The Challenge of Managing a Primary Aortic Mural Thrombus: Outcomes and Technical Considerations.

Background: Embolization to multiple arterial beds associated with primary aortic mural thrombus (PAMT) could result in high morbidity and mortality. There are no recommendations to dictate the best management. This study aims to describe our experience in managing this rare disease. Methods: A retrospective review of all patients affected by PAMT treated at our institution between January 2015 and December 2021 was performed. Recorded data included demographics, prothrombotic risk factors, imaging findings, clinical presentation, and treatment. Primary outcomes comprised thrombus recurrence, major amputation, and death. Results: Thirteen patients with PAMT have been included. The median age was 52 years (36-68 years), and the male/female ratio was 1:1.6. The diagnosis of PAMT was made by computed tomography angiography (CTA) in all cases. Prothrombotic conditions were identified in 92% of cases, and most patients (92%) had thoracic PAMT. The most common presentation was acute limb ischemia after thrombus embolization (85%), requiring surgical revascularization. Anticoagulation was promptly started in all patients. Two patients developed heparin-induced thrombocytopenia. Recurrence of embolization/thrombosis was observed in 54% of patients; two underwent endovascular thrombus exclusion with a stent graft. We identified one PAMT-related death and one major amputation with a median follow-up time of 39 months (12-64 months). Conclusion: Anticoagulation alone as initial therapy could completely resolve PAMT but is associated with high embolization recurrence. Thoracic endovascular aortic repair is feasible and could prevent additional embolization. However, the criteria for its use as a first-line therapy still need to be defined. Our study highlights the importance of closely monitoring these patients.

Intrastent HeROgraft deployment as a catheter-sparing procedure.

Current vascular access (VA) practice adopts arteriovenous fistulas (AVF) as first option for haemodialysis, relegating arteriovenous grafts (AVG) for patients with exhausted upper limb venous patrimony. The Hemodialysis Reliable Outflow graft (HeRO®) is a device assuring direct venous outflow to the right atrium, thus avoiding central venous obstructive disease. Its use together with early access grafts avoids the need for central venous catheters (CVC) bridging periods. We report the deployment of the HeRO device using a previous stentgraft as pathway for the placement of the outflow component, in a patient with no-option for further autogenous upper limb access. This technique spared the usual central vein's exit point for the HeRO graft and, using an early-access dialysis graft, allowed for next-day successful haemodialysis.

The Vascular Patient - Chronic Mesenteric Ischemia, AAA and Iliac Occlusion.

Peripheral arterial disease (PAD), abdominal aortic aneurysm (AAA) and chronic mesenteric ischaemia (CMI) are vascular diseases uncommonly observed in the same patient, especially when treatment is required. This case report illustrates a patient requiring mesenteric revascularization due to CMI. A long flush occlusion of the superior mesenteric artery (SMA) precluded endovascular revascularization. Therefore, we performed a retrograde bypass from the right common iliac artery (CIA) to the SMA. On the 6-month follow-up, the patient developed right limb ischemia despite the absence of intestinal angina. CT angiography revealed CIA occlusion, bypass patency through hypogastric retrograde filling and modest growth of a AAA. Due to the presence of contralateral CIA lesions and to achieve durable revascularization, we opted to perform a AAA repair with an aorto-uni-iliac endograft followed by a femorofemoral crossover bypass. This achieved AAA's repair, lower limb revascularization, and a suitable and durable inflow to the mesenteric bypass.

Sapheno-Cavernous Shunt: A Vascular Approach In The Treatment Of Ischemic Priapism.

Priapism is an urologic emergency defined as an erection that persists for more than 4 hours and is unrelated or lasts beyond sexual stimulation. Ischemic priapism, caused by prolonged venous occlusion within the corporal bodies, works as a compartment syndrome that requires prompt resolution in order to preserve erectile function. We present two cases of ischemic priapism refractory to conventional treatment that were treated with the help of vascular surgeons. In both cases a sapheno-cavernous shunt was effective in achieving detumescence and erectile function recovery. Despite rarely described in literature, this can be a safe and effective technique in the treatment of ischemic priapism.

