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Introduction: Intravascular foreign body (IFB) embolization is a potential complication of any vascular procedure. Intravascular foreign body retrieval (IFBR) can be achieved using percutaneous techniques, open surgery, or both combined. Methods: We completed a retrospective review of patients who underwent endovascular or open IFBR since 2011 on our institution. Primary end-point was technical retrieval success, and secondary end-points were procedure-related compli- cations and 30-days survival. Results: Twenty-seven patients underwent IFBR. Median time from intravascular device loss and retrieval was less than one day. 67% were non-endovascular guidewires and sheath fragments (N=28). 59% of IFBs were lost during their deployment (N=16); 41% during their removal attempts (N=11). 44% were lost in the arterial system (N=12) and 52% in the venous system (N=14). An endovascular procedure was used as the first approach in IFBR in 56% of patients (N=15) and open procedure in 44% (N=12). In the presence of IFB on the thoracic or abdominal cavity, it was always tried a first-endo approach; if IFB was present on the neck or limbs, 75% were retrieved by open surgery (N=20; p, Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 29 No. 2 (2022): Apr-Jun

Introduction: Visceral pseudoaneurysms are pathological dilations of the visceral arteries and/or their branches. They are a rare entity but with devastating consequences given their high potential for rupture and hemorrhage. The evolution of endovascular techniques has changed the paradigm in the treatment of this entity, making it the preferred option for the elective treatment of visceral pseudoaneurysms. Clinical case: The authors described the case of a pancreatic pseudoaneurysm in a young male patient, with past medical history of chronic pancreatitis and pancreatic pseudocyst, marked smoking and alcoholic habits, which presented with an abdominal pain and a drop in hemoglobin. After discussing the case with the Vascular Surgery department, it was decided towards an endovascular treatment given the patient's clinical stability and appropriate anatomical location for the proposed intervention. Coil embolization via humeral artery was performed with immediate angiographic success, and clinical, analytical and imaging improvement in the postoperative period. Conclusion: In addition to open surgical repair and laparoscopic surgery, there are also endovascular procedures for the treatment of visceral pseudoaneurysms, so the vascular surgeon must be aware with the available strategies, taking into account the patient, the characteristics and location of the visceral pseudoaneurysm.

BACKGROUND: Traumatic noniatrogenic vascular injuries in children are rare and rarely discussed in literature. Pediatric vascular injuries pose a set of challenges mainly because of continued growth and development in a child or adolescent. The purpose of the study is to characterize management strategies and outcomes in these cases. METHODS: This is a single-center retrospective review of patients less than age 18 years (pediatric age) with acute, noniatrogenic traumatic vascular injuries between January 2009 and December 2015. Patient's demographics, injury characteristics, surgical management, complications, and follow-up were analyzed. RESULTS: From 2009 to 2015, 3277 children with traumatic injuries were treated, of which 21 (0.6%) had 23 significant vascular injuries: 17 arterial and 6 venous injuries. The majority were males (n = 16), and the median age was 14 years (range 1 to 16 years). Penetrating injuries were the predominant mechanism (n = 21), mainly by glass (n = 13). At presentation, 4 patients were hemodynamically unstable, 3 of them in hypovolemic shock. All patients were managed operatively. Operations for arterial injuries included 5 primary arterial repairs, 4 repairs using vein grafts and 8 ligations. The following adjunct procedures were necessary: one 4-compartment leg fasciotomy due to associated soft tissue trauma, 8 tendon repairs, and 11 nerve repairs. Operations for venous injuries included 4 ligations and 2 primary repairs. There were no intraoperative or postoperative deaths, major complications, or limb loss. The median length of stay in the hospital was 6 days (range: 2-23 days). The median time of follow-up was 52 months (range: 20-94 months). Ten patients did not have any sequelae, and 11 patients reported impaired mobility and/or decreased sensation, which was transitory in most cases and related to associated neurological or muscle tendon injuries. All reconstructions remained patent over the course of follow-up. No limb asymmetry was observed. CONCLUSIONS: Noniatrogenic pediatric vascular trauma is uncommon. Penetrating mechanism is more common than blunt and extremities are more frequently affected. Overall complications come from associated injuries to tendons and nerves. info:eu-repo/semantics/publishedVersion

Introduction: Traumatic Thoracic Aortic Injury (TTAI) is a major cause of mortality in high-velocity trauma. While most cases result in instant death, TTAI may be present in patients with multiple traumatic injuries and therefore a high index of suspicion is necessary. Endovascular treatment offers significant advantages in this context and is now standard of care. The purpose of this study is to review our contemporary institutional experience with endovascular repair of TTAI. Methods: A retrospective analysis of discharge data for patients admitted with TTAI between 2010 and 2019 was performed from our institutional administrative database (level 1 trauma center). We extracted ICD-9 procedure code 39.73 ��� endovascular implantation of graft in the thoracic aorta and cross-checked with hospital registries to identify all TTAI cases. Follow-up was extracted from patient charts. The primary endpoints were primary technical and clinical success. Secondary endpoints were time to diagnosis and to surgical procedure relative to traumatic event, overall mortality, ongoing primary clinical success, and procedural details (upper limb revascularization, spinal drainage, systemic heparinization and endograft oversizing). Results: We identified six patients with TTAI who underwent TEVAR between 2010 and 2019. All were victims of high impact deceleration trauma, aged between 24 and 57 years old, and otherwise healthy. Additional major injuries were present in all patients (Injury Severity Score 14���57). All patients were submitted to CTA at admission which allowed for early diagnosis of TTAI and treatment in less than 24 hours in all cases expect one (which was treated in the first 48 hours). Grade III lesions were present in all six patients. All patients underwent TEVAR with 100% technical and clinical success. Three patients had a lesion that extended above the subclavian artery and consequently required subclavian coverage, but no patient was submitted to upper limb revascularization. Spinal drainage was not used in any case and there were no neurologic events. Half the patients were submitted to the procedure under systemic heparinization. The median oversizing of the endograft was 16% (10���35%). There was no in-hospital mortality nor mortality during follow-up (median duration of 35,5 months with an IIQ of 84,5 months) and the ongoing primary clinical success is 100%. Conclusion: Endovascular repair is a safe and effective therapy for TTAI even in patients with multiple trauma, and good mid-term results are expected. The procedure specifications such as the need for upper limb revascularization, use of spinal drainage, endograft oversizing, and systemic heparinization are still unclear. The long-term consequences need to be clarified., Angiologia e Cirurgia Vascular, Vol 17 No 2 (2021): June

