Deep Vein Thrombosis after a Supracondylar Fracture of the Humerus in a Child - A Rare Complication / Trombose venosa profunda após uma fratura supracondilar do úmero em uma criança - Uma complicação rara

Abstract Deep vein thrombosis in the upper extremities is uncommon, especially in the pediatric population and in the trauma setting. The diagnosis is challenging, due to its rarity, requiring a high degree of suspicion. We describe a rare case of humeral vein thrombosis after a displaced supracondylar fracture of the humerus in a 7-year-old girl. The risk factors for thromboembolism and sequelae are also discussed. The early detection and treatment are mandatory to prevent poor outcomes, such as fatal thromboembolism.

Resumo Trombose venosa profunda nas extremidades superiores é incomum, especialmente na população pediátrica e no ambiente do trauma. O diagnóstico é desafiador, devido a sua raridade, exigindo alto grau de suspeita. Descrevemos um caso raro de trombose venosa úmera após uma fratura supracondilar deslocada do úmero em uma menina de 7 anos. Os fatores de risco para tromboembolismo e sequelas também são discutidos. A detecção e o tratamento precoces são obrigatórios para evitar desfechos ruins, como tromboembolismo fatal.

Intravascular foreign body retrieval.

INTRODUCTION: Intravascular foreign body (IFB) embolization is a potential complication of any vascular procedure. Intravascular foreign body retrieval (IFBR) can be achieved using percutaneous techniques, open surgery, or both combined. METHODS: We completed a retrospective review of patients who underwent endovascular or open IFBR since 2011 on our institution. Primary end-point was technical retrieval success, and secondary end-points were procedure-related compli- cations and 30-days survival. RESULTS: Twenty-seven patients underwent IFBR. Median time from intravascular device loss and retrieval was less than one day. 67% were non-endovascular guidewires and sheath fragments (N=28). 59% of IFBs were lost during their deployment (N=16); 41% during their removal attempts (N=11). 44% were lost in the arterial system (N=12) and 52% in the venous system (N=14). An endovascular procedure was used as the first approach in IFBR in 56% of patients (N=15) and open procedure in 44% (N=12). In the presence of IFB on the thoracic or abdominal cavity, it was always tried a first-endo approach; if IFB was present on the neck or limbs, 75% were retrieved by open surgery (N=20; p<0.001). Success rates were 100% for open and 87% for endovascular procedures. IFB caused five acute complications: one IJV thrombosis, two strokes and three acute limb ischemia. There were no IFBR-related complications. 30 days-survival was 100%. CONCLUSION: Embolization of IFBs can be minimized with proper device selection, deployment and removal. In this study, open and endovascular retrieval had high success rates and minimal morbidity. Its choice is surgeon-dependent and restrained by devices availability.

Influence of interhospital transfer on outcomes of symptomatic and ruptured abdominal aortic aneurysms.

Objetive: Evaluate the influence of the geographic location of patients with symptomatic abdominal aortic aneurysms (AAA) or ruptured AAA (rAAA), on mortality. METHODS: Retrospective review of all cases of symptomatic AAA and rAAA submitted to surgery in a tertiary institution, between January 2011 and August 2017. The main outcome was in-hospital mortality. Secondary outcomes were admission to intensive care unit (ICU), length of ICU and hospital stay, type of repair and anesthesia and weekend presentation. Data was submitted to univariable analysis and logistic regression. Statistical significance was considered if the p value was <0.05. RESULTS: 135 patients were admitted with the diagnosis of symptomatic or rAAA and submitted to surgery, 83 (61.5%) by endovascular repair and 52 (38.5%) by open repair, 30.4% with local anesthesia and sedation. 92 patients (68.1%) were transferred from other hospitals, with a mean distance of 113±88 km. Subgroup analysis revealed that there were no significant differences between transferred and not transferred patients' groups concerning main outcome (31.5% vs 34.9%, p=0.35), baseline characteristics (age and gender), type of surgery and anesthesia, weekend presentation, ICU admission, length of ICU and hospital stay. Logistic regression analysis revealed that the variables associated with mortality were female gender (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.40-3.70; p<0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p<0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p<0.01). CONCLUSION: Our study revealed that interhospital transfer of patients for urgent repair of AAA was not associated with an increased mortality.

