Search

Background In countries without organized population screening, incidental detection remains the major form of abdominal aortic aneurysm (AAA) diagnosis. Despite the presumed homogeneity in AAA prevalence, its rate of repair is highly variable, with Portugal treating 2 to 6 times fewer AAA per habitant than other western countries. Objectives To evaluate the detection rate and monitoring of incidental AAA in a multicentre cohort from Portuguese hospitals. Methods All abdominal CT scans performed in men ≥ 65 years old in three major Portuguese hospitals between January and June 2018 were selected for review. CT scans prescribed by the Vascular Surgery or Emergency Departments were excluded. Patients with previously known AAA were also excluded. Subjects with newly detected aneurysms were assessed for the two primary outcomes: the description of the finding by the radiologist in the written report; the effective follow-up recommendations by the prescriber of the CT or by the general practitioner (GP). Patients with newly found AAA that met criteria for monitoring or treatment and failed to be given guidance were contacted and included in surveillance programs. Results Overall, 3292 abdominal CT scans were selected for review. A total of 133 newly found aneurysms were detected (4.2% prevalence in the cohort). Of those, 48 cases (36%) were not described by the radiologist in the written report. Further 42 patients (32%) were not successfully oriented by the ordering physician or GP, despite having had their AAA mentioned. Overall, only 32% (n = 42) of the newly diagnosed AAA were correctly identified and referred to monitoring. Conclusions Incidental AAA is a common occurrence in in-hospital abdominal CTs. A significant number is not documented by the radiologist and the vast majority is not referred to monitoring. This could be a major reason for the low elective treatment rate of AAA in Portugal.

Inflammation is an early feature of acute limb ischaemia (ALI), hence the potential prognostic significance of inflammatory biomarkers. This study aimed to assess the value of pre-operative inflammatory biomarkers, specifically the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR), for predicting an adverse outcome after revascularisation for ALI.All patients submitted to lower limb revascularisation for Rutherford IIa or IIb ALI at the authors' institution between 2009 and 2019 were screened retrospectively. Pre-operative NLR and PLR were analysed, along with other known prognostic factors. Primary outcome was the composite endpoint of 30 day death or amputation.A total of 345 patients were included, 84 of whom suffered the primary outcome (24.3%). The median follow up was 23.1 months (3.1 - 52.2). Higher age (OR 1.05 per year increase, 95% CI 1.01 - 1.09), diabetes (OR 2.63, 95% CI 1.14 - 6.06), Rutherford grade IIb vs. IIa (OR 5.51, 95% CI 2.11 - 14.42), higher NLR (OR 1.28 per unit increase, 95% CI 1.12 - 1.47), and fasciotomy need (OR 3.44, 95% CI 1.14 - 10.34) were independently associated with 30 day death or amputation, whereas pre-operative statin or anticoagulant medication were associated with a risk reduction (OR 0.23, 95% CI 0.53 - 0.96 and OR 0.20, 95% CI 0.05 - 0.84, respectively). PLR did not show an independent effect on this population. Pre-operative NLR presented a good discriminative ability (AUC 0.86, 95% CI 0.82 - 0.90). A cut off NLR level ≥ 5.4 demonstrated a 90.5% sensitivity and 73.6% specificity for 30 day death or amputation. Kaplan-Meier analysis showed that patients with pre-operative NLR ≥ 5.4 had significantly lower 30 day, six month and one year amputation free survival when compared with those with NLR5.4 (64.8 ± 4.0%, 44.1 ± 4.1%, and 37.5 ± 4.1% vs. 98.5 ± 0.9%, 91.9 ± 2.0%, and 85.9 ± 2.5%, log rank p.001).In this study, higher pre-operative NLR was associated with 30 day death or amputation following intervention for Rutherford grade IIa or IIb ALI. NLR potentially stands as a simple, widely available and inexpensive biomarker that can refine decision making and possibly contribute to ALI morbidity and mortality reduction.

