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INTRODUCTION: Due to their relative rarity, the natural history of iliac artery aneurysms and treatment outcomes are poorly understood. However, IAA treatment has evolved, and nowadays, there are a variety of open surgery, endovascular therapy, and hybrid options. This study aimed to compare the outcomes of endovascular treatment versus open surgery for patients with iliac artery aneurysms. METHODS: A systematic review was performed according to the PRISMA statement. An online search was conducted using the Medline database from January 2014 to January 31st, 2023. Only original articles in English or Portuguese, reporting on a minimum of 5 cases, were considered. Studies were included if reporting at least one of the following outcomes: peri-operative complications, length of stay (LS), and 30-day mortality. The software Review Manager 5.4 was used for data analysis. RESULTS: The database search identified 418 articles, of which 413 records were excluded by screening by title/ abstract, and five were read in full and subsequently included. A total of 1837 patients were included. Open surgery was performed in 29.02% (442/1523) and endovascular in 70.58% (1075/1523). More than half of endovascular cases included internal iliac artery preservation techniques (iliac branch design grafts). Patients undergoing endovascular treatment were significantly older (mean difference [MD]: 5.49, 95% confidence interval [CI]: 2.34 to 8.65) and more likely to have congestive heart failure (odd ratio [OR]: 3.74, 95% CI: 1.24-11.27). On the other hand, patients undergoing open surgery were more often smokers (OR: 0.59, 95% CI: 0.42-0.82). The primary outcome - 30-day mortality - was significantly higher for open surgery (OR 0.34, 95% CI 0.19-0.61). Considering other peri-operative outcomes, patients undergoing open surgery presented with longer length of hospital stay (MD: -4.68, 95% CI: -6.43 to -2.92), higher risk of surgical wound infection (OR: 0.31, 95% CI: 0.10- 0.94), renal failure (OR: 0.37, 95% CI: 0.18-0.75) and respiratory infection (OR: 0.19, 95% CI: 0.11-0.33). No significant differences regarding buttock claudication and leg and bowel ischemia were found. The 30-day reintervention rates weren ́t significantly different for open and endovascular surgery (OR 0.83, 95% CI 0.33-2.1). CONCLUSION: Endovascular treatment of iliac artery aneurysms can reduce 30-day mortality, peri-operative complications and length of hospitalization. No differences were identified regarding 30-day reintervention rates. Consequently, endovascular treatment has gained preference over open surgery as the initial approach for patients with suitable anatomy. No other meta-analysis in the literature compares the results of open surgery and endovascular treatment, particularly the results of new endovascular techniques (iliac branch design grafts). Comparing long-term reintervention rates will be essential in the future.

INTRODUCTION: Carotid revascularization is a well-established technique for preventing stroke in patients with significant symptomatic or asymptomatic carotid artery stenosis. Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy (CEA), especially in high-risk surgical patients. However, restenosis after CAS is a potentially severe complication that can impact the medium and long-term success of the procedure and increase the risk of cerebrovascular events. METHODS: Relevant articles on restenosis after carotid stenting were searched in the PubMed database. The selected studies were evaluated for quality and relevance, and the information was summarized to provide an overview of the causes, risk factors, diagnosis, and treatment options for restenosis after CAS due to atherosclerotic carotid artery disease. RESULTS: Restenosis after CAS can occur due to various factors, including thrombosis, intimal hyperplasia, and stent migration. Several risk factors have been identified, such as age, diabetes, hypertension, dyslipidemia, and smoking. Restenosis can be diagnosed with carotid Doppler ultrasound, contrast-enhanced computed tomography, or arteriography. Treatment options include angioplasty with or without rescue stent placement, CEA associated with stent explantation, or medical treatment. CONCLUSION: Restenosis after carotid stenting is a potentially serious complication. It is especially important to identify the risk factors for restenosis and maintain close follow-up with patients after the procedure. The treatment of restenosis should be individualized. Further studies are needed to define the best strategies for preventing and treating restenosis after carotid stenting.

INTRODUCTION: Treatment decision in patients with asymptomatic carotid artery stenosis (ACS) is a matter of current debate with a recent shift towards isolated best medical treatment (BMT) as treatment of choice in most patients. However, poor medical compliance is one of the main constraints to the success of BMT. We hypothesized that more invasive treatment approaches can influence how patients perceive the severity of their illness and hence, treatment compliance. METHODS: A cross-sectional study was performed including patients with asymptomatic >50% carotid artery stenosis (NASCET method) followed-up as outpatients in a Vascular Surgery department from January 2017 to December 2021. Optimal BMT was defined according to the European Society of Vascular Surgery Carotid Atherosclerotic Disease 2023 guidelines. Demographic and risk factor patient data was attained and subsequently a Portuguese translation of the Morisky medication-taking adherence scale (MMAS-4) questionnaire was given to all patients. Several additional questions developed by our group were also applied. RESULTS: A total of 320 patients were identified (186 under BMT alone and 134 submitted to BMT and carotid endarterectomy - CEA). Most patients were male in both groups (75%) and the mean age was similar. Furthermore, patients undergoing CEA presented higher rates of current smoking (51.4% vs 15.9%; p

BACKGROUND: Endovascular mechanical thrombectomy (MT) changed acute ischaemic stroke management and is considered the standard of care for patients with proximal anterior circulation occlusion. MT improves functional independence, without an increase in mortality. Despite its advantages, up to 20% of patients treated with MT do not have successful recanalization, leading to poor clinical outcome. We present a case of an acute ischaemic stroke of the anterior circulation due to occlusion of the common carotid artery successfully submitted to surgical thrombectomy after failed MT. CASE REPORT: A 43-year-old male, with prior history of diabetes, hypertension, dyslipidaemia and heart failure was admitted at the emergency unit with acute bilateral lower limb ischaemia, due to cardioembolic phenomena. He was submitted to bilateral femoral thrombectomy and started endovenous unfractionated heparin. On the fifth postoperative day he developed sudden depression of cognitive status and left side hemiplegia of brachial predominance. Computed tomography angiography revealed an occlusion of brachiocephalic trunk, right subclavian artery and common carotid artery, preserving its branches. MT, performed by interventional neuroradiology, was unsuccessful (no recanalization or clinical improvement). After multidisciplinary discussion, the patient underwent urgent surgical thrombectomy through carotid and transaxillary approaches. Postoperatively, the patient’s mental status and left sided motor function recovered progressively over time. Three months after, patient maintains anticoagulation with warfarin, without neurological sequalae. CONCLUSION: The low rate of recanalization and poor clinical outcome after MT failure underlines the need for alternative rescue approaches. Surgical thrombectomy could represent a lifeline. More studies are needed to corroborate its efficacy in patients with anterior circulation acute ischaemic stroke.

Dysfunction of the arteriovenous fistula for hemodialysis is a challenge for the nephrologist and the vascular surgeon. Although experience is limited, the use of the forearm basilic vein as outflow of the radiocephalic fistula has been considered. We report the case of a 60-year-old male, with cardiovascular comorbidities and a history of ischemic complications induced by the hemodialysis access. Drainage problems were present in the radiocephalic fistula and the forearm basilic vein was used in the vascular access repair. The procedure was successful, and the patient maintains a functional fistula, with secondary patency of 32 months, with no cardiac complications or hand access-induced distal ischaemia syndrome.

