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No século XIX, a proteção de monumentos históricos e obras de arte em tempos de guerra começou a ser codificada como um princípio jus gentium. Os primeiros instrumentos humanitários contudo não eram universais: o Código Lieber de 1863 dos Estados Unidos da América, a Convenção de Genebra para a Melhoria da Condição dos Feridos nos Exércitos em Campo de 1864, redigida por Estados europeus e americanos, a Declaração de Bruxelas de 1874, assinada por países europeus, e o Manual de Oxford de 1880, redigido e aprovado por advogados europeus e americanos, foi somente com a Convenção de Paz de Haia, em 1899, que houve um fórum universal para discutir princípios humanitários. Nessa conferência, um princípio versando sobre a proteção de uma determinada propriedade foi aceito por unanimidade. Contudo, esses princípios e os instrumentos que os estipulavam foram inspirados e estabelecidos pelos países ocidentais. No entanto, eles foram implementados no continente asiático durante conflitos cruciais nos séculos XIX e XX que marcaram sua história. Assim, um estudo sobre a aceitação desses princípios humanitários pelos Estados asiáticos, uma vez que eles não participaram do processo de elaboração, é importante para entender a amplitude do consenso desse princípio. No presente artigo, será discutida a aplicação do princípio para a proteção de monumentos históricos e obras de arte em tempos de guerra nos conflitos asiáticos antes da Primeira Guerra Mundial. A prática em dois conflitos, a Primeira Guerra Sino-Japonesa de 1894-1895 e a Guerra Russo-Japonesa de 1904-1905, será analisada.

Introduction: Horseshoe kidney (HK) is an anatomical variant characterised by abnormalities in the position, rotation, and vascular supply of the kidney, with functioning renal masses on both sides of the vertebral column fused together at the isthmus. Due to the altered pattern of kidney vasculature, endovascular aortic repair for aortic abdominal aneurysm (AAA) in the presence of HK requires vascular anatomy specific planning. Report: A 68 year old male, with multiple comorbidities, presented with an asymptomatic AAA and HK. The kidney vasculature was characterised by the presence of three arteries: two arising laterally at the same level and a third polar artery arising from below. The polar artery was 6 mm in diameter and larger than the other two; therefore, in order to preserve this artery, a custom-made device with a single side branch was implanted below the main renal arteries. A balloon expandable covered stent was used to complete the side branch into the polar renal artery. The follow-up computed tomography angiography revealed a successful outcome, with total aneurysm exclusion, branched graft patency, no endoleak, and unchanged renal function. Discussion: This case report shows a possible surgical solution for a case of HK with AAA and the importance of accurate endovascular planning. Large polar arteries, if present, need to be preserved, and custom-made devices in the modern endovascular era permit that. This approach could represent the best option for complicated patients.

INTRODUCTION: Spinal cord ischemia (SCI) is an uncommon but one of the most terrifying complications associated with the treatment of extensive aortic aneurysms. Its pathophysiology, risk factors, and event characteristics must be clarified. This study aimed to perform a descriptive analysis of the cases of SCI after complex aortic repair at our center and to understand which factors contributed to the event. METHODS: A retrospective, single-center, cohort study of prospectively collected data was performed. From January 2013 to October 2022, we included all consecutive patients with thoraco-abdominal aneurysms (TAAA) and complex abdominal aneurysms submitted to an endovascular procedure using fenestrated or branched endografts. According to the Society for Vascular Surgery (SVS) reporting standards, SCI was defined as the development of new motor or sensitive deficits after endovascular treatment. RESULTS: One hundred and thirty-five patients (87% male) were included, with a median age of 72. A total of 53,7% (n=72) had thoraco-abdominal aneurysms (type I-V), of which 63 were extent I-III\V and 9 were extent IV. In total, 12 (9%) SCI events were identified; 7 patients had a grade 2 SCI, 5 had a grade 3 injury, and all of them had a TAAA. Of these, 10 had pre-procedure cerebrospinal fluid (CSF) drainage. Five (42%) developed symptoms after 48 hours (delayed SCI), and seven patients developed early SCI, being identified on the first evaluation after surgery. Five cases received rescue CSF drainage (after the beginning of symptoms), with some degree of improvement observed in all cases. Among patients with grade 2 SCI (n=7), five recovered completely, one recovered partially (maintaining sensitive symptoms – grade 1), and one did not recover. This corresponded to an overall incidence of permanent SCI of 5.2% (n=7, any grade) and 1.5% of permanent paraplegia (n=2, grade 3, 2.8% only in TAAA). CONCLUSION: In this study, SCI only occurred in patients with TAAA, and the incidence of permanent paraplegia in this group was 2,8%. In five patients, rescue CSF drainage was applied, with some degree of clinical improvement. The small number of events precluded the investigation of predictors. Notably, 42% of SCI cases happened after 48 hours, showing a high prevalence of delayed SCI in this population. Consequently, more extended monitoring of these patients should be considered.

