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INTRODUCTION: Blunt thoracic aortic injuries (BTAI) are defined as a tear in the thoracic aorta caused by a high energy blunt trauma with sudden deceleration and increased intravascular pressure. The most common reported mechanism of injury is motor vehicle accidents, and it can be potentially lethal. The purpose of this study was to analyze and report our center’s experience in the treatment of blunt traumatic injuries of thoracic aorta and supra-aortic trunks. METHODS: A retrospective review of a single center's database was done to identify all patients treated for BTAI, in a four-year period, from January 2018 to December 2021. Follow-up period ranged from three to 24 months. Patients’ demographics, injury mechanism, location and grade of aortic injury, treatment details, timing of intervention, length of hospital stay, follow-up time, and postoperative morbidity and mortality were extracted from patients’ medical records. A descriptive analysis of all the data was performed. RESULTS AND DISCUSSION: We identified six patients to include in the study. Mean age was 29 years and 83.3% of patients were male. The mechanism of injury was motor vehicle accident for all cases. The most common injury grade was type III (pseudoaneurysm) in five patients (83.3%), and one patient presented with a type IV aortic injury with rupture. All injuries were in the aortic isthmus and all patients were suitable for TEVAR. Mean time to intervention was 17 days. Mean oversizing was 11%. Two patients had coverage of their LSA. No deaths occurred in the hospital or during the follow-up period, and there were no registered vascular procedure-related morbidities. CONCLUSION: This study reports a level one trauma center experience in management of BTAI. All patients underwent CTA for diagnosis and grading of aortic injury. TEVAR proved to be effective in the treatment of BTAI, with few complications and good outcomes at short and mid-term follow-up, and it should be the first-line treatment for these patients. OSR should be an option when a patient’s injury is not suitable for endovascular approach.

Introduction: Arteriovenous fistulas (AVF) are currently considered to be the best vascular access option for patients with end stage chronic kidney disease requiring haemodialysis. In rare cases of patients with chronic AVF, thrombosis or ligation of the access can lead to the development of brachial artery aneurysms. Despite being uncommon, reports of this phenomenon have arisen in recent decades due to an increase in the number of patients undergoing dialysis worldwide. This case presented with a brachial aneurysm that developed after AVF ligation. Case report: A 62 year old male presented to the emergency department with swelling of the medial aspect of his left arm associated with pain, inflammatory signs, and finger paraesthesia. Swelling had started two months previously but had worsened within the last week. He had history of kidney transplant 20 years ago and a chronic functioning radiocephalic fistula that had not been used since, and which had been ligated in the past year due to the development of venous aneurysms. Physical examination revealed a pulsatile mass in his left arm and absent radial and ulnar pulses, without signs of hand ischaemia. There was significant venous collateralisation of the arm and chest and numbness of the left fingers, suggesting venous and neurological compression. Computed tomography angiography showed a large left brachial artery aneurysm (108 x 87 x 180 mm). The patient underwent aneurysm sac emptying and collateral ligation followed by great saphenous vein interposition, with clinical improvement. Conclusion: The presence of a chronic AVF can lead to progressive changes in the arterial wall. Sudden ligation or thrombosis of a functioning AVF causes increased blood pressure within the artery, which may further contribute to its aneurysmal degeneration. In addition, immunosuppressive therapy following kidney transplant has been described as a synergistic risk factor leading to aneurysm formation. Despite being a rare complication, patients with a chronic AVF should be monitored closely after vascular access ligation.