Penetrating Vascular Trauma To The Brachial Artery.

Civilian penetrating injuries to the upper extremities are becoming seldom, with few case reports presented in the recent literature. Nevertheless, the brachial artery is the most frequently injured artery, accounting for approximately 30% of all vascular injuries. The authors present two clinical cases of brachial artery penetrating trauma with a stab corrected with an interposition saphenous bypass graft.

Asymptomatic Hypogastric Arteriovenous Fistula Detected 40 Years After Shotgun Injury.

84-year-old male, with a history of firearm incident with accidental gunshot shooting, and multiple projectile injuries, 40 years prior. No advanced medical treatment was required at the time. A CT was recently performed for unrelated reasons, and the scout view shows multiple projectiles, a total of 50, scattered in the thoracoabdominopelvic region as well as the lower limbs. CT angiography exposed CT's scout view of the multiple projectiles scattered. an arteriovenous fistula in posterior branches of the hypogastric artery with moderate dilations of the superior gluteal vein. The patient was completely asymptomatic and had no findings suggestive of AVF-related cardiac failure. Physical examination was unremarkable. Conservative treatment without further imagiological follow-up was decided, if patient continued asymptomatic.

Isolated common iliac artery aneurysm with specific anatomical considerations.

INTRODUCTION: Iliac artery aneurysms (IAA) are a rare entity with a prevalence lower than 2% in the general population involving typically the common iliac artery in 70-90%. CASE-REPORT: This is the clinical case of an 88 years-old male patient with an isolated giant IAA, 84mm maximum diameter, diagnosed following a four-month period of lower abdominal discomfort and pelvic hyperemic mass. The IAA was successfully excluded with an endovascular approach with an aorto-uni-iliac endograft Endurant II (Medtronic Cardiovascular, Santa Rosa, CA, USA) followed by a femorofemoral right to left bypass. DISCUSSION: Asymptomatic IAA are difficult to identify due to their anatomical location deep within the pelvis but once symptomatic they are associated with a high rate of morbidity and mortality. Their management has evolved toward an endovascular first approach over the past decades, nevertheless, the type of operative repair depends on patient anatomy, clinical stability and the presence of other concomitant aneurysms.

ISOLATED COMMON ILIAC ARTERY ANEURYSM WITH SPECIFIC ANATOMICAL CONSIDERATIONS.

INTRODUCTION: Iliac artery aneurysms (IAA) are a rare entity with a prevalence lower than 2% in the general popula- tion involving typically the common iliac artery in 70-90%. Literature describes that bilateral common IAA may be present in approximately 50% of the affected patients. CASE-REPORT: The authors present an 88 years old male patient with an isolated giant IAA, 84mm maximum diameter, diagnosed following a four-month period of lower abdominal discomfort and pelvic hyperemic mass. The IAA was successfully excluded with an endovascular approach with an Aorto-uni-iliac endograft Endurant II (Medtronic Cardiovascular, Santa Rosa, CA, USA) followed by a femorofemoral right to left bypass. DISCUSSION: Asymptomatic IAA are difficult to identify due to their anatomical location deep within the pelvis but once symptomatic they are associated with a high rate of morbidity and mortality. Their management has evolved toward an endovascular first approach over the past decades, nevertheless, the type of operative repair depends on patient anatomy, clinical stability and the presence of other concomitant aneurysms.

Emergency Repair of a Ruptured Para-Renal Abdominal Aortic Aneurysm in a Patient with a Functional Renal Graft: A Case Report and Review of the Literature.

