[Infra-inguinal prosthetic graft infection in vascular surgery. A case report and review of the literature]. / Infeção protésica infra-inguinal em cirurgia vascular. A propósito de um caso clínico.

Prosthetic vascular graft infection is a rare but very severe complication coursing with high morbi-mortality rates. Its treatment requires appropriate surgical procedures combined with adequate antimicrobial treatment in reference centers. The authors report the clinical case of a 71 years old patient, diagnosed with early prosthetic graft infection 3 months after implantation of a femoro-femoral crossover and a prosthetic- popliteal bypass, treated conservatively, with extensive surgical debridement, preservation of the graft and empirical bactericidal broad spectrum antibiotherapy. The clinical case offers the opportunity to review and discuss the diagnosis and therapeutic issues in prosthetic vascular graft infections. Research is needed to allow an estimation of the risks and benefits of the different therapeutic approaches.

[Surgical management of a dissecting aneurysm of the thoracic aorta in a patient with Marfan's syndrome - case report]. / Tratamento cirúrgico de um aneurisma dissecante da aorta torácica numa doente com síndrome de marfan - Caso clínico.

Marfan's Syndrome is a rare connective tissue disease whose surgical treatment presents several challenges. The existing criteria and recommendations on how and when to surgically approach this disease is almost exclusively confined to the root and ascending aorta, in contrast to the variability of indications on the involvement of the remaining segments of the thoracic and abdominal aorta, due to the multiplicity, morphology and topography of these involvements. This case report is related to a 39 year old woman with Marfan's syndrome, with a type B chronic dissection and a segmentar aneurysm of the proximal descending thoracic aorta with 6,1cm of maximum diameter. The clinical and imagiologic evaluation pointed out the absence of any disorder of the heart, root or ascending aorta. The patient underwent surgical management of the dissecting aneurysm through a transthoracic approach to the aneurysm, with fenestration of the distal aorta and exclusion of the aneurism and intercostal arteries. The efficacy and result of the procedure in addition to the rarity of the vascular pathology presented by the patient, even in the context of a Marfan, completely justify the presentation and disclosure of this clinical case.

[Endovascular femoro-popliteal revascularization in critical limb ischemia: predictive factors for patency]. / Prognóstico das intervenções endovasculares no sector femoro-popliteu em quadros de isqemia crítica dos membros inferiors: factores determinantes da permeabilidade.

OBJECTIVES: The objective of this study was to evaluate the results of endovascular treatment of the superficial femoral artery and to identify some possible predictors of poor prognosis. METHODS: All patients with femoropopliteal artery occlusive disease submitted to endovascular treatment in the internment section of the first author, between July 2007 to September 2010, were reviewed. Intention to treat analysis was performed. Patient's demographics and angiographic anatomic characteristics (results were standardized according to TransAtlantic Inter-Society Consensus II) were analyzed. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. We performed a univariate and bivariate analysis in order to determine factors temporally associated with a poor prognosis of endoluminal therapy. Results were evaluated in view of absence of re-stenosis, absence of re-intervention, patency and overall limb salvage rate. RESULTS: A total of 34 patients corresponding to 36 lower limbs were treated during this period (mean age 65±12 years; males: 80%). Seventy-five percent of patients presented with chronic lower limb ischemia stage IV according to the Leriche-Fontaine classification, while the remaining 25% presented with chronic lower limb ischemia stage III. The lesions classified according to the TASC II document included 9 lesions TASC II B (25%), 20 lesions TASC II C (55%) and 7 lesions TASC II D (19%). Runoff at the tibial level was 1.8±0.6 patent vessels. The success rate was 94%. Mean follow-up was 13.5 months (varying 1-31 months) from the date of initial intervention. Five lower limbs (14%) presented with re-stenosis. Primary patency rates were 91% at 1 month and 77% at 6 months. Limb salvage rate was 88% at 12 months. Subgroup analysis revealed that primary patency rates were highly dependent on patient gender, lesion type and infra-popliteal runoff patent vessels. CONCLUSIONS: Endovascular treatment of femoropopliteal sector is associated with high technical success rate. The best results were obtained in male patients with segmental, stenotic lesions and with a runoff of at least two vessels.

[Leiomyosarcoma of the superficial femoral vein. Case report]. / Leiomiossarcoma da veia femoral superficial. Caso clínico.

