[Joint recomendations for clinical priority in arterial surgery from Portuguese Society of Cardiothoracic and Vascular Surgery and Portuguese Society of Cardiology]. / RECOMENDAÇÕES CONJUNTAS DA SOCIEDADE PORTUGUESA DE CIRURGIA CARDIO-TORÁCICA E VASCULAR E SOCIEDADE PORTUGUESA DE CARDIOLOGIA-- PRIORIDADE CLÍNICA NA CIRURGIA ARTERIAL.

There is a gap in international guidelines for acceptable wait times for cardiovascular surgery. Most patients benefit from surgery as fast as possible after the establishment of an indication. However due to extrinsic factors a continuous and cost-effective response is not feasible to all of them. Priority criteria for surgery after the indication is heterogeneous. The physician/surgeon is responsible for the surgical prioritization upon experience-based criteria. The prioritization is accepted by the hospitals most of the times, but incorrections are verified in excess and defect. There is a press in need for evidence-based prioritization criteria in cardiac and vascular surgery that maintains an adequate waiting time with maximum benefit. Surgical waiting times superior to what is clinically reasonable affects not only the patient but also the health system by indirect costs (morbidity, absence from work). The objective is to establish recommendations in extra-carotid disease, abdominal aortic disease, peripheral artery disease and vascular access construction. A review from the data is made to define an appropriate balance between the surgical scheduling and the prevention of pre an perioperatory adverse events.

[Contemporary therapeutic management of adult's congenital aortic coarctation]. / Abordagem terapêutica contemporânea da coartação aórtica congénita do adulto.

Adult congenital aortic coarctation is an entity rarely seen in clinical practice. It is commonly diagnosed and managed in the early stages of life, mean in the neo-natal or young children's ages. Some cases however can be overlooked at this scrutinity and become recognizable at later stages, in adulthood, through symptoms and signs resulting from the deep hemodynamic deregulation caused by the disease in the proximal and distal aortic physiology, requiring often imperative therapeutic repair. In this paper, an extensive revision is made on the main pathologic, clinical and diagnostic features of the disease, culminating in a critical analysis on the contemporary therapeutic methods available, which includes the conventional open surgery and the endovascular intervention, which includes the balloon angioplasty, the stenting and the covered stents.

[Surgical management of a spontaneous dissection of the celiac axis caused by fibromuscular dysplasia. First clinical report]. / Tratatmento cirúrgico de uma dissecção expontânea do tronco celíaco causada por displasia fibromuscular. Primeiro caso da literatura.

The clinical case of a 46 years old male is reported, who complained of a sudden and sharp epigastric pain, with no other accompanying symptoms or signs. The patient was evaluated in the emergency department of a local hospital and the clinical and laboratory analysis excluded the occurrence of a common acute abdominal pathology. A CT and an angio CT study disclosed a spontaneous dissection and aneurismal dilatation of the celiac axis, along its extension. The patient underwent surgical management, consisting in the resection and prosthetic replacement of the celiac axis and the pathological studies of the specimen revealed a fibromuscular dysplasia, which seems to be, according to the literature, an exceptional situation, never reported before, thus justifying its publication and dissemination.

[Large infectious thoracoabdominal aortic aneurysm in a chronic contained rupture, treated successfully using the "simplified technique"]. / Volumoso aneurisma infeccioso da aorta toracoabdominal em rotura contida tratado com sucesso pela "técnica simplificada"

