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Introduction: Venous aneurysms are rare, so their natural history is not fully understood. Indications for treatment are often determined by the location and size of the aneurysm; however, considering the scarcity of data, there are no specific recommendations. Surgery is the mainstay for venous aneurysm treatment, but some authors reported successful endovascular treatment. We intend to describe our experience with this type of rare disorder. Methods: A post hoc observational study of a prospectively maintained registry including consecutive patients admitted with the diagnosis of a venous aneurysm at different locations between January 2007 and September 2021. Demographic data, anatomic location, and medical history, including trauma or venous surgery, were analyzed. All vascular reconstructions and outcomes have been evaluated. Results: We identified 30 venous aneurysms in 24 patients. Fifteen patients were male (63%). The most common anatomical location was the popliteal vein (n=19; 63%). Four patients had multiple venous aneurysms, and three patients had synchronous arterial aneurysms. Twelve (63%) of the popliteal vein aneurysms identified were surgically treated, most commonly by tangential aneurysmectomy and lateral venorrhaphy. The average diameter at the time of surgery was 22,8±3,6 mm. After discharge, all patients were anticoagulated for 6 to 12 months, in most cases with rivaroxaban. With a median follow-up time of 32 months (12 – 168 months), primary patency was 92%. Aneurysm recurrence was only observed in one case (1/12; 8%) with non-occlusive thrombosis of the aneurysm 14 years after surgery. One patient had a 21 mm gemelar vein aneurysm, having been proposed for surgery, with thrombosis before the intervention. Two patients had common femoral vein aneurysms treated with partial aneurysmectomy and lateral venorrhaphy without thromboembolic events during follow-up. Two patients presented with portal system aneurysms, one associated with portal hypertension. No treatment was performed, and an increase in aneurysm size was observed during follow-up. Another patient presented with acute deep vein thrombosis on chronically thrombosed bilateral iliac vein aneurysms. Three patients had aneurysms of the superficial venous system associated with previous trauma, which were treated with simple ligation and excision. Conclusion: Venous aneurysms are rare and most commonly located in the popliteal vein, which seems to be associated with chronic venous disease. Treating these aneurysms, even without symptoms, can be important to avoid thromboembolic complications. However, close long-term follow-up with duplex ultrasound should be considered to detect late recurrence. Aneurysms from other locations are even rarer, and treatment decisions should be individualized, weighing the risks and benefits of the intervention., Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 30 No. 2 (2023): Apr-Jun

Peripheral arterial disease (PAD), abdominal aortic aneurysm (AAA) and chronic mesenteric ischaemia (CMI) are vascular diseases uncommonly observed in the same patient, especially when treatment is required. This case report illustrates a patient requiring mesenteric revascularization due to CMI. A long flush occlusion of the superior mesenteric artery (SMA) precluded endovascular revascularization. Therefore, we performed a retrograde bypass from the right common iliac artery (CIA) to the SMA. On the 6-month follow-up, the patient developed right limb ischemia despite the absence of intestinal angina. CT angiography revealed CIA occlusion, bypass patency through hypogastric retrograde filling and modest growth of a AAA. Due to the presence of contralateral CIA lesions and to achieve durable revascularization, we opted to perform a AAA repair with an aorto-uni-iliac endograft followed by a femorofemoral crossover bypass. This achieved AAA’s repair, lower limb revascularization, and a suitable and durable inflow to the mesenteric bypass., Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 30 No. 1 (2023): Jan - Mar