INTRODUCTION: The development of a uretero-arterial fistula (UAF) is a rare and life-threatening condition. Owing to its low prevalence, diagnosis and management remains a challenge for both urologists and vascular surgeons and UAF’s high mortality rates may be at least partially attributed to delayed diagnosis. We present a case of UAF in a patient with previous pelvic surgery and indwelling ureter catheter. CASE REPORT: An 82-year-old male presented to the emergency department with haemodynamic instability and gross haematuria that started one hour prior to admission. The laboratory study performed showed an acute anaemia of 7.5g/dl and a contrast enhanced computed tomography revealed a ureteral fistula betweenthe stented left ureter and the common iliac artery. The patient was taken to the angiography suit and a balloon- expandable stent-graft (GORE® VIABAHN® VBX – 11mm diameter and 59mm in length) was deployed. Following the procedure, the haematuria resolved, and the patient had an uneventful post-operative stay. He was discharged two weeks after admission, following a course of large spectrum antibiotic therapy. The patient remained asymptomatic at 3 month follow up. CONCLUSIONS: Uretero-arterial fistula is an uncommon condition but with an increasing prevalence, at least in part due to improved pelvic cancer treatment.

INTRODUÇÃO: A doença quística adventicial é uma patologia que afeta principalmente o leito arterial, porém, em raros casos pode envolver o sistema venoso. O objetivo desta revisão foi padronizar a marcha diagnóstica, tratamento e vigilância de doentes com suspeita de doença quística adventicial venosa. MÉTODO: Para cumprir os objetivos supracitados, uma revisão narrativa sumarizando os principais achados da literatura usando as bases de dados PUBMED e EMBASE foi feita. RESULTADOS: Um total de 33 artigos foram selecionados traduzindo-se num total de 41 casos de vACD. Após analise dos dados, foi possível concluir que o vaso mais frequentemente atingido é a veia femoral comum, e a maior parte dos doentes refere edema unilateral de membro com tempo de evolução variável. Quando perante um doente com edema unilateral de membro, em que a TVP foi excluída, é necessário proceder a outros meios complementares de diagnóstico de forma a confirmar, ou excluir, a vACD.

As questões éticas da especialidade constituíram sempre uma preocupação da Sociedade Portuguesa Angiologia e Cirurgia Vascular traduzida, inclusivamente, na formação de um Núcleo de Ética Profissional. A necessidade de conferir aos médicos o consentimento para as intervenções após o devido esclarecimento é uma aquisição relativamente recente. Por exemplo, os gregos achavam que a participação do doente na tomada de decisões médicas prejudicaria a relação de confiança no médico. De facto, o relacionamento médico-doente foi sendo, ao longo dos séculos, o suporte das intervenções terapêuticas uma vez que o seu alcance era limitado e a sua validação, tal como hoje a concebemos, era inexistente. Este padrão foi-se alterando progressivamente após a revolução científica do século XVII com o desenvolvimento do que viriam a ser os métodos científico e experimental modernos. Já no decurso da segunda metade do século XX surge a chamada medicina baseada na evidência com a definição de resultados clínicos testados pela moderna metodologia científica. Este pensamento e forma de agir tornaram-se requisitos mais rigorosos na prestação de cuidados de saúde nos últimos anos. Por outro lado, valoriza-se, na atualidade, a participação dos doentes nas decisões após a devida partilha de informação conferindo o que se convencionou chamar de "consentimento informado". A autodeterminação, isto é, o direito de todo cidadão decidir ou determinar o curso da sua vida é, pois, um direito previsto na lei portuguesa. A autodeterminação no contexto dos cuidados de saúde significa que todo o adulto capaz, tem a liberdade de consentir ou recusar um tratamento médico mesmo quando os profissionais de saúde possam acreditar que ele é benéfico e necessário. Todos estes aspetos são de importância cardinal na nossa especialidade a qual envolve frequentemente questões de risco vital, de perda de função ou de modificação da imagem corporal. Conseguir que os doentes sejam adequadamente informados e tomem decisões partilhadas de forma consciente é um desafio para todos os médicos em geral e para os cirurgiões em particular. Deste modo, o consentimento informado é um processo colaborativo que requer um alto grau de maturidade emocional por parte dos profissionais de saúde os quais devem estar dispostos a explicar o que é conhecido e admitir o que não é. Tal implica que seja utilizado o tempo e o esforço necessários para que os doentes entendam os tratamentos propostos. Cada doente cirúrgico é único; cada um tem a sua própria personalidade, educação, condição emocional e social bem como a capacidade de compreender as informações apresentadas. Alguns doentes têm várias questões, informação prévia com diversos graus de qualidade, e exigem saber cada detalhe do tratamento proposto. Outros, porém, contentam-se com a informação básica e outros há que confiam sem questionar no que lhes é proposto. A todos devemos esclarecer e em especial informar do risco e benefício das intervenções. Para ajudar a lidar com estas questões, foram introduzidos os formulários de consentimento informado que proporcionam informação sobre as intervenções propostas, os benefícios esperados e os riscos inerentes numa linguagem e terminologia que possa ser entendida pela generalidade das pessoas. É importante também a leitura dos formulários uma vez que a informação escrita promove mais facilmente a retenção e compreensão dos conceitos-chave e muitas vezes é superior à explicação verbal fornecida pelos médicos à cabeceira ou em consultório onde os níveis de ansiedade dos doentes são elevados. Para além dos objetivos éticos, há outras dimensões dos "consentimentos informados" a ter em conta. Em primeiro lugar, o propósito médico-legal sendo atualmente indispensáveis às questões deste foro e atestando que a autorização respetiva foi adequadamente obtida. Em segundo lugar, a obtenção do consentimento é um fator de Qualidade do processo assistencial e a respetiva obtenção e preenchimento do formulário um requisito indispensável nas auditorias de acreditação de qualidade das instituições modernas. Finalmente, deve considerar-se que o esclarecimento do doente vascular e a obtenção do consentimento para intervenção devem ser efetuados pelo cirurgião em ambiente de consulta ou de gabinete hospitalar com tranquilidade e disponibilidade para a cabal explicação e esclarecimento de dúvidas. Refletindo sobre estas questões, e à imagem do que já acontece com outras Sociedades, a Direção atual da SPACV iniciou um processo de tentativa de padronização dos formulários de consentimento informado nas múltiplas intervenções da especialidade de Angiologia e Cirurgia Vascular procurando que sejam completos e exaustivos. Acreditamos, no entanto, que este é apenas o início de um projeto havendo a perspetiva futura de revisão e alargamento a outras áreas com uma lista mais completa e atualizada. Este será, portanto, o início da jornada esperando que possa ser útil aos Serviços de Angiologia e Cirurgia Vascular portugueses.

