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The authors report the clinical case of a 66 years old man who underwent, in November 2007, a cross-over femoro-femoral bypass, using a spiral protected 8 mms PTFE graft, to treat a disabling intermittent claudication of the left lower extremity. In April 2009, seventeen month later, he suffered a brutal kick injury in the suprapubic area, resulting in a local voluminous hematoma, including the scrotum, shock and left lower extremity ischemia. Angio-CT scans disclosed a complete fracture of the prosthesis. The patient underwent immediate surgical management, consisting in the local thrombectomy and reconstruction of the graft continuity, through an end-to-end anastomosis. He was discharged seven days later and one month later he was found asymptomatic and in good condition. Following an exhaustive revision of the literature, the authors conclude that this is the first report of such complication of a cross-over femoro-femoral bypass graft.

The celiac axis compression syndrome caused by the median arcuate ligament of the diaphragm is an exceedingly rare clinical entity, coursing with postprandial abdominal pain, nausea, vomiting and weight loss. Despite the original description made some decades ago, its existence is still challenged by some authors, due to a weak clinicopathological correlation and inconstant results obtained with its surgical management. The authors report the case of a 35 years old female with the clinical presentation above described, who underwent an exhaustive investigation in gastroenterology, leading to the diagnosis, made by CT-scans and conventional angiography, of celiac axis compression syndrome by the median arcuate ligament of the diaphragm. A definitive surgical repair was performed, consisting in the ligament division, followed by resection and replacement of the celiac axis, by a 6 mms PTFE grafts. The post-operative course was uneventful and reviewed one month later, the patient was found in excellent condition and completely free of symptoms. Pathological studies of the celiac axis disclosed significant proliferative and degenerative lesions of the arterial wall, consequence of the compression mechanism, a fact that has not been reported in previous similar publications. The main feature of this unique clinical entity and its surgical management are discussed, based on a review of the most recent publications of the literature.

The clinical case of a 39 years old female is reported, with the diagnosis of tumor of the right kidney extending into the infra-hepatic vena cava, assuming the shape of a floating thrombus. The patient underwent right radical nephrectomy, followed by resection of the intra caval tumor. Both the procedure and post operative course were uneventfull. Histopathological evaluation of the specimens, associated to specific imunohistochemistry studies, confirmed the diagnosis of angiomyolipoma of the kidney. A review of the literature concluded that this is the 27th case published of a kidney angiomyolipoma extending into the inferior vena cava, thus justifying its presentation and divulgation.

Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic sistemic disease of unknown etiology, primarily affecting muscular arteries of intermediate size. It has been most commonly observed in the renal, carotid, and intracerebral arteries, although it has been reported in other arterial beds. However, being an uncommon disease in general, the manifestation of FMD in the upper extremities is exceedingly rare. The authors report the case of a 69 years old female admitted with ischemia of the right hand, secondary to fibromuscular dysplasia of the midbrachial artery. The patient presented to vascular surgery clinic with a 4 month history of numbness, pain, and coolness of her right hand, with a small necrotic lesion on her right index finger. Peripheral pulses were barely palpable, and doppler-derived brachial and radial systolic pressures suggested midbrachial artery stenosis. Arteriography showed a normal arch and normal innominate, subclavian, and axillary arteries. The midbrachial artery was markedly abnormal and had alternating areas of stenosis and aneurysm formation - "string-of-beads" appearance. The patient underwent surgical excision of the abnormal right brachial artery, and reconstruction was accomplished with a reversed saphenous vein graft. Distal pulses were restored postoperatively. Pathologic examination confirmed the diagnosis of fibromuscular dysplasia. A review of the literature on the topic was made.

The authors report the clinical case of a 34 years old male, with a germ cell tumor of the testis, who developed large retroperitoneal metastasis, with compression and later on invasion of the inferior vena cava. The patient underwent chemotherapy followed by resection of the original tumor and of the retroperitoneal metastasis and the vena cava was replaced by a vascular prosthesis. The post operative course was uneventful and one year later he was found in excellent condition. The rarity of the situation as well as of its surgical management justifies the presentation and the discussion of the case, based on the most recent data of the literature dedicated to the topic.