Ruptured abdominal aortic aneurysm (rAAA) remains a critical life-threatening condition. We aimed to evaluate rAAA management in our center focusing on predictors of mortality at 48 hr of intensive care unit (ICU) and to develop a new mortality prediction score considering data at 48 hr postprocedure. External validation of the modified score with patient data from independent vascular surgery centers was subsequently pursued.Clinical data of all patients admitted in our center from January 2010 to December 2017 with the diagnosis of rAAA were retrospectively reviewed for the development of the mortality prediction score. Subsequently, clinical data from patients admitted at independent centers from January 2010 to December 2017 were reviewed for external validation of the score. Statistical analysis was performed with SPSS Version 25.A total of 78 patients were included in the first part of the study: 21 endovascular aneurysm repairs (EVARs), 56 open repairs (ORs), and 1 case of conservative management. Intraoperative mortality in EVAR and OR groups was 0% vs. 24.6%, respectively (P = 0.012). Thirty-day mortality reached 50% and 33% in the OR and EVAR groups. For patients alive at 48 hr, 30-day mortality diminished to 27.6%. Several preoperative predictors of outcome were identified: smoking (P = 0.004), hemodynamic instability(P = 0.004), and elevated international normalized ratio (P 0.0001). Dutch Aneurysm Score and Vascular Study Group of New England Score (VSGNE) were also significant predictors of outcome (area under the receiver operating characteristic curve [ROC AUC] 0.89 and 0.79, respectively; P 0.0001). At 48 hr of ICU stay, high lactate level, high Sequential Organ Failure Assessment score, need for hemodyalitic technique, and hemodynamic instability were significant risk predictors for 30-day mortality (P 0.05). VSGNE score was modified with the inclusion of 2 variables: hemodynamic instability and lactate level at 48 hr and a new score was attained-Postoperative Aneurysm Score (PAS). Comparing AUC for VSGNE and PAS for patients alive at 48 hr, the latter was significantly better (AUC 0.775 vs. 0.852, P = 0.039). The PAS was applied and validated in 3 independent vascular surgery centers (AUC VSGNE 0.782 vs. AUC PAS 0.820, P = 0.027).Despite recent evidence on preoperative predictors of survival in an era when both EVAR and OR are available, emergent decision to withhold life-saving treatment will always be extremely difficult. Therefore, the policy in our department is to try surgical repair in all cases. It remains important, however, to identify whether late deaths can be predicted, so that unnecessary prolonged treatment can be avoided. A PAS was delineated predicting 30-day mortality significantly better in patients alive at 48 hr. The score was externally applied and validated in independent centers, corroborating the score's usefulness.

Introduction Endovascular intracranial thrombectomy (IT) has established itself as the standard of care in treating large-vessel anterior circulation acute ischemic stroke (AIS). However, internal carotid artery (ICA) stenosis/occlusion hampers distal access and controversy about simultaneous emergency ICA stenting ensues. The purpose of this review was to evaluate the safety of emergency ICA stenting in combination with IT for AIS with tandem occlusions. To our knowledge this is the first meta-analysis to evaluate emergency ICA stenting in tandem occlusions, combining results from studies with a control group. Evidence acquisition A meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Evidence synthesis A total of 649 potentially relevant articles were initially selected. After reviewing at title or abstract level, 87 articles were read in full and 23 were included. These studies recruited 1000 patients, 220 submitted to IT with no emergency ICA stenting and 780 to IT and emergency ICA stenting. Successful revascularization (Thrombolysis in cerebral infarction scale [TICI] ≥2b) was achieved in 48.6-100%. Good outcome (modified Rankin scale [mRS] ≤2) ranged from 18.2-100%. Symptomatic intracranial hemorrhage (sICH) ranged from 0-45.7% (overall N.=168; 17.2%). Mortality at 90 days ranged from 0-45.4% (overall N.=114; 11.7%). Time to recanalization was significantly longer in the stenting group with an overall mean difference of 1.76 (95% CI: 1.59-1.93). Conclusions In this meta-analysis time to recanalization was significantly longer in the emergency ICA stenting group. There was no benefit from emergency stenting in parameters such as successful revascularization (TICI≥2b), clinical outcome (mRS≤2) or 90-day mortality. Data on sICH were scarce. Emergency ICA stenting appears to increase time to revascularization and increase the risk of complications with no demonstrated clinical benefit. Furthermore, no prospective, randomized controlled trials demonstrating relative efficacy and safety of concomitant ICA stenting have been published to date. Additional studies must be undertaken to define the role of angioplasty and stenting of the extracranial carotid arteries in the early management of acute stroke in tandem occlusions. Until then, we recommend that ICA stenting concomitant to thrombectomy in acute stroke patients should be avoided.