INTRODUCTION: Seat belt aorta is a rare but often severe complication arising from blunt trauma with compression of the abdominal aorta against vertebrae. Seat belt sign is often present as an ecchymosis across the abdomen. The association with abdominal wall disruption and hollow viscus injury has been named seat belt triad; the presence of Chance fracture is sometimes considered a fourth component. METHODS: Using Pubmed and Embase databases we reviewed all articles regarding abdominal seat belt aortic injuries and analysed presentation at admission, concomitant lesions, including presence of seat belt triad, treatment and outcomes. RESULTS: Fifty-two cases were reported, from 1968 to 2019. Twenty-nine males (56%), mean age 43 ± 19 years. Most patients were stable at admission, with 29 (55.8%) presenting acute abdomen, 26 (50%) limb ischemia, 9 (17.3%) hypovolemic shock and 2 (3.8%) late-onset claudication. Seat belt sign was identified in 40 patients (76.9%), seat belt triad in 38 (73.1%) and 22 (42.3%) had Chance fractures, of which only 2 were not associated with seat belt triad. Most patients presented with aortic dissection (90.4%), complicated with pseudoaneurysm (11.5%), contained rupture (7.7%) or uncontained rupture (3.8%); 2 patients presented isolated iliac thrombosis and 3 limb ischemia. All patients required immediate surgical intervention, of which 40 (76.9%) required urgent vascular surgery. Forty-eight patients (92.3%) underwent vascular surgery: 39 open revascularizations and 9 endovascular procedures; three were managed conservatively. Ten patients (19.2%) passed away or died, of which 7 had seat belt triad. No patients needed reinterventions for vascular lesions except one, yet 3 required limb amputation. Most patients with seat belt triad required further visceral and abdominal wall repair. CONCLUSIONS: Seat belt aorta and especially seat belt triad are severe complications associated with high morbimortality often requiring surgery and multiple interventions. As patients are usually conscious and stable upon admission, this condition should not be disregarded.

INTRODUCTION: The use of statins in hemodialysis patients is a topic of ongoing research and debate. Patients with chronic kidney disease on hemodialysis constitute a large proportion of patients treated in the vascular surgery field. Clinical data of the protective statin effect on this group is scarce and conflicting results exist regarding cardiovascular, cerebrovascular and limb outcomes. METHODS: We performed a thorough electronic search of the literature using PubMed and Embase databases to understand the relationship between statin effect and cardiovascular, limb outcomes and cerebrovascular outcomes. A narrative review was constructed, based on the obtained literature. RESULTS: Although the use of statins in hemodialysis patients may provide cardiovascular benefits, the optimal dosage and safety profile of these medications in this population remain uncertain. A carefully evaluation of the risks and benefits of statins should be made based on each patient's specific requirements and circumstances. CONCLUSION: The role of statins for patients with peripheral arterial disease who are on hemodialysis remains unclear. Further analyses should focus on this subgroup of dialysis patients, who are becoming more prevalent on the vascular surgery departments, allowing for an optimized treatment with better patient outcomes.

INTRODUCTION: The descending thoracic aorta (DTA) has been used as inflow mostly as a secondary option for revascularization after either graft failure/infection or other intra-abdominal pathologies contraindicating a standard abdominal aortic approach. The objective of this review is to summarize current evidence on the use of this inflow site for revascularization procedures. METHODS: A comprehensive electronic literature search was performed, using PubMed and Embase databases. All literature published in English in the last 30 years was considered. The main goal was to assess the feasibility and practicality of implementing this approach in cases of severe and complex aortoiliac lesions. RESULTS: Our review comprised 11 articles. DTA has been used predominately as a secondary option. The 30-day mortality rate was 4% (9/222). Secondary graft patency at 5-years was generally high across all studies. The use of DTA as inflow has been shown to be a safe and effective option for aorto-iliac reconstruction. CONCLUSION: DTA can be used safely as an inflow for lower-limb revascularization and it remains an important tool in the vascular surgeon's armamentarium.

Ilio-iliac arteriovenous fistula occurs in 1% of all common iliac artery aneurysms, a rare complication of this identity. A variety of symptoms appear depending on the size and location of the fistula, making the correct diagnosis quite difficult, only 37–52% of the cases are diagnosed before surgery. We report a case of an abdominal infrarenal aneurysm and right common iliac aneurysm, with fistula into the left common iliac vein, presenting with acute nocturnal paroxysmal dyspnea and left leg edema, inducing to the incorrect diagnosis of venous thromboembolism.

Descending thoracic aorta (DTA) inflow has been utilized as a secondary choice for restoring blood flow in cases of aortoiliac occlusive disease. This option is considered when graft failure, infection, or other intra-abdominal conditions contraindicates the use of the standard abdominal aortic approach. Additionally, when the abdominal aorta develops extensive and complicated circumferential calcified lesions, making it unsafe to clamp this segment, a DTA bypass can serve as a secure and effective alternative. It remains an important tool in the arsenal of vascular surgeons. The presence of coral reef aorta, a rare condition characterized by outwardly projecting calcified plaques on the juxtarenal and visceral aorta, poses a challenge in determining the best treatment approach, as it has yet to be defined.