Paradoxical embolism (EP) occurs when a venous thrombus passes into the arterial circulation, most commonly through an intracardiac shunt. A patent foramen ovale (FOP) is present in 25-35%of people at all ages. It is now possible to detect FOP by contrast echocardiography and it has been shown that there exists quite frequently a spontaneous transient right-to-left shunt during systole and, moreover, a right-to-left shunt during Valsalva maneuver and coughing. Acute or chronic pulmonary hypertension are also causes of shunt. This phenomenon has been associated with catastrophic outcomes such as stroke, visceral infarction and ischemic limb. We report the case of a 31-year old man with multiple paradoxical thromboemboli into his right kidney, spleen, small bowel and left brachial artery. Paradoxical embolism was suspected and confirmed by transoesophageal contrast echocardiography, disclosing FOP with right-to-left shunt. Successful percutaneous closure of patent foramen ovale with Amplatzer(R) PFO occluder 18 mm allowed subsequent oral antiaggregation with acetilsalicilic acid 150 mg/day and clopidogrel 75 mg/day. A new case gives the opportunity to review mechanisms, diagnosis and therapeutic issues. Treatment strategies for FOP in recurrent PE include antiplatelet agents, anticoagulants, surgical closure, or percutaneous closure devices. The completion of ongoing, randomized clinical trials comparing percutaneous closure devices with medical management is urgently needed to clarify if the risks of invasive endovascular device placement are outweighed by a long-term reduction in recurrent vascular events.

On July 11, 2008, expired in Houston, Texas, Michael Ellis DeBakey, who was a legendary figure of Medicine of the XX century and of cardiovascular surgery in particular, due to the enormous contributions he gave to the progress and development of contemporary cardiac and vascular surgery. Michael Ellis DeBakey can be remembered as well as a distinguished investigator, educator, academician and medical statesman, recognized and admired in his country and all over the world, including Portugal. The course of his life and major achievements are described and remembered, as a single tribute payed by a former disciple, bringing to the new generations of physicians the example of a fully active, criative and laborious life committed and devoted to the fight against disease and promotion of mankind welfare.

Aortic mural thrombosis is a rare situation in clinical practice. Its pathogeny is ignored in the majority of cases and clinical presentation is variable, according to the location of the thrombus and the multiple and diverse forms of embolism that can cause. For these reasons, clinical diagnosis may be extremally difficult. The authors report the cases of two women aged 52 and 41 years old respectivelly admitted in the Emergency Department with abdominal and lumbar pain, due splenic embolic infarctions, a diagnosis made by CT-Scans. The computed tomography disclosed also the presence of mural thrombus in the celiac aorta, one of them as a floating thrombus, which were regarded as the source of the embolism. Supraceliac aortic thrombectomy was performed, associated to splenectomy in both cases. Post operative course was uneventfull and reviewed 10 months and 9 years after the operation, they were found in pretty good condition, with no evidence of recurrence of the disease.

The authors report the clinical case of a 13 year old girl with the diagnosis of arterial hypertension, consequence of an upper abdominal aortic coarctation, involving the origin of both renal arteries and the superior mesenteric artery. Surgical exploration disclosed the coexistence of displasic aneurysms at the origin of both renal arteries. She underwent a complex revascularization procedure, which is described, and the post operative course was uneventfull, having normalised the values of the blood pressure. The main features of etiopathogeny, clinical presentation, diagnosis and surgical management of this entity are discussed, based on an extensive review of the literature.

Heparin was accidentally discovered in 1916 by Jay McLean, a second-year medical student working at the Department of Physiology of the Johns Hopkins Medical School in Baltimore, under the direction of the eminent scientist William Howell. The discovery of heparin was not followed by immediate practical use and only twenty years later was recognized its clinical utility in the treatment of post traumatic venous thrombosis of the lower extremities, by the canadians Charles Best and Gordon Murray. Jay McLean expired in 1957, dismayed and depressed with the indiference devoted by the scientific community to its discovery and only several years later the fact was recognized in a simple ceremony to testify its participation in the discovery of a drug that promoted the progress and development of vascular and cardiac surgery, the extracorporeal circulation, the haemodialysis, the organ transplantation and the treatment and prevention of arterial and venous thromboembolism.

The authors report the clinical case of a dissecting thoracoabdominal aortic aneurysm, in a 49-years old female, with the diagnosis of Marfan's syndrome, who underwent surgical treatment utilizing the "simplified technique", introduced by ourselves in 1983, for the management of this most demanding situation. Reviewed ten years later, having reassumed her social and professional life, a control angio-CT disclosed the procedure of aortic reconstruction and the revascularization of the digestive and renal arteries working in excellent condition. The unique and singular reconstructive procedure here utilized and its excellent long term result, justify its presentation and divulgation.

In the management of penetrating carotid injuries, the surgeon must act in an emergency way to prevent active bleeding and to restore cerebral blood flow. Preservation of the carotid circulation decreases morby-mortality in these patients. Controversial diagnostic and therapeutic approach remain when no signs of bleeding or neurological ischemia are evident. The authors report the case of a male patient submitted to an emergency operation to repair a internal carotid thrombosis consequence of a penetrating gunshot injury at the area II of the neck. We reviewed the literature related to this condition and the different methods of treatment that can be employed.