A 46-year-old male underwent previous endovascular repair for thoracic aortic coarctaction in 2017. Five years later he underwent an angio-computed tomography that revealed a 60mm x 53mm asymptomatic saccular costocervical artery aneurysm (A, yellow arrow). An angiography was subsequently performed, and selective catheterization was possible with a triaxial microcatheter system (B, circle defining the aneurysm extension). Costocervical trunk aneurysms are very rare vascular abnormalities and usually are associated with congenital heart defects or connective tissue disorders. The case is scheduled for discussion in a multidisciplinary meeting with cardiothoracic surgery for elaboration of a treatment strategy.

Introduction: Mycobacterium tuberculosis (MT) is a rare cause of mycotic aneurysms. Diagnosis and management of tuberculous arterial infection is challenging. A case of a patient diagnosed and successfully treated for an aortic pseudoaneurysm caused by MT infection is reported. Report: An 83 year old man was admitted with recurrent back pain over five months associated with constitutional symptoms. Computed tomography angiography (CTA) revealed a psoas collection associated with terminal aorta and proximal left common iliac artery posterolateral wall ulceration. Percutaneous drainage was performed and both the acid fast bacillus test and the molecular test for MT DNA were positive. The patient started on anti-tuberculous treatment, showing an excellent response. Three month CTA revealed arterial ulceration stability. However, the six month CTA revealed evolution to an asymptomatic 40 mm pseudoaneurysm. He was submitted to open repair with an aorto-bi-iliac interposition silver acetate/triclosan collagen coated polyester graft. The post-operative course was uneventful. Discussion: Increased awareness and pursuit of an histological and microbiological diagnosis along with close surveillance allow anticipation of complications that can develop without any warning symptoms, as reported in this case. Agent identification and a combination of prolonged anti-tuberculous drug therapy with extensive excision of the infected field along with aortic reconstruction contributed to a good outcome.

OBJECTIVE: Venous stenting of iliocaval obstructions has become a more frequent procedure over the last two decades. In-stent stenosis and thrombosis are potential complications, causing one of the main causes of symptoms recurrence and impacting quality of life. The aim of this review is to report on the impact of venous stent patency loss, as well on risk factors and management. METHODS: A systematic review was conducted according to the recommendations of the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. RESULTS: After a literature search, 12 studies (two prospective and 10 retrospective studies) were included in the analysis. A total of 1981 patients (34.1% male) and 2388 limbs (63.6% left side) were assessed. Mean age was 43.5 years (range 16-99). Indication for stenting included deep venous thrombosis (DVT) (4%), post-thrombotic syndrome (PTS) (18.8%) and non-thrombotic iliac vein lesions (NIVLs) (77.2%). Regarding treatment, most patients were submitted to angioplasty and stenting only (87%). Associated catheter directed thrombolysis or mechanical thrombectomy was performed when indicated (8.4%), and in the remaining an AVF/endophlebetomy was performed (4.6%). Primary, primary assisted and secondary patency rates at one year ranged from 68-100%, 79-90% and 85.8-100%, respectively. Reported anticoagulation duration after stenting ranged from 1-12 months. In one study involving only patients treated for NIVLs, no anticoagulation was prescribed, and antithrombotic therapy was continued for three months. Follow-up strategies included clinical and imagiological control with a mean follow-up of 19.7 months. Post-procedural stent re-stenosis was reported in 121 limbs (5.1%) and stent occlusion in 81 limbs (3.4%); the latter was distributed as follows: 11.1% after DVT, 77.8% PTS and 11.1% NIVLs. A total of 186 re-interventions were performed in symptomatic patients. The prognostic factor most consistently associated with stent failure was thrombotic inflow veins. Other reported factors were incomplete thrombolysis and age younger than 40 years. Stent placement below the inguinal ligament, type of stent and anticoagulation regimen do not seem to affect stent patency. CONCLUSION: Regarding venous lesions of the lower limbs, a selective approach and planning should focus on identification of risk factors for stent failure. It is noteworthy that most stent occlusions occur in post-thrombotic limbs. Stent failure continued after 6 months, emphasizing the importance of an extended surveillance especially on these patients.

INTRODUCTION: Aortoiliac occlusive disease (AIOD) can be treated using either open surgical revascularization (OSR) or endovascular revascularization (ER). METHODS: A Medline search was performed in order to identify articles focused on the treatment of aortoiliac occlusive disease. Additional articles of scientific interest for the purpose of this non-systematic review were included by cross-referencing. RESULTS: There are a few articles reporting direct results between both techniques based on retrospective or prospective single center or multicenter studies. In the majority of studies, primary patency is generally better for surgery in comparison to ER, but at a cost of more postoperative complications, with higher rates of respiratory failure and wound infection in the open group. On the other hand, endovascular recanalization is related to higher rates of limb ischemia/thrombosis, renal dysfunction and reinterventions. In the presence of femoral artery calcified disease, the hybrid approach should be considered. CONCLUSIONS: Endovascular treatment is a suitable alternative for extensive AIOD and can be accomplished in a less invasive manner, with most midterm outcomes comparable with open reconstruction. Surgery should be reserved for multilevel calcified disease and after endovascular failure.

INTRODUCTION: Inferior vena cava agenesis is one of the most uncommon anomalies of this vessel, with an estimated prevalence of 0.0005–1% in the general population. However, around 5% of the patients younger than 30 years with a diagnosis of deep vein thrombosis have this anomaly. METHODS AND MATERIAL: Report of two clinical cases of inferior vena cava agenesis with different clinical presentations. CLINICAL CASE 1: A 40-year-old man was admitted with a 3 days history of unilateral lower limb swelling and pain, gradually progressing to the inability to walk. On physical examination he had swelling, bruising and tenderness involving leg and thigh and prominent engorged superficial abdominal collateral veins. Venous Doppler Ultrasound showed left deep venous thrombosis extending from popliteal vein to common iliac vein. A computed tomography angiogram showed agenesis of the infrarenal vena cava and patent renal veins draining in to the azygous system and hemiazygous systems. The patient as discharged with rivaroxaban and compression stockings. At 2 months follow up he was asymptomatic and still anticoagulated. CLINICAL CASE 2: A 35 year- old woman, with a previous history of recurrent lower limb varicose veins surgery and left internal malleolar ulcer at 30 years presented at medical department 3 years later with complains of ulcer recurrence. A computed tomography angiogram revealed an absent infrahepatic vena cava, prominently dilated azygos and hemiazygos veins with enlarged retroperitoneal collaterals. The patient initiated dressing care with oxide zinc and oral rivaroxaban. DISCUSSION/CONCLUSION: The majority of cases remain asymptomatic. However, when symptomatic, the majority present as proximal DVT involving the iliac and femoral veins. CT or MRI should be the imagiological methods used to diagnose this anomaly. No clear consensus has been reached on therapeutic strategy, other than long-term antico- agulation and elastic stockings.

