[Sequential surgical treatment of multiple primary infectious aneurysms of the thoracic and abdominal aorta]. / Tratamento cirúrgico sequencial de múltiplos aneurismas infecciosos primários da aorta torácica e abdominal.

A 26-year-old woman, complained of repeated urinary infections at the beginning of February 2010. Several urine sample tests identified an Escherichia colli strain, which was treated with antibiotics, according to the antibiogram data. Shortly afterwards, as a result of a back pain, a pyelonephritis was diagnosed, which was also treated with antibiotics. The pain progressively intensified over time and in June 2011 she began to suffer from high and persistent fever, which led to her hospitalisation. The investigation through CT-angiography showed the existence of three aneurysms of the thoracic aorta (one of the aortic arch and two of the descending thoracic aorta) and a large aneurysm of the abdominal aorta, in a contained rupture, surrounding the origin of the renal arteries, of infectious etiology. The patient underwent three sequential and successful surgical operations, using the conventional approach that consisted in the resection and replacement of the aneurysms with "in situ" vascular prosthesis. The main aspects of the pathology, clinical presentation and treatment of this extensive, rare and challenging situation are presented and discussed herein.

[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.

[Surgical management of a congenital abdominal aortic coarctation, associated to renal and mesenteric arteries critical stenosis in a 12-years old young boy]. / Tratamento cirúrgico de uma coartação congénita da aorta abdominal associada a patologia obstrutiva das artérias digestivas e renais, num jovem de 12 anos de idade.

The clinical case of a 12-years old boy complaining of severe and refractory arterial hypertension is reported, in whom an angio-CT evaluation displayed the diagnosis of a congenital abdominal aortic coarctation, associated to a critical stenosis of both renal and superior mesenteric arteries. The patient underwent a complex revascularization procedure, consisting in the implantation of an aorto-aortic bypass graft, followed by both renals and superior mesenteric artery revascularization. The post-operative course was uneventful and blood pressure turned down immediately to normal values. A post-operative angio-CT control revealed the anatomic and functional integrity of the surgical revascularization procedure. The main features of pathology, clinical presentation, diagnosis and surgical management of this exceedingly rare condition are subjected to a discussion, based on an extensive review of the literature published on the topic.

[Synchronous revascularization surgery of supraaortic trunks and abdominal visceral arteries. Case report]. / Revascularização simultânea dos troncos supraórticos e das artérias viscerais do abdómen. Caso clínico.

The clinical case of a 50 years old female is reported, who was admitted at our hospital in very poor general condition, in a physical and psychologic state of exhaustion, due to a mesenteric vascular insufficiency syndrome (abdominal angina), for the last three years. She underwent a conventional angiographic evaluation, disclosing an occlusion of both the celiac axis and superior mesenteric artery and at the level of the aortic arch, an occlusion of the innominate artery associated to an ostial stenosis of the left common carotid artery was also found. The coronary circulation was normal. The patient underwent surgical management consisting in the bowel revascularization trough a supraceliac aortic bypass to both the hepatic and superior mesenteric arteries, followed by a supraaortic trunks revascularization by means of a bypass graft from the ascending aorta to both common carotid arteries. The extensive procedure was well tolerated by the patient and the post-operative course was normal, with the exception of an acute respiratory insufficiency promptly managed with intensive and non-invasive care and she was discharged on day 14th, asymptomatic and with a gain weight of 7 kilos. The unusual and eventually unique character of this simultaneous surgery justifies its presentation, as well as a discussion on the advantages and contraindications of such approach, that revealed itself as an efficient and extremely well succeeded procedure.

[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.

[Open surgery of infra-renal abdominal aortic aneurysm in octogenarians: Redefining the concept of high-risk patient]. / Cirurgia convencional do aneurisma da aorta abdominal infra-renal em octogenários: redefinindo o conceito de alto risco.

OBJECTIVES: Evaluation of the results of open surgery for infra-renal abdominal aortic aneurysm in octogenarians, characterizing the population, risk factors and fitness for surgery. Correlation of risk factors and morbidity/mortality. METHODS: Review of all octogenarian patients submitted to elective surgery for infra-renal abdominal aortic aneurysm between January 2005 and July 2011, in this department. Patient demographics and risk factors were analyzed. Kaplan Meier survival estimates were performed to assess time-dependent prognosis of the surgical procedure. Fitness for surgery was assessed based on Customized Probability Index ( CPI ) and quality of life after discharge according to the SF-8 questionnaire from IQOLA™. Software: IBM®SPSS®19. RESULTS: A total of 28 patients were treated during this period ( 82.1 % male, mean age 81.9 ± 2.3 years ). Mean follow-up was 29.3 ± 19.9 months. 17 patients presented with abdominal aortic aneurysm and 11 with aorto-iliac aneurysm. There were no cases of 30-day mortality and global morbidity was 21.4 %. Mortality was 3.6 % at 1 year, 17.9 % at 3 years and 21.4 % at 5 years. There was no aneurysm related mortality at 5 years. Average length of stay was 13.2 ± 10.3 days and 7.2 ± 7.5 days on ICU. 71.4 % of patients were considered ASA 3 and the average CPI was 6.2. Average quality of life 30 days post-operatory was 41.8 ( SF-8 ). CONCLUSIONS: Elective open repair of infra-renal abdominal aortic aneurysm has excellent results in octogenarians, even when comparing with the results of the most relevant studies for EVAR. Age is not a contra-indication for surgery and fitness for surgery was acceptable in the vast majority of patients. Durability of the procedure should not be discarded in this group, as the majority of patients are alive 3 years after surgery.

