Emergent Endovascular Repair For Primary Aortoenteric Fistula.

We report the case of a 64-year-old male with significant cardiac comorbidities who reported three episodes of gastrointestinal bleeding. In the third episode, he presented massive hematemesis, anaemia and hypotension. Despite a standard upper endoscopy, a computed tomography (CT) showed an infrarenal abdominal aortic aneurysm and densification of the aortic fat cover. A primary aortoenteric fistula, with acute bleeding and haemodynamic instability, was assumed, and an emergent endovascular repair was performed. Subsequent CT scans and endoscopies demonstrated control of the enteric lesion. After five months, there was no evidence of infection or rebleeding.

Vascular training does matter in the outcomes of saphenous high ligation and stripping.

OBJECTIVE: Varicose vein (VV) surgery is frequently performed by surgeons without formal vascular training. We aimed to compare the outcomes of the procedure based on the background of the surgeon. METHODS: All patients registered with VV surgery between 2004 and 2016 in Portuguese public hospitals were included in the study. Intrahospital outcomes were assessed from this administrative database. A random multicenter sample of 315 patients submitted to saphenous high ligation and stripping (175 patients from six vascular surgery departments and 140 patients from five general surgery divisions) were further queried over the phone, whereby additional nonregistered outcomes were evaluated: preoperative venous ultrasound, impact on quality of life by the 14-item Chronic Venous Insufficiency Quality of Life Questionnaire, visual analogue scale evaluation (score of 1 to 5) of the aesthetic results and general satisfaction, work absence days, and time to return to physical activities. RESULTS: In 13 years, there were 153,382 patients submitted to VV surgery. Of these, 49% were operated on by general surgeons and 40% by vascular surgeons; in 11%, it was not possible to identify the specialty performing the operation. Twenty-three deaths were registered (no differences between groups). In the general surgery group, 14% of patients were hospitalized for more than one night compared with 3% in the vascular group (P < .001). Reintervention rate during the period analyzed was significantly higher in the general surgery group (13.5% vs 8.2%; P < .001). Rate of outpatient surgery was higher in the vascular surgery group (60% vs 36%; P < .001). Phone query revealed similar overall satisfaction and improvement in quality of life in both groups (4.2 vs 4.0 [P = .275] and 35% vs 36% [P = .745], respectively). However, patients operated on by general surgeons reported worse surgical scars (2.8 vs 2.1; P = .007), higher number of residual VVs (2.4 vs 1.7; P = .006), and higher number of days absent from work (40 vs 27 days; P = .005) and took longer to resume physical activities (60 vs 41 days; P = .001). CONCLUSIONS: Despite that the majority of VV surgery in Portugal is executed by general surgeons, this study highlights important advantages when it is performed by surgeons with vascular training.

Laparoscopic treatment in Type IV Giant Paraesophagic Hernia and intestinal occlusion a case report.

INTRODUCTION: A Giant Hiatal Paraesophageal Hernia (GPEH) is a Hiatal Hernia (HH) that includes more than 30% of the stomach in the thorax. The gold standard form of repair today is the laparoscopic abdominal approach in elective scenarios. Laparoscopic HH repair advantages include, less postoperative pain, small incisions, reduced postoperative respiratory complications are reduced, shorter hospital stay. The objective of this paper is to describe a patient undergoing with upper intestinal obstruction and a GPEH Type IV, approached laparoscopically. CASE PRESENTATION: We received a female patient 59 years old, she came with symptoms abdominal pain, emesis of intestinal characteristics and obstipation, with an evolution of 5 days. She also referred dyspnea; she went to another institution where made a CAT scan finding a GPEH. We decided to realize the procedure laparoscopically. We follow the principal objectives, reducing the hernia, dissecting al de hernia sac excision, Hiatal reparation with no mesh, and Nissen type fundoplication without Collis Gastroplasty. The patient stayed for seven days for surveillance and when the leukocyte and LDH went to a regular rate patient was discharged. With no complications with normal intestinal function and nearly no pain. DISCUSSION: We present a GPEH case associated with upper intestinal obstruction, with clinical findings that suggested ischemia. The approach of the treatment was abdominal laparoscopy. CONCLUSION: In elective patients Laparoscopy is superior than abdominal approach. Randomized trials comparing laparoscopic versus open approach are needed to conclude that laparoscopic approach is superior to open approach, in potentially GPEH complicated patients.