Introduction: Involvement of the ascending/aortic arch in the thoracic aorta pathology can preclude thoracic endovas- cular aortic repair (TEVAR) due to the absence of an adequate proximal landing zone. Hybrid interventions combining ascending/aortic arch replacement with TEVAR of the descending thoracic aorta (DTA) are associated with good outcomes. Despite the existence of dedicated devices (E-vita®, Thoraflex®), they may not be available in good time in emergent cases that might require inventive solutions, like the one we present. Case Report: A 53-year-old hypertensive, active smoker male was admitted due to a non-A-non-B acute aortic dissection, complicated with a contained rupture at the aortic isthmus and a left haemothorax. Considering the absence of a secure proximal landing zone we decided on an aortic arch replacement and frozen stented elephant trunk using off-the-shelf devices. Debranching of the innominate and left common carotid arteries was performed with a 16×8mm bifurcated graft. The aortic arch replacement was performed with a 28 mm Dacron, under hypothermic circulatory arrest. A 30×30×157mm stent graft was anterogradely advanced to the DTA, under direct vision, with its proximal part parked at the level of the Dacron anastomosis. The proximal arch anastomosis was completed at the level of the sinotubular junction. Completion angiography revealed appropriately reconstructed aortic arch, successful exclusion of the entry tear and rupture site, as well as adequate renal and visceral perfusion. The patient had an uneventful postoperative course, being discharged on postoperative day 23. Control CTA demonstrated successful arch reconstruction, true lumen expansion and no signs of complications. Conclusion: This hybrid approach with off-the-shelf devices was successful and avoided the cumulative morbidity of an additional left thoracotomy as the technical difficulty of a full open surgery in this setting. In the absence of readily available dedicated devices, hybrid techniques will undoubtedly play a role in the treatment of acute aortic syndromes. The existence of an “Aortic Team” available to evaluate, decide and combine the expertise of cardiothoracic and vascular surgery was essential in this case.

Introduction: Traumatic popliteal artery injury is a rare clinical entity, but it is the most common cause of amputation in injured extremities. The aim of this study was to report the incidence of popliteal artery injury after knee trauma and report therapeutic management and results. Methods and material: ICD-10/ ICD-9 codes (S85.0/904.41; S83.1/836.5; S83.4; S83.5; S72,4/821.2; S82,1/823.0) were used to identify patients admitted with popliteal artery injury and/or knee trauma at our tertiary center from 1/1/2010 to 31/5/2021. A statistical analysis was realized using the SPSS program version27. Results: At our center from 1/1/2010 to 31/5/2021 535 patients were admitted due to knee trauma (28 with knee dislocation and 507 with fracture close to the knee) and 9 patients with popliteal artery injury (seven males, median age 39.0 years) The mechanism of PAI was motorcycle (4) or bicycle (1) or work (1) accidents (4); one fall, one running over and one iatrogenic injury. The incidence of PAI after knee trauma was 1.5%, after knee dislocation 17.9% and 0.8% after fracture close to the knee. Regarding associated injuries, four patients had severe soft tissue damage, two had venous injuries and two had nerve disruptions. The median ischemic time was 6.0 hours and mean vascular surgical time was 2.4 hours. Regarding vascular treatment, eight patients were submitted to bypass surgery and one was treated conservatively. Therapeutic fasciotomies were performed in three patients. No primary amputations were performed. A secondary major amputation was performed in one patient. The mean hospital length of stay was 24.9 days and mortality was 0%. Three patients returned to their normal activity level and six were limited in their daily activity. Discussion/Conclusion: The risk of PAI after knee dislocation is higher than after knee fracture (17,9% vs 0.8% in our study, and 3,4-8,2% vs 0,2 % in Swedish registration), so orthopedic surgeons must be aware of that increased risk, to avoid missing this diagnosis. The amputation rate in our serie was lesser than the Swedish registration and the United States National Trauma Data Bank (11% vs 28% and 14,5%, respectively). However, it ́s still a high rate considering that it mostly affects a young and active population and only 33.3% patients return to a normal life. A multidisciplinary approach is essential to decrease ischemia time and to promote a holistic treatment.

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

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

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

Adventitial cystic disease (ACD) is a rare condition. It affects mostly the popliteal artery, with few cases reported affecting the radial artery. This condition is characterized by accumulation of mucinous content at the adventitious layer.

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

Turner syndrome (TS) is a disorder of female development with cardinal features of short stature and congenital cardiovascular defects. Congenital or acquired cardiological problems occur commonly in TS, being potentially progressive and responsible for severe complications, such as aortic dissection in young women. Accordingly, we describe a case of type A aortic dissection occurring in a woman with TS, highlighting the need to prioritize investigation in those patients to avoid a catastrophic aortic scenario.

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

Endovascular aneurysm sealing (EVAS) using the Nellix system is an alternative method for abdominal aortic aneurysm (AAA) repair. Type 1 endoleaks are not an uncommon complication following conventional endovascular aortic aneurysm repair (EVAR), occurring in up to 10 % of cases. The incidence of these endoleaks following Nellix EVAS was determined to be up to 3,1% in short-term follow-up. Early detection and classification of this issue is crucial to avoid the potential of sac rupture, previously described. As so, we report a successful endovascular treatment of type 1a endoleak, twenty-four months after a Nellix EVAS implantation. An 82 year-old male underwent a Nellix endovascular repair for a 55 mm infra-renal aortic aneurysm in 2014. Final angiography showed successful aneurysm exclusion with no endoleaks. Regular follow-up using computed tomography angiography (CTA) showed a relatively satisfying good stentgraft positioning, no signs of endoleaks and shrinkage of the aneurysm sac. CTA of 2016 showed a new type 1a endoleak associated wit a significant growth of the aneurysm sac. The authors performed prompt embolization of the endoleak with 0,018” detachable coils and Onyx 34. Final angiography showed patency of the endografts with satisfactory exclusion of the endoleak. The incidence and significance of type 1 endoleaks following Nellix EVAS was previously studied in literature, with some cases reported and the natural history of untreated type 1 endoleak after EVAS might lead to sac rupture and death. The embolization of the endoleak with coils and Onyx appears to be a safe and effective management choice to achieve technical and clinical success in the treatment of these cases.

Introduction: Anemia is associated with increased adverse outcomes during the early postoperative period because of high physiologic stress and increased cardiac demand. The aim of this study was to assess the relationship between pre-operative anemia and morbi-mortality outcomes in patients undergoing elective carotid endarterectomy (CEA), open aortic repair (OAR) or endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) and infrainguinal bypass surgery in chronic limb-threatening ischemia. Methods: Retrospective analysis of all elective patients between 2016-2018, who underwent: CEA, OAR, EVAR and infrainguinal bypass surgery in chronic limb-threatening ischemia. Emergency procedures and transfusion of more than 4 units of red blood cells (RBC) were excluded. Hemoglobin levels were categorized according to the WHO definition for anemia: severe (< 8 g/dL), moderate (8-10.9 g/dL), mild (11-11.9 g/dL in women and 11-12.9 g/dL in men) and no anemia (≥12 g/dL in women and ≥13 g/dL in men). Results: Our study population comprised 257 patients, of which 74 (28%) underwent EVAR, 26 (10.1%) OAR, 67 (26.1%) CEA and 90 (35%) infrainguinal bypass. Pre-operative anemia was identified in 37.4% (n = 96) of the patients. Of those, 67.7% (n = 65) had mild anemia and 32.3% (n = 31) had moderate-severe anemia. Anemic patients have longer length of stay when compared with non-anemic patients (16.61±16.5; 7.68±4.92, respectively) (p = 0.022) and also longer stay in the post-operative care unite in comparison with patients with hemoglobin within the normal range (average 2.08 days ± 1.12; 1.77 days ± 1.01, respectively) (p