Objective Mechanisms of procedural stroke after carotid endarterectomy (CEA) or carotid artery stenting are surprisingly underresearched. However, understanding the underlying mechanism could (1) assist in balancing the choice for revascularization vs conservative therapy, (2) assist in choosing either open or endovascular techniques, and (3) assist in taking appropriate periprocedural measures to further decrease procedural stroke rate. The purpose of this study was to overview mechanisms of procedural stroke after carotid revascularization and establish reporting standards to facilitate more granular investigation and individual patient data meta-analysis in the future. Methods A systematic review was conducted according to the PRISMA statement. Results The limited evidence in the literature was heterogeneous and of low quality. Thus, no formal data meta-analysis could be performed. Procedural stroke was classified as hemorrhagic or ischemic; the latter was subclassified as hemodynamic, embolic (carotid embolic or cardioembolic) or carotid occlusion derived, using a combination of clinical inference and imaging data. Most events occurred in the first 24 hours after the procedure and were related to hypoperfusion (pooled incidence 10.2% [95% confidence interval (CI), 3.0-17.5] vs 13.9% [95% CI, 0.0-60.9] after CEA vs carotid artery stenting events, respectively) or atheroembolism (28.9% [95% CI, 10.9-47.0]) vs 34.3 [95% CI, 0.0-91.5]). After the first 24 hours, hemorrhagic stroke (11.6 [95% CI, 5.7-17.4] vs 9.0 [95% CI, 1.3-16.7]) or thrombotic occlusion (18.4 [95% CI, 0.9-35.8] vs 14.8 [95% CI, 0.0-30.5]) became more likely. Conclusions Although procedural stroke incidence and etiology may have changed over the last decades owing to technical improvements and improvements in perioperative monitoring and quality control, the lack of literature data limits further statements. To simplify and enhance future reporting, procedural stroke analysis and classification should be documented preemptively in research settings. We propose a standardized form enclosing reporting standards for procedural stroke with a systematic approach to inference of the most likely etiology, for prospective use in registries and randomized controlled trials on carotid revascularization.

Infective celiac artery aneurysm is an extremely rare diagnosis, with few reported cases in the literature. We present the case of a rapidly expanding celiac artery aneurysm involving the ostia, probably infectious, successfully treated in an urgent setting by aneurysm exclusion resorting to the chimney technique. On follow-up, computed tomography angiography revealed complete aneurysm thrombosis and patent celiac artery. Previous reports of endovascular treatment of infective celiac artery aneurysm involved its embolization. This is the first reported case of chimney technique used to exclude a celiac artery aneurysm, with a clinical suspicion of infectious etiology, preserving celiac artery patency. Short-term results are encouraging, but implantation of prosthetic material in an infected environment is a concern. Keywords: Aneurysm, Infected, Celiac artery, Endovascular procedures

Introduction Peripheral artery aneurysms are a rare manifestation of Kawasaki disease (KD), with an estimated incidence of approximately 2% of all KD patients. The case of a 14-year-old girl with past clinical history suggestive of KD is reported; she presented with an aneurysm located in the brachial part of a superficial brachioulnoradial artery, still with the genuine brachial artery in place (an anatomical variation with a reported incidence of 0.14–1.3% in general population). Relevant medical data were collected from the hospital database. Report This is a report of a case of a symptomatic superficial brachioulnoradial artery aneurysm, secondary to KD, treated with aneurysm exclusion and superficial brachioulnoradial to the genuine brachial artery transposition. Uneventful intra- and postoperative course with symptom resolution is reported. Discussion The coexistence of a rare manifestation of KD (peripheral aneurysm) with an even rarer brachial artery variation allowed a simple but elegant solution, making this a unique case., Highlights • Peripheral artery aneurysms (PAA) in Kawasaki Disease (KD) are rare (2%). • Although life-threatening coronary involvement is of paramount importance, KD associated PAA may present as limb-threatening conditions. • The correlation between a PAA and KD vasculitis may be difficult to establish if the aneurysm is diagnosed years after the acute phase. • Variations in number and course of upper limb arteries have clinical and surgical importance, as demonstrated in this case.

Introduction Systemic embolisation of stents represents a rare complication of coronary interventions. Report The case of a patient with peripheral embolisation of a coronary stent while undergoing a coronary procedure for an ischaemic event is reported. The stent lodged at a previously created iatrogenic fistula joining the profunda femoral artery and the common femoral vein. An endovascular attempt was ineffective in treating this complication. The stent was removed surgically and the fistula repaired. Discussion This unusual clinical setting of stent embolisation concomitant to an iatrogenic arteriovenous femoral fistula is reported., Highlights • A rare complication of coronary endovascular interventions. • The problems related to stent embolisation. • An anecdotal case where a stent embolised to a previously created iatrogenic femoral arteriovenous fistula.

