Discussão/conclusões: Na nossa experiência a presença de trombo do colo aneurismático teve relação com o desenvolvimento de LRA no pós-operatório imediato mas não parece ter impacto na função renal aos 6 e 12 meses. Os doentes tratados com endopróteses de fixação supra-renal desenvolveram mais LRA no pós-operatório mas esta diferença não se mostrou estatisticamente significativa.

Introdução: Após revascularização cirúrgica do membro inferior é habitualmente prescrito antiagregantes plaquetários e a anticoagulação é considerada em casos de risco aumentado de trombose. Realizamos uma revisão sistemática da literatura da evidência existente sobre o uso prolongado de anticoagulantes no pós-operatório de pontagens do membro inferior. Material e métodos: Revisão sistemática da literatura disponível na base de dados Pubmed. Resultados: Os estudos selecionados para a revisão final consistiam em: 6 estudos aleatorizados controlados (e 4 análises post-hoc), 1 estudo prospectivo com controlos históricos e 3 estudos retrospectivos. Conclusão: A eficácia da hipocoagulação depende do conducto utilizado e factores intrínsecos da pontagem. Existe benefício de hipocoagulação nas pontagens com o conduto venoso autólogo mas o nível de INR e os factores de risco para trombose poderão influenciar os resultados. Nas pontagens poderá haver benefício naquelas com calibre diminuído e baixa velocidade média. A incidência de hemorragia major é significativa, sendo essencial a cuidadosa avaliação do risco beneficio na prescrição de hipocoagulação crónica.

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.

A calcificação vascular está associada a um agravamento das categorias de isquemia nos doentes com doença arterial periférica de forma independente e representa um enorme desafio quer no tratamento endovascular quer na cirurgia de revascularização. Apresentamos um caso clínico de um doente com múltiplos fatores de risco cardiovasculares e com fatores de risco para calcificação (diabetes e a doença renal crónica), com isquemia crítica, adequadamente tratada com um bypass poplíteo-pedioso.

A fibrose retroperitoneal (FR) é uma doença rara, caracterizada por inflamação e fibrose na periferia da aorta abdominal com disseminação ao longo do espaço retroperitoneal, invadindo estruturas contíguas. Em cerca de dois terços dos casos esta condição é idiopática havendo uma etiologia definida nos restantes. Mais frequentemente as formas secundárias estão associadas a fármacos e neoplasias, no entanto outras situações podem levar ao desenvolvimento da doença. Na última década tem surgido alguma evidência de que a FR está associada à angioplastia, stenting ou implantação de endoprótese nos eixos aortoilíacos, no entanto a literatura publicada é muito escassa. Apresentamos a nossa experiência com dois doentes com isquemia grau IIb, um com estenose pré-oclusiva da artéria ilíaca comum esquerda tendo sido submetido angioplastia e stenting da lesão, outro com estenose morfologicamente significativa da aorta abdominal infrarrenal tendo sido submetido a angioplastia e colocação de dois stents cobertas aortoilíacos sob a forma de kissing stent. Ambos os doentes desenvolveram dor lombar marcada tendo sido visualizado em angio-TC um processo inflamatório periaórtico sugestivo de fibrose retroperitoneal que posteriormente evoluiu para aneurisma inflamatório da aorta abdominal. O mecanismo fisiopatológico desta alteração não se encontra descrito, no entanto, poderemos supor que a angioplastia e stenting poderá levar a rotura da integridade da placa aterosclerótica com exposição de antigénios contidos no seu interior desencadeando uma resposta inflamatória local. Por outro lado, poderá existir uma reação imunológica diretamente contra o stent. É importante pensar nesta possível complicação, uma vez que existe uma notável resposta à corticoterapia e pela possibilidade de desenvolvimento de aneurisma da aorta inflamatório.

Introdução/Objetivos: A dissecção aórtica tipo A (AD) geralmente requer tratamento cirúrgico urgente e a substituição do segmento aórtico continua o gold standard. No entanto, é um procedimento muito agressivo e alguns doentes são excluídos do tratamento pelas suas comorbilidades. Atualmente, o tratamento endovascular representa uma alternativa, ainda sem indicações precisas. O nosso objetivo é apresentar um caso de tratamento híbrido de uma AD tipo A com recurso a um acesso vascular cardíaco transapical. Material/Métodos: revisão de um caso clínico e literatura. Resultados: Homem de 65 anos com antecedentes de doença pulmonar obstrutiva crónica, fibrilação auricular e hipertensão arterial; recorreu ao serviço de urgência por dor abdominal. Realizou angio-TAC que revelou uma AD tipo A e uma úlcera (PAU) na aorta ascendente (AA). Após a avaliação por cirurgia cardíaca, foi considerado não candidato para cirurgia convencional. A angio-TAC foi repetida após duas semanas de tratamento médico e revelou crescimento do falso aneurisma, com risco iminente de rutura. Ponderamos o tratamento endovascular e diferentes opções foram consideradas, a decisão final foi propor um tratamento híbrido. O procedimento foi iniciado com um bypass femoro-axilar direito e embolização do tronco braquiocefálico. Em seguida, uma endoprótese (Valiant®) foi libertada abaixo da artéria subclávia esquerda e dois periscópios (Viabahn®) foram progredidos das artérias axilar e carótida esquerdas e a segunda endoprótese (Valiant®) foi libertada, dentro da primeira, com cobertura da carótida e subclávia esquerdas. Após várias tentativas, não foi possível progredir a terceira endoprótese para a Aorta Ascendente por falta de suporte e instabilidade hemodinâmica e o procedimento foi interrompido. Posteriormente, a angio-TAC foi repetida e revelou dissecção da AA permeável e o falso aneurisma não tratado. Foram discutidas outras opções e foi ponderado um acesso vascular anterógrado (transapical) com o objetivo de conseguir o suporte para progredir a endoprótese. Com o apoio de um cirurgião cardíaco, o ápice cardíaco foi abordado e puncionado e um fio guia rígido foi avançado, criando um throught-and-through, do apéx cardíaco até à artéria femoral, o que permitiu o avanço da endoprótese (Valiant®) por via retrógrada e a sua libertação em rapid pacing sem intercorrências e com bom resultado final. Discussão/Conclusões: o tratamento endovascular AD tipo A é uma alternativa em doentes de alto risco clínico e características anatómicas adequadas, ainda que tecnicamente possa ser desafiante. Quando a progressão da endoprótese por acesso vascular retrógrado não é conseguida, a abordagem cardíaca transapical é uma alternativa a ser considerada.