[Vascular Ehlers-Danlos syndrome with extensive involvement of thoracic and abdominal aorta in three young women of the same family]. / Síndrome de Ehlers-Danlos vascular com extenso envolvimento da aorta torácica e abdominal em três mulheres jovens da mesma família.

Vascular Ehlers-Danlos syndrome is a rare genetic and hereditary disorder that affects and weakens the structure and sustentability of medium and large size arteries, causing severe clinical complications, often fatal, such as is the case of spontaneous ruptures, aneurysms or arterial dissections. Concomitantly, spontaneous intestinal perforations may occur, as well as uterine ruptures, following a pregnancy and during the peripartum period. The authors report the clinical cases of three young females of the same family, with the diagnosis of vascular Ehlers-Danlos syndrome, coursing with severe involvement of the aorta (ascending aortic anerysm, dissection of the thoracoabdominal aorta), who underwent successful surgical management and were evaluated from 6 to 18 years after the operations. To complete the clinical presentation of the cases, the authors review the most recent literature and discuss the main features of this entity, namely its genetic origin, the arterial morphology and structural alterations, its clinical expression, the diagnosis and the challenges faced by the therapeutical approach, wether it would be the conventional arterial reconstructive surgery or the most recently introduced endovascular intervention.

[Nutritional status of patients with critical ischemia of the lower extremities]. / Desnutrição no doente com isquémia crítica dos membros inferiores.

INTRODUCTION: Critical limb ischemia is a manifestation of peripheral arterial disease and in Portugal the profile of these patients is yet unknown as well as the frequency of hospital malnutrition. The present study aims to contribute to the updating of knowledge on the nutritional status of patients with this condition. AIM: To evaluate the frequency of malnutrition in hospitalized patients with critical lower limb ischemia. METHODOLOGY: A prospective longitudinal study was conducted in the University Clinic of Vascular Surgery of Hospital Santa Maria between November 2010 and February 2011. Data were collected using PG-SGA ( Patient Generated-Subjective Global Assessment ) to assess nutritional status. RESULTS: 71 patients were evaluated of whom 21 % ( 22 ) were identified as malnourished, 40.8 % ( 29 ) at risk of malnutrition and 28.2 % ( 20 ) with normal nutritional status. According to the data, the risk of malnutrition is higher in people aged over 75 years ( OR: 5.12, 95 % CI: 3.03-51.47 ) and diabetic ( OR: 2.73, 95 % CI: 0.88-8.46 ). Concerning to education and occupation, the retired individuals ( OR: 3.85, CI: 0.86-17.15 ) and with an education level between 1 and 4 years ( OR: 2.64, 95 %CI: 0.78-8.90 ), had an increased risk of malnutrition. CONCLUSION: The frequency of malnutrition in patients with critical lower limb ischemia was quite high. Data have revealed that factors associated with malnutrition in these patients are age, low level of education ( less than 4 years ), diabetes and hypertension. To assess nutritional status of these patients the most suitable protocol was NRS-2002.

[The management of carotid reestenosis--an experience with the conventional surgery]. / Tratamento da reestenose carotídea: Uma experiência com a cirurgia convencional.

The authors report a series of 26 consecutive patients, 20 men and 6 women, age range 47-80 years, average age of 66 years, who underwent conventional surgery for the treatment of carotid reestenosis. The surgical management consisted in the resection of a segment of the common carotid-internal carotid arteries and interposition of a prosthetic graft, followed by ligation of the external carotid, in 3 patients; in the remainder 23 cases a venous bypass graft was interposed from the common carotid to the internal carotid artery, above the lesion, with preservation of the external carotid artery flow and ligation of the internal carotid, just below the anastomosis. There was no operative mortality and the significant morbility consisted in a cervical hematoma in one patient, transient disphonia in two cases and transient disphagia in one patient. During the mean follow up time of 43 months, one patient developed a significant reestenosis of the venous graft and another patient developed an aneurysm of the venous graft, both conditions requiring surgical repair. Based on the early and late results of this experience, the authors elect the open conventional surgery as the method of choice for the treatment of carotid reestenosis.

[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.

[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.

[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.