Introduction: Endoleaks are a common complication following endovascular aneurysm repair, yet type IIIb are rare, especially with newer devices, and associated with high morbidity due to repressurisation of the sac. As endografts are used in patients with longer life expectancy, late type IIIb endoleaks are to be expected. This is a report of a giant common iliac aneurysm resulting from a misdiagnosed type IIIb endoleak. Report: An 85 year old man with history of right common iliac artery aneurysm, treated in 2003 with an EXCLUDER AAA Endoprosthesis (WL Gore, Flagstaff, AZ, USA) with iliac limb extension into the external iliac artery, presented at the emergency department with abdominal pain, hypotension, and syncope. He had a known endoleak, unsuccessfully treated by relining the right iliac stent graft overlap zones for a suspected type IIIa endoleak (2009), coil embolisation, and computed tomography (CT) guided thrombin injection of the aneurysmatic sac for a type II (2010), none of which managed to treat the cause with continuous aneurysm growth. The patient refused further treatments, but agreed to maintain surveillance. At admission, CT angiography showed common iliac aneurysm (185 × 134 mm) sac rupture without a visible endoleak. Resuscitative endovascular balloon occlusion of the aorta (REBOA) technique was performed to obtain haemodynamic control, then the aneurysm was approached through a midline incision. A type IIIb endoleak was identified due to a fabric tear on the right iliac limb extension. Suture was attempted without success, then relining of the lesion with an Endurant II Limb (Medtronic, Minneapolis, MN, USA) was performed, which managed to repair the endoleak. Discussion: Type IIIb endoleaks are uncommon and underdiagnosed due to fabric defects being too small or leaking intermittently. They can mimic other types of endoleaks and may cause aneurysm growth and rupture. One should consider this type of endoleak if previous treatments for other types were unsuccessful.

INTRODUCTION: Blunt thoracic aortic injuries (BTAI) are defined as a tear in the thoracic aorta caused by a high energy blunt trauma. The most common reported mechanism of injury is motor vehicle accidents, and it can be potentially lethal. The Society for Vascular Surgery (SVS) and the European Society for Vascular Surgery (ESVS) guidelines recommend thoracic endovascular aortic repair (TEVAR) as the first line treatment for BTAI. Other controversies regarding BTAI management were reported in the literature, such as the best treatment for minimal aortic injuries with intimal tear, ideal stent graft oversizing, best timing for treatment and necessity to cover the left subclavian artery (LSA). The purpose of this review is to identify and analyze appropriate studies published so far about the management of BTAI. METHODS: We performed a thorough electronic search of the literature using PubMed and Embase databases. We used the following combination of key words in our search strategy ((aortic injury) AND (blunt thoracic trauma)) AND (vascular surgery* OR treatment* OR TEVAR*). Articles not in English were excluded. The primary subject was results of endovascular treatment. Secondary subjects were indications and results of OSR, best timing for intervention, ideal graft oversizing, need for left subclavian artery (LSA) coverage, and management of BTAI grade I (intimal tear). RESULTS: Data related to our primary and secondary subjects were extracted from the selected articles. TEVAR is considered the primary treatment for BTAI, if the patient has suitable anatomy, with good short and mid-term outcomes, with lower mortality and paraplegia rates at short and mid-term follow-up, compared to OSR. Despite good term results at short-term follow-up after TEVAR, long-term outcomes are still a concern. OSR is still a valid option in selected cases, and it should be considered for patients whose injury location is unsuitable for the endovascular approach. In most patients with BTAI, it is recommended around 10% of graft oversizing. However, a more aggressive approach with oversizing between 10-20% should be considered for patients with considerable hypotension and even >20% for patients presenting with severe hypotensive hemorrhagic shock. A necessity of LSA coverage has been reported in 30% of TEVAR for urgent treatment of BTAI, and it seems to be well tolerated. We should considered expectant approach with serial follow-up CT scans in patients with BTAI grade I injuries with asymptomatic intimal aortic tear. CONCLUSIONS: This literature review reports and synthetizes published data about the management strategies for BTAI. TEVAR seems to be effective in the treatment of BTAI, with few complications and good outcomes at short and mid-term follow-up, and it should be the first-line treatment for these patients. OSR should be an option when a patient’s injury is not suitable for endovascular approach.