Introduction Popliteal artery aneurysms (PAAs) are rare in the general population, but they account for nearly 70% of peripheral arterial aneurysms. There are several possible surgical approaches including exclusion of the aneurysm and bypass grafting, or endoaneurysmorrhaphy and interposition of a prosthetic conduit. The outcomes following the first approach are favorable, but persistent blood flow in the aneurysm sac has been documented in up to one third of patients in the early post-operative setting. Complications from incompletely excluded aneurysms include aneurysm enlargement, local compression symptoms, and sac rupture. Notably infection of a previously excluded and bypassed PAA is rare. This is the third reported case of PAA infection after exclusion and bypass grafting and the first due to Serratia liquefaciens. Methods Relevant medical data were collected from the hospital database. Results This case report describes a 54 year old male patient, diagnosed with acute limb ischaemia due to a thrombosed PAA, submitted to emergency surgery with exclusion and venous bypass. A below the knee amputation was necessary 3 months later. Patient follow-up was lost until 7 years following surgical repair, when he was diagnosed with aneurysm sac infection with skin fistulisation. He had recently been diagnosed with alcoholic hepatic cirrhosis Child–Pugh Class B. The patient was successfully treated by aneurysm resection, soft tissue debridement and systemic antibiotics. Conclusion PAA infection is a rare complication after exclusion and bypass procedures but should be considered in any patient with evidence of local or systemic infection. When a PAA infection is diagnosed, aneurysmectomy, local debridement, and intravenous antibiotic therapy are recommended. The “gold standard” method of PAA repair remains controversial. PAA excision or endoaneurysmorrhaphy avoids complications from incompletely excluded aneurysms, but is associated with a high risk of neurological damage., Highlights • Popliteal artery aneurysms (PAAs) are the most common cause of non-traumatic leg amputation. • Potential complications from PAA exclusion are aneurysm enlargement, local compression symptoms, sac rupture, and infection. • Infection of a previously excluded and bypassed popliteal artery aneurysm is exceedingly rare. • This is the third case of excluded aneurysm infection, and the first by the Serrate genus.

ResumoOs aneurismas do sistema venoso portal são entidades pouco comuns e definem‐se como uma dilatação do sistema venoso portal. Estes aneurismas têm sido classificados como congénitos ou adquiridos e, habitualmente, não requerem tratamento, exceto na presença de sintomas – que dependem do tamanho do aneurisma, da sua localização ou da presença de complicações, como trombose.Apresenta‐se um caso clínico relativo a um doente do sexo masculino, 68 anos de idade, com o diagnóstico incidental de um aneurisma assintomático da veia porta de 37mm, com envolvimento da confluência da veia esplénica com a veia mesentérica superior. Optou‐se por uma abordagem conservadora, com vigilância imagiológica periódica anual com ecoDoppler.AbstractPortal venous aneurysms are a rare condition characterized by dilatation of the portal venous system. These aneurysms can be congenital or acquired and usually do not require any treatment unless they are symptomatic–symptoms depend on the aneurysm size, location and complications, such as thrombosis.We report a case of a 68 year‐old man, who was incidentally diagnosed with an asymptomatic 37mm portal vein aneurysm, with the involvement of the splenic vein confluence with the superior mesenteric vein. A conservative approach with annual monitoring by Doppler ultrasound was recommended.

Objective/background Endograft limb occlusion is a potential complication of endovascular aneurysm repair (EVAR), being one of the major causes of secondary interventions and rehospitalisation. The aim of this review is to report on the impact of endograft kinking in endograft limb occlusion, as well as on risk factors, prevention, early diagnosis, and management. Methods A systematic review and meta-analysis was conducted according to the recommendations of the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. Results After a MEDLINE and Scopus search, 55 articles (27,509 patients) were included in the qualitative analysis and eight in the quantitative analysis. In this meta-analysis, 179 at risk limbs were treated by pre-emptive stenting, which significantly reduced the risk of limb occlusion: not pre-emptively stenting limbs at risk had a negative impact on graft limb patency (odds ratio 4.30, 95% confidence interval 1.45–12.78). Post-operatively, a kink was identified in 422 patients (1.5%), contributing to 42.8% of all limb occlusions. Relevant data support that completion angiography is an inadequate means of diagnosing high risk limbs, proposing cone beam computed tomography and intravascular ultrasound as adjuncts. The post-operative limb occlusion rate ranged from 0% to 10.6%, affecting 984 patients. Several risk factors for limb occlusion have been identified. Regarding treatment, most patients were submitted to femorofemoral bypass (52.3%) or to deployment of a bare metal stent, either alone or associated with catheter directed thrombolysis or mechanical thrombectomy (26.4%). Complications and outcome after re-intervention for limb occlusion are described infrequently in the literature, but single studies have reported on re-occlusion, major amputation, and limb occlusion related mortality rates. Conclusion Pre-EVAR planning should focus on identification of risk factors for kinking. Adjunctive stenting is an effective prophylaxis for selected high risk limbs, yet intra-operative identification remains problematic. Also, it is noteworthy that most limb occlusions occur in the first year after EVAR, emphasising the importance of careful early follow up of high risk patients.

