Infrapopliteal Bypass In Patients On Dialysis: Patency And Survival.

INTRODUCTION: Portugal has one of the highest prevalence of patients on a regular dialysis program. This population has a higher incidence of peripheral arterial disease with higher rates of postoperative morbidity and mortality. Our goal was to compare outcomes between dialysis and non-dialysis patients with chronic limb threatening ischemia (CLTI) submitted to infrapopliteal bypass. MATERIALS AND METHODS: A retrospective single-center study of infrapopliteal bypass for CLTI was performed between 2012 and 2019. Patients were divided in two groups based on dialysis status (group 1 incorporated patients on dialysis). Primary end point was 1-year freedom from CLTI. Secondary end points were limb-salvage, survival and primary (PP) and tertiary patency (TP) rates at 3 years of follow-up. RESULTS: A total of 352 infrapopliteal bypasses were performed in 310 patients with CLTI. Fourteen percent of the revascularizations were performed on dialysis patients (48/352). Median age was 73 years (interquartile range - IQR 15) and 74% (259/352) were male. Median follow-up was 26 months (IQR 42). Overall, 92% (325/352) had tissue loss and 44% (154/352) had some degree of infection. The majority of revascularization procedures were performed with vein grafts (61%, 214/352). The 30-day mortality was 4% (11/310), with no difference between groups (p = 0.627). Kaplan-Meier analysis showed no difference between groups regarding freedom from CLTI (76% vs. 79%; HR 0.96, CI 0.65-1.44, p=0.857), limb-salvage (70% vs. 82%; HR 1.40, CI 0.71-2.78, p=0.327) and survival (62% vs. 64%; HR 1.08, CI 0.60-1.94, p=0.799). PP rates were 39% in group 1 and 64% in group 2 (HR 1.71, CI 1.05-2.79, p=0.030). TP rates were not different between groups (57% and 78%; HR 1.79, CI 0.92-3.47, p=0.082). CONCLUSION: Infrapopliteal bypass for CLTI, on dialysis patients, resulted in lower PP rates. No differences were observed in freedom from CLTI, TP, limb salvage and survival.

Heparin-Bonded Expanded Polytetrafluoroethylene Is a Solution for Infrapopliteal Revascularization in the Absence of an Adequate Autologous Vein Graft.

BACKGROUND: To analyze the outcomes of heparin-bonded expanded polytetrafluoroethylene (HePTFE) graft as an alternative conduit in infrapopliteal revascularization of chronic limb-threatening ischemia (CLTI) in the absence of an autologous vein conduit. METHODS: A single-center retrospective analysis of patients with CLTI submitted to infrapopliteal bypasses with autologous vein graft (VEIN group) or HePTFE graft (HePTFE group) was implemented. Primary end points were freedom from CLTI at 12 months and recurrence of CLTI at 3 years. Secondary end points included freedom from major amputation, amputation-free survival (AFS), survival, and primary (PP) and secondary patency (SP) rates at 3 years of follow-up. RESULTS: A total of 348 limbs submitted to infrapopliteal bypasses, 214 with venous graft and 134 with HePTFE graft, were followed-up for a median of 25 months. Most patients of the HePTFE group were male (69%), with a median age of 76 years (interquartile range [IQR] 15). Fifty-nine percent of the limbs of the HePTFE group had Wound grade ≥2, being 46% of them infected. Eighty-eight percent were GLASS stage III. Freedom from CLTI was not significantly different between HePTFE and VEIN groups (75% vs. 84%, adjusted hazard ratio [aHR] 0.88, confidence interval [CI] 0.66-1.18, P = 0.401). Recurrence of CLTI was higher in the HePTFE group (42% vs.18% at 3 years; aHR 2.82, CI 1.59-5.00, P < 0.001). The VEIN group achieved higher rates of freedom from major amputation (87% vs.69% at 3 years; aHR 2.21, CI 1.31-3.75, P = 0.003) and AFS (59% vs. 37% at 3 years; aHR 1.39, CI 1.02-1.88, P = 0.036), but no significance in survival (aHR 1.10, CI 0.72-1.66, P = 0.667). Patency rates were inferior in the HePTFE group, with 2-year PP and SP rates of 52% vs. 74%, and 76% vs. 90%, respectively (PP: aHR 1.70, CI 1.11-2.59, P = 0.014; SP: aHR 2.51, CI 1.42-4.42, P = 0.001). CONCLUSIONS: Infrapopliteal bypass with autologous vein graft is the gold standard to treat CLTI limbs. HePTFE graft should be regarded as an alternative for complex infrapopliteal revascularization when lacking an autologous vein conduct.

