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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., Angiologia e Cirurgia Vascular, Vol. 18 No. 4 (2022): December

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: 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., Angiologia e Cirurgia Vascular, Vol. 18 No. 3 (2022): September

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., Angiologia e Cirurgia Vascular, Vol. 18 No. 3 (2022): September

Introduction: A right aortic arch and agenesis of internal carotid artery (ICA) are both extremely rare vascular devel- opment anomalies. Etiology of the both anomalies might be associated with the abnormal regression of the dorsal aorta. Most cases of ICA are asymptomatic due to sufficient collateral circulation and it is usually an incident finding on head and neck imaging by color Doppler ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI). ICA agenesis has a significant association – 24-67% – with intracranial aneurysms and their early detection can spare the patient serious complications. Clinical case: A 28-year-old male had a single episode of hypertension that motivated the realization of several tests. During the investigation he was submitted to a duplex ultrasonography that revealed a diffuse narrowing of the left common carotid artery (CCA), with a markedly decrease in the peak systolic velocity and the absence of the left internal carotid artery (ICA) was suspected. Contrast-enhanced computed tomography (CT) demonstrated no abnormalities, such as cerebral infarc- tion or intracranial vascular malformations, but confirmed a right-sided aortic-arch, with anomalous origin of the left subcla- vian artery with a common origin of both CCAs and the absence of the left ICA. Examination of the head CT in bone window demonstrated an absence of the left internal carotid canal. Conclusion: This clinical case emphasizes the importance of recognizing this condition due to the associated hemody- namic changes and in order to discover and evaluate other additional vascular malformations (aneurysms, collateral channels) and their life threatening potential risks (subarachnoid hemorrhage or ischemia). Also, it has a special importance in case of planning carotid or trans-sphenoidal hypophyseal surgery. To our knowledge, only 8 cases have been reported right aortic arch associated with agenesis of the left internal carotid artery., Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 29 No. 1 (2022): Jan - Mar

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., Angiologia e Cirurgia Vascular, Vol. 17 No. 4 (2021): December

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., Angiologia e Cirurgia Vascular, Vol 17 No 3 (2021): September

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 anticoagulation and elastic stockings.

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., Angiologia e Cirurgia Vascular, Vol 17 No 2 (2021): June

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: Extracorporeal membrane oxygenation (ECMO) has evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function. The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO. Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). Methods: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017). The primary outcome of this study was to investigate the prevalence of cannulation-related complications on VA ECMO and to determine its effect on patient morbimortality. Results: Eighty-two patients underwent ECMO during the period of study, 56,1% were male with a mean age of 55,8 years. The VA mode was used in 61 patients, 56 with peripheral cannulation. Femoral arterial access was established in 52 patients (73% percutaneously). Vascular complications were observed in 28,6% of the VA femoral ECMOs: 12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed limb ischemia. For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal: 8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction. There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation. Conclusions: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%). PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation., Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 26 No. 1 (2019): January - March

Introduction: Hostile anatomic characteristics in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) may lead to technical non-success, late complications, reintervention or death. Objective: To analyze specific anatomical features of abdominal aortic aneurysms and to study the association with postoperative endoleak and survival. Methods: Retrospective review of all consecutive elective EVARs between 2010 and 2016, with available data, at one institution, for infra-renal aortic aneurysms. Patients comorbidities and preoperative computed tomography scans were analyzed considering characteristics of the proximal and distal landing zones, the aortic aneurysm and eventual concomitant iliac aneurysm or peripheral occlusive disease. Outcomes were endoleak development and survival. Results: We analyzed 56 patients, 54 (96%) male with a mean age of 78 (min 61, max 89) years. During a mean of 3.4 years of follow up, 12 (21%) patients developed endoleak (10 type II and 2 type I) and 18 (32%) died. The adjusted analysis showed a significant association between aneurysm angulation (p=0.044), patency of the inferior mesenteric artery and the lumbar arteries (p=0.044) and aneurysm diameter (p=0.009) with endoleak development. All except one endoleak were diagnosed within the first year after EVAR. None of the deaths that occurred during the follow up period were correlated to post intervention aneurysm enlargement or rupture. Conclusion: Unfavorable aneurysm morphologic characteristics for EVAR may predict complicated endograft placement or higher incidence of post intervention endoleak, which should be taken into consideration. For such clinical cases, complementary endovascular procedures or a surgical approach should be considered., Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 26 No. 2 (2019): April - June