Influence of interhospital transfer on outcomes of symptomatic and ruptured abdominal aortic aneurysms.

Objetive: Evaluate the influence of the geographic location of patients with symptomatic abdominal aortic aneurysms (AAA) or ruptured AAA (rAAA), on mortality. METHODS: 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 was <0.05. RESULTS: 135 patients were admitted with the diagnosis of symptomatic or rAAA and submitted to surgery, 83 (61.5%) by endovascular repair and 52 (38.5%) by open repair, 30.4% with local anesthesia and sedation. 92 patients (68.1%) were transferred from other hospitals, with a mean distance of 113±88 km. Subgroup analysis revealed that there were no significant differences between transferred and not transferred patients' groups concerning main outcome (31.5% vs 34.9%, 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; p<0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p<0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p<0.01). CONCLUSION: Our study revealed that interhospital transfer of patients for urgent repair of AAA was not associated with an increased mortality.

Objetivo: Avaliar a influência da localização geográfica dos doentes com aneurismas da aorta abdominal (AAA) sintomáticos ou rotos (rAAA), na mortalidade. Métodos: Revisão retrospetiva de todos os casos de AAA sintomáticos ou rAAA submetidos a cirurgia numa instituição terciária, entre Janeiro 2011 e Agosto 2017. O outcome primário foi a mortalidade intrahospitalar. Os outcomes secundários foram a admissão em unidade de cuidados intensivos (UCI), duração do internamento na UCI e hospitalar, tipo de cirurgia e anestesia e a apresentação ao fim-de-semana. Os dados foram submetidos a análise univariável e regressão logística. Foi considerado um valor estatisticamente significativo quando o valor de p <0.05. Resultados: 135 doentes foram admitidos com o diagnóstico de AAA sintomático ou rAAA e submetidos a cirurgia, 83 (61.5%) por via endovascular e 52 (38.5%) por via convencional, 30.4% com anestesia local e sedação. 92 doentes (68.1%) foram transferidos de outros hospitais, com uma distância média de 113±88 km. A análise de subgrupos revelou que não existia diferença significativa entre os grupos de doentes transferidos e não transferidos relativamente ao outcome primário (31.5% vs 34.9%, p=0.35), características de base (idade e género), tipo de cirurgia e anestesia, apresentação ao fim-de-semana, admissão na UCI, duração do internamento na UCI e hospitalar. A análise de regressão logística revelou que as variáveis associadas com a mortalidade foram o género feminino (odds ratio [OR] 2.28; 95% intervalo de confiança [IC] 1.40- 3.70; p<0.01), cirurgia convencional (OR 2.79; 95% IC 1.68-4.63; p<0.01) e anestesia geral (OR 9.16; 95% IC 2.33- 36.06; p<0.01). Conclusão: Este estudo revelou que a transferência interhospitalar de doentes para a reparação cirúrgica urgente de AAA não está associada a aumento da mortalidade.

Surgical Treatment Options of Subclavian Artery Pseudoaneurysms: A Case Report and Litterature Review.

INTRODUCTION: Subclavian artery pseudoaneurysms are rare and occur mostly as a consequence of an inadvertent arterial puncture during central venous catheterization, endovascular therapeutic procedures or after penetrating or blunt trauma. They usually have a late clinical presentation, with pain, swelling or other compressive symptoms. The optimal treatment in this situation is still a matter of debate. The authors describe a case of late presentation of subclavian artery pseudoaneurysm after transjugular hepatic biopsy and discuss the several options for treatment. METHODS: A 41-year-old woman was admitted in our hospital due to symptomatic subclavian artery pseudoaneurysm. She underwent a biopsy 20 years earlier for an undetermined febrile syndrome. The pseudoaneurysm was diagnosed during investigation of a right non-pulsatile cervical mass that was associated to cervical edema and Horner's syndrome. CTA revealed a pseudoaneurysm of right subclavian artery with 35 mm of diameter and an arteriovenous fistula to jugular vein which presented with significant enlargement. Additionally, the vertebral venous plexus was also ingurgitated. The pseudoaneurysm caused a left shift of the thyroid, common carotid artery and trachea. The vertebral artery arised 4 mm distal to pseudoaneurysm. RESULTS: After a multidisciplinary evaluation including vascular surgery, neuroradiology and cardiac surgery, she underwent surgical exclusion of false aneurysm and arteriovenous fistula via partial upper sternotomy with cervicotomy. Care was taken to preserve the vertebral artery. There was a complete resolution of compressive symptoms and there were no complications during the first year of follow up. CONCLUSION: Subclavian artery pseudoaneurysms impose a major surgical challenge, especially when originating from the proximal third. Large pseudoaneurysms may rupture or produce signs and symptoms of compression. If intervention is considered necessary, several options are available: open surgical resection and vascular reconstruction, endovascular exclusion, stentgraft implantation or ultrasound-guided thrombin injection have all been described. The choice of procedure should be tailored to the patient, based on comorbidities, clinical presentation and anatomic characteristics. When compressive symptoms exist, an open approach is advised. However, because of their location, surgical exposure of the pseudoaneurysm may be technically difficult, requiring a sternotomy or a clavicular resection for adequate exposure. An endovascular approach demands an adequate landing zone and absence of severe tortuosity. When arteriovenous fistulae and enlargement of vertebral veins are verified, with subsequent increase in venous pressure, there is a risk of cervical radiculopathy (2-4%). This case report describes an uncommon presentation of subclavian pseudoaneurysm and exemplifies the complexity of their treatment.