INTRODUCTION: Percutaneous endovenous treatment is the first-line therapy for chronic nonmalignant iliocaval venous obstruction (ICVO) due to low morbidity and suitable medium and long-term results. Open surgical procedures are only used as a last resort therapy. However, there is a lack of updated data regarding surgical techniques and outcomes. We present two cases of surgical venous reconstructions to treat ICVO using expanded polytetrafluoroethylene (ePTFE) grafts and discuss the evidence regarding technical aspects to improve long-term patency. CASE REPORTS: The first case concerns a 69-year-old male with chronic edema and venous ulceration associated with ICVO secondary to iliocaval stent thrombosis. After an unsuccessful endovascular treatment attempt, we performed a surgical iliocaval bypass using a 10mm ringed ePTFE graft. After three months, complete ulcer healing was observed. The other patient was a 63-year-old female with disabling chronic edema of the right lower limb and venous claudication consequent to the ligation of the right common femoral vein to correct an iatrogenic vascular injury during orthopedic surgery. The patient underwent venous bypass between the deep femoral vein and the ipsilateral common iliac vein using a 12mm ringed ePTFE graft. A marked improvement in clinical symptoms was observed after treatment. A venous stent was used later to treat an anastomotic stenosis. CONCLUSION: Our experience supports open venous reconstruction as a viable option for patients with benign ICVO and debilitating symptoms not amenable to endovascular treatment. Important technical aspects such as adequate inflow vein, the choice of the prosthetic graft, long-term anticoagulation, and the creation of a distal arteriovenous fistula should be considered to improve patency., Angiologia e Cirurgia Vascular, Vol. 18 No. 4 (2022): December

Introduction: The lack of knowledge about Peripheral Arterial Disease (PAD) is worryingly high as it triggers and main- tains behaviors of denial, indifference, and non-adherence to therapeutics. Therefore, the aim of this study was to build and assess the reliability and validity of a knowledge questionnaire about PAD (Peripheral Arterial Disease Knowledge Questionnaire - PADKQ). Materials and methods: A longitudinal study was carried out with two evaluations that included a sample of patients with PAD and Intermittent Claudication, with no history of surgical interventions, in follow-up at the vascular surgery consulta- tion. The PADKQ was applied to 114 patients (85% men, with a mean age of 65 years, SD=7.2). Sociodemographic and clinical data were collected from clinical records, and physical activity level (International Physical Activity Questionnaire - IPAQ) and walking impairment (Walking Impairment Questionnaire - WIQ) were evaluated through questionnaires. A 2nd evaluation session took place two weeks after the 1st evaluation session where an educational intervention was performed. Internal consistency, temporal stability, content validity, and convergent validity were performed Results: The sample related results have reflected the good reliability (kr-20=0.775) and validity properties of the PADKQ. This sample showed a high level of knowledge about PAD (10.96 points, SD=3.28, from 0 to 16 possible points), which increased significantly from moment 1 to moment 2 (t= -7.457, p, Portuguese Journal of Cardiac Thoracic and Vascular Surgery, Vol. 29 No. 4 (2022): Oct - Dec

INTRODUCTION: Light induced amaurosis refers to a transient monocular or binocular vision loss triggered by bright lights. Like amaurosis fugax, light induced amaurosis is associated with carotid artery stenosis but they differ from each other in presentation and pathophysiology. It is thought to be an impairment in the regeneration of retinal visual pigments caused by the inability of carotid circulation to sustain the increased metabolic activity occurring when the retina is exposed to bright lights. With this report we aim to present a case of light induced amaurosis and its management. CASE REPORT: We describe a 74-year-old man with the isolated complaint of monocular visual loss from his left eye when exposed to bright lights. These episodes were self-limited and lasted for several minutes. His vision was reportedly good between episodes. He also complained of headache and dizziness. There were no other focal neurological deficits present. The patient had a history of peripheral artery disease, chronic heart failure, hypertension, dyslipidaemia, permanent atrial fibrillation and had a history of heavy smoking in the past. Chronic medical therapy included anticoagulation with rivaroxaban, antiplatelet therapy with acetylsalicylic acid and atorvastatin. Imaging studies (doppler ultrasonography and Computed tomography angiography) revealed a significant morphologic stenosis of the left common carotid artery, left internal carotid artery with sub occlusive disease and right internal carotid artery with 70-75% stenosis (North American Symptomatic Carotid Endarterectomy Trial - NASCET). The vertebral arteries study did not reveal significant morphologic disease. The patient was submitted to left common and internal carotid artery endarterectomy and Dacron patch angioplasty. The visual symptoms progressively improved after surgical treatment. The dizziness and headache were completely gone. CONCLUSION: Light induced amaurosis is a rare and less known symptom associated with severe carotid artery stenosis. Its timely recognition is important to not deprive patients of timely treatment., Angiologia e Cirurgia Vascular, Vol. 18 No. 3 (2022): September