Objective Acute carotid stent thrombosis (ACST) occurring in the first hours after the procedure is an exceedingly rare complication of carotid artery stenting, but it is potentially devastating. This review aimed to evaluate current literature, identifying all reported cases during the last two decades, with the final purpose of reporting predictive factors and early management. Methods A systematic review and meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Results A total of 464 potentially relevant articles were selected. After review of records at title and abstract level, 29 articles with 60 patients were included. Twelve studies reported on ACST incidence rate in their cohorts, ranging from 0.36% to as high as 33%. In considering etiology, antiplatelet noncompliance or resistance is the most frequently reported risk factor. Emergency procedures seemed to be associated with greater risk for ACST, reaching 5.6% to 33% incidence. Dual-layer stents were also associated with greater risk (45% vs 3.7%; P = .0001; odds ratio, 21.3). Use of an overlapping stent as a bailout procedure because of dissection, malposition, or long lesions was correlated with increased risk (7.3% vs 0.002%), as were long stenotic lesions (22.9 ± 6.83 mm vs 14.2 ± 6.42 mm; P = .0034) and stent length (3.8 ± 0.4 cm vs 2.8 ± 0.86 cm; P = .0055). ACST was associated with neurologic status deterioration in 56.7% of cases. Time to symptoms or ACST diagnosis had a median of 1.5 hours, with 30% occurring intraprocedurally. In asymptomatic ACST, conservative management was unanimous. Endovascular treatment was the most common approach to intraprocedural ACST. Surgical options included carotid endarterectomy with stent explantation (n = 9), which was also a bailout after failed endovascular treatment in two cases. Conclusions ACST incidence is higher in emergent, neurologically unstable patients. Antiplatelet noncompliance, antiplatelet resistance, long stenotic lesions, use of more than one stent, and dual-layer stents are also associated with increased risk. The decision as to the best approach depends on whether ACST occurs intraprocedurally or afterward, the development of neurologic status deterioration, and the center's experience. However, additional studies must be undertaken to better define optimal management.

Background Major pelvic ilio-iliac arteriovenous fistula (AVF) is an exceedingly rare diagnosis with only a few described cases in the literature, most of them related to congenital defects or trauma. In this case report, we aim to present a case of an ilio-iliac AVF with an atypical clinical presentation. Methods Relevant medical data were collected from hospital database. Results The patient is a 77-year-old woman, with a relevant medical history of a temporally remote hysterectomy. She developed an exuberant unilateral right leg edema and was diagnosed with a femoro-iliac deep vein thrombosis (DVT) and started on anticoagulation and daily use of elastic compression stockings. No improvement in leg edema was evident, and she reported painful complaints refractory to medication. She also progressively developed right foot numbness and foot drop. A computed tomography angiography (CTA) was performed to exclude any compressive or paraneoplastic syndrome, with no remarkable findings other than common iliac vein (CIV) occlusion. As the patient's symptoms continued to worsen, a new CTA was performed 5 months later, which revealed an ilio-iliac AVF that was confirmed by angiography. After 2 ineffective attempts to embolize AVF afferents, we chose to completely embolize the arterial component of the AVF with Helix EV3 coils and Onyx glue (Covidien, Irvine, CA, USA). CIV recanalization and deployment of a Venovo stent (Bard Inc, Tempe, AZ, USA) was also performed. The final angiograms showed exclusion of the AVF and rapid venous flow through the stent. There was progressive improvement of edema and pain but little improvement of foot drop. Conclusion AVF etiology and mechanism of neurologic deficits are controversial, with multiple possible explanations. Endovascular treatment modalities are promising a safer and more efficient approach when compared with open surgery. Our experience in this case was encouraging, but long-term results are currently lacking.