INDRODUCTION: Rupture of and abdominal aortic aneurysm (AAA) in a kidney transplant patient is a rare and rarely reported event. Emergent treatment can be challenging and should achieve effective aortic repair while minimizing ischemic damage to the renal graft during aortic cross-clamping. Several renal protective measures have been proposed such as permanent or temporary shunts, renal cold perfusion and general hypothermia. CASE REPORT: We report the effective treatment of a para-renal AAA in a patient with a functional renal allograft. A temporary extra-corporeal axillofemoral shunt was constructed to maintain graft's perfusion during open surgical repair. EVAR was not an option due to a short aortic neck. The postoperative period was complicated by colon ischemia and aortic graft infection. At 3 years follow-up the patient was well and graft's function was unchanged. CONCLUSION: This case is a reminder that renal graft protection must be accounted for when AAA rupture occurs in kidney transplant patients. We reviewed the literature to find previously reported cases and how they were managed.

SURGICAL TREATMENT OF A SPONTANEOUS RUPTURE OF A MYCOTIC ANEURYSM.

Saccular mycotic aorto-iliac aneurysms are rare but, when ruptured, they are an important life-threatening condition. We present the case of a 52 years-old male transferred from another hospital and admitted to the emergency room with a ruptured iliac artery aneurysm. He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Image study with computed tomographic angiography revealed a ruptured left common iliac artery saccular aneurysm. The patient was instantaneously and successfully submitted to endoaneurismorraphy of the hypogastric artery, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femorofemoral bypass. Blood culture revealed a Streptococcus anginosus and the patient received appropriate targeted antibiotics. Post-operative period was uneventful and the patient discharged ten days after admission. He has now eleven months of follow up with no intercurrences. Even though surgical approach carries a relative risk of perioperative morbidity, it is a feasible and durable solution for extreme situations like the one here described.

Hemodialysis Acess - A Creative Attitude is Necessary.

Creating and maintaining a functional vascular access (VA) is a critical factor in the survival of a dialysis patient. It implies a creative attitude either to maintain its functionality or to build a new one wherever possible, being it autologous or synthetic. We describe the VA history of a 59 years-old male patient, with extreme obesity, which started in 2012 with failed attempts of VA construction in both forearms until a functional brachiocephalic arteriovenous fistula (AVF) in the right upper limb was achieved. However, it required ligation due to severe venous hypertension secondary to central venous disease related to previous CVC use. As he had no good superficial conduit in the left arm we decided to harvest the arterialized right cephalic vein and implant it in the left arm, creating an autologous arteriovenous shunt between the brachial artery and axillary vein (AV). Despite initial patency, it failed irreversibly approximately one year after creation. As no more superficial veins were available in the upper limbs, a prosthetic access was the next step. We decided for a hybrid graft (HG) between the left brachial artery and the AV because of the patient's biotype and scarred axilla that impeded a safe re-intervention on the AV. This graft was used between 2015 and 2017 with multiple interventions to maintain patency. In 2017 a significant diffuse prosthesis deterioration and reduced AVF flow were noticed with no possible segmental reconstruction. We were then forced to proceed with subtotal graft substitution preserving the outflow stented segment of the HG, using an early cannulation graft to prevent CVC use. After this successful reconstruction, the patient started hemodialysis on the following day with no intercurrences registered.

[Hilar Renal Artery Aneurysm - Ex-vivo Reconstruction and Autotransplantation]. / Aneurisma Hilar da Artéria Renal - Reconstrução Ex-vivo e Autotransplante.

Renal artery aneurysm (RAA) is a rare entity with an estimated prevalence of 0.09%. The majority present asymptomatically and the diagnosis is made incidentally during an imaging test. Indications to treat have been subject of intense debate, nevertheless, there seems to be some consensus that RAA's greater than 2 cm in diameter, expanding, with thrombus or in pregnant women should be treated. Treatment options vary between surgical or endovascular approach. Hilar RAA presents a therapeutic challenge because of their anatomic location and may require extracorporeal arterial reconstruction and auto-transplantation. We describe a 71-year-old woman, with an incidentally diagnosed complex RAA, following the study for an abdominal discomfort. Computed tomographic angiography revealed a 13mm, saccular aneurysm located at the right renal hilum. We performed hand-assisted laparoscopic nephrectomy with ex-vivo repair of the RAA. The intervention and postoperative course were uneventful. At six months of follow up the patient keeps a well-functioning auto-transplant. RAA may be nowadays more frequently diagnosed due to the increasing use of imaging techniques. Hand- -assisted laparoscopic nephrectomy with ex-vivo repair and auto-transplantation is a challenging but feasible option for treating hilar RAA.