ResumoIntroduçãoA correção cirúrgica do aneurisma da aorta abdominal (AAA), por Endovascular Aneurysm Repair (EVAR) ou cirurgia convencional (CC), pode agravar a função renal a curto prazo. Esta complicação, mais frequente nos doentes com insuficiência renal crónica (IRC), associa‐se a pior prognóstico a longo prazo. O objetivo deste trabalho foi quantificar o agravamento da função renal após reparação do AAA em doentes com IRC prévia e demonstrar o consequente aumento da morbimortalidade.MétodosEstudo retrospetivo em doentes com IRC estádios Chronic Kidney Disease 3‐4 (TFGe 15‐59ml/min), submetidos a correção eletiva de AAA entre fevereiro/2011 e fevereiro/2015 numa instituição terciária. Variáveis estudadas: idade, sexo, tipo de intervenção (convencional/EVAR) e estádio CKD. Endpoints: variação da creatinina e taxa de filtração glomerular com a cirurgia, complicações renais pós‐operatórias, necessidade de reintervenção cirúrgica e mortalidade. A análise estatística foi realizada em SPSS.ResultadosForam incluídos 71 doentes. Quinze doentes (21%) foram operados por CC e 56 (78%) por EVAR. À data da intervenção, os doentes encontravam‐se nos seguintes estádios da DRC: CKD 3 – 65 (91%) e CKD 4 – 6 (9%). A variação da TFG com a cirurgia foi −1,08±18,01mg/dl. Verificou‐se IRC agudizada pós‐operatória em 22 (31%) doentes e necessidade de diálise em 5 (7%). A mortalidade global foi 8,5%. Os doentes operados por EVAR tinham DRC mais avançada pré‐operatoriamente, mas apresentaram menor agravamento da função renal. Variação TFG: EVAR 1,14±16,26ml/min vs. CC 9,40±22,11ml/min (p=0,022); variação creatinina: EVAR 0,17±1,03mg/dl vs. CC 0,81±1,47mg/dl (p=0,02). A agudização da IRC pós‐operatória foi superior no grupo CC (53,3 vs. 28,6%; p=0,072), assim como a necessidade de diálise (20 vs. 3,6%, p=0,06). Os 6 doentes que faleceram (EVAR: 3; CC: 3) apresentaram maior agravamento da função renal (variação da creatinina: 1,41±1,63mg/dl vs. 0,20±1,07mg/dl, p=0,001; variação da TFG: −19,0±16,55ml/min; 0,57±17,34ml/min, p=0,007) e necessidade de diálise (50 vs. 3,1%, p=0,003).ConclusãoOs resultados demonstraram uma tendência para uma menor probabilidade de IRA, menor necessidade de diálise pós‐operatória e menor mortalidade nos doentes tratados por EVAR. Contudo, o impacto da administração de contraste a médio/longo prazo, decorrente dos programas de vigilância pós‐EVAR, deve ser considerado.Julgamos ser possível considerar que a realização de EVAR para o tratamento de doentes com AAA e IRC é um procedimento pelo menos tão seguro como a CC.AbstractIntroductionSurgical repair of AAA through EVAR or conventional surgery (CS) can worsen renal function in the short‐term. This complication, more common in patients with CKD, is associated with worse long‐term prognosis. The aim of this study was to quantify the deterioration of renal function after AAA repair in patients with previous IRC and demonstrate the resulting increase in morbidity and mortality.MethodsRetrospective study of patients with CKD stages 3‐4 (eGFR 15‐59mL/min) undergoing elective repair of AAA between February/2011 and February/2015 in a tertiary institution. Studied variables: age, gender, type of intervention (CS/EVAR) and CKD stage. Endpoints: change in creatinine and GFR with surgery, postoperative renal complications, need for another surgical intervention and mortality. Statistical analysis was performed in SPSS.ResultsWe included 71 patients. Fifteen (21%) underwent CS and 56 (78%) EVAR. At the time of intervention, patients had the following stages of CKD: CKD 3 ‐ 65 (91%); CKD 4 ‐ 6 (9%). GFR change with surgery was −1.08±18.01mg/dl. Worsened postoperative IRC occurred in 22 (31%) patients and 5 (7%) needed dialysis. Overall mortality was 8.5%. Patients operated by EVAR had more advanced CKD preoperatively, but showed less worsening of renal function. GFR variation: EVAR 14.1±16.26ml/min vs CS −9.40±22.11ml/min (p=0.022); creatinine variation: EVAR 0.17±1.03mg/dl vs CS 0.81±1.47mg/dl (p=0.02). CKD worsening was superior in the CS group (53.3% vs 28.6%; p=0.072) as well as the need for dialysis (20% vs 3.6%, p=0.06). The 6 patients that died (EVAR: 3; CC: 3) showed greater worsening of renal function (creatinine variation: 1.41±1.63mg/dl vs. 0.20±1.07mg/dl, p=0.001; GFR change: −19.0±16.55ml/min; 0.57±17.34ml/min, p=0.007) and need for dialysis.ConclusionThe results showed a trend towards a lower probability of acute renal failure, less need of post‐operative dialysis and lower mortality in patients treated by EVAR. However, the medium/long term impact of contrast administration, due to post‐EVAR surveillance programs, should be regarded.We believe that it is possible to consider that the use of EVAR for the treatment of patients with AAA and CKD is a procedure at least as safe as CS.