Objetivo: Avaliar a influência da localização geográfica dos doentes com aneurismas da aorta abdominal (AAA) sintomáticos ou rotos (rAAA), na mortalidade. Métodos: Revisão retrospetiva de todos os casos de AAA sintomáticos ou rAAA submetidos a cirurgia numa instituição terciária, entre Janeiro 2011 e Agosto 2017. O outcome primário foi a mortalidade intrahospitalar. Os outcomes secundários foram a admissão em unidade de cuidados intensivos (UCI), duração do internamento na UCI e hospitalar, tipo de cirurgia e anestesia e a apresentação ao fim-de-semana. Os dados foram submetidos a análise univariável e regressão logística. Foi considerado um valor estatisticamente significativo quando o valor de p <0.05. Resultados: 135 doentes foram admitidos com o diagnóstico de AAA sintomático ou rAAA e submetidos a cirurgia, 83 (61.5%) por via endovascular e 52 (38.5%) por via convencional, 30.4% com anestesia local e sedação. 92 doentes (68.1%) foram transferidos de outros hospitais, com uma distância média de 113±88 km. A análise de subgrupos revelou que não existia diferença significativa entre os grupos de doentes transferidos e não transferidos relativamente ao outcome primário (31.5% vs 34.9%, p=0.35), características de base (idade e género), tipo de cirurgia e anestesia, apresentação ao fim-de-semana, admissão na UCI, duração do internamento na UCI e hospitalar. A análise de regressão logística revelou que as variáveis associadas com a mortalidade foram o género feminino (odds ratio [OR] 2.28; 95% intervalo de confiança [IC] 1.40- 3.70; p<0.01), cirurgia convencional (OR 2.79; 95% IC 1.68-4.63; p<0.01) e anestesia geral (OR 9.16; 95% IC 2.33- 36.06; p<0.01). Conclusão: Este estudo revelou que a transferência interhospitalar de doentes para a reparação cirúrgica urgente de AAA não está associada a aumento da mortalidade.

Median Arcuate Ligament Syndrome of Diaphragm - Literature Review and Case Report.

OBJECTIVES: To report a case of median arcuate ligament syndrome (MALS) and to review current literature. METHODS: Case report and literature review using PubMed with the terms "median arcuate ligament", "Dunbar syndrome" and "MALS treatment" as major topics. The bibliography of relevant articles has been checked to identify other significant papers. RESULTS: Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare clinical entity characterized by celiac trunk compression by median arcuate ligament and variable gastrointestinal symptoms. However, some degree of radiographic compression is observed in 10%-24% of asymptomatic patients, so MALS is a diagnosis of exclusion. Treatment options include release of median arcuate ligament (open, laparoscopic or robot-assisted) and open vascular reconstruction. Endovascular treatment is currently used only as adjuvant procedure after surgical release of median arcuate ligament. A 34-year-old woman, previously healthy, presented with a epigastric pain, mainly postprandial, for 6 months, associated to anorexia and unprovoked weight loss of 8kg over 3 months. Physical examination was normal. Other gastrointestinal pathologies were ruled out. Abdomino-pelvic computed tomography angiography revealed a focal 80% stenosis of proximal celiac trunk. An open decompression of the celiac trunk was performed. The postoperative period was uneventful and the patient was discharged 5 days later, with normal gastrointestinal transit and without abdominal pain recurrence. CONCLUSION: MALS diagnostic and therapeutic approach must be patient focused, bearing in mind the multiple clinical presentation and treatment options. Open surgical decompression of median arcuate ligament is the base of treatment.

Objetivos: Descrever um caso clínico de síndrome do ligamento arqueado do diafragma (SLA) e realizar uma revisão da literatura. Métodos: Descrição de um caso clínico e revisão da literatura com recurso ao PubMed com os termos "median arcuate ligament", "Dunbar syndrome" e "MALS treatment". A bibliografia dos artigos relevantes foi verificada para identificar outros artigos pertinentes. Resultados: A síndrome do ligamento arqueado (SLA) ou síndrome de Dunbar é uma entidade clínica rara caracterizada pela compressão do tronco celíaco associada a sintomas gastrointestinais variáveis. No entanto, algum grau de compressão radiográfica é observado em 10-24% de doentes assintomáticos, o que torna o diagnóstico de SLA de exclusão. As opções terapêuticas incluem a secção do ligamento arcuato (via convencional, laparoscópica ou robótica) e a reconstrução vascular. A abordagem endovascular é atualmente utilizada apenas como procedimento adjuvante após a secção do ligamento arqueado. Doente do sexo feminino de 34 anos de idade, previamente saudável, recorre ao médico assistente por um quadro de dor epigástrica, especialmente pós-prandial, com 6 meses de evolução, associada a anorexia e perda ponderal não provocada superior a 8kg, num período de 3 meses. O exame objetivo não relevou alterações. Outras patologias gastrointestinais foram excluídas. A angiografia por tomografia computorizada revelou uma estenose focal de 80% na porção proximal do tronco celíaco. A doente foi submetida a uma descompressão cirúrgica por via convencional. O período pós-operatório decorreu sem intercorrências, tendo alta 5 dias após a intervenção com o trânsito gastrointestinal restabelecido e sem recorrência da dor abdominal. Conclusão: A abordagem diagnóstica e terapêutica do SLA deve ser individualizada e focada no doente, tendo em conta as múltiplas apresentações clínicas e possíveis opções terapêuticas. A descompressão cirúrgica convencional do ligamento arqueado continua a ser a base do tratamento.

