[Chronic mesenteric ischemia revisited]. / Isquemia mesentérica crónica revisitada.

The authors report two clinical cases of rare and complex situations - an aortic dissection and an aortitis -, which had as a common denominator a chronic mesenteric ischemia. They discuss the indications and surgical strategies adopted.

[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.

["Ex-vivo" surgical repair of renal artery branches aneurysms]. / Tratamento cirúrgico "ex-vivo" de aneurismas de ramos da artéria renal.

The authors report the clinical case of complex aneurysms of intra-hilar branches of the renal artery, managed recently through a renal auto-transplantation procedures with "ex-vivo" repair, discussing the technique, the principles and the indications for this kind of procedure.

[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.

[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.

[Surgical management of abdominal aortic aneurysms in kidney transplanted patients]. / Tratamento cirúrgico dos aneurismas da aorta abdominal em doentes portadores de transplante renal.

From April 1995 to April 2006, four patients, three male and one female, age range 56 to 68 years (average 62), with a renal transplant, underwent the surgical management of an abdominal aortic aneurysm. As a consequence of the high vulnerability of the transplanted kidney to the ischemia and the occurrence of frequent calcifications of the arterial wall in these patients, the aortic clamping time required for the aneurysm repair is sometimes unpredictable and prolonged ischemia may have deleterious effects on the renal function. To avoid this potential and ominous complication, the authors employed a method for renal protection, consisting in the temporary implantation of an extracorporeal axillary-femoral bypass, removed at the end of the operation. Average aortic clamping time was 36,5 minutes, all patients passed urine during that period of time and no significant alterations were noticed in the daily serum creatinine levels, following the procedure. There was no mortality nor significant morbidity and the implantation and removal of the shunt were uneventfull. The extracorporeal transient axillo-femoral bypass seems to be, according to our experience, an easy and valuable method for protection of the kidney transplant in patients requiring abdominal aortic aneurysm repair.

[Infectious endocarditis: a current overview on an "old" disease]. / Endocardite infecciosa: uma visão actual sobre uma "velha" doença.

The infectious endocarditis, first described by William Osler in 1885, is and still remains nowadays as a severe disease, with difficult diagnosis and coursing with high morbi-mortality rates. However, along the years, the disease showed significant modifications in its epidemiology, risk factors, etiologic agents, new study and diagnostic tests and new treatment modalities, medical and surgical, which are the subject of an extensive review by the author, based on an accumulated clinical experience during the last three decades.

[Aneurysm of the superior mesenteric artery in the context of a multianeurismatic disease. Case report]. / Aneurisma da artéria mesentérica superior no contexto de doenca multineurismática: a propósito de um caso clínico.

Aneurysms of the superior mesenteric artery are one of the most uncommon visceral artery aneurysms. Despite its rarity they course with high risks of rupture and many constitute a permanent threat to patients's life. The authors report the clinical condition of a male patient, with a large aneurysm of the superior mesenteric artery, diagnosed through the image techniques made during the follow-up of a previously operated aorto-iliac and bilateral popliteal aneurysms. Its clinical presentation and the surgical management are subjected to presentation and discussion.

[Eversion carotid endarterectomy]. / Endarteriectomia por eversão da bifurcação carotídea.

It is widely accepted and proved the role of carotid endarterectomy in the prevention of cerebrovascular insufficiency. Some mater of controversy lies, presently, apart the role of the endovascular treatment, in the techniques of choice for the endarterectomy, as well as in the method employed for the arteriotomy closure. The authors report their experience with the eversion endarterectomy technique, discussing the results and enhancing the main indications of this alternative method for carotid endarterectomy.

[The use of superficial femoral veins in reconstructive surgery of aortic prosthesis infection (Clagett's operation)]. / A utilização das veias femorais superficiais na cirurgia reconstrutiva da infecção protásica aórtica (operação de Clagett).