Objetivo: Determinar a influência da anatomia do aneurisma da aorta abdominal (AAA) nos resultados a curto e médio prazo após Endovascular Aneurysm Repair (EVAR). Métodos: Estudo retrospetivo de todos os doentes com AAA infrarrenal sem menção de rotura resultados a curto e médio prazo após Endovascular Aneurysm Repair (EVAR). Métodos: Estudo retrospetivo de todos os doentes com AAA infrarrenal sem menção de rotura submetidos a EVAR aorto-biilíaco programado na nossa instituição entre 2011-2013 (n = 112). Todos os exames de follow-up imagiológico foram analisados numa plataforma com Osirix® e foram realizadas medições anatómicas com center lumen line. Apenas foram incluídos os doentes com um follow-up imagiológico superior a 12 meses, o que resultou na exclusão de 33 (29%) casos. Os doentes foram divididos em 2 grupos: grupo com «anatomia favorável para EVAR» (f-IFU); grupo com «anatomia desfavorável para EVAR» (df-IFU). Resultados: Dos 79 doentes elegíveis para o estudo, 35,5% (n = 28) foram realizados em doentes do grupo df-IFU. Estes doentes apresentaram AAA com maiores dimensões (64,4 ± 10,1 mm vs. 60,6 ± 10,8 mm, p = 0,046) e colos mais curtos (19,8 ± 11,8 mm vs. 30,4 ± 14,4 mm, p = 0,001). A endoprótese mais utilizada foi a Endurant® (54,5%). Constatou-se que o grupo df-IFU é tratado mais frequentemente com endopróteses com sistema de fixação suprarrenal (85,7% df-IFU vs. 69% f-IFU, p = 0,048). O tempo médio de follow-up foi de 21,9 ± 9,8 meses (12-46 meses). A taxa de mortalidade perioperatória (0% df-IFU vs. 2% f-IFU) e a taxa de mortalidade global por todas as causas (12% df-IFU vs. 11,9% f-IFU) foi semelhante nos 2 grupos (p > 0,05). Não por todas as causas (12% df-IFU vs. 11,9% f-IFU) foi semelhante nos 2 grupos (p > 0,05). Não se verificaram diferenças significativas nas taxas de endoleak (curto prazo 25% df-IFU vs. 22% f-IFU; médio prazo 12% df-IFU vs. 23,8% f-IFU) nem nas taxas de reintervenção (curto prazo7,2% df-IFU vs. 8% f-IFU; médio prazo 4% df-IFU vs. 4,8% f-IFU) (p > 0,05). Conclusão: A realização de EVAR em doentes com anatomia desfavorável produziu resultados que são comparáveis aos dos doentes com anatomia favorável, quer a curto quer a médio prazo. São necessários estudos a longo prazo para confirmar estes achados. Background: The goal of this study is to determine the influence of abdominal aortic aneurysm (AAA) anatomy in endovascular aneurysm repair (EVAR) short and mid-term outcomes. Methods: A total of 112 patients underwent programed aorto-biiliac EVAR at a single center between January 2011 and December 2013. Pre and postoperative imaging follow-up were retrospectively reviewed and anatomical measures were calculated on Osirix® with center lumen line. Only patients with a postoperative imaging follow-up of more than 12 months were included, resulting in the exclusion of thirty three (29%) cases. Patients were divided into 2 groups: the ‘‘EVAR suitable anatomy'' group (f-IFU) and the ‘‘EVAR challenging anatomy'' group (df-IFU). Results: A total of 35.5% (n = 28) patients were in the df-IFU group. These patients had larger AAA diameter (64.4 ± 10.1 mm vs 60.6 ± 10.8 mm) and shorter proximal neck (19.8 ± 11.8 mm vs 30.4 ± 14.4 mm) (p < 0.05). The device preferentially used was Endurant® (54,5%). The df-IFU group was more likely to be treated with suprarenal fixation devices (85.7% df-IFU vs 69% f-IFU, p = .048). Mean follow-up was 21,9 ± 9,8 months (12-46). Perioperative mortality (0% df-IFU vs 2% f-IFU) and all-cause mortality rates (12% df-IFU vs 11,9% f-IFU) were similar between the two groups (p > 0.05). There was no significant difference in endoleak rate (short-term 25% df-IFU vs 22% f-IFU; mid-term 12% df-IFU vs 23.8% f-IFU) and in re-intervention rates (short-term 7.2% df-IFU vs 8% f-IFU; mid-term 4% df-IFU vs 4.8% f-IFU)(p > 0.05). Conclusion: Endovascular treatment of AAA patients with challenging anatomy for EVAR provided acceptable short and mid-term results that are comparable to those in patients with suitable anatomy. Long-term follow-up is unreliable necessary to confirm these results.

Symptomatic or ruptured abdominal aortic aneurysms (rAAA) maintains a high mortality index despite technical advances in its treatment. The influence of patients' geographic location on rAAA outcomes, when the rupture occurs or when the AAA becomes symptomatic, has not been a commonly studied issue. Due to the lack of research on this matter, the impact of interhospital transfer on mortality is ambiguous.Evaluate the influence of the geographic location of patients with symptomatic AAA or rAAA on AAA mortality.Retrospective review of all cases of symptomatic AAA and rAAA submitted to surgery in a tertiary institution, between January 2011 and August 2017. The main outcome was in-hospital mortality. Secondary outcomes were admission to intensive care unit (ICU), length of ICU and hospital stay, type of repair and anesthesia and weekend presentation. Data was submitted to univariable analysis and logistic regression. Statistical significance was considered if the p value was0.05.During the defined period of 80 months, a total of 135 patients were admitted with the diagnosis of symptomatic or rAAA and submitted to surgery. Most patients had a ruptured AAA (90.4%, n=122), while symptomatic AAA represented a minority (9.6%, n=13). All patients (91.1% male gender, mean age 74±10 years) were submitted to surgery, 83 (61.5%) by endovascular repair and 52 (38.5%) by open repair, 30.4% with local anesthesia and sedation (n=41), all in the endovascular group. 92 patients (68.1%) were transferred from other hospitals, with a mean distance of 113±88 km. In this cohort, in-hospital mortality was 31.5% in transferred patients and 34.9% in not transferred patients. Subgroup analysis revealed that there were no significant differences between transferred and not transferred patients' groups concerning main outcome (p=0.35), baseline characteristics (age and gender), type of surgery and anesthesia, weekend presentation, ICU admission, length of ICU and hospital stay. Logistic regression analysis revealed that the variables associated with mortality were female gender (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.40-3.70; p0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p0.01).Our study revealed that transfer of patients for urgent repair of AAA was not associated with an increased mortality. The hypothetical increased mortality due to transfer might have been compensated by endovascular treatment and local anesthesia in some cases. Further studies must be carried out, particularly comparing endovascular and open repair in emergency setting.