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Introduction: Over the past decade, endovascular treatment (EVT) is taking over visceral arterial aneurysms treatment considering its effectiveness, safety and minimal invasiveness. Methods: We retrospectively evaluated our department experience in visceral arterial aneurysms endovascular approach from 2009 to 2019. Results: From 2009 to 2019, nineteen visceral artery aneurysms were submitted to EVT (mean age 62,5 years, 53% women). The addressed arterial segments were: the splenic artery (52%, n=10) followed by the renal artery (21%, n = 4), the hepatic artery (11%, n = 2), the superior mesenteric artery (11%, n = 2) and the celiac arrtery (5%, n = 1). Average diameter was 26,9 ± 5,4 mm [range 21–39 mm]. The majority were asymptomatic incidental findings (74%). Concomitant aneurysms were found in 3 patients (15,8%). EVT included: stent-graft exclusion (n = 9), aneurysm-sac coil embolization (n = 6), stent-assisted coil embolization (n=2) and segmental artery exclusion (n=2). Median radiological follow-up was 46,8 months [range 1,1–128 months]. Early SMA occlusion was reported in one case after stent-assisted coil embolization, however without ischemic symptoms. End-organ loss was reported in one case (renal artery coil embolization, without overall renal function worsening). Conclusion: Nowadays, endovascular approach is the first-line intervention for most visceral arterial aneurysms. Although still limited, the reported results are favourable and are in line with the current literature.

Introduction: Endovascular techniques have been revolutionizing the revascularization of patients with chronic limb threatening ischemia (CLTI), showing consistently high limb salvage rates. However, endovascular recanalization of infrapopliteal occlusive disease can be technically demanding and the failure rate for these types of lesions is about 20%. In that case, an alternative vascular access may be required. We report our experience concerning CLTI patients who underwent retrograde access and recanalization of chronic occlusions after failure of anterograde attempts. Methods: Retrospective institutional review of consecutive patients requiring retrograde punctures to obtain endovascular revascularization (2013–2018) – 51 limbs in 50 patients. The primary outcome was to evaluate the technical success and the limb salvage - major-amputation free survival. The secondary outcomes were the rate of major and minor amputation, the global survival of this population and the characterization of the population and the endovascular procedures performed. Results and conclusion: The technical success was achieved in 76,5% of the procedures. The major amputation free-survival rate was 81,4% at 6 months. The femoro-popliteal and distal territories were concomitantly treated in 63,3% of the procedures and isolated distal territory was treated in 32,7%. Femoral approach was always initially performed (90,2% anterograde). Direct revascularization according to the angiosome concept was obtained in 64,6% of the cases. Anterior tibial artery was punctured in 33,3% of cases followed by pedal artery (27,5%), peroneal artery (19,6%), common plantar artery (7,8%), posterial tibial artery above the ankle (3,9%), supra-articular popliteal artery (3,9%), lateral plantar artery (2%) and metatarsal artery (2%). Percutaneous transluminal angioplasty (PTA) was performed in 69,4% of the procedures (2% with Drug Elluting Balloons) and PTA and stenting in 28,6%. During follow-up 19,4% of patients were submitted to major amputation and 29,4% to minor amputation. The rate of healing at 6 months was 43,3%. The results of the retrograde access and recanalization of chronic occlusions are comparable to data reported in the literature, confirming it as a valuable alternative. As so, the retrograde access approach for revascularization of CLTI patients appears to be a safe and effective alternative that expands revascularization options after the failure of a conventional endovascular anterograde approach, allowing the salvaging a greater number of limbs, particularly in patients with significant co-morbidities.

Introdução: A maioria dos pseudoaneurismas (PSA) da artéria femoral profunda apresentam-se de forma assintomática ou através da presença de uma massa pulsátil. Clinicamente variáveis poderão desenvolver sintomas por compressão das estruturas adjacentes ou mesmo levar a choque hemorrágico, em caso de rutura. Relativamente à orientação terapêutica, quando sintomáticos deverão ser corrigidos. Contudo, nos casos assintomáticos a melhor atitude permanece discutível, uma vez que a maioria dos pequenos PSA, com diâmetro inferior a 20-30mm, acabam por trombosar dentro de quatro semanas, aceitando-se assim uma atitude expectante e reservando a correção no caso de apresentarem crescimento, não trombosarem ou desenvolverem clínica/sintomatologia. Materiais e métodos: Os autores apresentam dois casos de PSA de ramos da artéria femoral profunda (AFP) no contexto de procedimentos ortopédicos. Caso clínico I — Doente do sexo feminino, 83 anos, admitida no Serviço de urgência por trauma a nível do fémur e côndilo lateral esquerdo. Submetida a osteossíntese trocantérica, complicada no pós-operatório de trombose venosa profunda (femoro-ilíaca). Teve alta hipocoagulada sendo readmitida dois meses após com dor a nível da coxa tendo sido diagnosticado PSA da AFP. Realizou-se embolização com coils: um 2D Helical-35® de 3x52mm e um VortXTM Diamond® de 3x23mm. Caso clínico II — Doente do sexo feminino, 70 anos, admitida eletivamente para realização de prótese total da anca direita. No pós-operatório imediato apresentou hematoma da coxa associada a hipotensão persistente e queda de 2g/dL de hemoglobina, sem reposta clínica a medidas conservadoras. Realizado estudo com diagnóstico de PSA da AFP tendo sido tratado com embolização com dois coils Tornado Cook® de 2-5x50mm. Discussão: O diagnóstico de PSA da AFP é difícil dada a sua raridade (incidência descrita de 2% para feridas arteriais periféricas(1)), sendo mais frequentes após procedimentos ortopédicos e vasculares(2). Os procedimentos endovasculares na abordagem dos PSA permitem uma precisa localização do ponto de hemorragia e a sua correção de forma minimamente invasiva. A taxa de sucesso técnico aproxima-se de 100% quando as características anatómicas permitam a sua realização.

Treatment of aortic pathologies involving the aortic arch represents a great challenge for vascular surgeons. Endografting techniques, comparing to open surgery, are less invasive approaches. However, an adequate proximal landing zone remains a challenge and, regarding this issue, parallel graft techniques represent a viable endovascular treatment option in patients with challenging aortic arch pathology by extending the proximal landing zone while maintaining aortic side branches perfusion. Parallel graft techniques required a thorough planning and the clinical and imagiological follow-up are mandatory. They appear to be a safe and minimally invasive alternative techniques in selected fragile patients. The authors report three clinical cases that required the use for parallel grafts to treat complex pathology of aortic arch.