Prosthetic aortic infection still represents an enormous challenge to the possibilities of contemporary reconstructive vascular surgery, particularly in terms of diagnosis and surgical management, and is accompanied by high mortality and morbidity rates. Several surgical methods have been devised and employed, including the extra-anatomic bypasses and the in "situ" revascularization. The later uses either antibiotic bounded prosthesis, or biologic homologous conduits, including cryopreserved allografts or autologous arteries and veins. The authors report the clinical condition of a 73 years old male with an infected aortic prosthesis, who underwent the complete removal of the infected graft, followed by an interposition of a venous autograft composed by two superficial femoral veins, removed from both thighs (Clagett's operation). The procedure was extremely well succeeded and the patient was discharged one month later. Reviewed one year later he was found in good condition and free of symptoms.

[Rupture of an abdominal aortic aneurysm with concomitant aorto-caval fistula]. / Rotura de aneurisma da aorta abdominal com fístula aorta-cava concomitante.

Aorto-caval fistulas are one of the most uncommon complications of infrarenal aortic aneurysms and have a high pre and perioperative mortality rates. Its prompt diagnosis and early treatment may be helpful in lowering the surgical morbidity and mortality. One successfully treated case of a ruptured aortic aneurysm with concomitant aorto-caval fistula is reported, discussing the clinical presentation, the diagnosis and the details of the surgical techniques employed.

[Lemierre's syndrome]. / Síndrome de Lemierre.

Lemierre's syndrome (LS) is an uncommon but potentially life-threatening complication of an anaerobic oropharyngeal infection, affecting young adults and adolescents. The disease is characterised by a septic thrombophlebitis of the internal jugular vein and "metastatic" infections, which can be followed by fulminant sepsis and rapid death. More recently, it has been reported a recrudescence of this condition, which could be attributable to alterations in antibiotic usage patterns. The authors report the case of a LS secondary to a bout of intense cough, a cause not yet described in the literature, highlighting the importance of a quick diagnosis and the institution of an appropriate therapy.

[Isolated obstructive lesions of the cervical common carotid: clinical and surgical aspects]. / Lesões obstrutivas isoladas do segmento cervical da carótida primitiva: aspectos clínicos e cirúrgicos.

Isolated lesions of the extra-thoracic common carotid arteries are unusual in clinical practice. Contrarily to the well known lesions of carotid bifurcation, its natural history is poorly understood and indications for surgical management are not well defined. In this paper, seven patients with isolated lesions of the common carotid arteries are reported, being two symptomatic (TIA's). Patients underwent successful surgical management. The main features of clinical presentation, diagnosis and surgical management are presented and discussed

[Mycotic rupture of the reno-external iliac artery anastomosi following kidney transplantation]. / Rotura micótica da anastomose arterial reno-ilíaca externa após transplantaçãa renal.

Two clinical cases of an unusual complication of the renal transplantation are reported, consisting in the infection of the arterial wall by fungi of the species Candida Albicans and Aspergillus, which caused acute ruptures of the external iliac artery and hypovolemic shock. The main features of the pathogenesis of the infection, its diagnosis, management and prevention are subjected to analysis and discussion.

[Penetrating ulcers of the descending thoracic aorta: Diagnosis and surgical management].

In this paper two patients with penetrating ulcers of the descending thoracic aorta are presented, a clinical condition recognized only recently, that may have a severe or even fatal outcome, due to rupture of the aorta. It is a peculiar form of the atherosclerotic disease, and its clinical and imagiologic presentation may mimics the classic aortic dissection of the distal type type. Computed tomography, nuclear magnetic resonance and transesophageal ecocardiography are the most apropriate methods for studying and diagnosis and the surgical management, aimed at the prevention or treatment of the aortic rupture, and based on the prosthetic aortic replacement, is the only alternative allowing the definite cure of the disease. The main features of pathology, clinical manifestations, diferential diagnosis and surgical management of this entity are described and discussed, according to the most recently articles published in the literature, on the subject.