The clinical case of a 72-years old male is reported, admitted into a Medical Department through the Emergency Service, with a clinical picture of heavy lumbar pain, with walking compromise and acute urinary retention, lasting for several hours. Laboratory analysis revealed a marked elevation of acute inflammatory parameters and a renal failure, expressed by 108 mg/dl of urea and 4.4 mg/dl of creatinine. The patient was admitted with the provisional diagnosis of acute prostatitis, pos-renal acute renal insufficiency and dorso-lumbar pathology of unknown etiology. Three consecutive and subsequent hemocultures allowed the isolation of a Streptococcus pneumonae strain and a CT dorso lumbar spine evaluation disclosed a D11 to D12 spondylodiscitis, with a partial destruction of the vertebral bodies and an extensive throracoabdominal aortic aneurysm adjacent to those vertebrae, with some characteristic features of an infectious aneurysm. Simultaneously, an hemothorax on the left chest was noticed, consequence of a chronic contained rupture of the aneurysm. Following an intensive and specific antibiotic therapy and with an almost completed recovery of the renal function, he underwent surgical management, consisting in the evacuation and drainage of the hemothorax, followed by resection of the aneurysm and extensive tissular debridmente, culminating in the vascular reconstruction utilizing the "simplified technique", introduced in 1984 by A. Dinis da Gama for the surgical management of thoracoabdominal aortic aneurysms. The patiente tolerated the procedure well, with no intercorrences or complications and the post operative course was unventfull. One month later, a CT-angio control disclosed the revascularization procedure working in excellent condition. Finally, an orthopedic artrodhesis of the injuried vertebrae was performed, allowing an easy and pain-free walking and he was discharged on day 60, under antibiotic treatment. The main features of this clinical case are emphasized and discussed, namely those aspects related to its pathogenesis, clinical presentation, diagnosis and surgical management.

[High output heart failure due to an iatrogenic arteriovenous fistula after cardiac catheterization]. / Insuficiência cardíaca de alto débito secundária a fístula arterio-venosa iatrogénica pós cateterismo cardíaco.

The occurrence of an arteriovenous fistula is a potential complication of cardiac catheterization. Most of these fistulas cause no harm. We report the clinical case of a 70 years old woman with high-output heart failure caused by an arteriovenous fistula (FAV) in the groin. The fistula was successfully closed by surgical repair and the heart failure was resolved. This case confirms the potential harmfulness for the vascular bed of certain surgical/endovascular interventions and intravascular monitoring techniques. When heart failure of uncertain etiology appears in patients previously submitted to one of the above mentioned procedures, a careful clinical examination can lead to a correct diagnosis of iatrogenic FAV, whose surgical correction is usually followed by the restoration of a normal cardiac function.

[Chronic contained rupture of a descending thoracic aortic aneurysm simulating an esophagus tumor. Conventional surgical management]. / Aneurisma da aorta torácica descendente em rotura contida simulando neoplasia do esófago. Traramento cirúrgico convencional.

The authors report the clinic case of a 54 years old male, whose chief complaints were dysphagia for solid foods, epigastralgias and remarkable weight loss, of 20 kilos in two months. Admitted in another hospital with the diagnosis of esophagus tumor, an upper G.I. endoscopy disclosed an extensive external compresion of the esophagus middle third and the CT-chest scans revealed a large descending thoracic aortic aneurysm, in chronic contained rupture, as the cause of the compression. The patient was immediately transferred to our hospital and underwent the conventional surgical management, consisting in the aneurysm resection and replacement with a 30 mm Dacron prosthesis. The post-operative course was uneventful and reviewed four months following the operation he was found in good condition, asymptomatic and displaying a remarkable weight gain. In era of a progressive expansion of the field of the endovascular management of thoracic aortic aneurysms, some cases, like the present clinical case, seem to represent a formal contraindication to the endovascular technology, due to the irreducible external compression of organs such as the esophagus, thus remaining an exclusive indication for the conventional surgical management.

[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.

[Surgical management of a chronic post traumatic dissection of the abdominal aorta]. / Tratamento cirúrgico de uma dissecção traumática crónica da aorta abdominal.