Vascular reconstructive surgery has faced, since the beginning, with a complex biologic phenomenon, jeopardizing the results, which is the miointimal hyperplasia and anastomotic fibroplasia, developed at the vascular anastomosis or following balloon angioplasty, leading often to a vessel occlusion and failure of the revascularization procedure. Multiple and diversified research projects have been dedicated, along the years, to the study of the intimal mechanisms and attempts to control the phenomenon by pharmacotherapeutic agents, but the results are still far of being regarded as satisfactory. The author makes a review on the pathogenesis of the miointimal hyperplasia and anastomotic fibroplasia and proceeds to a critical analysis on the most recently introduced innovations, such as is the case of the drug eluting stents, the brachitherapy and the molecular and genetic therapies.

The endoluminal interventional has played nowadays, a significant role as an alternative to the revascularization surgery of digestive arteries, but its therapeutic efficacy and duration of results have not yet been fully demonstrated. The authors report the clinical case of a 64 years old male, suffering of abdominal angina and significant weight loss, due to a pre-occlusive ostial stenosis of the celiac axis. He underwent three angioplasty/stenting attempts for the last three years, with no success to dilate the lesion and persistence of the clinical symptoms. As a consequence of the failure of the endoluminal intervention, he underwent a conventional revascularization procedure, consisting in the implantation of an aorto-hepatic prosthetic bypass graft, with immediate resolution of the symptoms and a progressive and consistent weight gain. The authors conclude by discussing the advantages and inconvenience of these two modalities for the management of chronic intestinal ischemia.

The clinical case of a 46 years old female is reported , admitted with the diagnosis of cerebral transient ischemic attacks, and subjected to an extensive evaluation. Conventional angiography disclosed the diagnosis of dissection and complete occlusion of the right internal carotid artery and a complex angulated lesion, with microaneurisms, of the middle third of the left internal carotid artery, compatible with the diagnosis of arterial fibrodysplasia. Due to the anatomy of the lesion, an endovascular procedure was judged inapropriate and the patient underwent an excisional surgery, followed by replacement with autologous saphenous vein. The operation and the post operative course were uneventfull and the patient was discharged asymptomatic. One month later she was found in pretty good condition and an echodoppler revealed the graft working in excellent condition. The main aspects of this peculiar pathologic entity are subjected to analysis and discussion.

The clinical case of a 44-year old female is reported, whose chief complaints were arterial hypertension and disabling intermittent claudication of both legs. Angiography disclosed a segmental occlusion of the para-renal aorta, associated to an occlusion of superior mesenteric and left renal arteries and a critical stenosis of the right renal artery, probably of degenerative etiology ("coral reef"), but not comproved by pathological studies. The patient underwent a complex revascularization procedure, consisting in the implantation of a bypass graft from the supraceliac aorta to both common femoral arteries through a retropancreatic way, followed by superior mesenteric and both renal arteries revascularization by means of independent PTFE grafts attached to the main bypass graft. Post-operative course was uneventful and blood pressure returned to normal values. An angio-CT control study revealed the integrity of the revascularization procedure and the recovery of the left kidney functionality, whose artery was completely occluded. Te etiology, topography and surgical management of this most demanding situation are subjected to an analysis and discussion.

In this paper, the authors report their experience in the preoperative evaluation of the superficial veins of the lower limbs, using the color-coded Eco-Doppler, aimed at the evaluation of morphofunctional aspects of the veins, allowing an objective and reliable selection of the vein grafts to be used in peripheral arterial revascularization surgery. The advantages and disadvantages of the methodology are analysed and discussed, and they concluded by stating that the method can replace favourably the tradicional surgical exploration, avoiding the frequent unnecessary , unusefull or inconvenient surgical exploration for the veins assessment.

From April 1995 to April 2006, four patients, three male and one female, age range 56 to 68 years (average 62), with a renal transplant, underwent the surgical management of an abdominal aortic aneurysm. As a consequence of the high vulnerability of the transplanted kidney to the ischemia and the occurrence of frequent calcifications of the arterial wall in these patients, the aortic clamping time required for the aneurysm repair is sometimes unpredictable and prolonged ischemia may have deleterious effects on the renal function. To avoid this potential and ominous complication, the authors employed a method for renal protection, consisting in the temporary implantation of an extracorporeal axillary-femoral bypass, removed at the end of the operation. Average aortic clamping time was 36,5 minutes, all patients passed urine during that period of time and no significant alterations were noticed in the daily serum creatinine levels, following the procedure. There was no mortality nor significant morbidity and the implantation and removal of the shunt were uneventfull. The extracorporeal transient axillo-femoral bypass seems to be, according to our experience, an easy and valuable method for protection of the kidney transplant in patients requiring abdominal aortic aneurysm repair.