The authors report the clinical case of a 56 years old man who developed a deep venous thrombosis of the left lower extremity, managed conventionally with subcutaneous heparin. Physical examination revealed a large tumor of the middle third, antero lateral view of the left thigh. CT and NMR studies, disclosed an extensive multilobulated tumor along the femoral vessels, with medial deviation of the superficial femoral artery and a surgical biopsy revealed the diagnosis of leiomyosarcoma of the femoral vein, grade 3 of malignancy. The patient underwent a complete resection of the tumor, followed by chemotherapy. Two months after the operation a staging CT scan disclosed multiple micronodular metastasis in both lungs and six months later he was found asymptomatic and in good condition. A review of the literature concerning primary malignant tumors of the veins of the extremities is made, with emphasis on main features of its biology, clinical presentation, methods of diagnosis, treatment and results.

[The utilization of the "simplified technique" in the simultaneous management of independent thoracic and abdominal aortic aneurysms. A clinical report]. / Aneurismas independentes da aorta torácica e abdominal tratados simultaneamente pela "técnica simplificada". Caso clinico.

The coexistence of independent aneurysms of the thoracic and abdominal aorta in a single individual, with operative indication has been regarded, since ever, as an enormous challenge to the vascular surgeons and is a source of controversy, regarding the hierarchy, priorities and methods of expeditious management. The authors report the clinical case of a 65 years old male, with a descending thoracic aortic aneurysm, extended to the abdominal visceral vessels, having 6.5 cm of maximum size, together with an infrarenal aortic aneurysm, with 4.5 cm of major diameter. The patient underwent the surgical treatment of both aneurysms, in the same operation, utilizing the "simplified technique", introduced by ourselves in 1984, for the management of thoracoabdominal aortic aneurysms. The efficacy, safety and excellency of the procedure as well as of the clinical result, assessed by angio-CT scans, allow us to enhance one more indication for the "simplified technique" in the management of complex aortic pathology, thus justifying its presentation and divulgation.

[Fibromuscular dysplasia of the brachial artery, an unusual cause of upper extremities ischemia. A case report and review of the literature]. / Displasia fibromuscular da artéria umeral, uma causa rara de isquemia dos membros superiores. A propósito de um caso clínico.

Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic sistemic disease of unknown etiology, primarily affecting muscular arteries of intermediate size. It has been most commonly observed in the renal, carotid, and intracerebral arteries, although it has been reported in other arterial beds. However, being an uncommon disease in general, the manifestation of FMD in the upper extremities is exceedingly rare. The authors report the case of a 69 years old female admitted with ischemia of the right hand, secondary to fibromuscular dysplasia of the midbrachial artery. The patient presented to vascular surgery clinic with a 4 month history of numbness, pain, and coolness of her right hand, with a small necrotic lesion on her right index finger. Peripheral pulses were barely palpable, and doppler-derived brachial and radial systolic pressures suggested midbrachial artery stenosis. Arteriography showed a normal arch and normal innominate, subclavian, and axillary arteries. The midbrachial artery was markedly abnormal and had alternating areas of stenosis and aneurysm formation - "string-of-beads" appearance. The patient underwent surgical excision of the abnormal right brachial artery, and reconstruction was accomplished with a reversed saphenous vein graft. Distal pulses were restored postoperatively. Pathologic examination confirmed the diagnosis of fibromuscular dysplasia. A review of the literature on the topic was made.

[Obstruction of para-renal aorta, associated to mesenteric and renal occlusion, of unknown etiology. Surgical management]. / Obstrução da aorta para-renal, associada A obstrução mesentérica e renal, de etiologia não esclarecida. Tratamento cirúrgico.

The clinical case of a 44-year old female is reported, whose chief complaints were arterial hypertension and disabling intermittent claudication of both legs. Angiography disclosed a segmental occlusion of the para-renal aorta, associated to an occlusion of superior mesenteric and left renal arteries and a critical stenosis of the right renal artery, probably of degenerative etiology ("coral reef"), but not comproved by pathological studies. The patient underwent a complex revascularization procedure, consisting in the implantation of a bypass graft from the supraceliac aorta to both common femoral arteries through a retropancreatic way, followed by superior mesenteric and both renal arteries revascularization by means of independent PTFE grafts attached to the main bypass graft. Post-operative course was uneventful and blood pressure returned to normal values. An angio-CT control study revealed the integrity of the revascularization procedure and the recovery of the left kidney functionality, whose artery was completely occluded. Te etiology, topography and surgical management of this most demanding situation are subjected to an analysis and discussion.