Introduction: Percutaneous endovenous treatment is the first-line therapy for chronic nonmalignant iliocaval venous obstruction (ICVO) due to low morbidity and suitable medium and long-term results. Open surgical procedures are only used as a last resort therapy. However, there is a lack of updated data regarding surgical techniques and outcomes. We present two cases of surgical venous reconstructions to treat ICVO using expanded polytetrafluoroethylene (ePTFE) grafts and discuss the evidence regarding technical aspects to improve long-term patency. Case reports: The first case concerns a 69-year-old male with chronic edema and venous ulceration associated with ICVO secondary to iliocaval stent thrombosis. After an unsuccessful endovascular treatment attempt, we performed a surgical iliocaval bypass using a 10mm ringed ePTFE graft. After three months, complete ulcer healing was observed. The other patient was a 63-year-old female with disabling chronic edema of the right lower limb and venous claudication consequent to the ligation of the right common femoral vein to correct an iatrogenic vascular injury during orthopedic surgery. The patient underwent venous bypass between the deep femoral vein and the ipsilateral common iliac vein using a 12mm ringed ePTFE graft. A marked improvement in clinical symptoms was observed after treatment. A venous stent was used later to treat an anastomotic stenosis. Conclusion: Our experience supports open venous reconstruction as a viable option for patients with benign ICVO and debilitating symptoms not amenable to endovascular treatment. Important technical aspects such as adequate inflow vein, the choice of the prosthetic graft, long-term anticoagulation, and the creation of a distal arteriovenous fistula should be considered to improve patency.

INTRODUCTION: Ectopic kidneys with concomitant aortoiliac aneurysmal disease have been previously reported in the literature, however its exact prevalence is unknown. The objective of this review is to summarize current knowledge on the treatment this special group of patients. METHODS: A non-systematic literature research was performed on the treatment of aortoiliac aneurysmal disease in patients with ectopic kidneys. RESULTS: Literature on the management of patients with aorto-iliac aneurysms and concomitant ectopic kidneys is limited to case reports and very small series. Treatment modalities which include open, endovascular or hybrid techniques, should preserve the variable vasculature of the ectopic kidney. Several different surgical solutions have been proposed, highlighting the uncertainty on the optimal management strategy. However, a growing number of reports suggest safety and efficacy with adapted endovascular techniques. CONCLUSION: In parallel to the general trend in the management of abdominal aortic aneurysm, it is expected that a growing number of patients will concomitant aorto-iliac aneurysm and ectopic kidneys will be treated with endovascular techniques., Angiologia e Cirurgia Vascular, Vol. 18 No. 2 (2022): June