Introduction: Type B aortic intramural hematoma (B-IMH) has a complex and variable natural history: it can remain stable and resolve spontaneously or progress to dissection, aneurysm, ulcer or even rupture. The possibility of disease progression, frequently with mild or no symptomatology, poses a significant treatment dilemma. Clinical Case: We report a case of a 60 year-old-female diagnosed with an acute B-IMH, initially treated medically. However, 1-month control CTA revealed disease progression (increased B-IMH thickness and evolution to an ulcer-like-projection with 20 mm diameter and 11 mm depth). She was submitted to a left carotid-subclavian bypass followed by TEVAR and left-subclavian ostial embolization. During follow-up (5 months) patient remain asymptomatic, demonstrating favorable aortic remodeling. Conclusion: Type B-IMH is a dynamic pathology. From presentation to late follow-up, patients remain at high risk for abrupt catastrophic complications. As reported, TEVAR seems to be a safe and effective approach in the event of unfavorable evolution.

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. Keywords: Kawasaki disease, Brachial artery aneurysm, Superficial brachioulnoradial artery, Brachial–antebrachial arterial pattern variations

Introduction: Kawasaki Disease (KD) is a self-limited, unknown-cause febrile vasculitis that predominantly addresses medium-sized arteries and most patients are under 5-years-old. In addition to life-threatening coronary artery involvement, aneurysms may develop in almost any medium-sized vessel, however systemic artery aneurysms (SAA) are described in only 2% of cases. The objective of this study was to identify cases of KD associated SAA and to analyze their frequency, anatomical distribution, treatment and outcomes. Methods: systematic literature review, performed using MEDLINE database. Results: Literature review retrieved a total of 9 reports corresponding to 38 patients and a total of 134 KD-SAA. The most affected arteries were the brachial artery (29.8%), the internal iliac artery (18,6%), the common iliac artery (16,4%) and the subclavian artery (11,2%) with bilateral involvement being a common feature. History of concomitant coronary involvement was present in almost every patients. Only 5 SAA (3,7%) required intervention. Medical therapy was associated with SAA regression in approximately half of the patients, with better results when initiated promptly after diagnosis. Worst outcomes were found in younger patients, showing higher rates of morbimortality. The underlying coronary sequelae dictated the prognosis. Conclusions: Considering their rarity, only multicenter collaboration and literature research can provide more insight about KD-SAA treatment and outcomes, defining the potential role of KD as a primary cause of late vascular lesion. Late presentation KD-SAA may present some diagnostic and therapeutic challenges in view of a more likely need for intervention once the benefit of medical treatment has been outweighed.

Introduction: Infectious celiac artery aneurysm (ICAA) is an extremely rare diagnosis, and only a few cases have been reported in the literature to date. We aimed to review this rare clinical entity, focusing on diagnosis and treatment strategies. Methods: A systematic literature review was performed using MEDLINE database according to the PRISMA guidelines. Results: A total of 11 cases of ICAA were identified in the literature to date. Treatment options were extremely variable and included both open and endovascular surgery. Open surgery included aneurysm ligation or aneurysmectomy with or without revascularization with bypass. Endovascular options are increasingly used and include embolization of the aneurysm and collaterals, stentgraft exclusion of the ICAA and in one case report, Chimney technique was used to exclude the aneurysm maintaining celiac trunk patency. Unsurprisingly, antibiotherapy was consistently an essential part of the treatment strategy. Conclusions: Due to the rarity of ICAA, natural history is unclear. Still, surgical treatment is unanimous regardless of aneurysm size. Short term results of endovascular treatment are encouraging, but endovascular implantation of prosthetic material in an infected environment is a concern, so lifelong antibiotherapy and close monitoring are advisable.

Introduction: Splenic artery pseudoaneurysms (SAP) represent a rare clinical entity typically caused by sequelae of pancreatitis or abdominal trauma. Unprovoked, spontaneous SAP are exceedingly rare, with only two other case reports in the literature up to date. In this paper we pretend to present a case of a ruptured idiopathic SAP successfully treated endovascularly. Methods: Relevant medical data were collected from hospital database. Results: The patient is a 75-year-old male with no past history of pancreatitis, abdominal trauma or abdominal surgery. He was admitted in the emergency department with thoracalgia with interscapular irradiation with few hours of evolution. He referred food intolerance with vomiting for approximately 7 days. In the diagnostic work-up, a computed tomography angiogram (CTA) was performed and revealed a previously unknown voluminous hiatus hernia and a ruptured 25 mm SAP with active bleeding into a 104x98 mm perigastric collection in the left hypochondrium extending to the thorax, a 34 mm peri-pancreatic and a 35 mm pararenal collection. Urgent treatment was planned in the angiography suite, and after selective catheterization of the splenic artery, pseudoaneurysm origin was identified and embolized both proximally and distally with coils. The end result angiogram was apparently successful. CTA was repeated and revealed complete embolization of the pseudoaneurysm, with no evidence of bleeding. Peri-aneurysmatic collections remained unchanged in size and splenic infarction was evident in 50% of parenchyma. He was discharged 10 days after the initial procedure. Conclusions: Endovascular surgery seems a good option for SAP even in rupture, with good short-term results. In this case, it was admitted that it could be a bridge to open surgery with aneurysmectomy and splenectomy. However, given the good clinical recovery post-embolization, no further surgery was considered. Nowadays there is little consensus on follow-up, and long term results are largely unknown.

Introduction: Currently, the prevalence of Diabetes Mellitus (DM) in Portugal is 13,3% in adult population. Patients with DM have a 15-25% lifetime risk of developing a foot ulcer. Additionally, diabetic angiopathy is a unique vascular disease that has predilection for below-the-knee arteries. Meanwhile, endovascular techniques have been revolutionizing the revascularization of neuroischemic diabetic foot (NIDF) patients, showing consistently higher limb salvage rates. The survival of NIDF patients reaches 50% at 5 years after revascularization and limb salvage, but decreases to 50% at 2 years after a major amputation. With this study, the authors intend to describe their experience on endovascular revascularization for the treatment of NIDF patients. Methods: Retrospective institutional review of consecutive patients requiring endodistal revascularization (January 2010 - December 2017) - 464 limbs in 326 patients. We evaluated demographics and co-morbidities data and performed statistic analysis to determine factors and outcomes as limb salvage, major and minor amputation rates. The primary outcome was to evaluate the technical success, the limb salvage, the rate of major and minor amputation and the global survival of this population. The secondary outcomes were to characterize the population, the endovascular procedures performed and the evolution over the last years. Operative reports were reviewed to analyze the endovascular procedures and techniques. Results and conclusions: The technical success was achieved in 85% of the procedures. The iliac sector was only treated in 0,7% of the procedures and femoro-popliteal sector in 63,2%. Antegrade femoral approach, was obtained in 91, 3% of the procedures. A complementary retrograde distal approach was performed in 7,6% of procedures. Direct angiossomic revascularization was obtained in 60,9% of the cases. In the femoral and popliteal arteries, PTA was performed in 56,3% of the procedures and recanalization, PTA and stenting in 42,4%. During FU, 14,1% of patients was submitted to major amputation and 36,4% to minor amputation. The major amputation free-survival rate was 80,1% at 12 mo and the rate of healing at 12 mo was 63,2%. The 12 mo global survival was 79,8%. Direct angiossomic revascularization (p=0,014) and the number of tibial arteries recanalized (p=0,01) were both associated with a higher limb salvage rate and a faster healing of the ulcer. In the opposite side, there was an association between the increasing of renal dysfunction and poor healing (p=0,04). The endovascular reintervention rate was 20,4%. The results of the author’s study on endodistal revascularization, highlights the need to prioritize investigation and revascularization in NIDF patients to improve the outcome of foot ulcer, giving the possibility of salvaging a greater number of limbs.