Penetrating aortic ulcer (PAU) is classically included in acute aortic syndromes, together with aortic dissection and intramural hematoma. These three disorders are considered different stages of the same disease. PAU is the result of medial degeneration with disruption of the intima, mainly due to atherosclerotic risk factors. Most of them are located on descending thoracic aorta and only a few small series and case reports demonstrate location on infrarenal abdominal aorta. Clinical presentation varies in spectrum, from asymptomatic to fatal aortic rupture. Treatment options include medical therapy, particularly strict blood pressure control, and surgical approach. Nowadays endovascular exclusion is commonly performed, although open surgical reconstruction remains the gold standard.Report a case of endovascular repair of an infrarenal abdominal PAU.A 72-year-old man, with hypertension, type 2 diabetes, hypercholesterolemia, lumbar osteoarthrosis, was referred to Vascular Surgery outpatient clinic with the diagnosis of infrarenal abdominal PAU on a Computed Tomography Angiography (CTA). This exam was performed due to chronic lumbar complaints from lumbar osteoarthrosis. The patient denied any other complaint. Physical examination was normal. A thoraco-abdomino-pelvic CTA revealed two sites of PAU in the infrarenal aorta with 10mm and 21mm of depth and associated aortic enlargement of 39mm maximum diameter. This exam revealed an enlargement of the depth of the PAU and the aorta diameter in 2 and 3mm, respectively, in the course of 2 months. An EVAR was performed, in a standard aorto-biiliac fashion. The post-operative period was uneventful and the patient discharged 3 days later. 1 month after the surgery, patient remained asymptomatic and the follow-up CTA demonstrated exclusion of both PAU, no endoleaks and stability of aortic diameter. A long term follow-up should be maintained, as for regular EVAR.PAU is a rare clinical entity, with infrarenal abdominal aorta location even scarcer. Asymptomatic patient must be regularly followed and threshold to treatment low, bearing in mind the possible catastrophic evolution of the disease. Endovascular approach should be considered as a first approach, considering the technical feasibility and the comorbidities associated with this elderly population.

With increasing use of percutaneous vascular procedures, access complications that present to a vascular surgeon increase. The most limb-threatening condition is acute limb ischaemia. Acute limb ischaemia is the most common vascular surgical emergency. In spite of recent advances in vascular surgery, it continues to carry a poor prognosis, if not early diagnosed and managed.This is a case-report of 2 patients referenced to a vascular surgery emergency department of a tertiary hospital with late acute limb ischaemia.Patient 1: Male, 42 years, alcoholic, autonomous, presented with pain with elbow active movements in a secondary hospital. Excluded acute orthopaedic injury, doctor recorded signs of acute limb ischaemia and referenced patient to a tertiary hospital, where vascular surgeon diagnosed an acute advanced upper limb ischaemia. Bed-side Eco-Doppler showed an echogenic linear material on a thrombosed umeral artery, surgically confirmed to be a guidewire (Fig.1. Surgical extraction of intra-umeral guidewire). Reviewing patient history, this guidewire should have been missed over 6 months, by the time the patient was hospitalized on an ICU for alcoholic coma. Patient underwent umeral, radial and ulnar thromboembolectomy and had a no-reflow status. However, poor persistent global status, with limited mobilization, pressure forces and prolonged vasotropic support, promoted progression of a cyanotic leg plaque to a necrotic evolving leg ulcer with septic response, despite persistent good perfusion of the foot (Fig.2. Necrotic evolving leg ulcer). Unfortunately, the two reported patients underwent urgent major limb amputation, patient 1 above the elbow, and patient 2 above the knee.Acute limb ischaemia continues to carry a poor limb and life prognosis if not early diagnosed. We should be alert for the increasingly prevalence of iatrogenic acute limb ischaemia, and regularly evaluate perfusion status of limbs after any percutaneous procedure.

Nowadays, axillofemoral bypass is viewed as an end-of-line solution for lower limb revascularization, owing to its classically described poor long-term patency, and recent advances in endovascular options for patients with complex aortoiliac anatomy not suitable for open reconstruction. There is a marked difference in patient profiles in published series of axillofemoral bypass, reflecting changing procedures indications due to technical innovations. The objective of this study is to determine the contemporary profile of patients treated with axillofemoral bypass and their outcome.Patients who underwent axillofemoral bypass surgery in a tertiary hospital from April 2011 to September 2017 were identified. Surgical indication, patency, amputation and death rates were recorded. Patients were grouped in axillouni vs axillobifemoral, 1st revascularization procedure vs reintervention, and primary aortoiliac occlusive disease vs primary aneurysmal disease, and were compared using Kaplan-Meier survival analysis.54 patients were included. 80% underwent an axillobifemoral bypass. Median age was 67 years; 96% were male. The most prevalent cardiovascular risk factors were HTA (81%) and history of smoking (76%). Primary vascular disease was aneurysmal in 24% of patients. The remaining group had peripheral occlusive arterial disease. In 53%, axillofemoral bypass was the first revascularization performed (naif group). On these, indications for this procedure were aorto-iliac occlusive disease (89%) and AA thrombosis (19%). In patients previously submitted to revascularization (47%), the most common first procedures were aortobifemoral bypass (56%), femoro-femoral bypass (44%) and EVAR (36%). Indications for axillofemoral bypass on this group were: prosthesis thrombosis (64%), secondary aorto-enteric fistulae (28%) and prosthesis infection (8%). Primary patency of axillofemoral bypass was 93% at 1 month and 80% at 5 years (Graphic 1). Differences were not significant regardless the vascular surgery status (naif vs reintervention), but axillobifemoral bypass and aneurysmal disease groups had a higher patency than axillounifemoral bypass and occlusive disease groups, respectively. No patient with aneurysmal disease required amputation over a 5-year follow-up. In primary occlusive disease group, 88% of patients were free-of-amputation at 1 month and 83% at 5 years. Patients who underwent this procedure had a survival rate of 78% at 1 month and 59% at 5 years (Graphic 2). No major difference was recorded between study groups.Axillofemoral bypass, although being an increasingly uncommon procedure, still allows acceptable rates of patency and limb salvage. As patients with aortoiliac disease usually have multiple comorbidities and a short life- -expectancy, axillofemoral bypass is attractive owing to its less invasive character.

Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare clinical entity characterized by celiac trunk compression by median arcuate ligament and variable gastrointestinal symptoms (postprandial epigastric pain, nausea, weight loss, anorexia and diarrhea). However, some degree of radiographic compression is observed in 10%-24% of asymptomatic patients. Besides the extrinsic vascular compression, MALS has a multifactorial etiology and it has been suggested as a neurogenic disease resulting in altered sensation and pain from the somatic nerves in the splanchnic plexus. MALS is a diagnosis of exclusion, so other causes must be excluded. Treatment options include release of median arcuate ligament (open, laparoscopic or robot-assisted) and open vascular reconstruction. Endovascular treatment is currently used only as adjuvant procedure after surgical approach, in refractory cases with residual stenosis of celiac trunk.To report a case of MALS and to review current literature.The authors report a clinical case and present a literature review using PubMed with the terms "median arcuate ligament", "Dunbar syndrome" and "MALS treatment" as major topics. The bibliography of relevant articles has been checked to identify other significant papers.A 34-year-old woman, previously healthy, recurred to a General Practitioner with a recurrent epigastric pain, exacerbated by ingestion, without relieving factors, in the previous 6 months. Patient also reported anorexia and unprovoked weight loss of 8Kg over 3 months. Physical examination was normal. Other gastrointestinal pathologies were ruled out. Computed Tomography Angiography (CTA) abdomen revealed a focal 80% stenosis of the celiac trunk, located 8mm from its origin in aorta and a post- -stenotic enlargement of 9mm. An open decompression of the celiac trunk was performed. Through an 8cm median supraumbilical laparotomy, supraceliac abdominal aorta was approached. The compressive band across the celiac trunk was identified and cut. Further dissection was performed until the celiac artery became completely exposed and its branches identified. The postoperative period was uneventful and the patient was discharged 5 days later, with normal gastrointestinal transit and without recurrence of the abdominal pain. 1 month later, the patient remained asymptomatic. A long-term follow-up with annual duplex scan and clinical evaluation must be done, in order to evaluate the need of a revascularization due to persistent stenosis or aneurysmal degeneration.MALS diagnostic and therapeutic approach must be patient focused, bearing in mind the multiple clinical presentation and treatment options. Open surgical decompression of median arcuate ligament is the base of therapy.

To report a case of median arcuate ligament syndrome (MALS) and to review current literature.Case report and literature review using PubMed with the terms "median arcuate ligament", "Dunbar syndrome" and "MALS treatment" as major topics. The bibliography of relevant articles has been checked to identify other significant papers.Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare clinical entity characterized by celiac trunk compression by median arcuate ligament and variable gastrointestinal symptoms. However, some degree of radiographic compression is observed in 10%-24% of asymptomatic patients, so MALS is a diagnosis of exclusion. Treatment options include release of median arcuate ligament (open, laparoscopic or robot-assisted) and open vascular reconstruction. Endovascular treatment is currently used only as adjuvant procedure after surgical release of median arcuate ligament. A 34-year-old woman, previously healthy, presented with a epigastric pain, mainly postprandial, for 6 months, associated to anorexia and unprovoked weight loss of 8kg over 3 months. Physical examination was normal. Other gastrointestinal pathologies were ruled out. Abdomino-pelvic computed tomography angiography revealed a focal 80% stenosis of proximal celiac trunk. An open decompression of the celiac trunk was performed. The postoperative period was uneventful and the patient was discharged 5 days later, with normal gastrointestinal transit and without abdominal pain recurrence.MALS diagnostic and therapeutic approach must be patient focused, bearing in mind the multiple clinical presentation and treatment options. Open surgical decompression of median arcuate ligament is the base of treatment.Objetivos: Descrever um caso clínico de síndrome do ligamento arqueado do diafragma (SLA) e realizar uma revisão da literatura. Métodos: Descrição de um caso clínico e revisão da literatura com recurso ao PubMed com os termos “median arcuate ligament”, “Dunbar syndrome” e “MALS treatment”. A bibliografia dos artigos relevantes foi verificada para identificar outros artigos pertinentes. Resultados: A síndrome do ligamento arqueado (SLA) ou síndrome de Dunbar é uma entidade clínica rara caracterizada pela compressão do tronco celíaco associada a sintomas gastrointestinais variáveis. No entanto, algum grau de compressão radiográfica é observado em 10-24% de doentes assintomáticos, o que torna o diagnóstico de SLA de exclusão. As opções terapêuticas incluem a secção do ligamento arcuato (via convencional, laparoscópica ou robótica) e a reconstrução vascular. A abordagem endovascular é atualmente utilizada apenas como procedimento adjuvante após a secção do ligamento arqueado. Doente do sexo feminino de 34 anos de idade, previamente saudável, recorre ao médico assistente por um quadro de dor epigástrica, especialmente pós-prandial, com 6 meses de evolução, associada a anorexia e perda ponderal não provocada superior a 8kg, num período de 3 meses. O exame objetivo não relevou alterações. Outras patologias gastrointestinais foram excluídas. A angiografia por tomografia computorizada revelou uma estenose focal de 80% na porção proximal do tronco celíaco. A doente foi submetida a uma descompressão cirúrgica por via convencional. O período pós-operatório decorreu sem intercorrências, tendo alta 5 dias após a intervenção com o trânsito gastrointestinal restabelecido e sem recorrência da dor abdominal. Conclusão: A abordagem diagnóstica e terapêutica do SLA deve ser individualizada e focada no doente, tendo em conta as múltiplas apresentações clínicas e possíveis opções terapêuticas. A descompressão cirúrgica convencional do ligamento arqueado continua a ser a base do tratamento.