INTRODUÇÃO: O fenómeno de nutcracker refere-se à compressão da veia renal esquerda (VRE), habitualmente entre a aorta e a artéria mesentérica superior. Quando sintomático, designa-se síndrome de nutcracker. Os sintomas/sinais estão relacionados com o desenvolvimento de hipertensão venosa renal e o diagnostico depende da conjugação da clínica e alterações laboratoriais na presença de critérios imagiológicos. Habitualmente a indicação terapêutica depende da severidade dos sintomas. Existem várias opções terapêuticas: transposição/ pontagem da VRE para uma implantação mais distal na veia cava inferior, transposição da veia gonadal, auto- transplante renal, e tratamento endovascular. CASO CLÍNICO: Doente de 40 anos, sexo feminino, observada em consulta de cirurgia vascular por varizes pélvicas e vulvares recidivadas. Por suspeita de síndrome de congestão pélvica, realizou estudo complementar com venoTAC que revelou fenómeno de nutcracker com dilatação importante da veia ovárica (VO) e varizes pélvicas. O exame sumário de urina revelou hematúria. Foram ponderadas várias opções de tratamento, tendo sido decidido fazer uma transposição da VO para a veia ilíaca comum (VIC). Através de uma pequena incisão paramediana esquerda (com cerca de 5cm) foi realizada uma abordagem retroperitoneal dos vasos. Procedeu-se à identificação e isolamento da VO (sinalizada com fio guia colocado pela veia femoral comum direita no início do procedimento). Localizada posteriormente à VO, isolou-se a VIC. Procedeu-se à secção transversal da VO e anastomose em termino-lateral da VO à VIC. O tratamento foi complementado com esclerose com espuma de varizes vulvares por via endovascular. A doente teve alta no primeiro dia de pós-operatório. Ao 6o mês de pós- operatório mantem-se sem recidiva das varizes e sem hematúria. DISCUSSÃO: O Síndrome de nutcracker pode implicar uma morbilidade importante, com risco de trombose da VRE e perda da função renal. O melhor tratamento ainda não está definido e a seleção da melhor opção é dificultada pelo reduzido número de casos, ausência de estudos prospetivos randomizados, e pela ausência de follow-up a longo prazo de algumas das opções terapêuticas. A transposição da VRE é o procedimento mais habitual, seguido pelo auto-transplante renal. O nosso serviço tem vasta experiência na transplantação renal e o auto-transplante tem tido bons resultados; no entanto, não deixa de ser uma intervenção complexa, com riscos potenciais não desprezíveis, com uma convalescença prolongada e um impacto estético importante, sobretudo se aferido à idade jovem dos doentes. Corroborado pelo resultado do caso clínico apresentado, os autores consideram que a transposição da VO é uma alternativa terapêutica menos invasiva a ser considerada., Angiologia e Cirurgia Vascular, Vol. 18 No. 2 (2022): June

Introduction: Renal artery aneurysms are rare clinical entities whose treatment criteria are not fully established. Endovascular treatment has gained acceptance in the case of renal artery trunk aneurysms. However, in the case of aneurysms of the renal artery branches, such procedures are often impossible due to high morbidity, so the question remains about the best treatment modality. We present a clinical case of multiple bilateral aneurysms of the renal artery branches in a young patient adequately treated with ex-vivo reconstruction and renal autotransplantation. Case-presentation: A 35-year-old woman was diagnosed with bilateral renal artery aneurysms during an investigation of secondary arterial hypertension (AHT). The patient underwent surgical treatment with renal autotransplantation, and the right kidney was initially treated. Transperitoneal laparoscopic nephrectomy was performed. She underwent ex vivo repair of aneurysms, on the bench, with aneurysmectomy and aneurysmorrhaphy. The graft was implanted in the right iliac fossa with anastomoses to the external iliac artery and vein. After three months, an identical procedure was performed on the left. Upon inspection, a large aneurysm was observed in the renal artery bifurcation and another small aneurysm in one of the branches; both corrected with aneurysmec- tomy and aneurysmorrhaphy. Ex-vivo angiographic control ensured the preservation of graft arteries patency without evidence of residual aneurysms. The kidney was implanted in the left external iliac vessels uneventfully. A study with renal scintigraphy confirmed the adequate function of both kidneys. The patient is asymptomatic at nine months of follow-up with serum creatinine and glomerular filtration rate within normal values. Conclusion: Renal autotransplantation with ex vivo arterial repair seems to be a good solution in treating aneurysms of the renal artery, particularly in complex cases with multiple aneurysms., Angiologia e Cirurgia Vascular, Vol. 17 No. 4 (2021): December