Abdominal compartment syndrome is a possible complication after aneurysm repair and has a high mortality rate. Although there has been an increment in patient survival rates after aneurysm repair, there has also been an increase in this entity. However, there are few data about the incidence and management of this complication after endovascular repair of a ruptured iliac artery aneurysm. The objective of this report is to describe a case of abdominal compartment syndrome after endovascular correction of a ruptured iliac artery aneurysm, emphasizing the importance of the accurate monitoring of intra-abdominal pressure, medical therapy and timely laparotomy. An 85-year old male was submitted to the endovascular repair of a ruptured iliac artery aneurysm. On the first day after the intervention, he developed abdominal compartment syndrome which did not resolve with medical therapy. Consequently, on the second postoperative day, a decompressive laparotomy was performed, removing the retroperitoneal haematoma, which was the main cause of the high intra-abdominal pressure and the abdominal compartment syndrome. At 12 months of follow-up, there was no evidence of complications. This case stresses the importance of early recognition of abdominal compartment syndrome.

Duodenocaval fistula is a rare and potentially lethal condition. We report a case of a 61-year-old female with a duodenocaval fistula resulting from a fish bone perforation of the duodenum who survived with conservative treatment. To our knowledge, this is the first reported case of a duodenocaval fistula caused by a fish bone. Additionally, besides revising the other possible etiologies for duodenocaval fistulae, we also discuss its diagnosis and treatment.

Objectivos: Determinar se nos doentes com Doença Arterial Periférica (DAP), o tipo de tratamento e o grau de isquemia infl uencia os hábitos tabágicos. Material e métodos: De Janeiro de 2010 a Dezembro de 2011 foram tratados 317 fumadores, 304 homens e 13 mulheres, média de idades 66±9,7 anos. Destes, 44% foram sujeitos a tratamento médico, 22% a revascularização endovascular e 34% a cirurgia. Estudaram-se as características demográficas da população, presença de factores de risco e eventos cardiovasculares, indicações para tratamento e a cessação tabágica após a revascularização ou durante o seguimento. Resultados: A análise estatística revelou uma proporção maior de doentes que cessaram hábitos tabágicos quando submetidos a um procedimento endovascular em relação àqueles em tratamento médico (66% vs 51%, p = 0,036) e ainda superior quando revascularizados cirurgicamente (66% vs 80%, p = 0,021). No grupo de tratamento endovascular, 65% dos ex-fumadores correspondiam a claudicantes e 69% a doentes com isquemia crítica (p = 0,36). No grupo de tratamento cirúrgico, a percentagem de doentes que deixou de fumar foi superior entre aqueles com isquemia crítica em relação aos tratados por claudicação (86% vs 72%, p = 0,039). Conclusões: Os doentes com Doença Arterial Periférica que são submetidos a procedimentos de revascularização mais invasivos, como a cirurgia, são mais propensos à cessação tabágica do que os sujeitos a tratamento endovascular ou médico. A presença de isquemia crítica aquando do tratamento cirúrgico infl uenciou, de forma estatisticamente signifi cativa, a cessação tabágica. Assim, a proposta de tratamento constitui um momento crucial para fomentar a desabituação tabágica. Objectives: To determine in patients with Peripheral Arterial Disease (PAD) whether if the type of treatment and the degree of ischemia infl uences smoking habits. Material and methods: From January 2010 to December 2011 317 smokers were treated, 304 men and 13 women, mean age 66 ± 9,7 years. Of these, 44% were medically managed, 22% underwent endovascular revascularization and 34% surgery. We studied the demographic characteristics of the population, presence of risk factors and cardiovascular events, indications for treatment and smoking cessation after revascularization or during follow-up. Results: Statistical analysis revealed a higher proportion of patients who stopped smoking when they underwent endovascular procedure compared to those undergoing medical treatment (66% vs. 51%, p = 0,036) and also higher when undergoing surgery (66% vs 80% p = 0,021). In the endovascular treatment group, 65% of ex-smokers were claudicants and 69% had critical limb ischemia (p = 0,36). In the surgical group, the percentage of patients who quit smoking was higher among those with critical limb ischemia compared to claudicants (86% vs 72%, p = 0,039). Conclusions: Patients with Peripheral Arterial Disease who are undergoing more invasive revascularization procedures such as surgery, are more likely to quit smoking than those subjected to endovascular or medical treatment. The presence of critical limb ischemia during surgical treatment infl uenced, in a statistically signifi cant way, smoking cessation. Therefore, the moment of surgical proposal is crucial to promote smoking cessation.