ResumoIntroduçãoA neurofibromatose tipo I (NF1), também designada doença de Von Recklinghausen, é causada por uma anormalidade no cromossoma 17, de transmissão autossómica dominante, responsável pela produção deficiente de neurofibromina. Caracteriza‐se por displasia nos tecidos mesodérmicos e neuroectodérmicos, e tem uma incidência de um para 2.500‐3.300 nascimentos. A presença de manchas café‐au‐lait, neurofibromas cutâneos e hamartomas da íris são sinais cardinais da doença.Primeiramente descrita por Ruebi em 1945, a patologia vascular é uma complicação subestimada e pouco reconhecida na NF1.A ocorrência de hemorragia fatal ou quase fatal está reportada ocasionalmente nas cavidades pleural, abdominal, retroperitoneu, tecidos moles do tronco e extremidades. Esta hemorragia massiva é causada pela rutura de vasos sanguíneos friáveis, característicos pelos níveis reduzidos de neurofibromina e consequente proliferação endotelial e de músculo liso nas artérias e veias. Uma das consequências clínicas mais sérias descritas na NF1 é a ocorrência de hemorragia severa e dificuldade em alcançar controlo hemostático.ObjetivoExposição de caso clínico de extenso hematoma cervical e hemotórax espontâneos por rutura troncos venosos braquiocefálico, veia subclávia e junção subclávio‐jugular em doente com NF1.Caso clínicoRelata‐se caso clínico de mulher de 51 anos, com antecedentes conhecidos de NF1 e hipertensão arterial.Foi admitida no serviço de urgência em choque hipovolémico hemorrágico, no contexto de dor súbita no ombro direito e volumosa tumefação cervical direita. Em angioTC foi objetivado volumoso hematoma, envolvendo a região cervical direita, a região retrofaríngea‐prevertebral, escavado supraclavicular direito, mediastino, associando a importante hemotórax direito.Procedeu‐se a abordagem supraclavicular com drenagem do hematoma e identificação de fontes hemorrágicas, nomeadamente: tronco venoso braquicefálico, veia subclávia e confluência subclávio‐jugular. Foi necessária secção da clavícula para controlo hemorrágico e realização de rafias dos troncos venosos com prolene. Intraoperatoriamente, foi evidente a fragilidade e friabilidade excessiva dos vasos sanguíneos. Após controlo hemorrágico, foi realizada videotoracoscopia para drenagem de hemotórax e evacuação de coágulos, confirmando‐se a ausência de hemorragia ativa.No pós‐operatório a doente recuperou estabilidade hemodinâmica, sem evidência analítica de queda de hemoglobina. Realizou‐se angioTC, onde se confirmou franca melhoria do hematoma cervical direito e retrofaríngeo em critérios quantitativos, e ausência de extravasamento de contraste. Objetivou‐se adicionalmente aneurisma sacular da artéria vertebral direita, corrigido ulteriormente através de embolização com coils.ConclusãoA NF1 é uma doença genética que raramente se pode associar a hemorragia life‐threatening. A vasculopatia é uma complicação subestimada e pouco reconhecida na NF1. A existência de friabilidade vascular excessiva com consequente hemorragia espontânea na NF1 é rara e pode ser fatal, exigindo um diagnóstico rápido e tratamento atempado.AbstractIntroductionNeurofibromatosis type1 (NF1), also known as Von Recklinghausen disease, is caused by an autosomal dominant abnormality in chromosome 17, responsible for the impaired production of neurofibromin. The presence of cafe‐au‐lait spots, neurofibromas and iris hamartomas are cardinal signs of the disease. The occurrence of a fatal or near‐fatal haemorrhage is reported in pleural, peritoneal, retroperitoneum, soft tissues of the trunk and extremities. The massive hemorrhage is caused by rupture of friable blood vessels as a consequence of impaired expression of neurofibromin in the arteries and veins. One of the most serious clinical consequences described in NF1 is the occurrence of severe haemorrhage and difficulty achieving hemostatic control.ObjectivesWe report a case of spontaneous massive cervical hematoma and hemothorax as a result of venous rupture of innominate, subclavian and subclavian‐jugular veins junction in a NF1 patient.Case reportA 51 year‐old woman with past history of neurofibromatosis type I and hypertension was admitted to the emergency department with an haemorrhagic shock in the clinical set of a sudden right shoulder pain and a expansive right cervical swelling. The CT angiography showed a massive hematoma, involving the right cervical, retropharyngeal‐prevertebral, right supraclavicular and the mediastinum regions, associated with an important right haemothorax.Through a supraclavicular approach, it was performed hematoma drainage and identification of bleeding sources including: brachycephalic venous trunk, the subclavian vein and subclavian‐jugular confluence. It was required clavicle section to achieve haemorragic control and suture the ruptured venous trunks. A VATS was performed for haemothorax drainage and confirmed the absence of active bleeding.A postoperative CT angiography confirmed the resolution of the right cervical hematoma and absence of contrast extravasation. Additionally it was found a saccular aneurysm of the right vertebral artery corrected later by embolization with coils.ConclusionNF1 is a genetic disorder that rarely can be associated with life‐threatening haemorrhage. The vasculopathy is an underestimated complication with limited recognition in NF1. The excessive vascular friability with spontaneous bleeding in NF1 is rare and can be fatal, requiring a timely diagnosis and prompt treatment.