An Epithelioid Hemangioma Camouflaged As Radial Aneurysm.

Epithelioid hemangioma (EH) is an uncommon benign vascular lesion usually present as subcutaneous nodules in the head and neck area. Sometimes, these lesions can occur in the peripheral arteries, and when they do, they can be mistaken for aneurysmal dilatations of that respective vessel. We report a case of a 43-year-old male who underwent surgical recession of a radial aneurysm, which after anatomopathological examination, revealed an EH.

Evaluation of global limb anatomic staging system for patients with chronic limb-threatening ischemia treated with autogenous bypass grafts.

OBJECTIVE: We evaluated the relationship of the global limb anatomic staging system (GLASS) stage with the clinical outcomes for patients with chronic limb-threatening ischemia (CLTI) who had undergone distal bypass with vein grafting. METHODS: We performed a single-center, retrospective analysis of patients with CLTI who had undergone distal bypass with vein grafting from January 2012 to December 2019. The primary end point was freedom from CLTI, including amputation-free survival, complete wound healing, and no ischemic rest pain. The secondary end points included a composite outcome of recurrence (patients who had achieved freedom from CLTI but had developed a new wound or ischemic rest pain), major limb amputation, amputation free-survival, overall survival, major adverse limb events, limb-based patency, and primary and secondary patency rates. RESULTS: A total of 190 patients had undergone 211 distal bypasses with a median follow-up of 30 months. Of these patients, 80% had had diabetes or end-stage renal disease requiring dialysis. Most patients (63%) had experienced major or extensive tissue loss (WIfI [wound, ischemia, foot infection] wound class ≥2), and more than one half of these had had some degree of infection of the foot. A severe anatomic pattern (GLASS stage III) was predominant, with a prevalence of 78%. No significant differences were found between GLASS stage I and II and GLASS stage III groups for all the outcomes analyzed. Approximately 80% of the 211 revascularized limbs were free of CLTI at 12 months after treatment. At 4 years of follow-up, we observed that 25% of the patients had had CLTI recurrence, 83% were free from major amputation, and 61% were free from major adverse limb events. Limb-based patency, primary patency, and secondary patency were 79%, 80%, and 93% at 1 year and 64%, 65%, and 81% at 4 years, respectively. CONCLUSIONS: The GLASS stage was not related to patency or the clinical outcomes after distal bypass with vein grafting. Distal open revascularization resulted in excellent rates of freedom from CLTI with low rates of CLTI recurrence, two key time-integrated outcomes of clinical disease severity for patients with CLTI.

RECURRENT VARICOSE VEINS FOLLOWING SMALL SAPHENOUS VEIN SURGERY: A 5-YEAR FOLLOW-UP DUPLEX ULTRASOUND STUDY.