Even though the majority of abdominal aortic aneurysm s(AAAs) are asymptomatic, they can occasionally manifest as a result of adjacent structures involvement. Although the most frequent venous complication of AAA is rupture into the inferior vena cava (IVC), venous compression can infrequently occur. The authors report a particularly rare case of compression and thrombosis of the IVC by AAA. Patient was treated by preoperative placement of an IVC filter to impede pulmonary embolism and subsequently by open surgical repair. Besides discussing the circumstances associated with IVC compression by AAA, the authors also discuss the treatment strategy adopted and the possible alternatives.

Objectives To review the experience of our institution in repairing isolated iliac artery aneurysm (isolated IAA) in the last six years. Methods The medical records of patients who underwent isolated IAA repair were reviewed, to obtain information on patients' demographics, vascular risk factors, type of treatment and outcome. Results A total of 11 patients with 16 aneurysms, all men, with a mean age of 69.2+/-6.0 years were treated. The mean diameter was 3.7+/-1.0 cm (3.5+/-1.1 cm at elective repair; 5.7+/-2.9 cm on the emergency cases). The majority of aneurysms were at the common iliac artery and 27.3% of them were multiple. The diagnosis of multiple aneurysms was performed 10 years later, compared with the mean age of the diagnosis of single aneurysms, and this difference is statistically significant. Seven (63.6%) had elective operations, and one elective endovascular repair. Analysing the vascular risk factors, it was evident that hypertension was the most prevalent and the diagnosis of aneurysm was done 10 years sooner in the smoker patients. There was no postoperative death in this series. The mean follow-up period was of 21 months, and during it, one patient developed a non-infection anastomotic aneurysm of common femoral artery, one died with a myocardial infarction, one presented with limb graft thrombosis and another was lost. Conclusion This series contributes to a better characterization of a rare pathology demonstrating that both surgical and endovascular treatment can be performed with very low morbidity and mortality.

ResumoOs autores apresentam um caso clínico de duplicação da veia cava inferior (VCI) com drenagem pela veia ázigos diagnosticada durante flebografia diagnóstica, prévia à introdução de filtro.Doente de 69 anos, sexo feminino, internada por acidente vascular cerebral hemorrágico com diagnóstico, ao 20.° dia de internamento, de trombose venosa profunda poplíteo‐femoro‐ilíaca esquerda com indicação para colocação de filtro da veia cava. Foi efetuada flebografia diagnóstica com acesso pela veia jugular interna direita tendo sido possível observar duplicação da VCI com drenagem cardíaca posterior anómala. Colocado filtro da VCI suprarrenal por acesso na veia femoral comum direita.A duplicação da veia cava é rara com uma prevalência de 0,2‐3%. A sua abordagem em contexto da colocação de filtro torna‐se um desafio invulgar.AbstractThe authors describe the case of an inferior vena duplication with azygos vein drainage diagnosed during diagnostic venography, prior to filter introduction.In a 69 years old medical inpatient woman with hemorrhagic stroke, a left popliteal‐femoro‐iliac DVT was diagnosed on the 20th day of admission. She was referred for vena cava filter placement. We performed a diagnostic venography with access from the right internal jugular vein. It has been possible to observe an inferior vena cava duplication with an anomalous posterior heart drainage. We placed an inferior vena cava filter in suprarrenal position, accessing the right common femoral vein.Duplication of vena cava is rare with a prevalence of 0.2‐3%. Its approach in the context of placing a filter becomes an unusual challenge.

Introduction Carotid artery stenting (CAS) is a valid alternative to carotid endarterectomy with proper indications. In-stent restenosis (ISR) is a possible complication and there are multiple therapeutic options for severe ISR (>70%). The use of drug-eluting balloons (DEB) has increasing evidence as a new endovascular treatment for ISR. The authors report a case of recurrent ISR treated with a DEB. Case report Male patient, 67 years-old, with a history of cervical radiation in 2006. In 2007, he had a stroke in the territory of the right internal carotid artery (ICA). The duplex ultrasound (DUS) showed right ICA occlusion and left ICA stenosis >70%. He underwent left CAS under filter protection, without complications. He was kept as an outpatient and in 2009 he presented ISR >70%. The patient was treated with re-stenting, without residual stenosis and had an uneventful course. In 2012, DUS revealed recurrent ISR >70%. Angioplasty with a paclitaxel-eluting balloon was performed, with distal cerebral protection, good imaging and hemodynamic results and an uneventful course. At 6 months of follow-up, the patient has no complications and no ISR documented by ultrasound. Conclusions The use of DEB in the treatment of ISR after CAS is an emerging strategy with promising results.