Objetivos: Avaliar as vias de referenciação dos doentes com estenoses carotídeas sintomáticas que foram operados na nossa instituição; estruturar os tempos de espera desde os primeiros sintomas neurológicos à data da cirurgia; identificar os fatores responsáveis pelos atrasos e criar estratégias que permitam reduzi-los. Material e métodos: Realizou-se um estudo observacional retrospetivo de todos os doentes com estenoses carotídeas sintomáticas submetidas a endarterectomia carotídea na nossa instituição entre 2011-2013. Foram identificadas as etapas essenciais no processo de referenciação dos doentes e foram colhidos dados referentes às datas do início dos sintomas, primeiro contacto médico, exames de imagem vascular, referenciação ao cirurgião, consulta de cirurgia vascular e da endarterectomia carotídea. O tempo decorrido entre o evento neurológico e a cirurgia foi calculado em dias e todos os atrasos identificados foram analisados detalhadamente. Resultados: A mediana do tempo de espera do evento neurológico à cirurgia foi de 27,5 dias (intervalo 7-581). Os maiores atrasos verificaram-se entre a data em que é colocada a indicação cirúrgica e a endarterectomia carotídea (mediana 9 dias; intervalo 1-349); na referenciação dos doentes à consulta de cirurgia vascular (mediana 6,5 dias; intervalo 0-97) e entre o primeiro contacto médico e a realização dos exames de imagem vascular (mediana 6 dias; intervalo 1-71). Dos 60 doentes incluídos, apenas 21,7% foram operados nos primeiros 14 dias após o evento neurológico. O atraso foi significativamente menor nos doentes admitidos de forma urgente por transferência inter/intra-hospitalar (n = 30; mediana 15 dias, intervalo 7-163) comparativamente aos doentes admitidos eletivamente pela consulta (n = 30; mediana 86 dias, intervalo 13-581 dias) (p < 0,0001). Discussão: Apesar da evidência atual, ainda existem atrasos significativos no processo de referenciação dos doentes com estenoses carotídeas sintomáticas. Estratégias direcionadas à redução destes atrasos poderão aumentar substancialmente a proporção de doentes submetidos a endarterectomia carotídea até 14 dias após o evento neurológico inicial. Goals: Examine the referral process of patients with symptomatic carotid stenosis submitted to carotid endarterectomy in our institution; organize and analyse wait times since the index ischemic event to carotid surgery; identify reasons for delays and create improvement strategies. Methods: We conducted a retrospective study of all patients with symptomatic carotid stenosis submitted to carotid endarterectomy between 2011 and 2013 in our institution. The milestones of the referral process were noted and the date of symptom onset, first medical contact, vascular imaging, referral to and evaluation by vascular surgery, and carotid endarterectomy were recorded. The length of time between each milestone was calculated and reasons for delays were analysed. Results: Median time from index ischemic event to carotid endarterectomy was 27.5 days (range 7-581). The largest wait time intervals occurred between vascular surgical assessment and carotid endarterectomy (median of 9 days; range 1-349); between referral to vascular surgery and completion of vascular surgical assessment (median of 6.5 days; range 0-97) and between the first medical contact and completion of vascular imaging (median of 6 days; range 1-71). A total 60 patients were included. Only 21.7% received carotid endarterectomy within the recommended 14 days. Inpatient referral was associated with a shorter delay to carotid endarterectomy (n = 30; median 15 days, range 7-163) comparing to outpatient referral (n = 30; median 86 days, range 13-581) (p < 0.0001). Discussion: Although current evidence, delays in carotid endarterectomy are still meaningful. Strategies to reduce these delays are needed in order to ensure that a greater proportion of patients with symptomatic carotid disease receive carotid endarterectomy within the recommended 14 days from the index ischemic event.

Lightweight aggregate is an important material in reducing the unit weight of concrete and it is essential in the construction of high-rise buildings; besides, the use of recycled PET bottles as lightweight aggregate in concrete is an effective contribution for environmental preservation. So, the objective of the present work is to study the flexural strength of PET-concrete and PET thermal degradation in the concrete, when the blends with 10 and 20 vol% of PET are exposed to different temperatures ( 200 , 400, 600 °C). The flexural strength of PET-concrete exposed to a heat source is strongly dependent on the temperature, the water/ cement ratio, as well as on the content and particle size of PET. Furthermore, the activation energy for PET degradation is affected by temperature, location of PET particles on the slabs and the water/cement ratio. A higher content of water gives rise to hydrolytic degradation on PET and a higher vapor pressure that increases the formation of cracks on the concrete. The values of activation energy are higher on the center of the slabs than on the surface, due to the poor heat conduction of concrete.