The clinical case of a 34 years old male is reported, who was referred to our clinic complaining of disabling claudication of the lower extremities. No risk factors for atherosclerotic disease could be identified. Six years previously he sustained a severe automobile crush injury, resulting in cranio-encephalic and abdominal trauma, and fractures of the left knee and both legs. Appropriate medical and surgical care were delivered and he recovered completely, with no restrictions. Six months before the observation, he started to complain of intermittent claudication of both legs. An angio-CT evaluation disclosed the diagnosis of a chronic dissection of the abdominal aorta of post traumatic etiology, causing significant restriction of blood flow to the lower extremities. The patient underwent surgical management consisting of the resection and prosthetic replacement of the abdominal aorta. The post operative course was uneventful and he became asymptomatic. A control angio-CT study revealed the graft working in excellent condition. The main features of this clinical entity are analyzed and discussed based on a clinical revision of the bibliography on the subject.

[Thrombotic occlusion of an abdominal aortic aneurysm]. / Oclusão trombótica de aneurisma da aorta abdominal.

The clinical condition of a 78 years old male is reported, with a thrombotic occlusion of an abdominal aortic aneurysm, expressed by the acute onset of intermittent claudication of both legs, two months previously to the observation. On physical examination a pulsatile mass was observed in the abdomen, with no expansion, with 7 cms of diameter; femoral pulses were absent. CT-scans confirmed the clinical diagnosis, revealing the presence of a recent thrombus occluding the aortic lumen. The patient underwent the conventional open surgery, consisting in the resection of the aneurysm and replacement with a prosthetic graft, from the aorta to both common femoral arteries. The post-operative course was uneventful and the patient was discharged, asymptomatic, having recovered peripheral pulses in both legs. The main aspects of this rare complication of the abdominal aortic aneurysm are reviewed and discussed, based on the information of the literature on the subject.

[Endovascular management of abdominal aortic aneurysm: a critical analysis on the DREAM, EVAR 1 and EVAR 2 randomized controlled trials]. / Tratamento endovascular do aneurisma da aorta abdominal: análise crítica dos estudos randomizados "DREAM" e "EVAR-1 e 2".

Fourteen years after its introduction in clinical practice and being subject to a large and widespread utilization, the endovascular management of the abdominal aortic aneurysm was evaluated through controlled randomized trials, to assess its efficacy facing the conventional open surgery. The results of these trials, recently published in the international literature, are the subject of a critical analysis by the author, who concludes that they are so significantly important that will probably influence the future, the indications and the range of utilization of the endovascular management of the abdominal aortic aneurysm.

[Primary aneurysms of carotid bifurcation: surgical management]. / Aneurismas primários da bifurcação carotídea: tratamento cirúrgico.

From 1980 to 2005, eight patients, four male and four female, age range between 33 to 86 years (average 55.2) with the diagnosis of primary aneurysm of the carotid bifurcation, underwent surgical management. Patients with postendarterectomy pseudo-aneurysms (also rotulated as "secondary") were excluded from the study, due to different pathogenic, clinical and therapeutic features. Four aneurysms were degenerative by nature, occurring in the older patients of the series. Some other etiologies include arterial fibrodysplasia, brucellosis, Behçet's disease and penetrating wound of the neck. All patients underwent the surgical resection of the aneurysm, followed by reestablishment of the carotid continuity in 6 cases; two patient had a definite ligation of the internal and external carotid artery, respectively. There was no operative mortality nor significant morbidity. From 1 to 25 years after the operation, three patients died for different reasons, two were lost for follow up and the remaining three are found alive and well. The main features of clinical presentation, etiology, diagnosis and surgical management of this entity are presented and discussed and compared with similar experiences reported in the international literature.

[Egas Moniz and the obstructions of the internal carotid artery]. / Egas Moniz e as obstruções da carótida interna.