Introduction: Acute carotid stent thrombosis (ACST), defined according to the Academic Research Consortium as occurring in the first 24 hours after the procedure, is described as an exceedingly rare complication of CAS but it can lead to catastrophic neurologic consequences. The European Society for Vascular Surgery updated guidelines state thrombolysis and intravenous abciximab may be effective, but provide no specific recommendations. Given the lack of data concerning the optimal management, the purpose of this review was to evaluate the current literature and report on ACST aetiology and management strategies. Methods: Literature review was performed in the MEDLINE database. Results: No data on ACST is evident in large randomized controlled trials. ACST incidence rate ranges from 0.5-0.8%, reaching as high as 33% in acute-setting. Considering aetiology, it can be subdivided into 2 main groups: systemic causes and technical complications. In the first antiplatelet non-compliance/resistance were the most reported while in the latter carotid artery dissection and plaque protrusion were the most common causes. Also, dual layer stents were associated with greater risk for ACST There are three main approaches for ACST: pharmacologic, endovascular and surgical. Pharmacologic management included anticoagulation, thrombolysis and facilitated thrombolysis. A role for thrombolysis and facilitated thrombolysis is still to be determined. Endovascular treatment was the most common approach to intraprocedural ACST: mechanical thrombectomy with or without concomitant facilitated thrombolysis. Surgical options included carotid endarterectomy with stent explantation which was a bail-out after failed endovascular treatment with excellent recanalization rates. In asymptomatic ACST conservative management with anticoagulation was unanimous. Discussion: As a conclusion, ACST is probably an underestimated clinical entity associated with multiple risk factors. Decision on the best approach depends if ACST occurs intraprocedural or afterwards, on the development of neurologic status deterioration and on centre´s experience. Additional studies must be undertaken to better define optimal management.

Introduction: Unfractionated heparin (UFH) has been used for decades to prevent thrombotic events during vascular surgery. Although it is known that UFH has a complex and nonlinear pharmacokinetics, with great individual variability, anticoagulation monitorization in vascular surgery is not routine and a standard empirical dose is often used. Activated clotting time (ACT) has been shown to be a simple, reliable and inexpensive way to monitor UFH anticoagulant effect, being routinely used during cardiac surgery. However, heparinisation remains a dilemma in vascular surgery and few studies emphasized the role of anticoagulation monitoring in this setting. Objectives: To investigate whether a fixed heparin dose of 5000 IU in arterial vascular surgery results in adequate and homogeneous heparinisation in all patients. Secondary endpoints: to identify preoperative factors for heparin response, intraoperative events and outcomes. Methods: This observational prospective pilot study included 30 consecutive patients undergoing arterial vascular surgery. ACT monitoring was performed before clamping and at 3, 30 and 60 minutes after 5000 IU UFH bolus. Preoperative and intraoperative data were also accessed. A target ACT of ≥ 200 s was set, taking in account of the lowest ACT value admitted by vascular surgery recommendations. Results: The average ACT value increased to 210.20 ± 28.82 s (1.61 ± 0.25 times vs baseline) 3 minutes after bolus, then declined to 191.60 ± 21.86 s and 173.4 ± 21.37 s after 30 and 60 minutes, respectively. Three minutes after UFH bolus, 53% patients had ACT ≥ 200 s, decreasing to one third and 7% at 30 and 60 minutes, respectively. Even when weight-based, a correlation between heparin dose per kilogram and ACT change was not found (r = 0.187; p = 0.322). There was also no correlation between ACT values and preoperative hemoglobin, platelet count, creatinine clearance or INR. There was a positive correlation between preoperative aPTT and intraoperative ACT measurements (r = 0.432; p = 0.017). There was no difference between ACT values and previous antithrombotic/anticoagulant therapy and between intraoperative ACT and intraoperative blood loss. Conclusions: This study confirms that administrating a fixed or even a weight-based heparinisation is insufficient to provide consistent anticoagulation levels in all patients. Perioperative anticoagulation should be monitored and ACT-based. Larger clinical RCT's are warranted.

Popliteal vein aneurysm is a rare but potentially fatal entity due to possible thromboembolic complications. The purpose of this paper is to describe two institutional cases and to review the literature. In one case the diagnosis was made after the occurrence of symptomatic pulmonary embolism and in another, incidentally. In both cases the treatment was by conventional surgery without perioperative complications. From the literary review, a total of 43 popliteal vein aneurysms published between 206 and 2016 were analyzed.

Introdução: A Isquemia Mesentérica Aguda (IMA) e Colite Isquémica (CI) são duas entidades clínicas indissociáveis que podem aparecer no mesmo doente, simultaneamente ou em períodos temporais distintos. No entanto, a maioria dos doentes com CI não apresentam causa vascular obstrutiva major identificável, por oposição à IMA. Segundo o American College of Gastroenterology (ACG), a exclusão de IMA por angio-tomografia computorizada deve ser realizada em todos os doentes com critérios de CI severa. Este estudo teve como objetivos determinar se existe uma associação entre a gravidade da CI e a presença de IMA e identificar preditores de IMA na CI severa. Métodos: Foram selecionados todos os doentes admitidos com o diagnóstico de CI, no período de 2010 a 2014. Resultados: Durante o período estudado foram selecionados 241 doentes, 213 com CI isolada e 28 com CI+IMA. A gravidade da CI foi estratificada de acordo com os critérios do ACG, não se identificando casos de IMA concomitante na CI ligeira, enquanto 1,5% dos doentes com CI moderada e 56,8% dos doentes com CI severa apresentaram IMA concomitante. O grupo CI severa foi comparado com o grupo IMA+CI severa. A presença de hematoquézias foi mais frequente no grupo CI isolada (p

Aim: Carotid blowout syndrome is a rare but devastating complication of head and neck malignancy, and is associated with a reported mortality and neurologic morbidity of 40% and 60% respectively. The aim of this case report is to present our experience with a single case of massive haemorrhage from the internal carotid artery (ICA) in a previously irradiated neck treated with a stentgraft, hence maintaining carotid artery patency. Methods: Relevant medical data were collected and literature review was performed. Results: The patient is a 61-year-old male with a previous history of head and neck cancer submitted to radical surgery and chemo and radiotherapy. Seven years later, the patient was diagnosed with osteoradionecrosis of the mandibula and submitted to surgery. Hospital stay was prolonged due to local infection and suture dehiscence with carotid artery exposure. No previous episodes of sentinel bleeding were registered. Life-threatening haemorrhage from the surgical wound started acutely. Under manual compression, the patient was rushed to the angiography suite and the diagnostic angiography ascertained active bleeding from the ICA. A stentgraft Atrium Advanta V12 (Maquet Getinge group, Hudson, NH, USA) was deployed maintaining ICA patency. The patient was subsequently submitted to surgical reconstruction and had an uneventful recovery. Discussion: Management of acute carotid blow syndrome is critical, often requiring a multidisciplinary approach. Stentgraft placement is a highly feasible and effective approach with lower morbimortality rates when compared to surgical repair/ ligation or endovascular embolization. However long term results with patency rates are currently lacking.