INTRODUCTION: Chronic venous disease (CVD) of the lower limbs is a very prevalent medical condition with important socioeconomic repercussions. Small saphenous vein (SSV) incompetence, although less frequent than great saphenous vein (GSV) incompetence, presents a more challenging treatment, with higher rates of complication and recurrence. OBJECTIVES: To determine the incidence and associated risk factors of varicose veins recurrence in patients submitted, for the first time and exclusively, to SSV surgery with 5 years of follow-up. METHODS: Retrospective analysis of all exclusively first-time SSV surgeries, at Angiology and Vascular Surgery Service of Hospital Beatriz Ângelo, between January 1st, 2013, and December 31st, 2014. In March 2019, the authors performed clinical and venous doppler ultrasound reassessment of all included patients. RESULTS: A total of 23 limbs were evaluated, 56.5% were female and the mean age was 51.8 years. All patients were symptomatic and underwent ligation of the saphenopopliteal junction (SPJ), 26.1% and 43.5% had total and partial SSV stripping, respectively. After venous doppler ultrasound at 5-year follow-up, we found that 21.7% did not present a correct SPJ ligation due to failure to identify its location, with a statistically significant association between SPJ ligation and varicose vein recurrence. In follow-up, we also diagnosed GSV incompetence in 21.7% for the first time, which is in agreement with the fact that this is a chronic disease. Finally, we found that all patients with symptomatic recurrence at 5-year follow-up had CVD, however, some asymptomatic patients also had ultrasound changes. CONCLUSION: Routine preoperative localization of the SPJ by doppler ultrasound guidance could have an impact in minimizing varicose vein recurrence. Imaging recurrence does not always translate into clinical recurrence. Because this is a chronic disease, patients should keep general care to prevent disease progression, even after surgery.

Behçet Syndrome and Crohn's Disease: What Are the Differences?

Behçet syndrome (BS) is a variable vessel vasculitis that has pleiotropic manifestations. A 43-year-old male with a previous diagnosis of Crohn's disease (CD) presented with deep venous thrombosis and bilateral superficial femoral artery aneurysms. A diagnosis of BS was made, and the patient was treated aggressively with immunosuppressive therapy and bilateral bypass surgery, attaining a favourable outcome. CD has many features that overlap with BS, and it may be challenging to distinguish between these two conditions, as our case illustrates. Nonetheless, the combination of venous thrombosis and arterial aneurysms should point the clinician towards a diagnosis of BS. LEARNING POINTS: Behçet syndrome is a variable vessel vasculitis of unknown aetiology that has pleiotropic manifestations.Crohn's disease has many overlapping features with Behçet syndrome, namely gastrointestinal, cutaneous, articular, ocular and cardiac manifestations.The combination of venous thrombosis and arterial aneurysms should point the clinician towards a diagnosis of Behçet syndrome.

[Abdominal angina due to fibromuscular dysplasia of the celiac axis. Surgical management]. / Angina abdominal por displasia fibromuscular do tronco celíaco. Tratamento cirúrgico.

The clinical case of a 27-year old man with the diagnosis of chronic mesenteric ischemia ("abdominal angina") is reported, whose chief complaints were severe postprandial pain and remarkable weight loss, for the last 4 months. Following na inconclusive observation in gastroenterology, he underwent an angiographic-CT examination, that disclosed a critical stenosis at the origin of the celiac axis. The remaining digestive vessels, superior and inferior mesenteric arteries, were found free of lesions. The patient was submitted to a revascularization procedure, consisting in the celiac axis resection and its replacement by a prosthetic graft, arising from the supraceliac aorta. The post-operative course was uneventfull, followed by a complete remission of the pain and a progressive weight gain. The histopathological study of the removed artery revealed the diagnosis of arterial fibrodysplasia, a very rare entity in clinical practice, of unknown etiology, affecting predominantely young people and in a decreasing order of frequency the renals, the internal carotids and the external iliac arteries. The localization of the fibrodysplastic disease to the celiac áxis seems to be a unique case, never reported before in the literature, thus justifying its publication and dissemination.

[Post EVAR rupture of an iliac artery aneurysm complicated with an iliac arteriovenous fistula. Clinical report]. / Rotura de aneurisma ilíaco pós EVAR complicada com fístula artério-venosa. Caso Clínico.

Since the original description by Parodi in 1991, the aim of endovascular treatment of aortic and iliac aneurysms has been the prevention of rupture, with fewer risks than the conventional management. Much has been discussed about its technical feasibility, durability, and follow-up, however little emphasis has been given to the treatment of its emergent complications, namely the aneurysm rupture after endovascular treatment. The authors report the clinical case of a patient that underwent endovascular treatment of a left common iliac artery aneurysm four years before, which presented in the emergency department with symptoms suggestive of aneurysm rupture, together with high output iliac arteriovenous fistula. The patient underwent conventional open surgical procedure, which consisted in partial resection of the aneurysm and repair of the iliac arteriovenous fistula.