INTRODUCTION: Heterogeneity in the epidemiology, management, and in-hospital outcomes of patients with acute aortic syndromes can be found among male and female populations. This study aims to analyze sex-related differences in a cohort of patients treated in a tertiary university center. METHODS: All patients admitted with acute aortic syndromes between January 2012 and January 2023 were retrospectively analyzed. A descriptive analysis of the data was performed, and the results were queried to explore sex-related differences according to the type of aortic syndrome, type of treatment (medical or surgical – conventional or endovascular), and the temporal phase of the disease in which this treatment occurred. A multivariable logistic regression was undertaken to identify variables associated with higher in-hospital mortality. Variables were included if statistically significant in the univariable analysis or if considered medically relevant. RESULTS: A total of 116 patients (69% male) were included. Women were older (median age [interquartile range]: 64.6 years [40–85 years], n=36 versus 58.7 [23–84], n=80; P=0.034), had a higher proportion of intramural hematoma (19.4% versus 5.0%, P=0.014) and a lower proportion of aortic dissection (72.2% versus 88.8%, P=0.026) compared to men. Both sexes were more frequently treated with medical therapy alone (33.6%). However, women had a trend towards a lower proportion of open surgical management compared to men (16.7% versus 23.8%, P=0.391), as well as higher in-hospital mortality associated with this type of treatment (50.0% versus 21.1%, P=0.169). Additionally, women were associated with a higher conversion to endovascular or open surgery when first managed conservatively (13.9% versus 3.8%, P=0.046). In binary logistic regression, age was associated with higher in-hospital mortality (OR 1.056 [95% CI, 1.01-1.10]; P=0.014), but not female sex (OR 1.133 [95% CI, 0.39-3.30]; P=0.819). CONCLUSION: Women were older, had more intramural hematoma, and were associated with a higher conversion from medical to surgical treatment. After multivariable regression, age was associated with higher in-hospital mortality, but female sex was not. Larger cohorts are needed to understand if intervention in female patients will have an impact on intra-hospital mortality.

O texto propõe uma reflexão sobre a influência da noção de tempo na determinação de uma reparação adequada. A partir de um novo paradigma defendido pelo Professor Antônio Augusto Cançado Trindade, temos a defesa de uma humanização no direito internacional. Desta humanização, uma nova problemática surge: se o tempo do Estado é diferente do tempo do indivíduo, devemos repensar o tempo da reparação. Analisa-se, assim, como a temporalidade pode impactar os modos de reparação reconhecidos pelo direito internacional clássico: a restituição, a indenização e a satisfação, que pode incluir a reabilitação e as garantias de não repetição. Nesta releitura, identifica-se novos princípios que devem guiar a reparação.

INTRODUCTION: Guidelines state that ruptured abdominal aortic aneurysms should be treated shortly after the diagnosis and ideally within 90 minutes. The main aim of this study is to assess the referral pattern of our centre regarding the intervals between the diagnosis of ruptured AAA and the surgical repair, considering the geographical referral areas of our hospital. METHODS: We conducted an observational, retrospective cohort study from a single centre. The study population included all patients with the diagnosis of symptomatic or ruptured abdominal aortic aneurysm referred to Centro Hospitalar e Universitário Lisboa Norte (CHULN) between 2012 and 2021. The moment of diagnosis was assumed to be the time of the CT angiography and the moment of treatment was assumed as the time of entering the operating room (OR). RESULTS: During the study period a total of 150 patients (90.7% men, mean age 78.3, SD 8.7) were treated. Of these, 86% presented as ruptured aneurysms while 14% presented as symptomatic aneurysms. The median time between the diagnosis and the initiation of surgical treatment was 150 (+/- 132) minutes. Only 22% of patients were treated within 90 minutes of diagnosis and this remained unchanged throughout the study period. No statistically significant difference was observed between the median time intervals registered for survivors and deceased patients at 24 hours (p = 0.907), 48 hours (p = 0.743) and 30 days (p = 0.605) post-surgery. CONCLUSION: In our study, only 22% of patients with ruptured or symptomatic abdominal aortic aneurysms are treated within the recommended time frame. Although there is no significant impact on mortality, the authors recognize unavailability of information regarding patients that died before arrival to our hospital as a relevant limitation.