O aneurisma da artéria renal é uma entidade rara com uma prevalência estimada de 0.09% na população geral. A sua maioria apresenta-se de forma assintomática sendo o diagnóstico feito de forma incidental durante o estudo imagiológico por outra suspeita. As indicações para o seu tratamento têm vindo a ser alvo de grande debate na literatura contudo, parece haver algum consenso no sentido de tratar aqueles maiores que 2 cm de diâmetro, com crescimento ao longo do período de vigilância, na presença de trombo e em mulheres grávidas. As opções de tratamento variam entre cirurgia direta ou endovascular. Os aneurismas hilares representam um desafio em termos de abordagem cirúrgica pela sua localização requerendo em algumas circunstâncias reconstrução extracorporal e auto-transplante renal. Os autores descrevem um caso clínico de uma doente do sexo feminino, 71 anos de idade, a quem tinha sido incidentalmente diagnosticado um aneurisma hilar da artéria renal, no seguimento de estudo por desconforto abdominal. O estudo por angiotomografia computorizada revelou um aneurisma de 13mm, de conformação sacular, localizado a nível do hilo renal direito. Procedeu-se a nefrectomia via laparoscopia e reparação ex-vivo do aneurisma. O procedimento decorreu sem intercorrência bem como o seguimento efetuado à doente, mantendo-se o enxerto funcionante aos seis meses. O aneurisma da artéria renal é, hoje em dia, mais frequentemente diagnosticado no contexto do crescente uso de técnicas de exame imagiológicas. A nefrectomia via laparoscopia e reparação ex-vivo seguida de auto-transplante é um procedimento desafiante mas exequível com elevada taxa de sucesso no tratamento desta patologia.

Giant Ruptured Common Iliac Artery Infected Aneurysm.

INTRODUCTION: Saccular mycotic aorto-iliac aneurysms are extremely rare and when presented with ruptured, they are an important life- threatening condition. METHODS: We present a 52 years old male transferred from another Hospital and admitted to the emergency room with a ruptured iliac artery aneurysm. RESULTS: He complained of persistent fever and abdominal discomfort that swiftly established as hemorrhagic shock. Imagiological study with angioCT revealed a ruptured left common iliac artery saccular aneurysm with 90mm. The patient was instantaneously and successfully submitted to endoaneurismorraphy, common and external iliac artery ligation and construction of an extra anatomic bypass, right to left femoro-femoral bypass. Blood culture revealed a Streptococcus anginosus and the patient received appropriate targeted antibiotics. Post-operative period was uneventful and the patient discharged ten days after admission. He has now eleven months of follow up with no intercurrences. CONCLUSION: Long term antibiotics along with aggressive surgical debridement of the infected tissue and vascular revascularization with an extra anatomic bypass remain the most definitive solution while endovascular aneurysm repair may generally constitute a bridge life-saving procedure in mycotic infected aneurysms. Even though surgical approach carries a relative risk of perioperative morbidity it is a feasible and durable solution for extreme situations like the one here described.

Carotid Stenosis in Cardiac Surgery Patients.