Introdução: A endarterectomia carotídea é um procedimento cirúrgico de elevada diferenciação cujo benefício é inegável, mas que apresenta riscos importantes, nomeadamente o risco trombótico e possível precipitação de um acidente vascular cerebral. O risco hemorrágico perioperatório é baixo. O protocolo de atuação do nosso serviço contempla a reserva perioperatória de 2 unidades de glóbulos rubros, o que na maioria dos casos parece excessivo. Se, por um lado, as perdas hemáticas durante este procedimento podem justificar o suporte transfusional deste hemoderivado, por outro, a crescente necessidade de poupança que o Sistema Nacional de Saúde vive remete-nos a refietir acerca de possíveis gastos desnecessários. Métodos: Avaliaram-se retrospetivamente os casos de endarterectomia carotídea no nosso serviço no período de 2010-2012. Procedeu-se à quantificação do número de transfusões de glóbulos rubros efetuadas perioperatoriamente. Foram avaliados os possíveis fatores de risco para a eventual necessidade de suporte transfusional como a hipocoagulação, coagulopatia, anemia e trombocitopenia. Procedeu-se à avaliação dos parâmetros técnicos da cirurgia como a técnica utilizada (angioplastia com patch de dacron ou eversão), a necessidade de uso de shunt, o tempo operatório e de outros fatores relevantes como as perdas hemáticas intraoperatórias, a presença de hematoma cervical ou outras complicações perioperatórias. Resultados e conclusões: Foram submetidos a endarterectomia carotídea 66 doentes, dos quais apenas 2 (3%) necessitaram de suporte transfusional no período pós-operatório (2 unidades de glóbulos rubros). Um caso ocorreu em contexto de hemorragia incisional e hematemeses (lesões de Mallory-Weiss) num doente hipocoagulado cronicamente por uma fibrilação auricular. O outro caso ocorreu em contexto de hemorragia incisional numa doente com anemia prévia e cardiopatia isquémica (no pós-operatório imediato apresentava hemoglobina de 8,1 g/dL). O valor médio das perdas intraoperatórias foi de 138,70 ± 78,82 ml. Apenas um (1,5%) necessitou de drenagem cirúrgica por hematoma cervical. Estes resultados sugerem que o protocolo de atuação, no que se refere ao suporte transfusional na cirurgia carotídea eletiva, merece ser revisto. Perante estes resultados haverá razões para presumir que neste procedimento não será necessária a reserva de glóbulos rubros de forma rotineira, podendo esta ser protocolada apenas para casos específicos identificados como de maior risco. © 2014 Sociedade Portuguesa de Angiologia e Cirurgia Vascular. Publicado por Elsevier España, S.L.U. Todos os direitos reservados. Introdution: The carotid endarterectomy is a highly differentiated procedure, with a clear known benefit, although it envolves the risk of stroke. The bleeding risk related to the surgery is low. In our departpment we routinely ask for two red blood cell units, which seems excessive. In one hand there is the risk of bleeding related to any surgery, on the other, there is a growing need to review and end unnecessary expenses because of the socio-economic crisis we live in. Methods: We retrospectively reviewed our experience in carotid endarterectomy between January 2010 and December 2012. We noted the number of red blood cell transfusions were made perioperatively. We characterized the population, as well as a number of risk factos that would be related to increased bleeding and thus transfusion risk as in hypocoagulation, known coagulophy, anemia or thombocytemia. We characterized the procedure it self as in used technique, the need for shunt, operative time, the bleeding ocurred perioperatively as in other procedural complications as cervical hematoma. Results and Conclusions: Sixty six patients were submited to carotid endarterectomy during the time of study. Two patients (3%) did need a red blood cell transfusion (two units). One case of bleeding throught the incision plus Mallory-Weiss lesions with bleeding in a hypocogulated patient. The other case of bleeding throught the incision in a already anemic patient with a coronary artery disease (postoperatively with hemoglobin of 8.1 g/dL). The mean value of bleeding was 138.70 ± 78.82 ml. Only one patient did need reinterverntion because of a cervical hematoma. These results suggest that there could be changes to make in our way of preparing for bleeding risk perioperatively in carotid endarterectomy. We can conclude that there is no need for routinely asking for two red blood cell units and can do that in selected cases. Asking for a Type and Screen routine may be enough for most situations. © 2014 Sociedade Portuguesa de Angiologia e Cirurgia Vascular. Published by Elsevier España, S.L.U. All rights reserved.