Objective: We evaluated the patency of the spinal arteries (intercostal and lumbar) after the STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique. Methods: A retrospective analysis of all patients with aortic dissection treated with the STABILISE technique between April 2018 and July 2021 was performed. Imaging analysis of the spinal cord vascular supply was accomplished using multiplanar and maximum intensity projection reconstructed images of pre- and postoperative computed tomography angiograms at 1 month, 12 months, and annually thereafter. Results: Twelve patients were treated for complicated aortic dissection. Primary technical success was 100% and mid-term clinical success, at a mean follow-up of 27 ± 12 months, was 90%. No cases of spinal cord ischemia were identified. One patient died after 1 year (non–aortic related), and one patient was lost to follow-up. A significant decrease was found in the mean number of patent spinal arteries in the stent graft area at 1 month (P < .001), 1 year (P < .001), and 2 years (P = .004). However, no significant reduction was found in the number of spinal arteries in either the bare metal stented or nonstented aorta (P > .05). Conclusions: Use of the STABILISE technique decreased intercostal artery patency in the thoracic stent graft area, but spinal artery patency was not significantly affected by the bare metal stent nor its aggressive ballooning. These findings constitute a step toward a better understanding of the safety of this technique.

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.

Acute aortic dissections are unpredictable aortic catastrophes. Although significant recent improvements have been accomplished in the treatment and management of aortic dissections, a significant amount is still not fully understood regarding this deadly condition. Comprehension of aortic dissections is especially important due to the impact of the disease, since a lot of patients die before reaching the hospital and a significant number of the ones who do survive the initial event end up dying during follow-up. The epidemiology and disease characteristics of these conditions are still under investigation and not completely clear. In this article we aim to review the current knowledge on the epidemiology and clinical characteristics of aortic dissections.

INTRODUCTION: Renal angioplasty emerged as an alternative for renal artery stenosis (RAS). In 2009 and 2014, two clinical trials (ASTRAL and CORAL) led to a paradigm shift in renovascular disease. Neither showed a clear benefit over best medical treatment, although there were methodological flaws. This study aims to evaluate the impact of these trials in clinical practice. METHODS: We designed a retrospective cross-sectional study from patients submitted to renal artery angioplasty between 1999 and 2021 in a tertiary center. Patients were selected from the center’s surgical records. Diagnostic arteriograms, open interventions and renal graft failures were excluded. Patients were divided in two cohorts: a historical group from 1999 to 2013 and a contemporary cohort, from 2014 to 2021. We compared the number of angioplasties per year and patient comorbidities, preoperative lesion severity, renal function, and the number of antihypertensive drugs. RESULTS: 152 patients were included: 104 patients between 1999-2013 (7 cases per year [5-8]) and 48 patients between 2014-2021 (6.5 cases per year [4.5-7]), with no significant difference between medians (p=0.53). Patients included between 2014-2021 were taking more antihypertensive drugs (3 [2-4] vs. 2 [1-3]; p=0.001) with a worse renal function (eGFR 44,2 ± 25,9 vs. 68,6 ± 29,2; p

INTRODUCTION: Out of Hospital Cardiac Arrest (OHCA) is one of the main causes of death worldwide. Most of the intrinsic causes of OHCA tend to be of cardiac origin, however, non-cardiac etiologies such as acute aortic dissection (AAD) may be more common than previously thought. The aim of this focused review is to summarize current knowledge on the association between OHCA and AAD. METHODS: A systematic review was previously performed on the incidence of AAD in the context of OHCA. For this publication, the selected references were reviewed to address three pre-determined questions: 1) How prevalent is Acute Aortic Dissection in Patients presenting with Out of Hospital Cardiac Arrest? 2) What clinical signs are associated with OHCA due to Acute Aortic Dissection? 3) How can we treat these patients and what is their prognosis? RESULTS: AAD may cause OHCA due to several reasons, such as retrograde involvement of the coronary arteries, aortic valve insufficiency, pericardium tamponade, aortic rupture, massive stroke, visceral malperfusion or hypertensive induced heart failure, for example. Since both the treatment and diagnosis of acute aortic dissections have improved, a growing number of OHCA due to AAD patients have been diagnosed and managed, however, the epidemiology and outcomes of these patients are still not fully understood.

Objetivo: descrever o perfil epidemiológico, as indicações e complicações pós-operatórias de pacientes submetidos à esplenectomia. Método: trata-se de um estudo transversal, realizado por meio de coleta de dados em prontuários de pacientes submetidos a esplenectomia entre 2015 e 2019 em um hospital terciário. Resultados: a amostra foi composta por 57 pacientes, com idade média de 33,4 anos (+-19,9), a maioria crianças/adolescentes (33,3%), do sexo masculino (57,9%), solteiros (57,9%), de religião católica (80,7%), atuantes no setor terciário do mercado de trabalho (43,9%), ensino fundamental incompleto (42,1%), procedentes de outras cidades, que não Passo Fundo (66,7%). A principal indicação para esplenectomia foi o acometimento de Púrpura Trombocitopênica Idiopática (33,3%) e a principal alteração pós-operatória associada foi a leucocitose persistente (25%). Conclusões: a esplenectomia é mais comum em crianças/adolescentes, sexo masculino e tem como principal indicação o Púrpura Trombocitopênica Idiopática conforme maioria dos estudo e apresenta alterações pouco frequentemente e, quando presentes, estão relacionadas a leucocitose persistente.