INTRODUCTION: Ischemic stroke is a potential perioperative complication after an open heart surgery (OHS). Whether a carotid stenosis or occlusion is associated with an increased risk of perioperative stroke in patients or just a risk factor has been a concern of intense debate in the literature. METHODS: We retrospectively analyzed patients submitted to OHS between January and December2016 with known asymptomatic carotid disease. The data from 85 consecutive patients undergoing coronary artery bypass grafting, valve replacement, or both was collected. The final events registered were stroke, acute myocardial infarct or death. Our aim was to assess whether the presence of carotid stenosis precluded a higher rate of stroke after cardiac surgery. RESULTS: 70 male and 15 female patients, with a medium age of 74(min 45,max84) years were analyzed. 45(53%) patients were submitted to bypass grafting, 21(25%) to valve replacement and 19(22%) to both. Of these patients,42(49%) had unilateral significant carotid stenosis equal or greater than 50%, 12(14%) had bilateral significant stenosis and 20(24%) had a stenosis equal or greater than70%. 2(2%) patients had a previous history of neurologic event. In the peri-operative period, 3 patients (3,5%) developed transient ischemic attack (TIA) or stroke, 3(3,5%) a cardiac event and 6(7%) patients died (3 due to a cardiac event and 2 due to a neurologic event). Two (67%) of the neurologic events occurred in the corresponding side of an hemodynamic carotid stenosis although both this patients had also significant aortic arch calcification and atrial fibrillation. None of the patients that developed post-operative TIA or stroke had previously a neurologic event. CONCLUSION: Some studies reported an average stroke incidence around 1.9%following OHS. Despite carotid stenosis, other risk factors should be taken into consideration before considering OHS such as advanced age, prior stroke/TIA, unstable angina, predicted prolonged time for cardiopulmonary bypass, severe aortic arch disease and atrial fibrillation. In our studied population two of the post-operative neurologic events occurred in patients with significant bilateral stenosis, one side between50-69% and the other side 70-99%. According to the new guidelines "Management of Atherosclerotic Carotid and Vertebral Artery Disease:2017 Clinical Practice Guidelines of the European Society for Vascular Surgery" staged or synchronous carotid intervention may be considered for OHS patients with bilateral asymptomatic 70-99% carotid stenosis, or a 70-99% stenosis with contralateral occlusion. Our results may suggest that a sub-group of patients with bilateral significant (>50%) carotid stenosis may benefit from staged or synchronous carotid intervention.

Renal Autotransplantation - The Solution for Different Pathologies.

INTRODUCTION: Renal autotransplantation (RA) is a safe and effective procedure to reconstruct the urinary tract which first successful surgery was performed by Hardy in 1963. The main indications reported for performing RA generally includes renovascular disease, ureteral pathologies and neoplastic disease. RA may be also useful as the last recourse in preventing kidney loss in highly selected patients, especially when conventional methods have failed. METHODS: The authors pretend to describe four total different situations where the RA was the key solution for the pathology initially presented. RESULTS: 1- 52 years old male with a previous history of right nephrectomy that occurred during an exacerbation of his basal Chron disease so as left ureter cutaneostomie, presented with repetitive urinary tract infections that led to renal function impairment; 2- 57 years old female with the diagnosis of renal artery aneurysm while being studied as a potential renal donor; 3- 49 years old male admitted in the emergency room after a penetrating trauma which conditioned bowel and ureteral lesions with postoperative consecutive and recurrent peritoneal infections that compounded a necessity for a left ureter cutaneostomie, that the patient accurately refused; 4- 24 years old female with the diagnosis of Nutcracker syndrome identified after being studied regarding repetitive urgency admissions with frank hematuria. Every patient was submitted to RA. The intervention and postoperative course were uneventful. We performed an ultrasound evaluation on the day after each procedure to attest normal renal perfusion. CONCLUSION: The RA were realized in the two patients with ureteral lesions because there was no viable alternative but kidney loss. The other two clinical cases were treated with RA because they concerned a complex renovascular disease (one arterial and the other venous). Despite the existence of an endovascular option for these patients, long term follow up studies are still lacking. The RA is a viable option in specific situations for kidney salvage. The recent development of laparoscopic nephrectomy significantly decreased the surgical hostility to the patient and promoted the RA value on the treatment of complex vascular pathologies, traumatic disease and specific medical situations. It represents a credible alternative with attested results already described in the literature thus requiring a vast Institutional experience with conventional renal transplantation.

Creative Vascular Access Construction in Same Patient.