[Secondary aortoenteric fistula, multidisciplinary surgical management]. / Fístula aorto-entérica secundária, tratamento cirúrgico multidisciplinar.

The authors report the clinical case of a 77-year old man, who underwent the surgical treatment of an abdominal aortic aneurism 11 years before, admitted in the hospital emergency department complaining of abdominal pain and melena. Clinical and laboratorial findings, together with CT-scan and endoscopy data, lead to the diagnosis of secondary aortoenteric fistula. This is a rare clinical entity, coursing with high morbimortality levels of and is still one of the most controversial issues in vascular surgery. The successful surgical treatment of this patient is described and the solution of choice is discussed, as well as other alternative approaches.

[Prosthetic revascularization of the midpopliteal artery through a posterior approach: a clinical experience]. / Revascularização protéstica da artéria popliteia media por abordagem posterior: Experiência clínica.

Bypass grafting to the proximal or distal popliteal artery through a lateral approach is the most commum surgical technique used to treat patients with femoro-popliteal obstructive disease. We report all the patients who underwent a bypass graft to the midpopliteal artery through a posterior approach, in whom an autologous vein was not avalaiable, thus avoiding the use of a prosthetic graft implantation in to the infragenicular popliteal artery. Ten bypass grafts to the midpopliteal artery through a posterior approach were performed, for the last 6 years, in patients with critical limb ischaemia. Polytetrafluoroethylene ( PTFE ) grafts were used in all patients. With a mean follow-up of 16,1 months, the 1-year primary patency rate was 85,7 % and the 2-year primary patency rate was 66,7 %. Bypass grafting to the midpopliteal artery through a posterior approach seems to be a safe and sustainable procedure and is an alternative techinique to be considered in patients without autologus vein avalaiable, when an above-knee bypass grafting is not feasible or when a below-knee prothesis should be avoided.

[Large and extensive thoracoabdominal aortic aneurysm in a seropositive young woman, treated with the "simplified technique"]. / Volumoso e extensor aneurisma da aorta toracoabdominal em mulher jovem seropositive, tratado pela "técnica simplificada". Caso clínico.

The clinical case of a 37 years old female with the previous diagnosis of human immunodeficiency virus infection (HIV), under medical control, is reported, in whom an extensive and large thoracoabdominal aortic aneurysm was diagnosed (type II of the Stanley Crawford's classification), completely asymptomatic. The patient underwent surgical management, consisting in the resection of the aneurysm and prosthetic replacement, utilizing the "simplified technique", that was once again extremely well succeeded in this most demanding situation. The clinical and pathological features of this infection and the potential involvement in the pathogenesis of this uncommon aneurysm are discussed, according to the data published in the literature. Furthermore, the main aspects of the surgical management are described and discussed, facing the diverse technical alternatives nowadays used in clinical practice.

[Reconstructive surgery of deep veins of the lower extremities: the Palma operation revisited]. / Cirurgia reconstrutiva das veias profundas dos membros inferiores: a operação de Palma revisitada.

It has been grossly estimated that one fifth of the patients with post thrombotic chronic venous diseases suffer from obstructive or hypertensive symptoms, due to a failure of the physiologic repermeabilization mechanisms. In clinical practice, only a small group of these patients, with disabling symptoms, fill the essential requirements for a deep vein reconstructive surgery. The authors report the clinical case of a 27 years old male, with a chronic segmentar thrombotic occlusion of the right external iliac and common femoral veins, causing disabling symptoms to his normal professional activity. The patient underwent a surgical reconstructive surgery, consisting in the classic Palma operation followed by an excellent anatomic and functional result. The main features of this procedure, its indications and results are discussed, based on the most recent data published in the literature.