Influence of Interhospital Transfer on Outcomes of Symptomatic and Ruptured Abdominal Aortic Aneurysms.

INTRODUCTION: 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. OBJECTIVE: Evaluate the influence of the geographic location of patients with symptomatic AAA or rAAA on AAA mortality. METHODS: 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 was <0.05. RESULTS: 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; p<0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p<0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p<0.01). CONCLUSION: 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.

In the Current Era of Endovascular Surgery, What is the Role of Axillofemoral Bypass?

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Infrarenal Abdominal Penetrating Aortic Ulcer, an Atypical Location of a Rare Disease.

INTRODUCTION: 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. METHODS: Report a case of endovascular repair of an infrarenal abdominal PAU. RESULTS: 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. CONCLUSION: 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.

Acute Iatrogenic Limb Ischaemia, a Report of 2 Late Presentation Cases.

INTRODUCTION: 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. METHODS: This is a case-report of 2 patients referenced to a vascular surgery emergency department of a tertiary hospital with late acute limb ischaemia. RESULTS: 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. CONCLUSION: 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.

Acute upper limb ischemia, a rare presentation of giant cell arteritis.

Giant cell arteritis (GCA) is a systemic large vessel vasculitis, with extracranial arterial involvement described in 10-15% of cases, usually affecting the aorta and its branches. Patients with GCA are more likely to develop aortic aneurysms, but these are rarely present at the time of the diagnosis. We report the case of an 80-year-old Caucasian woman, who reported proximal muscle pain in the arms with morning stiffness of the shoulders for eight months. In the previous two months, she had developed worsening bilateral arm claudication, severe pain, cold extremities and digital necrosis. She had no palpable radial pulses and no measurable blood pressure. The patient had normochromic anemia, erythrocyte sedimentation rate of 120 mm/h, and a negative infectious and autoimmune workup. Computed tomography angiography revealed concentric wall thickening of the aorta extending to the aortic arch branches, particularly the subclavian and axillary arteries, which were severely stenotic, with areas of bilateral occlusion and an aneurysm of the ascending aorta (47 mm). Despite corticosteroid therapy there was progression to acute critical ischemia. She accordingly underwent surgical revascularization using a bilateral carotid-humeral bypass. After surgery, corticosteroid therapy was maintained and at six-month follow-up she was clinically stable with reduced inflammatory markers. GCA, usually a chronic benign vasculitis, presented exceptionally in this case as acute critical upper limb ischemia, resulting from a massive inflammatory process of the subclavian and axillary arteries, treated with salvage surgical revascularization.

Avaliação do perfil de armazenamento e descontaminação das escovas dentais / Evaluation the profile of storage and descontamination of toothbrushes