O priapismo isquémico é uma ereção persistente, sem relação com estímulo sexual, caracterizada pela redução ou ausência de fluxo sanguíneo intracavernoso. Apresenta-se um caso clínico de um homem de 30 anos, com priapismo com 48 horas de evolução. Foi submetido noutra instituição à drenagem dos corpos cavernosos, instilação de efedrina e criação de shunt cavernoso-esponjoso, sem melhoria do quadro. Ao ecoDoppler observou-se ausência de fluxo nas artérias cavernosas, trombose das veias cavernosas e fluxo venoso dorsal normal. Foi submetido a cirurgia de Grayhack, com construção de pontagens cavernoso-femoral bilateral por transposição segmentar da veia grande safena. Apresentou boa evolução clínica e resolução do priapismo. No 7.◦ dia de pós-operatório apresentou trombose das pontagens, com fluxo de baixa resistência nas artérias cavernosas.

Introduction: Comparatively to open repair, endovascular aneurysm repair has reduced transfusion rates but there’s no recommendation about number of red blood cells units to be crossmatched preoperatively. Our aim is contribute to the analysis of red blood cells units needs in endovascular and hybrid aortic aneurysm repair and developing a protocol for maximum surgical blood orders schedule. Material and Methods: We retrospectively analyzed our prospective database of elective endovascular aneurysm repair from 2001 to 2012. We analyzed patients’ age, gender, ASA classification, maximum surgical blood orders schedule, red blood cells units transfused and timings, types of endoprosthesis, red blood cells units consumption/endoprosthesis’ type ratio, crossmatch to transfusion ratio, conversion to open repair, hemoglobin concentrations before surgery and discharge. Results: We selected 187 patients, 90% men, mean age 73.1, ASA mode III. The endoprosthesis were aorto-bi-iliac in 71%, aorto-uni-iliac in 23% and thoracic in 6%. Of these, 72,6% of the patients did not require blood transfusion. We transfused 171 red blood cells units. Crossmatch to transfusion ratio was 10.1 until 2010 and 7.3 after. The ratio of red blood cells units consumption/endoprosthesis in the first 24 hours was 0.21 red blood cells units/aorto-bi-iliac, 0.46 red blood cells units/aorto-uni-iliac, 0.8 red blood cells units/thoracic, 1.3 red blood cells units/hybrid-thoracic and 2 red blood cells units/hybrid-aorto-bi-iliac. A statistical correlation was observed between red blood cells units transfused postoperatively and type of endoprosthesis (p < 0.001) and between ASA classification and red blood cells units transfused after 24 hours (p < 0.01). Discussion: Guidelines from the British Society of Haematology are based on a crossmatch to transfusion ratio of 2:1. Our crossmatch to transfusion ratio was 10.1 until 2010 and 7.3 from 2011 to 2012. Conclusion: These results changed our policy of maximum surgical blood orders schedule for endovascular aneurysm repair. We now type and screen aorto-bi-iliac and aorto-uni-iliac. We crossmatch two red blood cells units for thoracic, three red blood cells units for hybrid thoracic and four red blood cells units for hybrid abdominal procedures. This may lead to financial savings, improved efficiency and reduce workload in hematology department.

Kikuchi-Fujimoto disease, also called Histiocytic necrotizing lymphadentis, is a rare, benign and self-limited disease, with unknown etiology, that affects mainly young women, and is characterized by adenopathy (usually localized in the cervical region) and fever. Diagnosis is based on histopathological findings in ganglionar tissue obtained in excisional biopsy, which allows, in most cases, the differential diagnosis with other similar clinical conditions, but which have a completely different clinical evolution and therapeutic needs. We report a case of a twenty four year old woman with persistent cervical lymphadenopathy, in which histopathological examination followed by immunohistochemical analysis of ganglionar tissue revealed to be Kikuchi-Fujimoto disease.