INTRODUCTION: Creating and maintaining a functional vascular access(VA) is a critical factor in the survival of a dialysis patient. However, it will not function forever, implying a creative attitude from the vascular surgeon either to maintain its functionality or built a new one wherever possible, being it autologous or synthetic. METHODS: Describe the VA history of a 59years-old male with morbid obesity and end-stage chronic kidney disease. RESULTS: His VA construction started in2012 with failed attempts in both forearms until a functional brachiocephalic artery-venous fistula(AVF) in the right upper limb was achieved, but was deemed to ligation as severe venous hypertension secondary to central venous disease related to CVC use. As he had no good superficial conduit in the left arm we decided to harvest the deemed right cephalic vein and implant it in the left arm, creating an autologous arteriovenous shunt between the brachial artery and axillary vein(AV). Despite initial patency, it failed irreversibly weeks after creation. As no more superficial veins were available in the upper limbs, a prosthetic access was the next step. We decided for a hybrid graft(HG) between the left brachial artery and the AV because the patient biotope and a scarred axilla impeded a safe reintervention on the AV. This graft was being used since 2015 with multiple interventions for maintaining patency (PTA, segmental graft replacement and thrombectomies). Recently we noticed a significant diffuse prosthesis deterioration and reduced AVF flow with no possible segmental reconstruction. We were then forced to proceed with total graft substitution preserving the outflow stented segment of the HG, using an early cannulation graft(ECG) and prevent CVC use. After this successful reconstruction, the patient started hemodialysis on the following day with no intercurrences registered. DISCUSSION: Generally, CVC's are related with poorer dialysis quality and patient survival.Hence, fighting for any other functional access is very important. The range of solutions will depend on the vascular surgeon capacities, imagination and device access. Once faced with no more feasible direct autologous access, there is a range of complex autologous fistulas, including veins translocations. When no more native vessel can be used for puncture, we still have a wide armamentarium (normal grafts, ECG or HG) that should be considered according to patient specifications. HG besides some hemodynamic advantages, can be very useful when the landing vessels are difficult to access. ECG offer the advantage of almost immediate cannulation, preventing CVC placement and its associated comorbidities.

Surgical Thrombectomy, Fibrinolysis, Angioplasty and Stenting: A Combined Approach for Treatment of a May-Thurner Syndrome Presenting as Phlegmasia Cerulea Dolens.

INTRODUCTION: Phlegmasia cerulea dolens (PCD) is a rare complication of deep venous thrombosis (DVT). Massive ileo-femoral DVT is usually the cause and prompt treatment is mandatory as it represents a medical emergency. Reported amputation rates range from 12% to 25% and mortality ranges from 25% to 40%. Limb ischemia results from obstruction to arterial inflow secondary to extreme levels of venous hypertension. Primary treatment goal is restoration of venous outflow and can be achieved by endovascular or surgical techniques. After thrombus removal an underlying iliac vein stenosis may be present. May-Thurner syndrome, a condition where the left common iliac vein is compressed by the right iliac artery, is the most prevelant iliac stenotic lesion. METHODS: We report a case of a 57 years-old male, smoker, with no significant medical history, who presented to the emergency department with excruciating sudden left limb pain and swelling, with no trauma history, with a 2-hour onset. On physical examination he showed significant edema, purplish discoloration of the entire leg and absent dorsalis pedis artery pulse. RESULTS: Hipocoagulation with intravenous heparin was immediately initiated and emergent surgical venous thrombectomy was performed associated with direct intravenous fibrinolytic agent injection. Postprocedure phlebography showed a left common iliac vein lesion which was treated with angioplasty and venous stent placement. Pain, edema and coloration improved markedly after procedure without any complications. The patient was discharged home with anticoagulation treatment and compression stocking. CONCLUSION: Endovascular approaches such as catheter-directed thrombolysis (CDT) or pharmacomecanical thrombolysis (PMT) are becoming the treatment of choice to achieve venous outflow in DVT. In cases of PCD, when rapid restauration of venous outflow is mandatory, CDT has the disadvantage of having a long mean treatment time. This way, surgical thrombectomy still plays an important role in cases of PCD, especially if PMT is not available. In our case, the combined used of surgical thrombectomy with direct intravenous thrombolytic infusion provided effective treatment of PCD and uncovered an underlying left common iliac vein stenosis, which was successfully managed by angioplasty and stenting.