INTRODUCTION: Chronic intestinal ischemia accounts for approximately 1:1,000,000 admissions in some epidemiological studies. This condition usually affects individuals with known atherosclerotic lesion in other territories. Although typically found in female patients in their seventh decade of life with established arterial disease, chronic intestinal ischemia may manifest itself in younger patients. In the latter case, unusual causes, such as vasculitis, must be included in the differential diagnosis. CASE REPORT: We report the case of a 31-year-old man with a known history of intermittent left and right upper limb claudication and smoking. He complained of postprandial epigastric pain in the previous year, with unvoluntary weight loss (6kg in the previous 6 months) and fear of eating. An angio CT scan was performed, which showed occlusion of the celiac trunk and superior mesenteric artery at its origin. The diagnosis of chronic intestinal ischemia was formulated, and the patient was submitted to an antegrade bypass from the supraceliac aorta to the superior mesenteric artery and common hepatic artery, with a bifurcated Dacron graft. DISCUSSION: Given the inflammatory nature of the collected fragment of aorta, the onset of intestinal ischemia at a young age and the remaining peripheral arterial manifestations, a presumptive diagnosis of Takayasu’s arteritis was formulated. This vasculitis is typically found in patients in their third decade and is associated with diffuse arterial thickening. Mesenteric manifestations in this condition can occur up to 30%.

Introduction: The aim of this study was to assess the pattern of anti-atherosclerosis medicines in patients admitted to a vascular surgery department, the effective control of the target values and its subsequent modification by the vascular surgery team. Material and Methods: A retrospective single-center cohort study of prospectively collected data was performed between May 2017 and May 2018 in a tertiary center. The STROBE guidelines were followed. All patients undergoing a primary elective surgery for carotid disease, aortic aneurysm and peripheral arterial disease were included. ‘Best medical treatment’ was defined as treatment with both anti-thrombotic and lipid-lowering treatment and, when appropriate, antihypertensive and anti-diabetic drugs. Both baseline and post-discharge best medical treatment were recorded. Blood work-up was performed at admission and ‘adequately controlled patient’ was defined if all blood test values were in agreement with the guidelines. Results: A total of 279 patients (78% male; mean age 69 years-old) were included. Optimal medical therapy was registered in 58.8% upon admission but improved to 73.8% (95% CI, 2.197 – 7.781; p < 0.001) after discharge. At baseline, a total of 65.4% of patients were on lipid-lowering agents and of these, only 37% had LDL-C values within the targets. Likewise, only 34.6% of the 78 patients with diabetes had glycated hemoglobin within the normal range. Additionally, 8.5% of the remaining cohort had undiagnosed diabetes. Conclusion: In our current practice, only 75% of the patients receive best medical treatment. Although the admission in a Vascular Surgery department was an opportunity to optimize medical therapy, treatment remains suboptimal in one-quarter of patients. Further efforts should be carried out to alert vascular surgeons to this problem and to find future multidisciplinary solutions that can improve the cardiovascular risk profiles of these patients.

Abstract Living kidney donors’ follow-up is usually focused on the assessment of the surgical and medical outcomes. Whilst the psychosocial follow-up is advocated in literature. It is still not entirely clear which exact psychosocial factors are related to a poor psychosocial outcome of donors. The aim of our study is to prospectively assess the donors’ psychosocial risks factors to impaired health-related quality of life at 1-year post-donation and link their psychosocial profile before donation with their respective outcomes. The influence of the recipient’s medical outcomes on their donor’s psychosocial outcome was also examined. Sixty donors completed a battery of standardized psychometric instruments (quality of life, mental health, coping strategies, personality, socio-economic status), and ad hoc items regarding the donation process (e.g., motivations for donation, decision-making, risk assessment, and donor-recipient relationship). Donors’ 1-year psychosocial follow-up was favorable and comparable with the general population. So far, cluster-analysis identified a subgroup of donors (28%) with a post-donation reduction of their health-related quality of life. This subgroup expressed comparatively to the rest, the need for more pre-donation information regarding surgery risks, and elevated fear of losing the recipient and commitment to stop their suffering.