[Arterial reconstructive surgery of a coarctation of the abdominal aorta with involvement of renal and visceral arteries. Clinical and imagiologic evaluation 26 years after the operation]. / Cirurgia reconstrutiva de uma coartação congenital da aorta abdominal com envolvimento das artérias digestivas e renais. Avaliação clínica e imagiológica 26 anos após a operação.

The clinical case of a 13 years old female is reported, with the diagnosis of congenital coarctation of the abdominal aorta, with involvement of renal and visceral arteries, causing arterial hypertension and a systolic bruit in the auscultation of the epigastric and umbilical areas. Conventional angiography disclosed a stenotic process of the upper abdominal aorta, with concomitant ostial stenosis of the renal and digestive arteries, and post-stenotic dilatation of the celiac axis and superior mesenteric artery. The physical development of the patient, close to the adult pattern, allowed the performance of a complex revascularization procedure,accomplished in May 1984, consisting in the implantation of an aorto-aortic bypass graft, through the diaphragm, followed by visceral and renal revascularization, by means of independent prosthesis taken from the aortic bypass. The post-operative course was uneventful and blood pressure returned immediately to normal levels. Reviewed recently, the patient was found in good clinical condition,asymptomatic and with normal blood pressure, developing a normal family, social and Professional life. An Angio-CT evaluation, performed in February 2010, almost 26 years after the operation, revealed the complex revascularization procedure patent and working in excellent condition. To our knowledge, this seems to be the longest follow up of such a procedure employed successfully in a very rare clinical entity, thus justifying its presentation and divulgation.

[Large post traumatic internal carotid artery aneurysm simulating a neurogenic tumor. Surgical management]. / Volumoso aneurisma pós-traumático da carótida interna simulando tumor neurogénio. Tratamento cirúrgico.

The clinical case of a 60 year old female is reported who, incidentally, had the diagnosis of a retropharyngeal tumor, causing the anterior dislocation of the right tonsil. Imagiological studies (CT and NMR scans) were compatible with the diagnosis of "neurogenic tumor" or "vagal paraganglioma" and an attempt to a biopsy was failed, having collected only blood. An angio-RM allowed the definitive diagnosis of a large sacular aneurysm of the internal carotid artery, of unknown etiology. The patient underwent surgical management, consisting in the resection of the aneurysm and re-establishment of the arterial continuity by end-to-end anastomosis. Pathological studies of the specimen revealed an unsuspected traumatic etiology, probably related to a violent cervical blunt trauma occured several years before. The main features of the pathogenesis, topography, clinical manifestations and treatment of this condition are discussed, based on the most recent data published in the literature.

[The blue toe syndrome and its pathogenic significance. A case report]. / A síndrome do dedo azul e o seu significado patogénico. A propósito de um caso clínico.

A 64-years-old woman complained of fixed cyanosis and rest pain of the 2nd, 3rd and 4th toes of the right foot, after a sudden onset one month previously to the clinical examination. The diagnosis of "blue toe syndrome" was then made. She was in a post-menopause state, with no hormonal substitution therapy, complaining also of obesity, arterial hypertension and hyperlipidemia, under medication but no laboratory control. Blood tests excluded an hypercoagulable state and the ECG revealed no significant abnormalities. Angio-CT scans and conventional angiography disclosed an atherosclerotic lesion at the femoropopliteal level, with an adherent and floating thrombus in the arterial lumen, causing microemboli to the collateral digital arteries. The complex lesion was removed through a local thromboendarterectomy, followed by a Carrel-DeBakey patch graft angioplasty, using autologous saphenous vein. Post operative course was uneventfull, with an immediate recovery of the clinical picture. Double antiplatelet therapy was advised and an extensive investigation of the possible relationship of this event with an occult malignancy was started, with no conclusive results, until now. The patient was placed in a clinical, laboratory and imagiologic surveillance program and the main features of this entity are emphasized and discussed, according to the data published in the literature on the subject.

[Complete traumatic rupture of a cross over femoro-femoral bypass graft. First case report]. / Rotura traumática completa de um bypass protésico femoro-femoral. Primeiro caso da literatura.

The authors report the clinical case of a 66 years old man who underwent, in November 2007, a cross-over femoro-femoral bypass, using a spiral protected 8 mms PTFE graft, to treat a disabling intermittent claudication of the left lower extremity. In April 2009, seventeen month later, he suffered a brutal kick injury in the suprapubic area, resulting in a local voluminous hematoma, including the scrotum, shock and left lower extremity ischemia. Angio-CT scans disclosed a complete fracture of the prosthesis. The patient underwent immediate surgical management, consisting in the local thrombectomy and reconstruction of the graft continuity, through an end-to-end anastomosis. He was discharged seven days later and one month later he was found asymptomatic and in good condition. Following an exhaustive revision of the literature, the authors conclude that this is the first report of such complication of a cross-over femoro-femoral bypass graft.