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 (>38��C) and leukocytosis (>12000/��L), 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., Angiologia e Cirurgia Vascular, Vol 16 No 4 (2020): December

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., Angiologia e Cirurgia Vascular, Vol 16 No 4 (2020): December

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., Angiologia e Cirurgia Vascular, Vol 16 No 4 (2020): December

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., Angiologia e Cirurgia Vascular, Vol 16 No 4 (2020): December

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., Angiologia e Cirurgia Vascular, Vol 16 No 3 (2020): September

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., Angiologia e Cirurgia Vascular, Vol 16 No 3 (2020): September

Angiologia e Cirurgia Vascular, Vol 16 No 3 (2020): September

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, Angiologia e Cirurgia Vascular, Vol 16 No 3 (2020): September

Angiologia e Cirurgia Vascular, Vol 16 No 2 (2020): June

Objective/Background: Peripheral artery disease (PAD) is an important manifestation of systemic atherosclerosis. Obesity is a risk factor for atherosclerosis and for cardiovascular events. However, the relationship between obesity and PAD is unclear. We hypothesized that anthropometric measures of adiposity, in particularly of central obesity will be associated with PAD severity, in patients undergoing aorto-bifemoral bypass. Methods: A prospective observation study was conducted. From 2009 and 2012 a total of 46 males who underwent aorto-bifemoral bypass were enrolled prospectively. 17 with intermittent claudication (IC) and 29 with chronic limb threatening ischemia (CLTI). They were followed for 5 years. The anthropometric measures, weight, body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and the seric levels of hemoglobin, triglycerides, and albumin were recorded. The mortality and cardiovascular events in following five years were also registered. Results: The groups did not differ in the mean age (IC 60.69��7.46 versus CLTI 64.51 ��8.42 years, p=0.712), diabetes (IC 18% versus CLTI 45%, p=0.06), hypertension (IC 70% versus CLTI 52%, p=0.21), hypercholesterolemia (IC 18% versus CLTI 45%, p=0.47) and smoking habits prevalence (IC 100% versus CLTI 86%, p=0.11). The anthropometric measures: weight, WC and WHR were significant lower in CLTI compared to IC patients (IC 72.74��9.84 Kg versus CLTI 65.92��10.89 Kg, p=0.043; IC 98.65��8.19 cm versus CLTI 89.38��15.91 cm, p=0.017; IC 1.06��0.06 versus CLTI 1.01��0.06, p=0.038). The serum levels of hemoglobin, albumin and triglycerides were also lower in CLTI patients (IC 14,40��1.63g/dL versus CLTI 13.3��1.89g/dL, p=0.048; IC 4.6��0.81g/dL versus CLTI 4.3�� 0.67g/dL, p=0.007; IC 212��95.60mg/Dl versus CLTI 111��41.53 mg/dL, p=0.001). No relation was found between the anthropometric measures at admission and the cardiovascular events or mortality at five years. Conclusion: CLTI patients had lower anthropometric measures of obesity, when compared to IC patients. These results could be explained by the fact that CLTI patients with severe atherosclerotic disease are in a state of chronic inflammation, with consequent cardiometabolic demands and catabolism., Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 27 No. 2 (2020): April - June

Axillary artery injuries due to penetrating trauma are relatively uncommon. Management of these injuries is challenging due to the complex local anatomy, rigid chest walls, and associated injuries. Open exposure with direct open vascular repair has been the mainstay of operative management. We report a clinical case of a 51-year-old man victim of penetrating trauma to the axillary artery caused by a chain-saw and repaired by open surgery with a great saphenous vein interposition graft., Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 27 No. 2 (2020): April - June

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., Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

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., Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