Objectives: Acute Aortic dissection (AAD) may present as out-of-hospital cardiac arrest (OHCA). However, the incidence of this presentation is not well known. Our aim was to perform a systematic review and meta-analysis of all observational studies reporting on the incidence of AAD in patients with OHCA. Methods: We searched MEDLINE, CENTRAL, PsycInfo, Web of Science Core Collection and OpenGrey databases from inception to March-2021, for observational studies reporting on the incidence of AAD in patients with OHCA. Data was pooled using a random-effects model of proportions. The primary outcome was the incidence of AAD in OHCA patients. Secondary outcomes were the incidence of type A aortic dissections (TAAD) and type B aortic dissections (TBAD) in OHCA patients, overall mortality following AAD-OHCA and risk of death in AAD-OHCA patients compared to risk of death of non-AAD-OHCA patients. Results: Fourteen studies were included. The pooled calculated incidence of OHCA due to AAD was 4.39% (95 %CI: 2.55; 6.8). Incidence of OHCA due to TAAD was 7.18% (95 %CI: 5.61; 8.93) and incidence of OHCA due to TBAD was 0.47% (95 %CI: 0.18; 0.85). Overall mortality following OHCA due to AAD was 100% (95 %CI: 97.62; 100). The risk of death in AAD-OHCA patients compared with non-AAD-OHCA patients was 1.10 (95 %CI: 0.94; 1.30). Conclusion: AAD as a cause of OHCA is more frequent than previously thought. Prognosis is dire, as it is invariably lethal. These findings should lead to a higher awareness of AAD when approaching a patient with OHCA and to future studies on this matter.

Caso clínico de uma mulher com aneurisma da artéria renal direita com envolvimento dos 3 ramos distais. A angio-TC permitiu o diagnóstico e a caracterização morfológica. A arteriografia mostrou o padrão de fibrodisplasia da média mas foi pouco útil na definição tridimensional dos ramos. A impressão de um modelo 3D baseado na angio-TC, permitiu uma melhor definição da anatomia o que ajudou na decisão e planeamento da cirurgia, que consistiu na reconstrução ex-vivo da artéria renal, que se mantêm permeável com 1 ano de follow-up.

Introduction: The stent assisted balloon induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique is being increasingly used for the treatment of complicated aortic dissections. However, as it is a fairly recent technique, the scientific information is limited. Report: In this paper we report two cases of the STABILISE technique associated with procedures in the ascending aorta and supra-aortic trunks, consisting of a “frozen elephant trunk” procedure in one case and in the other, a carotid endarterectomy associated with reimplantation of the vertebral artery and partial arch debranching. Discussion: In conclusion, while acknowledging the need for longer follow up and greater experience to support the safety and efficacy of this procedure, the two cases reported confirm that the STABILISE technique is a valid endovascular alternative in the treatment of complicated aortic dissections. Keywords: Aortic dissection, STABILISE, Bare stent, Stent graft, Endovascular

Introduction/Objectives: Repair of post-dissection thoraco-abdominal aortic aneurysms (PD-TAAA) is a complex challenge. Choosing the correct approach to manage these aneurysms is not straightforward as both open and endovascular strategies are valid. Our aim was to analyze and compare the results of PD-TAAA treated by endovascular or open surgery. Methods: A seven-year (January-2013 and May-2020) single-center retrospective cohort study of patients with PD-TAAA treated by endovascular (group-1) or open (group-2) surgery was conducted. Primary outcome was in-hospital mortality. Secondary outcomes were organ lesion, in-hospital infections, length of stay (LOS), endoleaks, branch occlusions, re-interventions and mortality during follow-up. Results: Twenty-one patients (15-men) were treated: 8 in group-1 and 13 in group-2. The mean age was lower in group-2 [68 (SD:11) versus 48 (SD:12), p=0.004]. Three patients had connective tissue disease (CTD). Group-1 patients had a higher ASA score (p

Com o surgir da pandemia a SARS-CoV-2 no início de 2020, os serviços de saúde sofreram várias adaptações de forma a mitigar e controlar a progressão do surto a nível europeu e nacional. Estes ajustes repercutiram-se inevitavelmente na dinâmica da maioria dos serviços hospitalares, nomeadamente no nosso serviço de Cirurgia Vascular. Perante a previsível chegada de uma segunda vaga na Europa e em Portugal, com desfechos e repercussões imprevisíveis nos serviços de saúde, é fundamental aprender com as experiências anteriores e partilhar estratégias para prestar o melhor cuidado aos nossos doentes, apesar das restrições impostas pela pandemia. Através deste artigo, analisamos as adaptações no Centro Hospitalar Universitário Lisboa Norte para superar a pandemia e, em particular, no serviço de cirurgia vascular. Avaliamos ainda o impacto dessas mudanças na nossa atividade global, em comparação com a experiência vivenciada noutros centros nacionais e internacionais. Perante uma segunda vaga iminente, é crucial tirar lições desta pandemia por forma a evitar uma potencial crise na saúde.