Use of external iliac artery in renal revascularization surgery: long-term angiographic assessment.

PURPOSE: The external iliac artery has physical characteristics, in particular, caliber and length, similar to those of the renal artery and would thus seem to be an ideal substitute for it. However, there are no studies in the literature designed to confirm this possibility. The present study was designed to demonstrate the feasibility of use of the external iliac artery as a substitute for the renal artery in surgical revascularization of renal artery fibrodysplasia and to assess the long-term biologic behavior of the external iliac artery so used. METHODS: Twelve patients (11 female, 1 male), ages 1 to 43 years (mean, 24.4 years), with severe hypertension underwent aortorenal bypass grafting with use of the external iliac artery to treat preocclusive stenotic lesions (n = 7), complete occlusion (n = 3), or aneurysm (n = 2) of the renal artery. It was considered unnecessary to reestablish circulation in the donor limb in 2 patients (young children), and transposition of the ipsilateral internal iliac artery was performed in 9 patients; in the remaining patient circulation was reestablished with insertion of an iliofemoral prosthesis. RESULTS: There were no operative deaths. In 1 patient nephrectomy was necessary because of occlusion of the graft as a consequence of technical complications. In 8 patients there was immediate normalization of blood pressure without aid of medication, and in the remaining 3 patients an antihypertensive drug was prescribed. Two patients were lost to follow-up; the other 9 were assessed with angiography at a mean of 8.8 years after the operation. All grafts were found to be in excellent condition, with no evidence of dilatation, kinking, twisting, anastomotic fibroplasia, or wall irregularities. CONCLUSION: On the basis of this experience, the external iliac artery is confirmed as a substitute for the renal artery, and the excellent long-term results would seem to make it particularly useful in young patients with long life expectancy, such as those with renal artery fibrodysplasia.

A new approach for the surgical management of unilateral iliac artery occlusive disease: the iliofemoral crossover transposition.

Aortobifemoral bypass remains the standard therapy for aortoiliac occlusive disease. Extraanatomic revascularization has been considered as an acceptable alternative and provides reasonable long-term results. Because some of the causes for its failure are related to the prosthetic material used, a technique that uses autologous material and is applicable in patients with unilateral common iliac lesions was developed. Iliofemoral crossover transposition is a femorofemoral bypass procedure in which the external iliac artery is used as a graft. The procedure is easily performed and avoids the use of prosthetic materials, minimizing the risks of their related complications. Because its biologic behavior, including hemodynamic performance, has proven to be excellent, satisfactory long-term results can be anticipated.

Cirurgia Vascular: substitutos arteriais: passado, presente e futuro / Vascular surgery: arterial substitutes: past, present and future

O desenvolvimento histórico da substituiçäo arterial constitui um capítulo interessante e particularmente instrutivo da história da cirurgia das artérias. Desde o início do século até à actualidade, numerosos materiais foram empregues e avaliados na substituiçäo das artérias no homem, contando-se entre homosexuais cadáveres, autoenxertos (arteriais e venosos), heteroenxertos e próteses arteriais. Os substitutos protésicos têm sido, de longe, os materiais mais utilizados, sobretudo os enxertos de Dracon e PTFE. Recentes aquisiçöes tornaram-se mais eficazes e credores de melhor tolerância e adaptaçäo às suas funçöes bem como à interaçäo com o hospedeiro. Todavia, estäo ainda longe de se poderem assumir o substituto ideal das artérias. O seu comportamento biológico é insatisfatório e o índice de complicaçöes que registram é elevado e por vezes de consequências fatais. Neste trabalho é descrito o estado actual da substituiçäo arterial protésica e säo analisadas e discutidas as perspectivas de desenvolvimento, dando particular enfase à utilizaçäo dos homoenxertos arteriais criopreservados, aos heteroenxertos e à biosíntese laboratorial de artérias