Introdu����o: A maioria dos pseudoaneurismas (PSA) da art��ria femoral profunda apresentam-se de forma assintom��tica ou atrav��s da presen��a de uma massa puls��til. Clinicamente vari��veis poder��o desenvolver sintomas por compress��o das estruturas adjacentes ou mesmo levar a choque hemorr��gico, em caso de rutura. Relativamente �� orienta����o terap��utica, quando sintom��ticos dever��o ser corrigidos. Contudo, nos casos assintom��ticos a melhor atitude permanece discut��vel, uma vez que a maioria dos pequenos PSA, com di��metro inferior a 20-30mm, acabam por trombosar dentro de quatro semanas, aceitando-se assim uma atitude expectante e reservando a corre����o no caso de apresentarem crescimento, n��o trombosarem ou desenvolverem cl��nica/sintomatologia. Materiais e m��todos: Os autores apresentam dois casos de PSA de ramos da art��ria femoral profunda (AFP) no contexto de procedimentos ortop��dicos. Caso cl��nico I ��� Doente do sexo feminino, 83 anos, admitida no Servi��o de urg��ncia por trauma a n��vel do f��mur e c��ndilo lateral esquerdo. Submetida a osteoss��ntese trocant��rica, complicada no p��s-operat��rio de trombose venosa profunda (femoro-il��aca). Teve alta hipocoagulada sendo readmitida dois meses ap��s com dor a n��vel da coxa tendo sido diagnosticado PSA da AFP. Realizou-se emboliza����o com coils: um 2D Helical-35�� de 3x52mm e um VortXTM Diamond�� de 3x23mm. Caso cl��nico II ��� Doente do sexo feminino, 70 anos, admitida eletivamente para realiza����o de pr��tese total da anca direita. No p��s-operat��rio imediato apresentou hematoma da coxa associada a hipotens��o persistente e queda de 2g/dL de hemoglobina, sem reposta cl��nica a medidas conservadoras. Realizado estudo com diagn��stico de PSA da AFP tendo sido tratado com emboliza����o com dois coils Tornado Cook�� de 2-5x50mm. Discuss��o: O diagn��stico de PSA da AFP �� dif��cil dada a sua raridade (incid��ncia descrita de 2% para feridas arteriais perif��ricas(1)), sendo mais frequentes ap��s procedimentos ortop��dicos e vasculares(2). Os procedimentos endovasculares na abordagem dos PSA permitem uma precisa localiza����o do ponto de hemorragia e a sua corre����o de forma minimamente invasiva. A taxa de sucesso t��cnico aproxima-se de 100% quando as caracter��sticas anat��micas permitam a sua realiza����o., Angiologia e Cirurgia Vascular, Vol 16 No 1 (2020): March

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. Introduction: Most of the deep femoral artery (DFA) pseudoaneurysm (PSA) present asymptomatically or as a pulsatile mass. Clinical signs are variable and, normally, result from compression from adjacent structures but when ruptured it may present as haemorrhagic chock Symptomatic PSA should be treated. However, the decision to treat asymptomatic PSA is controversial. The majority of small PSA (less than 20-30 mm in diameter) are prone to spontaneous thrombose within 4 weeks, so literature recommends observing small, asymptomatic PSA and treating only if they enlarge, do not thrombose, or become symptomatic. Materials and methods: The authors present two cases of PSA from a DFA branch after an orthopedic procedure. Clinical case I - 83-year-old female admitted in the emergency department with left femoral shaft and lateral condyle trauma. Submitted to trochanteric osteosynthesis, complicated with deep vein thrombosis but no diagnosis of PSA by that time, so she was discharged with anti-coagulation. Re-admitted two months later with thigh pain and a diagnosis of DFA PSA. She was submitted to selective coil embolization with 2D Helical-35® of 3x52mm and one VortXTM Diamond® of 3x23mm. Clinical Case II - 70-year-old female electively admitted for a total right hip replacement. Post procedure, she developed thigh hematoma, persistent hypotension and 2gr/dL haemoglobin decrease, not responsive to conservative measures. After diagnosed of a DFA PSA, she was submitted to selective embolization with two Tornado Cook® embolization coil of 2-5x50mm. Discussion: Accurate diagnosis of DFA PSA is difficult, not only due to its rarity but also to a frequent delayed presentation. It has an incidence of 2% of all peripheral arterial wounds being more common after orthopaedic and vascular procedures. An endovascular approach has emerged as a minimum invasive technique that allows a precise localization and exclusion of the lesion identified. It has a successful rate near 100% when anatomically feasible.