Background The prevalence of thoracic aortic aneurysms (TAA) in patients with known abdominal aortic aneurysms (AAA) is not well known and understudied. Our aim was to conduct a systematic review and meta‐analysis of the overall prevalence of synchronous and metachronous TAA (SM‐TAA) in patients with a known AAA and to understand the characteristics of this sub‐population. Methods and Results We searched MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) from inception to November 2019 for all population‐based studies reporting on the prevalence of SM‐TAAs in a cohort of patients with AAA. Article screening and data extraction were performed by 2 authors and data were pooled using a random‐effects model of proportions using Freeman‐Tukey double arcsine transformation. The main outcome was the prevalence of SM‐TAAs in patients with AAAs. Secondary outcomes were the prevalence of synchronous TAAs, metachronous TAAs, prevalence of TAAs in patients with AAA according to the anatomic location (ascending, arch, and descending) and the differences in prevalence of these aneurysms according to sex and risk factors. Six studies were included. The pooled‐prevalence of SM‐TAA in AAA patients was 19.2% (95% CI, 12.3–27.3). Results revealed that 15.2% (95% CI, 7.1–25.6) of men and 30.7% (95% CI, 25.2–36.5) of women with AAA had an SM‐TAA. Women with AAA had a 2‐fold increased risk of having an SM‐TAA than men (relative risk [RRs], 2.16; 95% CI, 1.32–3.55). Diabetes mellitus was associated with a 43% decreased risk of having SM‐TAA (RRs, 0.57; 95% CI, 0.41–0.80). Conclusions Since a fifth of AAA patients will have an SM‐TAA, routine screening of SM‐TAA and their clinical impact should be more thoroughly studied in patients with known AAA.

Endovascular aneurysm sealing (EVAS) was a relatively new concept that aimed to reduce the incidence of complications after endovascular aneurysm exclusion. However, EVAS device was recently recalled from market due to high risk of graft failure beyond two years after implantation(1,2). The aim of this paper is to report a case of a post-EVAS ruptured abdominal aortic aneurysm. A 72 year-old-man underwent EVAS and a bilateral sandwich technique of the iliac bifurcation for an aorto-bi-iliac aneurysm in 2015 in another institution. Follow-up CTA at three years showed a type Ib endoleak in the left iliac bifurcation and the patient was kept under clinical and imagiological surveillance (protocol unkown, again at another institution). Four years after the initial procedure the patient was admitted in the emergency department of our hospital after syncope and with abdominal pain. The CT-angiography (CTA) revealed a post-EVAS rupture in the distal aorta suggesting an endobag rupture (Fig 1). The patient underwent open surgical repair with explantation of the EVAS device (Fig 2 and 3) and an aorto-bifemoral interposition with a Dacron graft. The procedure was uneventful and the post-operative CTA showed a patent aorto-bifemoral graft without evidence of any complications (Fig. 4). One week later the patient was discharged home in good clinical condition. Post-operative surveillance is important in any aortic aneurysm endovascular procedure. However, since the last EVAS studies, all patients submitted to this technology must be under strict surveillance to identify complications like endobag rupture that can lead, as in the reported case, to aneurysm rupture which in turn can lead to stent graft explantation in an emergency setting

Os endoleaks (EL) do tipo IIIb resultam de um defeito no tecido da endoprótese e são uma complicação tardia rara, mas grave, inerente à correção endovascular de aneurismas da aorta (EVAR). Neste trabalho, os autores descrevem o caso de um homem de 81 anos submetido em 2013 a EVAR, devido a aneurisma da aorta abdominal (AAA) de 87mm. O procedimento decorreu sem intercorrências, assim como os primeiros dois anos de follow-up, após os quais, houve um crescimento gradual do saco aneurismático até aos 100mm, sem haver, no entanto, qualquer evidência de EL na angiotomografia computorizada (angioTC). O doente foi submetido a laparotomia exploradora, com abertura do saco aneurismático e constatação intra-operatória de EL tipo IIIb, tendo sido realizada hemostase e epiploplastia. O diagnóstico deste tipo de EL é difícil e muitas vezes apenas realizado intra-operatoriamente. Contudo, dado o elevado risco associado a esta complicação do EVAR, deve ser mantido um elevado índice de suspeição diagnóstica e a sua correção realizada atempadamente. Neste cenário, e dado não haver atualmente um gold standard de tratamento, a cirurgia aberta assume-se como uma arma terapêutica valiosa que permite não só o diagnóstico, como uma correção definitiva destas complicações.

Introduction: Renal venous graft restenosis is an uncommon event usually associated with significant clinical impact. Its treatment by endovascular stenting is seldom reported in the literature. Report: Two cases of successful stenting for restenosis in aorto-renal venous grafts are described, detailing the technique and in one case reporting for the first time the use of a covered stent in this condition. Discussion: Technical success may be achieved with proper material selection for the patient's anatomy and with dilation at relatively high pressures. The use of a covered stent may provide extra safety when treating vein grafts. Keywords: Renal artery disease, Restenosis, Stent graft

Post-endarterectomy pseudoaneurysms (PEPA) are a rare complication of carotid endarterectomy (CEA), but are associated with high morbidity risk. Therefore, once they are diagnosed, treatment is urgent to prevent possible complications such as rupture, embolisation, thrombosis, or airway and cranial nerve compression. In this video, the surgical procedure is shown in a case of PEPA 10 years after CEA with patch angioplasty, which was successfully managed by surgical excision and interposition of great saphenous vein graft. Follow up duplex examination at six months was normal, with patency of the vein graft. This case reiterates the importance of open surgery as the treatment of choice for this difficult clinical setting. Keywords: Carotid endarterectomy, Carotid pseudoaneurysm