Claude Miller Fisher is quoted as the discoverer of the pathogenic relationship between the carotid artery occlusive disease and cerebral ischemia, through his work published in 1951, where he describes the cerebral consequences arising from the internal carotid artery occlusion and, later on, the diverse clinical manifestations that it can cause (TIA's and CVA's). However, 20 years before, Egas Moniz, following the research work which lead to the discovery of cerebral angiography, had already mentioned and demonstrated such relationship, and published their observations in the portuguese, spanish and french medical literatures. As he did not published his works in the english literature, he did not get credit nor recognition on the fact, that was later developed by Miller Fisher who dedicated extensive contribution and divulgation on the subject. The present paper is dedicated to an historical review of the pionier work of Egas Moniz and co-workers, aimed to a better understanding of the pathogenic relationship between internal carotid artery occlusions and cerebral ischemia.

[Guidelines for the management of the abdominal aortic aneurysm: a comparison of the 1992 to the 2003 recommendations]. / "Guidelines" para o tratamento do aneurisma da aorta abdominal: uma comparação das recomendações de 1992 com as de 2003.

In this paper a comparison is made between the recommendations for the management of the abdominal aortic aneurysm in 1992, to the recommendations published in 2003, through different subcommittees of the Society for Vascular Surgery and American Association for Vascular Surgery. Substantive differences, in the format and content can be found, due to the enormous progress and technical achievements occurred during that period of time, the endovascular treatment becoming the most important and relevant but not yet regarded as valid alternative to the conventional surgical treatment, being indicated only in particular and well defined circumstances. But despite that fact, the spirit of the recommendations seems to be heavily influenced by the large transformations in the health care organisation and management area, occurred during that period of time, together with the powerful forces and interest moving around the medical act, a fact that allow us to conclude, according to the H E Sigerist's statement that "...changes in medical concepts are tightly connected to the culture as a whole, and are influenced by the changes of the ideas of each epoch".

[Hypoplasias of the thoracic and abdominal aorta: presentation of two cases, with evaluation 11 and 20 years after surgical management]. / Hipoplasias da aorta torácica e abdominal: apresentação de dois casos clínicos, com avaliação 11 e 20 anos após tratamento cirúrgico.

Two cases of hypoplasia of the thoracic and abdominal aorta are reported, diagnosed in two individuals, a girl 13 years old and a boy aged 16 years. The malformation involved the upper abdominal aorta and the visceral arteries in the first case, and simply the descending thoracic aorta in the remainder. Arterial hypertension was the principal manifestation who lead to the diagnosis, which was confirmed through the conventional angiography. Both patients underwent surgical management, which consisted in the aortic revascularization associated to complete visceral revascularization in the first case, and in the single aortic revascularization in the second patient. Surgical therapy course was uneventful in both cases and blood pressure returned to normal values following the operation. Reviewed 11 and 20 years after the procedure, they were found in good condition, with normal blood pressure without any medication; angio CT studies disclosed the prosthetic grafts working in excellent condition. The main features of etiopathogeny, clinical presentation, diagnosis and surgical management are subjected to a discussion, based on an extensive review of the literature dedicated to this clinical entity.

[Surgical management of Takayasu's arteritis with extensive vascular involvement and bilateral renal artery stenosis]. / Tratamento cirúrgico da arterite de takayasu com envolvimento vascular extenso e estenose bilateral das artérias renals.

Proximal renal artery stenosis, in association with stenoses and/or aneurysms of aorta and its branches, suggests a Takayasu's disease and is an important, treatable cause of hypertension in young people. A 29-year-old black woman presents with systodiastolic hypertension and suprasternal and abdominal bruits. An aortography disclosed multiple aneurysms and stenosis of the aorta and its main branches, and bilateral stenosis of renal arteries. The patient underwent an unusual and well-succeeded surgical procedure consisting in the creation of a "ventral aorta", a bypass from the ascending aorta down to the aortic bifurcation, and revascularization of both kidneys. Takayasu's disease frequently courses with extensive involvement of vasculature and bilateral renal stenosis. Renovascular hypertension is a major complication, contributing to the high mortality of this disease. Renal revascularization plays an important role in the modification of the natural history of Takayasu's disease and is essential for long-term survival and prevention of ischaemic renal failure.