INTRODUCTION: Recently published studies on peripheral arterial occlusive disease (PAOD) have revealed marked sex disparities in patient selection and treatment outcomes. In a recent retrospective study with data from 11 different countries, Portugal was highlighted as one of the countries with greater sex discrepancies related to PAOD treatment. We aimed to analyze sex specific differences in the treatment of symptomatic PAOD, concerning different variables, in a single hospital center, in Portugal. METHODS: Data on treatment of symptomatic PAOD patients from October 1st, 2020, to December 31st, 2021, were retrospectively collected from clinical registries from a single hospital center in Portugal. Different variables and post-operative outcomes were analyzed dichotomized by sex, with descriptive statistics. Statistical analyses were conducted using the IBM Statistical Package for Social Sciences (SPSS) software v28. RESULTS: A total of 220 patients, 15,9% female and 84,1% male, were treated for PAOD, in the selected period, in a hospital center from Portugal. Female patients were older (mean age of 73.8 years versus 69.5 years in male); were less likely to be treated for intermittent claudication (3% versus 6% of men); more often treated at a more advanced stage of the disease with trophic lesions (91% versus 74% of men); more likely to be offered primary major amputation (14% versus 3% of male patients); less likely to be taking statins as part of PAOD medical management (65.7% versus 77.8% of male); and had a higher 90-day mortality rate (17.1% versus 6.5% in men). They were also more frequently treated with endovascular procedures (40%) than with OSR (26%). CONCLUSION: Remarkable sex discrepancies in the treatment of PAOD were found in our hospital center. This study brings awareness to the scientific medical community for sex disparities in the management of patients with PAOD.

BACKGROUND: Individualized risk assessment using comorbidity adjustment is an important component in modern clinical practice and can be performed considering individual comorbidities or through the use of summary measures. The Charlson Comorbidity Index adjusted to age (CCIa) is the most widely validated and used comorbidity assessment tool. Studies have proved CCIa as a strong predictor of mortality for a variety of medical and surgical conditions; however, its utility in patients submitted to elective endovascular abdominal aortic aneurysm repair (EVAR) has not been studied. METHODS: Patients submitted to EVAR between January 1, 2017 and December 31, 2021 in our tertiary, academic Vascular Surgery Department were retrospectively evaluated and 123 patients fulfilled the inclusion criteria. Patient characteristics and peri-operative variables were collected and CCIa was calculated. Surgical complications were classified according to Clavien-Dindo. The area under the curve of the receiver operating characteristic curves was calculated to validate and determine the discriminating ability of CCIa in predicting complications and mortality and the Youden index used to determine the critical value. RESULTS: Mean age was 73.49±7.95 years and mean follow-up was 30.55±16.49 months. 30-day complication rate was 16%, 30-day mortality 1.63% and overall mortality 16%. Patients with higher CCIa had higher overall mortality (p=.002) but CCIa had no impact on 30-day complication rate and on 30-day mortality. Logistic regression showed that even after adjusting for patient ́s comorbidities individually, CCIa was the only independent mortality predictor (p=.003). The optimal cutoff associated with higher overall mortality was found to be ≥6. CONCLUSION: CCIa does not seem to predict complications and early mortality after EVAR but it seems to be a useful predictor of mid-term survival after EVAR. These results show the limited role of this score in predicting outcomes after surgery but may help identify a sub-population whose shorter life-expectancy should be considered towards the benefits of EVAR.