Introduction: Aneurysms of small abdominal vessels are extremely rare; however, even minor aneurysmal accessory arteries can rupture, leading to potentially fatal consequences. The purpose of this paper is to report a case of coil embolisation of an aneurysmal posterior gastric artery. Case presentation: The authors describe the case of a 66 year old female patient with an aneurysm of the posterior gastric artery. Coil embolisation was performed. The six month follow up computed tomography angiogram revealed exclusion of the aneurysm. Discussion: The presented case is exceedingly rare. This type of aneurysm has to be kept in mind as a possible cause of bleeding, despite the limited information regarding their natural history. Conclusion: Owing to the safety and applicability of the endovascular technique, it is nowadays probably the best treatment alternative for this type of aneurysm. Keywords: Posterior gastric aneurysm, Coil, Embolisation, Visceral aneurysm, Endovascular procedure

Introduction: Endovascular treatment of type B aortic dissection has focused on the covering of the proximal entry tear. However, recently, concern has emerged regarding the distal aortic remodeling and new techniques such as the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination (STABILISE) technique have gained more acceptance. We describe a technical note regarding the combination of the STABILISE technique in addition to the Covered Reconstruction of the Aortic Bifurcation (CERAB) technique to achieve complete aortic remodeling. Methods: The authors describe a stepwise approach regarding the endovascular repair of type B aortic dissections. A simple TEVAR is performed first. If the patient still shows signs of true lumen compression, a STABILISE technique is performed in order to achieve true lumen expansion and complete aortic remodeling. However, in some patients, false lumen perfusion and true lumen compression at the very distal aorta is maintained due to distal comunicating tears. In these patients, if there are still signs of infra-renal aortic or iliac compression/occlusion or distal thrombosis of the false lumen, a simultaneous CERAB is performed. Conclusion: By combining these techniques, we aim to cover both the proximal tear and the distal comunicating tears resulting in a complete flap apposition, false lumen obliteration, re-expansion of the true lumen and achieve optimal remodeling.

Aortic abdominal aneurysm (AAA) is an uncommon etiology of disseminated intravascular coagulation (DIC). The authors report a case of an 81-year-old male patient who presented with hematuria, intraoral hemorrhage, melaenas and ecchymosis of the lower back and of the abdominal wall, after being medicated with etoricoxib for a back pain. During the study, an abdominal aortic aneurysm, which prolonged to the left common and internal iliac artery, was discovered. The diagnosis of AAA induced DIC was made. After endovascular aneurysm repair (EVAR), the patient’s hemorrhagic manifestations disappeared and the laboratory findings normalized. In conclusion, the state-of-the-art treatment of DIC is the elimination of the underlying disease; in this case, EVAR was proven to be effective in treating the aortic aneurysm and the AAA-related DIC.

Doente do sexo masculino, 82 anos, fumador e com fibrilhação auricular, internado noutra instituição hospitalar por pneumonia adquirida na comunidade. Transferido para o nosso hospital após colocação de catéter venoso central na veia jugular interna esquerda a qual foi complicada de punção transfixiva e cateterização acidental da artéria carótida primitiva ipsilateral com progressão para o arco aórtico (Figura 1 e 2). O doente foi operado confirmando-se o diagnóstico pré-operatório (Figura 3) e sendo realizada a remoção cirúrgica do catéter por abordagem cervical seguida de venorrafia e arteriorrafia primárias. O pós-operatório decorreu sem complicações pelo que o doente foi transferido para o hospital da área de residência no 4º dia de pós-operatório.

As técnicas endovasculares são actualmente o tratamento de escolha da dissecção aórtica tipo B complicada (cDATB). Entre elas encontra-se a técnica STABILISE cujo objectivo é alcançar, num único tempo cirúrgico, um remodeling imediato da aorta tóraco-abdominal com consequente obliteração do falso lúmen através da reaposição do flap de dissecção à parede externa da aorta. Trata-se de uma técnica relativamente recente, ainda com poucas séries publicadas. Assim sendo, este trabalho tem como objectivo sistematizar a informação existente até à data sobre esta técnica de importância crescente no tratamento das dissecções aórticas agudas tipo B.