Introdução: A escova dental é um instrumento de higiene bucal eficiente na prevenção de doenças; no entanto, também é um meio favorável a proliferação e disseminação de microrganismos. Objetivo: O objetivo deste trabalho foi avaliar quais os cuidados relativos ao armazenamento e à descontaminação das escovas dentais, realizados por famílias assistidas por um projeto de extensão universitária. Metodologia: A metodologia consistiu na realização de um estudo observacional, por meio da aplicação de um formulário específico. Resultado: Das 88 pessoas entrevistadas, constatou-se que 71,6% lavavam toda a escova com água corrente e 10,2% passavam os dedos nas cerdas para retirar o excesso de água. Quanto ao armazenamento das escovas, 37,5% guardavam dentro do armário do banheiro, enquanto 28,4% armazenavam todas juntas, em cima da pia. Com relação à transmissibilidade, 88,6% sabiam que as escovas podiam ser um meio de transmissão de doenças; porém, 40,9% não sabiam como ocorreria tal transmissão. Sobre a desinfecção de escovas dentais, 71,6% nunca tinham ouvido falar e 77,3% não utilizavam nenhuma solução desinfetante. Conclusão: Observou-se que a maioria das famílias não está realizando os procedimentos necessários para manter suas escovas livres de contaminação.

Introduction: Toothbrush is an oral hygiene instrument efficient prevention of disease, however, it is suitable in the proliferation and spread of microorganisms. Objective: The objective of this study was to evaluate which cares for storage and descontamination of toothbrushes, held by families assisted by a university extension project. Methodology: The methodology consisted of an observational study, through the application of a specific form. Result: Of the 88 people interviewed, 71.6% washed all the brush under running water and 10.2% ran his fingers on the bristles to remove excess water. As for the storage of brushes, 37.5% kept inside the bathroom cabinet, while 28.4% holding it all together over the sink. With respect to the transfer, 88.6% knew that the toothbrushes could be a means of transmission of disease, but 40.9% did not know how it made transmission. About disinfecting toothbrushes, 71.6% have never heard of and 77.3% did not use any disinfectant solution. Conclusion: Found that most families are not performing the procedures necessary to keep your brushes free of contamination.

[Reconstructive surgery of the large intrathoracic veins, four case reports]. / Cirurgia Reconstrutiva das Grandes Veias Intratorácicas, a Propósito de Quatro Casos Clínicos.

The resection and reconstruction of the large venous vessels of the chest is a procedure intended to treat the symptoms of venous hypertension caused by the Superior Vena Cava Syndrome and to allow resection of mediastinal tumors that invade the superior vena cava (SVC) and the left and right innominate veins. We report four clinical cases of mediastinal tumors involving the large intrathoracic venous vessels, submitted to surgery between 2010 and 2013. In all cases our purpose was to completely resect the tumor. We intended to evaluate the surgical results in terms of improvement of symptoms, complications of the procedures, permeability of the bypasses in the short and medium term and mortality rates. We used ringed ePTFE grafts to perform the following vascular reconstructions: - Y configuration bypass from the left subclavian vein and the left internal jugular vein to the left inominate vein; - two bypasses from the top of the left innominate vein to the right atrial appendage; - bypass from the left innominate vein to the right atrial appendage and a bypass from the right innominate vein to the SVC. All patients were discharged, and all the bypasses were patent at discharge and after 30 days . There were two cases of late thrombosis, but patients remained asymptomatic. Our series shows the feasibility of these technically complex surgeries, which are an excellent example of the benefits of multidisciplinary collaboration between vascular and thoracic surgeons.

Tratamento precoce da classe 111 de angle com protração da maxila sem disjunção prévia: apresentação de caso clínico / Early treatment of angle class III malocclusion with maxillary protraction without previous palatal expansion: case report

A protração da maxila seguida da disjunção palatina como parte do tratamento ortodôntico precoce da maloclusão Classe III de Angle é bastante frequente na clínica ortodôntica. O presente trabalho tem como objetivo apresentar e discutir um caso clínico de uma paciente de 6 anos e 7 meses de idade com maloclusão de CIIII de Angle com protração da maxila sem realizar a disjunção palatina. Os resultados apresentados foram bastante satisfatórios em relação aos dados cefalométricos, perfil facial e principalmente, com a oclusão da paciente. Assim sendo, a protração maxilar sem disjunção prévia pode ser aplicada neste caso com bons resultados.

The maxillary protraction followed by rapid palatal expansion as part of the early orthodontic treatment of the Angle Classlll malocclusion is frequent in orthodontic clinic. This work objective to present and argue a clinical case of a patient of 6y and 7m age with Angle Class III malocclusion where we used maxillary protraction without carrying through the rapid palatal expansion. The presented results had been sufficiently satisfactory in regard of cefalometrics data and mainly in patient's occlusion and profile. Thus maxillary protraction without previous palatal expansion can be applied in growing patients with good results.