The present study is aimed at the evaluation of the consequences of the supra-renal aortic clamping in the surgical management of justa-renal aortic aneurysms, based on a personal experience of 44 cases operated on for the last 25 years. The series includes 42 men (95.5%) and 2 women (4.5%) with an average age of 70 years. All patients were operated on transperitonealy and the transection and reconstruction of left renal vein was made in 15 instances. Supra-renal aortic clamping and renal average ischemic time was 13'3 minutes, and no significant functional renal alterations could be noticed, nor the need for hemodialysis support. Contrarily, significant occlusive lesions of the renal arteries (4 instances) or the superior mesenteric artery (1 case) resulted as a mechanical consequences of the supra-renal aortic clamping. Three cases were recognized and repaired intraoperatively, through renal revascularization, one case was not diagnosed, coursed with anuric renal failure and death (mortality 2.2%). Patient with mesenteric artery occlusion developed an acute mesenteric ischemia which was successfully managed conservatively. The author concludes by enhancing the risks of the mechanical consequences arising from the supra-renal aortic clamping, namely renal or mesenteric ischemia. Its prompt recognition and repair seems mandatory, in order to avoid the severe and even fatal consequences that it may cause, raising the morbi-mortality rates that sometimes accompanies the surgical management of justa-renal aortic aneurysms.

An original technique consisting in the revascularization of the midpopliteal artery through a posterior approach is described, in patients with critical ischemia of the lower extremities, utilizing a prosthetic substitute. This technique can be regarded as an alternative to the infragenicular revascularization and it is particularly suited for patients with no autologous material available. Two successful cases operated on with this technique are reported, with a 6 months and 1 year follow up and documented patency of the grafts.

Coexistence of thrombotic occlusion of the terminal aorta with a "pancake" kidney is reported in 63-year old man, diagnosed by CT-scans and selective angiography, to assess the renal circulation and for surgical planning. Surgical exposure was transperitoneal and revascularization was accomplished through a bifurcation Dacron graft from the supraceliac aorta to both femorals, associated to the renal revascularization, by means of PTFE graft from the prosthesis to the renal artery. The success of procedure was later demonstrated by angio-RM, showing both grafts working in excellent condition. According to an extensive bibliographic review, this seems to be the first case reporting the association of a thrombotic occlusion of the terminal aorta to a "pancake" kidney, thus justifying its presentation and divulgation.

The surgical management of aorto-iliac prosthetic infections and infectious aneurysms still remains nowadays as a serious and controversial issue, coursing with high morbi-mortality rates and having not reached completely satisfactory or consensual therapeutic solutions. Among the diverse surgical alternatives, the author enhances the extra-anatomic revascularization and the "in situ" procedures, which are different according to the material employed, including the prosthetic grafts, the arterial and venous autografts and the cryopreserved arterial allografts, describing its indications, advantages and disadvantages and biological behavior of these diverse materials commonly employed in the revascularization surgery in infected fields.

This study was undertaken to assess retrospectively the epidemiology and risk factors for amputation of combined vasculo-orthopaedic traumatic lesions, during a 18-year period, from March 1987 to May 2005, comprising the review of the clinical charts of 149 patients. The series includes a predominance of male patients (84%) with an average age of 34 years. Eighty-five per cent of the lesions resulted from traffic accidents (49% velocipedes, 39% automobiles, 12% trampling), 10% were consequence of falls and 5% resulted from agriculture activities. Orthopaedic lesions include 83 fractures of upper limbs (22 open), 123 of lower limbs (67 open), 21 scapulo-thoracic dissociations and 27 knee dislocations. Vascular lesions include 8 subclavian, 20 axillary, 25 braquial, 10 radial, 6 ulnar and 2 diverse, in the upper limbs; and in lower limbs 4 iliac, 27 femoral, 52 popliteal, 5 tibio-peroneal trunk, 5 anterior tibial, 12 posterior tibial and 12 peroneal. Overall mortality was 3.3% and the amputation rate was 17%. Knee dislocations were responsible for one third of amputations, followed by fractures of bone legs. The association of femur to bone legs fractures from one side and of the knee to bone legs fractures from the other, coursed with high levels of amputation, together with lacerations and crushing of the limbs. The prompt diagnosis of the lesions and the immediate, hierarchic and multidisciplinary approach were considered also as relevant prognostic factors in the management of these most demanding conditions.

The surgical management of aortic prosthesis infection remains an enormous challenge for the vascular surgeon and a critical issue for the patient's well-being and life. Several techniques for its management have been devised and employed over the years, but none of them has been totally satisfactory. Thus new alternatives are needed. We present the clinical case of an infected aortic prosthesis in a 41-year-old man that was complicated by duodenal and ureteral erosion. The autologous superficial femoral artery was used successfully in the treatment of this most demanding situation.