[High output heart failure due to an iatrogenic arteriovenous fistula after cardiac catheterization]. / Insuficiência cardíaca de alto débito secundária a fístula arterio-venosa iatrogénica pós cateterismo cardíaco.

The occurrence of an arteriovenous fistula is a potential complication of cardiac catheterization. Most of these fistulas cause no harm. We report the clinical case of a 70 years old woman with high-output heart failure caused by an arteriovenous fistula (FAV) in the groin. The fistula was successfully closed by surgical repair and the heart failure was resolved. This case confirms the potential harmfulness for the vascular bed of certain surgical/endovascular interventions and intravascular monitoring techniques. When heart failure of uncertain etiology appears in patients previously submitted to one of the above mentioned procedures, a careful clinical examination can lead to a correct diagnosis of iatrogenic FAV, whose surgical correction is usually followed by the restoration of a normal cardiac function.

[An exceptional case of renal angiomyolipoma extended to the inferior vena cava. Successfull surgical management]. / Um caso excepcional de angiomiolipoma renal com extensão à veia cava inferior. Tratamento cirúrgico com êxito.

The clinical case of a 39 years old female is reported, with the diagnosis of tumor of the right kidney extending into the infra-hepatic vena cava, assuming the shape of a floating thrombus. The patient underwent right radical nephrectomy, followed by resection of the intra caval tumor. Both the procedure and post operative course were uneventfull. Histopathological evaluation of the specimens, associated to specific imunohistochemistry studies, confirmed the diagnosis of angiomyolipoma of the kidney. A review of the literature concluded that this is the 27th case published of a kidney angiomyolipoma extending into the inferior vena cava, thus justifying its presentation and divulgation.

[Non-atherosclerotic lower limbs ischemia in young athletes]. / Isquemia cronica dos membros inferiores, de etiologia não aterosclerótica, em desportistas jovens.

Although rare, the iliac endofibrosis and the popliteal artery entrapment syndrome are undoubtfully recognised as causes of intermittent claudication in young patients, particularly in athletes. The authors report the clinical case of a young female athlete, with disabling claudication of the right lower limb due to a stenosis of the external iliac artery and a case of an acute ischemia in a male cyclist owing to an extrinsic compression of the popliteal artery by anomalous muscular bundles. Both cases underwent successful surgical management. The early suspicion and diagnosis of these situations is of utmost importance to prevent complications that may be particularly severe.

[Thrombotic occlusion of an abdominal aortic aneurysm]. / Oclusão trombótica de aneurisma da aorta abdominal.

The clinical condition of a 78 years old male is reported, with a thrombotic occlusion of an abdominal aortic aneurysm, expressed by the acute onset of intermittent claudication of both legs, two months previously to the observation. On physical examination a pulsatile mass was observed in the abdomen, with no expansion, with 7 cms of diameter; femoral pulses were absent. CT-scans confirmed the clinical diagnosis, revealing the presence of a recent thrombus occluding the aortic lumen. The patient underwent the conventional open surgery, consisting in the resection of the aneurysm and replacement with a prosthetic graft, from the aorta to both common femoral arteries. The post-operative course was uneventful and the patient was discharged, asymptomatic, having recovered peripheral pulses in both legs. The main aspects of this rare complication of the abdominal aortic aneurysm are reviewed and discussed, based on the information of the literature on the subject.

[Preoperative evaluation of superficial veins to be used in peripheral arterial revascularization surgery]. / Avaliação pré-operatória das veias superficias a utilizar na cirurgia de revascularização periférica.

In this paper, the authors report their experience in the preoperative evaluation of the superficial veins of the lower limbs, using the color-coded Eco-Doppler, aimed at the evaluation of morphofunctional aspects of the veins, allowing an objective and reliable selection of the vein grafts to be used in peripheral arterial revascularization surgery. The advantages and disadvantages of the methodology are analysed and discussed, and they concluded by stating that the method can replace favourably the tradicional surgical exploration, avoiding the frequent unnecessary , unusefull or inconvenient surgical exploration for the veins assessment.