Autores da Saúde Mental Global defendem, de um lado, o aumento do acesso aos cuidados de saúde mental, inclusive com o uso de intervenções padronizadas. De outro lado, na Atenção Primária à Saúde no Brasil, a apresentação sintomatológica do sofrimento emocional pelos pacientes dificulta sua identificação pelos profissionais, comprometendo o cuidado e exigindo uma abordagem culturalmente sensível. Objetivando conhecer a percepção de pacientes sobre o sofrimento emocional e seu cuidado na Atenção Primária, adotou-se método qualitativo de abordagem narrativa, com coleta de dados em grupos em salas de espera e roteiro baseado no instrumento McGill Ilness Narrative Interview. As narrativas foram tratadas por Análise de Conteúdo e revelaram que limitar a comunicação do sofrimento é negar o acesso ao cuidado. Contrapondo tal limitação, apontaram-se estratégias para nortear a estruturação de um cuidado que seja integral e culturalmente sensível.

A Saúde Mental Global é um campo de ensino, pesquisa e prática, cuja prioridade é melhorar o acesso e assegurar a equidade no cuidado em saúde mental para todas as pessoas do mundo, propondo ações especialmente em países de média e baixa renda, como o Brasil. Diante desse panorama mundial e considerando o avanço local dos processos das reformas sanitária e psiquiátrica, torna-se importante investigar o estado atual da literatura brasileira e sua relação com a Saúde Mental Global, descrevendo como a produção nacional aborda assuntos enfatizados nesse campo. Assim, adotando abordagem qualitativa e perspectiva descritiva, foi realizada revisão integrativa da literatura do período de 2014-2015, por meio de pesquisa bibliográfica em português e inglês, utilizando os termos saúde mental e Brasil combinados a palavras-chave correspondentes aos principais tópicos discutidos por autores da Saúde Mental Global. Foram encontrados 88 artigos apreciados segundo sua autoria, periódicos e regiões de publicação, metodologia e de acordo com as categorias de análise e acesso; atenção primária; atenção psicossocial; determinantes sociais da saúde; direitos humanos; e equidade. Constatou-se haver na produção científica nacional um conjunto de estudos muito rico e diversificado com paralelos com a literatura da Saúde Mental Global, mas apresenta um baixo índice de sistematização. Esses achados revelam, portanto, que, apesar dos esforços para a geração de conhecimento local, existem barreiras que, possivelmente, comprometem a participação brasileira no debate internacional.

Os aneurismas aorto-ilíacos envolvem ambas as artérias ilíacas primitivas em 30% dos casos. O seu tratamento por via endovascular pode ser efetuado com recurso a técnicas de revascularização e de embolização combinadas, mas em alguns casos, existe vantagem na preservação das duas artérias hipogástricas. Assim, torna-se necessário recorrer à colocação de endopróteses ilíacas ramificadas (iliac branch devices- IBD) bilaterais cuja utilização implica estratégias técnicas próprias e tem sido relatada pouco frequentemente na literatura. Neste trabalho, os autores descrevem a técnica, discutem as suas particularidades e relatam dois casos clínicos operados recentemente. Os registos dos processos clínicos dos doentes submetidos a este procedimento foram revistos. Eram ambos do sexo masculino, com idades de 70 e 73 anos. Ambos os doentes tinham concomitantemente aneurisma da aorta abdominal infra-renal (diâmetros da aorta de 61mm e 37mm e artérias ilíacas primitivas de 37/38mm e 32/44mm respectivamente). Foi utilizado em ambos os casos acesso femoral bilateral e axilar esquerdo. No primeiro caso a ordem das próteses foi EVAR, IBD esquerdo e IBD direito, e no segundo realizou-se primeiro o IBD direito, de seguida o EVAR e por fim o IBD esquerdo. O sucesso técnico foi obtido em ambos dos casos. Não existiram complicações pós-operatórias. O seguimento médio foi de 3 e 12 meses. Não ocorreram endoleaks ou oclusões de ramo. Os IBD bilaterais podem ser utilizados com segurança em pacientes apropriadamente selecionados, com excelentes taxas de sucesso técnico e de permeabilidade dos ramos. Os aspetos técnicos a equacionar em cada caso são as vias de acesso e a ordem de abertura das endopróteses.

No presente estudo pretende-se apresentar e avaliar benefícios no organismo humano associados ao consumo de oleaginosas. Para isso foi realizada uma intensa pesquisa nas bases de dados PubMed e Medline em busca de artigos relacionados ao tema. O consumo das oleaginosas tem vindo a aumentar, e vários estudos têm sido realizados com o intuito de aprofundar os efeitos benéficos desse consumo. Diversos foram os resultados que apontam benefícios das oleaginosas, destacando-se o efeito protetor a nível cardiovascular, a redução do risco de desenvolver câncer e a redução do risco de mortalidade. Em conclusão, é possível afirmar que o consumo de oleaginosas tem diversos efeitos benéficos ao organismo humano.

Analyses the curriculum policies developed by the Lula Government. It concludes by stating that they belong to the same epistemological community as those developed by the previous Fernando Henrique Cardoso Government. It also mentions the main possible turning points, as far as Balls analysis of curriculum policy, Bernsteins recontextualization and Canclinis hybridism are concerned.