[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.

[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.

[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.

[A complex form of internal carotid artery fibrodysplasia. Surgical management]. / Tratamento cirúrgico de uma fibrodisplasia complexa da carótida interna.

The clinical case of a 46 years old female is reported , admitted with the diagnosis of cerebral transient ischemic attacks, and subjected to an extensive evaluation. Conventional angiography disclosed the diagnosis of dissection and complete occlusion of the right internal carotid artery and a complex angulated lesion, with microaneurisms, of the middle third of the left internal carotid artery, compatible with the diagnosis of arterial fibrodysplasia. Due to the anatomy of the lesion, an endovascular procedure was judged inapropriate and the patient underwent an excisional surgery, followed by replacement with autologous saphenous vein. The operation and the post operative course were uneventfull and the patient was discharged asymptomatic. One month later she was found in pretty good condition and an echodoppler revealed the graft working in excellent condition. The main aspects of this peculiar pathologic entity are subjected to analysis and discussion.

[Revascularization surgery of chronic intestinal ischemia following failure of endoluminal treatment]. / Cirurgia de revascularização da isquémia intestinal crónica após fracasso do tratamento endoluminal.

The endoluminal interventional has played nowadays, a significant role as an alternative to the revascularization surgery of digestive arteries, but its therapeutic efficacy and duration of results have not yet been fully demonstrated. The authors report the clinical case of a 64 years old male, suffering of abdominal angina and significant weight loss, due to a pre-occlusive ostial stenosis of the celiac axis. He underwent three angioplasty/stenting attempts for the last three years, with no success to dilate the lesion and persistence of the clinical symptoms. As a consequence of the failure of the endoluminal intervention, he underwent a conventional revascularization procedure, consisting in the implantation of an aorto-hepatic prosthetic bypass graft, with immediate resolution of the symptoms and a progressive and consistent weight gain. The authors conclude by discussing the advantages and inconvenience of these two modalities for the management of chronic intestinal ischemia.

[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.

[Revascularization to the midpopliteal artery through a posterior approach. Two case reports]. / Revascularização da artéria popliteal media por abordagem posterior. A proposito de dois casos clinicos.

An original technique consisting in the revascularization of the midpopliteal artery through a posterior approach is described, in patients with critical ischemia of the lower extremities, utilizing a prosthetic substitute. This technique can be regarded as an alternative to the infragenicular revascularization and it is particularly suited for patients with no autologous material available. Two successful cases operated on with this technique are reported, with a 6 months and 1 year follow up and documented patency of the grafts.

[Traumatic vasculo-orthopedic combined lesions: 18-years retrospective evaluation of epidemiology and risks factors for amputation]. / Lesoes traumáticas vasculo-ortopédicas combinadas: estudo retrospectivo des 18 anos centrado na epidemiologia e factores de risco para a amputação.

This study was undertaken to assess retrospectively the epidemiology and risk factors for amputation of combined vasculo-orthopaedic traumatic lesions, during a 18-year period, from March 1987 to May 2005, comprising the review of the clinical charts of 149 patients. The series includes a predominance of male patients (84%) with an average age of 34 years. Eighty-five per cent of the lesions resulted from traffic accidents (49% velocipedes, 39% automobiles, 12% trampling), 10% were consequence of falls and 5% resulted from agriculture activities. Orthopaedic lesions include 83 fractures of upper limbs (22 open), 123 of lower limbs (67 open), 21 scapulo-thoracic dissociations and 27 knee dislocations. Vascular lesions include 8 subclavian, 20 axillary, 25 braquial, 10 radial, 6 ulnar and 2 diverse, in the upper limbs; and in lower limbs 4 iliac, 27 femoral, 52 popliteal, 5 tibio-peroneal trunk, 5 anterior tibial, 12 posterior tibial and 12 peroneal. Overall mortality was 3.3% and the amputation rate was 17%. Knee dislocations were responsible for one third of amputations, followed by fractures of bone legs. The association of femur to bone legs fractures from one side and of the knee to bone legs fractures from the other, coursed with high levels of amputation, together with lacerations and crushing of the limbs. The prompt diagnosis of the lesions and the immediate, hierarchic and multidisciplinary approach were considered also as relevant prognostic factors in the management of these most demanding conditions.

[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.

[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

["Ex-vivo" renal artery revascularization].

Three patients with renovascular hypertension due to complex and branch lesions of the renal artery are reported, successfully managed by a technique consisting in the "ex-vivo" repair of the lesions followed by kidney autotransplantation. The indications and technical details of the procedure are subjected to a description 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.