Introdução: O tratamento endovascular da aorta torácica (TEVAR) é uma modalidade terapêutica emergente que tem vindo a revolucionar a abordagem de diferentes tipos de patologia da aorta na sua localização torácica. Objetivos: Avaliação da experiência institucional do serviço de angiologia e cirurgia vascular. Métodos: Análise retrospetiva da série consecutiva de todos os doentes com patologia da aorta torácica e/ou toracoabdominal submetidos a TEVAR na nossa instituição. Foram excluídos aqueles com uso concomitante de endopróteses fenestradas/ramificadas abdominais. Resultados: Desde abril de 2005 até abril de 2014, 79 doentes foram submetidos a TEVAR, com idade média de 66 ± 12,83 anos (máx: 86; mín: 14). As indicações incluíram: 46 aneurismas (58%), 17 dissecções aórticas clássicas tipo B (22%), 13 no contexto de outras síndromes aórticas agudas (16%), 2 por ateroembolismo (3%) e um por fístula aortoesofágica (1%). Na patologia aneurismática, a distribuição anatómica da doença foi a seguinte: 5 na aorta ascendente e arco aórtico (11%), 35 na aorta torácica descendente (76%) e 6 toracoabdominal (13%). O diâmetro médio das dilatações aneurimáticas foi de 69,64 mm (máx: 150 mm). A rotura foi uma apresentação da patologia em 21,5% dos doentes (n = 17); 20,9% dos doentes tinham antecedentes de cirurgia aórtica prévia. A dissecção aórtica tipo B complicada foi a segunda indicação mais comum, sendo de apresentação aguda em 13 (76%) e crónica em 4 (24%). As complicações na base da intervenção foram dilatação aneurismática em 35% (n = 6), malperfusão com isquemia de órgão alvo 47% (n = 8), desconhecida em 18% (n = 3). Foi realizada extensão distal com stent descoberto (Petticoat) em 9 casos (41,2%) e foram realizados procedimentos adjuvantes em 18% (stenting renal n = 2; stenting ilíaco n = 1). Dentro das outras síndromes aórticas agudas, o TEVAR foi realizado no contexto de úlcera aórtica penetrante (n = 4), hematoma intramural (n = 4) e os restantes por rotura/pseudoaneurisma (n = 5). As endopróteses utilizadas foram: 32 Valiant Medtronic®, 15 TAG Gore®, 25 Zenith TX2 Cook®, 2 Zenith TX1 Cook®, uma Relay Plus®, 3 Talent Medtronic® e outras em 1%. A mediana de dias de cuidados intensivos foi 2 (intervalo 0-42) e a mediana de suporte tranfusional foi de 2 UCE. A taxa de mortalidade aos 30 dias ou intra-hospital foi de 18% (n = 14). Atendendo ao timing da cirurgia, a taxa de mortalidade aferida nos casos electivos foi de 8% (4/50) e nos urgentes atinge os 35% (10/29). Intraoperatoriamente foram tratadas 7 complicações relacionadas com vaso de acesso membro, 2 casos de dissecção aórtica iatrogénica, um caso de trombose arterial inferior e um endoleak tipo IA. A taxa de reintervenções foi de 17%, com as seguintes indicações: 9 endoleaks, 2 isquemias mesentéricas e 2 fístulas aortoesofágicas. Conclusões: A série apresentada traduz uma experiência institucional favorável com resultados reprodutíveis e que o TEVAR é um procedimento seguro e eficaz para o tratamento de diferentes patologias da aorta torácica, quando comparado com o tratamento cirúrgico aberto. Introduction: Endovascular treatment of the thoracic aorta is a technique which has revolutionized the treatment of different aortic pathologies. Objectives: Our purpose is to evaluate our institutional experience Methods: We present a retrospective analysis of a consecutive series of patients who underwent TEVAR at our Instituition. Patients who received fenestrated/branched abdominal devices were excluded. Results: From April 2005 to Abril 2014, 79 patients with a mean age of 66 ± 12.83 years (range 14 to 86) underwent TEVAR. The indications included: 46 thoracic aortic aneurysms (TAA) (58%), 17 aortic dissections (AD) Stanford B (22%), 13 due to other acute aortic syndromes (AAS) (16%), 2 due to atheroembolism (3%) e 1 due to an aortic-esophageal fistula (1%). The aortic aneurysms were located to the ascending aortic and arch in 5 cases (11%), the descending thoracic aorta in 35 (76%) and the thoracoabdominal aorta in 6 (13%). Mean aneurysm diameter was 69.64 mm (max 150 mm). Rupture was the clinical presentation in 21.5% of the patients (n = 17). 20.9% of the patients had previous aortic surgery. TEVAR was performed for acute complicated Stanford type B AD in 13 patients (76%) and for chronic AD in 4 (24%). AD-related complications included aneurysmatic dilatation in 35% (n = 6), organ malperfusion in 47% (n = 8). The Petticoat technique was performed in 9 cases (41.2%) and adjuvant procedures were necessary in 18% (renal artery stenting in 2; iliac artery stenting in 1). Regarding the other AAS, TEVAR was performed due to penetrating aortic ulcer in 4 cases, intra-mural hematome in 4 and in 5 cases due to rupture/pseudoaneurysm. The deployed endografts included 32 Valiant Medtronic®, 15 TAG Gore®, 25 Zenith TX2 Cook®, 2 Zenith TX1 Cook®, 1 Relay Plus®, 3 Talent Medtronic®. The median length of stay in the intensive care unit was 2 days (range 0-42) and median 2 units of erythrocytes was transfused per patient. Thirty-day/intrahospitalar mortality was 18% (n = 14). Mortality in elective procedures was 8% (4 in a total of 50) and 35% in urgent cases (10/29). Intraoperative additional interventions were required in 7 patients due to access vessel complications, in 2 due to iatrogenic AD, in 1 case due to acute limb thromboembolic ischemia and in 1 case to to a type IA endoleak. Reintervention rate was 17%, with the following indications: 9 endoleaks, 2 mesenteric ischemias and 2 aortic-esophageal fistulae. Conclusions: Our series represents an encouraging institutional experience, with reproducible outcomes. TEVAR is a safe and effective intervention for the management of different thoracic aortic pathologies, when compared to open surgery

The aim of the present work was the recycling of rubber from automobile tyre treads, as a partial substitute of fine aggregates in concrete. Composites obtained were characterized by destructive and non-destructive testing, in order to find a liable application. According to results obtained, it was found that when weight proportion increased and particle size of scrap rubber decreased (0.59 and 0.29 mm), flow and density of composite in the fresh state decreased, as well as compressive strength and splitting tensile strength in the dry state. Previous treatment of rubber with NaOH and silane (A-174) did not produce significant changes on compressive strength and splitting tensile strength of composites, when compared to the untreated rubber–concrete composite. On the other hand, from the behavior showed by the ultrasonic pulse velocity with time, one can infer that the addition of rubber decreased this variable, being the effect more notorious when rubber content increased. This was due to the greater volume that rubber occupies, as well as water absorption. It can be concluded that the ultrasonic pulse velocity was relatively independent of particle size and coupling agent employed.

The goal of this work was to study the mechanical behavior of concrete with recycled Polyethylene Therephtalate (PET), varying the water/cement ratio (0.50 and 0.60), PET content (10 and 20 vol%) and the particle size. Also, the influence of the thermal degradation of PET in the concrete was studied, when the blends were exposed to different temperatures (200, 400, 600 degrees C). Results indicate that PET-filled concrete, when volume proportion and particle size of PET increased, showed a decrease in compressive strength, splitting tensile strength, modulus of elasticity and ultrasonic pulse velocity; however, the water absorption increased. On the other hand, the flexural strength of concrete-PET when exposed to a heat source was strongly dependent on the temperature, water/cement ratio, as well as on the PET content and particle size. Moreover, the activation energy was affected by the temperature, PET particles location on the slabs and water/cement ratio.

ResumoA revascularização dos membros inferiores a partir da aorta torácica, apesar de exequível, representa uma opção incomum. Os autores descrevem o caso clínico de um doente com estenose aórtica severa, coartação da aorta ao nível do istmo, disseção crónica da aorta tipo B e oclusão da artéria ilíaca externa esquerda. Foi submetido, no mesmo tempo operatório, à substituição da válvula aórtica e construção de uma pontagem da aorta torácica ascendente para ambas as artérias femorais comuns. O doente evoluiu favoravelmente tendo alta hospitalar ao 13.° dia pós‐operatório, encontrando‐se agora em seguimento. Trata‐se de um procedimento raro, complexo e realizável graças à colaboração multidisciplinar entre cirurgiões vasculares e cirurgiões cardiotorácicos.AbstractThe revascularization of the lower limbs from the thoracic aorta, although feasible, is an unusual choice. The authors describe the clinical case of a patient with chronic aortic type B dissection, severe aortic stenosis, coarctation of the aorta at the isthmus, and occlusion of the left external iliac artery. He underwent simultaneous aortic valve replacement and construction of a bypass from the ascending thoracic aorta to both femoral common arteries. The patient was discharged at the 13th postoperative day, and is now being followed. This is a rare and complex procedure possible due to multidisciplinary collaboration between vascular surgeons and cardiothoracic surgeons.