Additional file 1. SPIRIT 2013 checklist

INTRODUCTION: In situ lesser saphenous vein (LSV) graft has been advocated in cases of lower limb revascularization where target arteries are confined to the lower leg and the greater saphenous vein (GSV) is neither available nor suitable. This often occurs in diabetic or end-stage renal diseased patients, whose occlusive disease pattern typically affects the tibioperoneal vessels, sparing the femoropopliteal segment. In situ technique offers the potential advantages of decreased surgical trauma to the vein, better size-matching and improved hemodynamics. The posterior approach simplifies the surgical procedure; it achieves similar graft patency and limb salvage rates compared to standard procedures. CASE REPORT: We report a case of an 89 years-old male diabetic patient with previous attempts of endovascular revascularization of the posterior tibial and peroneal arteries; he presents with a nonhealing ulcer of the first toe of the right foot. Ultrasonographic vein mapping revealed varicose GSV in both limbs and a linear, ~3mm diameter, LSV in the right leg. The patient underwent right limb retrogeniculate popliteal to distal posterior tibial artery bypass with in situ LSV through a posterior approach. Post-operative bypass thrombosis occurred after seven days; it was resolved with surgical thrombectomy, vein angioplasty and arteriovenous shunt ligation. During follow-up at the outpatient clinic, the bypass remains patent and skin lesions healing without complications. CONCLUSION: In situ LSV is a safe and viable option conduit for popliteal to distal arteries bypasses. Vascular surgeons should be aware of the posterior approach, which simplifies and comfortably exposes the anatomic structures required for this surgery., Angiologia e Cirurgia Vascular, Vol 17 No 3 (2021): September

Introduction: The development of aneurysms in iliac arteries excluded from high-pressure direct flow from the aorta is very uncommon. We report a case of successful treatment of bilateral metachronous iliac artery aneurysms (MIA), found 10 years after an aortobifemoral bypass, with perfusion only by retrograde flow from the common femoral arteries (CFA). Case Report: A 76-year-old man came for consultation after incidental finding of bilateral MIAs, 10-years after aorto- bifemoral bypass for treatment of an aortic abdominal aneurysm (AAA). Computed tomography angiography (CTA) showed a right internal iliac artery (IIA) aneurysm of 43-mm diameter and a left common iliac artery (CIA) aneurysm of 45-mm diameter that were not present 10-years before. Exclusion of the left CIA aneurysm was achieved with a left IIA to external iliac artery (EIA) endograft using two covered stents (���banana��� technique). The right IIA aneurysm was excluded with embolization of the distal internal iliac branches and aneurysm sac with coils and occlusion of the proximal EIA with an occluder. There were no postoperative complications. A CTA two months after surgery showed total exclusion of the left CIA aneurysm and normal filling of the left IIA, as well as complete occlusion of the right IIA aneurysm. Conclusion: This case highlights that aneurysmal degeneration of iliac arteries can be generated by retrograde blood flow after treatment of AAAs with aortobifemoral grafts. An endovascular approach using the ���banana��� technique proved to be effective in treating MIAs while maintaining patency of one IIA., Angiologia e Cirurgia Vascular, Vol 17 No 3 (2021): September

Introduction: Renal artery aneurysms are rare clinical entities whose treatment criteria are not fully established. Endovascular treatment has gained acceptance in the case of renal artery trunk aneurysms. However, in the case of aneurysms of the renal artery branches, such procedures are often impossible due to high morbidity, so the question remains about the best treatment modality. We present a clinical case of multiple bilateral aneurysms of the renal artery branches in a young patient adequately treated with ex-vivo reconstruction and renal autotransplantation. Case-presentation: A 35-year-old woman was diagnosed with bilateral renal artery aneurysms during an investigation of secondary arterial hypertension (AHT). The patient underwent surgical treatment with renal autotransplantation, and the right kidney was initially treated. Transperitoneal laparoscopic nephrectomy was performed. She underwent ex vivo repair of aneurysms, on the bench, with aneurysmectomy and aneurysmorrhaphy. The graft was implanted in the right iliac fossa with anastomoses to the external iliac artery and vein. After three months, an identical procedure was performed on the left. Upon inspection, a large aneurysm was observed in the renal artery bifurcation and another small aneurysm in one of the branches; both corrected with aneurysmec- tomy and aneurysmorrhaphy. Ex-vivo angiographic control ensured the preservation of graft arteries patency without evidence of residual aneurysms. The kidney was implanted in the left external iliac vessels uneventfully. A study with renal scintigraphy confirmed the adequate function of both kidneys. The patient is asymptomatic at nine months of follow-up with serum creatinine and glomerular filtration rate within normal values. Conclusion: Renal autotransplantation with ex vivo arterial repair seems to be a good solution in treating aneurysms of the renal artery, particularly in complex cases with multiple aneurysms.