Hilar Renal Artery Aneurysm - Ex-vivo Reconstruction and Autotransplantation.

INTRODUCTION: Renal artery aneurysm (RAA) is a rare clinical entity with an estimated prevalence of 0.15% to 0.1%in the general population. The majority of patients present asymptomatically and the diagnosis is made incidentally during a hypertension study test, and more rarely, fortuitously after backache. Indications to treat have been subject of intense debate, nevertheless there seems to be some consensus that RAAs greater than 2 cm in diameter, expanding RAA, with thrombus or in pregnant women should be treated. Treatment options vary between surgical or endovascular approach. The complex (hilar) RAA constitute a subset of RAA that present a therapeutic dilemma because of their anatomic location and may require extracorporeal arterial reconstruction and auto-transplantation. METHODS: We describe a 71-year-old woman with a personal history of hypertension for more than twenty years but normal renal function. Following the study for an abdominal discomfort a complex RAA was incidentally diagnosed. Computed tomographic angiography with three-dimensional reconstruction revealed a 13mm, saccular aneurysm located at the right renal hilum. RESULTS: We performed hand-assisted laparoscopic nephrectomy with ex vivo repair of the RAA. The aneurysm was resected and a polar renal artery was implanted over the resected area with a latero-terminal anastomosis. Complementarily, the renal vein was augmented with a spiral great saphenous vein graft and finally the kidney was implanted into the right iliac fossa. The intervention and postoperative course were uneventful and the patient submitted to ultrasound evaluation on the day after procedure. It revealed normal renal perfusion with normal flow indices. In the last follow-up realized, two months after surgery the patient was alive with a well-functioning auto-transplant. CONCLUSION: RAA may be nowadays more frequently diagnosed due to the increasing use of imaging techniques. While renal artery trunk aneurysms are most often treated using an endovascular procedure it is not suitable for renal artery branch aneurysms. Hand-assisted laparoscopic nephrectomy with ex vivo repair and auto-transplantation is a challenging but feasible option for treating hilum RAA.

[Acute mesenteric ischemia: the importance of early diagnosis and aggressive revascularization]. / Isquemia Mesentérica Aguda: a Importância do Diagnóstico Precoce e da Revascularização Agressiva.

AIM: Despite the advances in diagnostic and therapeutic approaches, acute mesenteric ischemia (AMI) remains associated with a dismal prognosis. The goal of this study was to review and report our department's experience in the surgical treatment of AMI and to identify predictive factors of postoperative morbidity and mortality. MATERIALS AND METHODS: We performed a retrospective analysis of the patients that underwent surgical revascularization after embolic or thrombotic AMI, between January 2008 and December 2015. Patient's comorbidities/cardiovascular risk factors, chosen diagnostic and therapeutic strategies, and postoperative complications were studied. RESULTS: Fifteen patients (66.7% female) were treated, with a mean age of 68.6±16.3 years (41-88). The most common cause of AMI was embolism (n=9; 60%). The most prevalent cardiovascular risk factor was hypertension (86.7%). All patients complained of abdominal pain, and in 66.7% of cases leukocytosis and elevated lactate dehydrogenase levels were observed. All patients were studied with abdomino-pelvic CT angiography. The mean ischemic time was 27.9±29.5 hours (3-96 hours). Midline laparotomy was performed in 14 patients [thromboendarterectomy of the superior mesenteric artery (SMA) (n=1; 6.7%); embolectomy of the SMA (n=8; 53.3%); mesenteric bypass (n=3; 20%); retrograde PTA and stenting of the SMA (n=2; 13.3%)]. One patient (6.7%) underwent thromboaspiration and catheter fibrinolysis. Four patients required enterectomy (26.7%). Second-look surgery was performed in 9 patients (60%). The 30-day mortality rate was 33%. CONCLUSIONS: A serum lactate level above 2 mmol/L on admission may be associated with an unfavorable prognosis. Early diagnosis, referral, and rapid revascularization are critical for therapeutic success in AMI.