Introdução e Objetivos: A administração de heparina constitui um passo standardizado na cirurgia carotídea dada a redução de complicações tromboembólicas no período perioperatório. Esta prática não está livre de riscos visto que as complicações hemorrágicas estão associadas a um aumento de reintervenções. Historicamente, a protamina, enquanto agente capaz de reverter os efeitos anticoagulantes da heparina, tem gerado controvérsia pela alegada associação a trombose carotídea e AVC. Este artigo tem como objetivo rever a literatura publicada sobre a reversão com protamina na cirurgia carotídea. Métodos: Com recurso à plataforma Pubmed foram selecionados todos os artigos publicados desde janeiro de 2010 até à presente data tendo sido selecionados 10 artigos, onde se incluem duas meta-análises, uma revisão sistemática e seis estudos observacionais multicêntricos de larga escala. Procurou-se avaliar o risco de enfarte, AVC ou morte, bem como as complicações hemorrágicas com a administração de protamina. Resultados: De entre os artigos selecionados, seis avaliaram o efeito da protamina durante endarterectomia carotídea, três no stenting carotídeo transfemoral e um no stenting transcarotídeo (TCAR). Nos doentes submetidos a endarterectomia, todos os estudos demonstraram uma diminuição estatisticamente significativa na redução de complicações hemorrágicas nos doentes em que se administrou protamina, nomeadamente com redução nas reintervenções e na necessidade de transfusões, não tendo sido relatado em nenhum destes estudos uma diferença estatisticamente significativa na mortalidade, ocorrência de AVC ou enfarte. O único estudo que analisou a utilização da protamina no TCAR obteve resultados semelhantes aos da endarterectomia. O uso de protamina no stenting carotídeo transfemoral, não demonstrou diferenças na incidência de AVC, enfarte, morte ou redução de complicações hemorrágicas em estudos observacionais, no entanto, relacionou-se a um aumento de AVC aos 30 dias numa revisão sistemática. Analisando os doentes submetidos a reintervenção cirúrgica concluiu-se que independentemente do uso de protamina, houve um aumento estatisticamente significativo no enfarte, AVC e morte. Conclusão: A reversão com protamina na cirurgia carotídea demonstrou-se eficaz e segura, à luz da evidência científica publicada na última década, não se associando a um aumento do número de eventos trombóticos e contribuindo para a diminuição das complicações hemorrágicas, sendo estas afirmações suportadas por meta-análises e estudos observacionais com grandes populações amostrais, contrariando a controvérsia relacionada com o uso de protamina resultante de estudos históricos com base em análises de amostras de pequenas dimensões ou na experiência da própria instituição. Reforça-se deste modo a importância da administração rotineira de protamina na abordagem carotídea.

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Introduction: Suture techniques are mandatory methods to shape the nasal cartilages. For purposes of achieving a better contour on thick or globose nasal tips, the authors have approached a controlled intercrural and minimally invasive suture technique and the results obtained by submitting 34 patients to rhinoplasty. Objective: Illustrate the intercrural suture technique as a treatment for a thick or globose nasal tip under closed rhinoplasty and explain the esthetical results. Method: Retrospective study with 34 patients' clinical documents and photographs (5 male and 20 female) aged between 16 and 52, who were submitted to the thick or globose nasal tip rhinoplasty as an anatomic element found in the physical examination. In all the cases, closed rhinoplasty technique was used. A suture that cannot be absorbed is performed throughout the intermediate process. The study was performed at the Brazilian Red Cross Hospital in the State of Paraná and Sugisawa Hospital in 2009 and 2010. Patients were operated on by the main author and the junior doctors under training. Results: The controlled intercrural suture enabled the nasal tip to be narrowed and improved the shape in the frontal and lateral angles of the nasal tip. Conclusion: Controlled intercrural suture is a minimally invasive method providing the thick nasal tip narrowing with satisfactory results.

Aim: The objective of this study was to compare the effects of submucosal cauterization of the inferior turbinate with or without outfracture., Study Design: Clinical prospective., Method: Twenty patients with inferior turbinate hypertrophy were randomized and divided into two groups. The first one was submitted to submucosal cauterization associated with outfracture, and the second one without fracture. Five items were assessed to compare both methods: pain, nasal bleeding, scarring--analyzed through anterior rhinoscopy, observing edema, hyperemia and seropurulent secretion; crust formation (seen through anterior rhinoscopy); and nasal airway patency. Follow-up was performed on days 7, 14, 30., Results: In both groups crusting formation was similar. Scarring showed better results in the outfracture group in the first two weeks postoperative. The analysis of nasal airway patency showed good results in 80% of the patients submitted to submucosal cauterization with outfratcture on day 30 postoperatively., Conclusions: We concluded that submucosal cauterization of inferior turbinate with outfracture is better than the procedure without outfracture.