Introdu����o: O kinking da art��ria renal p��s-transplante �� uma complica����o rara, geralmente associada �� disfun����o precoce do enxerto. M��todos: Apresentamos um caso cl��nico de um kinking da art��ria renal p��s-transplante com uma apresenta����o cl��nica incomum. Foi realizada uma revis��o dos registos cl��nicos com o consentimento do doente. Resultados: Homem de 52 anos com doen��a renal terminal secund��ria a nefropatia por IgA foi submetido a transplante renal de doador cadav��rico. O doente apresentou boa fun����o renal no p��s-operat��rio, no entanto, ap��s tr��s meses iniciou uma redu����o gradual da diurese e agravamento da fun����o renal a necessitar de permanecer em "posi����o de c��coras" 5 horas por dia para manter um d��bito urin��rio adequado. Foi realizada uma pontagem entre a art��ria il��aca externa esquerda e a art��ria renal do enxerto com veia grande safena aut��loga para corre����o de um kinking da art��ria renal com recupera����o da fun����o do enxerto. Conclus��o: A tor����o da art��ria renal comumente manifestada como disfun����o do enxerto renal pode-se apresentar de forma singular. A interven����o precoce �� essencial para preservar a viabilidade do enxerto., Angiologia e Cirurgia Vascular, Vol 17 No 2 (2021): June

Background: The surge of the COVID-19 pandemic in Portugal and the implemented public health measures were accompanied with a noticeable decrease in patients��� attendance to the Emergency Department (ED). Objectives: This study aims to evaluate the impact of COVID-19 pandemic on Vascular Surgery ED admissions, by comparing clinical and demographic characteristics of patients visiting the ED during the pandemic and the homologous period of 2019. Methods: We retrospectively collected data from patients admitted to the ED of a Portuguese tertiary hospital centre between March 4th and April 1st, 2020 ��� two weeks before and two weeks after the governmental implementation of the state of emergency in our country due to the COVID-19 pandemic ��� and the homologous period of 2019. Individual medical records were revised to obtain patients demographics and characteristics, clinical severity under the Manchester Triage System (MTS), final diagnosis, need for hospitalization or emergent/urgent surgery, in-hospital length of stay and mortality within 30 days of hospital discharge. Results: A total of 119 and 210 patients visited the Vascular Surgery ED during the pandemic and the homologous period of 2019, respectively. Males comprised the majority of patients in both years and the proportion of women visiting the ED was lower in 2020 compared to 2019 (P=0.015). The MTS attributed a lower number of high-priority levels (yellow and orange) to patients visiting the ED in 2020 (P=0.048). A higher proportion of patients required in-hospital treatment or emergent/ urgent surgery (P, Angiologia e Cirurgia Vascular, Vol 17 No 1 (2021): March

Resumo Introdução: O kinking da artéria renal pós-transplante é uma complicação rara, geralmente associada à disfunção precoce do enxerto. Métodos: Apresentamos um caso clínico de um kinking da artéria renal pós-transplante com uma apresentação clínica incomum. Foi realizada uma revisão dos registos clínicos com o consentimento do doente. Resultados: Homem de 52 anos com doença renal terminal secundária a nefropatia por IgA foi submetido a transplante renal de doador cadavérico. O doente apresentou boa função renal no pós-operatório, no entanto, após três meses iniciou uma redução gradual da diurese e agravamento da função renal a necessitar de permanecer em "posição de cócoras" 5 horas por dia para manter um débito urinário adequado. Foi realizada uma pontagem entre a artéria ilíaca externa esquerda e a artéria renal do enxerto com veia grande safena autóloga para correção de um kinking da artéria renal com recuperação da função do enxerto. Conclusão: A torção da artéria renal comumente manifestada como disfunção do enxerto renal pode-se apresentar de forma singular. A intervenção precoce é essencial para preservar a viabilidade do enxerto.