Introduction: Iliac artery dissection without aortic involvement is a rare entity, with most cases associated with predisposing factors such as trauma, atherosclerosis, connective tissue disorders or vigorous exercise. The best treatment is not unanimous, and depends on the acuteness and severity of symptoms. Criteria for intervention include prevention of aneurysmatic degeneration, acute limb ischemia, inguinal pain and aneurysm rupture. Recent results using endovascular technique showed comparability with open repair, but there is paucity of data concerning long term results. Methods: Relevant medical data were collected from hospital database. Results: The patient is a 65 years old male, referred to the emergency department for abdominal pain in the left lower quadrant with inguinal irradiation. No signs or symptoms of acute limb ischemia were present. He had no previous history of connective tissue disease, cardiovascular risk factors, trauma or vigorous exercise. A CTA was performed, which identified an acute common left iliac artery dissection, with no evidence of vascular compromise of the ipsilateral limb He was submitted to surgical left femoral approach and percutaneous right femoral approach and dissection exclusion with two stentgrafts. Resolution of abdominal pain occurred immediately. Imagiologic follow-up with CTA was performed 12 and 24 months later with no signs of dissection or residual stenosis. Conclusion: In this case, an hybrid procedure with femoral surgical approach was performed for access site control. The use of bilateral femoral access was useful to identify the true lumen more accurately and to accommodate a more precise stent placement assuring adequate sealing. At 24 months follow-up, the patient maintains asymptomatic with no evidence of complications in the imagiologic follow-up. No signs or symptoms suggestive of connective tissue disease developed.

As lesões da artéria axilar e subclávia por trauma penetrante, excluindo aquelas ocorridas em teatro de guerra, são relativamente raras e com poucos casos descritos na literatura. Contudo, se não diagnosticadas atempadamente, estas poderão estar associadas a uma elevada morbilidade e mortalidade. A dificuldade e complicações frequentemente associadas à abordagem por cirurgia direta tornaram o tratamento endovascular uma alternativa mais atrativa, particularmente em caso de formação de pseudoaneurisma ou fístula arterio-venosa. Os autores descrevem um caso clínico de um jovem de 24 anos, admitido por lesão da artéria axilar em contexto de trauma penetrante e submetido a correção endovascular.

Introdução: A democratização da reparação aórtica endovascular (EVAR) alterou significativamente a estratégia terapêutica do aneurisma da aorta abdominal (AAA), devido ao seu carácter minimamente invasivo e à menor morbi-mortalidade perioperatória associada. No entanto, complicações específicas, como o endoleak tipo 1a (T1aE) e o endoleak tipo 2 persistente (pT2E), foram associadas a outcomes adversos, sendo o mais grave a rotura aneurismática. Apresentamos um caso de rotura de AAA pós EVAR devido a T1aE e pT2E tratado na nossa instituição. Caso Clínico: Trata-se de um doente do sexo masculino, de 73 anos, submetido a EVAR noutra instituição por AAA infrarrenal sem intercorrências. Cerca de 7 anos após-EVAR, o doente é observado no Serviço de Urgência da nossa instituição por quadro de dor abdominal e síncope com recuperação espontânea. Um AngioTC foi realizado e revelou crescimento do saco aneurismático, hiperdensidade espontânea do trombo, elevada densidade da gordura retroperitoneal direita e um pT2E com origem em artérias lombares. Foi decidida intervenção cirúrgica aberta mas intra-operatóriamente, após a abertura do saco aneurismático, foram detetados tanto pT2E quanto T1aE. Foi então submetido a aneurismectomia parcial, laqueação dos óstios das artérias lombares, preenchimento do saco anerismático com produtos pró-trombóticos a selar o colo proximal e encerramento do saco de aneurisma com ajuste do colo proximal. O doente teve alta clínica 15 dias após o procedimento. A AngioTC realizado 1 mês após o procedimento revelou ausência de endoleaks e estabilidade do tamanho do saco aneurismático preenchido com produtos pró-trombóticos. No follow-up a 2 anos, o doente manteve-se assintomático e os achados da AngioTC permaneceram inalterados. Discussão: A rotura pós-EVAR é um desafio terapêutico significativo para cirurgiões vasculares. Neste caso, os achados pré-operatórios da AngioTC levaram à decisão terapêutica de endoaneurismorrafia de colaterais. O achado intra-operatório de T1aE no contexto da rotura aneurismática e instabilidade hemodinâmica, forçou-nos a uma solução inventiva com o objetivo de recuperar a selagem adequada do colo proximal. Esta foi essencialmente uma variante do banding proximal previamente descrito para T1aE. A explantação da endoprótese foi considerada demasiado time-consuming e agressiva num doente já instável. Resultados do follow-up a 2 anos são encorajadores.

O acidente vascular cerebral (AVC) isquémico agudo no contexto de lesões síncronas, define-se como a combinação de estenose da artéria carótida interna (ACI) extra-craniana com trombo intracraniano. Apesar de corresponder a cerca de 10–20% de todos os AVC, a sua abordagem permanece controversa e variável de acordo com a experiência do centro. Na literatura, é consensual que a lesão com implicação imediata mais importante na apresentação clínica aguda é o trombo intracraniano. A revascularização intracraniana deve ser o mais célere possível, estando demonstrada a superioridade da trombectomia mecânica com stent retriever na oclusão de grande vaso da circulação anterior quando comparadas com a trombólise isolada. No entanto, no contexto de lesão aterosclerótica carotídea síncrona, é controverso o benefício e perfil de segurança do stent carotídeo emergente concomitante. O objetivo da presente revisão foi avaliar a importância clínica e os riscos associados a revascularização emergente da artéria carótida interna com recurso a angioplastia e stenting no contexto de lesões síncronas. Com esse objetivo foi realizada uma revisão da literatura existente utilizando a base de dados da Medline. Ultrapassar uma lesão da ACI extra-craniana e colocação de stent emergente parece ter uma elevada taxa de recanalização, mas é um procedimento time-consuming, podendo assim atrasar o tempo para a recanalização distal e potencialmente condicionar resultados neurológicos menos favoráveis. Na literatura, não existe evidência de uma melhoria do outcome do doente com o recurso a stent emergente no que concerne a recanalização intracraniana (Thrombolysis in Cerebral Infarction≥2b), outcome clínico (modified Rankin Scale≤2) e taxa de mortalidade aos 90 dias. Adicionalmente, expõe o doente a risco de complicações como AVC associado ao procedimento e hemorragia intracraniana. Conclui-se assim não existir atualmente evidência na literatura que suporte a realização de stenting carotídeo emergente no contexto de AVC devido a lesões síncronas.