Median Arcuate Ligament Syndrome - Literature Review and Case Report.

INTRODUCTION: Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare clinical entity characterized by celiac trunk compression by median arcuate ligament and variable gastrointestinal symptoms (postprandial epigastric pain, nausea, weight loss, anorexia and diarrhea). However, some degree of radiographic compression is observed in 10%-24% of asymptomatic patients. Besides the extrinsic vascular compression, MALS has a multifactorial etiology and it has been suggested as a neurogenic disease resulting in altered sensation and pain from the somatic nerves in the splanchnic plexus. MALS is a diagnosis of exclusion, so other causes must be excluded. Treatment options include release of median arcuate ligament (open, laparoscopic or robot-assisted) and open vascular reconstruction. Endovascular treatment is currently used only as adjuvant procedure after surgical approach, in refractory cases with residual stenosis of celiac trunk. OBJECTIVE: To report a case of MALS and to review current literature. METHODS: The authors report a clinical case and present a literature review using PubMed with the terms "median arcuate ligament", "Dunbar syndrome" and "MALS treatment" as major topics. The bibliography of relevant articles has been checked to identify other significant papers. RESULTS: A 34-year-old woman, previously healthy, recurred to a General Practitioner with a recurrent epigastric pain, exacerbated by ingestion, without relieving factors, in the previous 6 months. Patient also reported anorexia and unprovoked weight loss of 8Kg over 3 months. Physical examination was normal. Other gastrointestinal pathologies were ruled out. Computed Tomography Angiography (CTA) abdomen revealed a focal 80% stenosis of the celiac trunk, located 8mm from its origin in aorta and a post- -stenotic enlargement of 9mm. An open decompression of the celiac trunk was performed. Through an 8cm median supraumbilical laparotomy, supraceliac abdominal aorta was approached. The compressive band across the celiac trunk was identified and cut. Further dissection was performed until the celiac artery became completely exposed and its branches identified. The postoperative period was uneventful and the patient was discharged 5 days later, with normal gastrointestinal transit and without recurrence of the abdominal pain. 1 month later, the patient remained asymptomatic. A long-term follow-up with annual duplex scan and clinical evaluation must be done, in order to evaluate the need of a revascularization due to persistent stenosis or aneurysmal degeneration. CONCLUSION: MALS diagnostic and therapeutic approach must be patient focused, bearing in mind the multiple clinical presentation and treatment options. Open surgical decompression of median arcuate ligament is the base of therapy.

Influence of Interhospital Transfer on Outcomes of Symptomatic and Ruptured Abdominal Aortic Aneurysms.

INTRODUCTION: Symptomatic or ruptured abdominal aortic aneurysms (rAAA) maintains a high mortality index despite technical advances in its treatment. The influence of patients' geographic location on rAAA outcomes, when the rupture occurs or when the AAA becomes symptomatic, has not been a commonly studied issue. Due to the lack of research on this matter, the impact of interhospital transfer on mortality is ambiguous. OBJECTIVE: Evaluate the influence of the geographic location of patients with symptomatic AAA or rAAA on AAA mortality. METHODS: Retrospective review of all cases of symptomatic AAA and rAAA submitted to surgery in a tertiary institution, between January 2011 and August 2017. The main outcome was in-hospital mortality. Secondary outcomes were admission to intensive care unit (ICU), length of ICU and hospital stay, type of repair and anesthesia and weekend presentation. Data was submitted to univariable analysis and logistic regression. Statistical significance was considered if the p value was <0.05. RESULTS: During the defined period of 80 months, a total of 135 patients were admitted with the diagnosis of symptomatic or rAAA and submitted to surgery. Most patients had a ruptured AAA (90.4%, n=122), while symptomatic AAA represented a minority (9.6%, n=13). All patients (91.1% male gender, mean age 74±10 years) were submitted to surgery, 83 (61.5%) by endovascular repair and 52 (38.5%) by open repair, 30.4% with local anesthesia and sedation (n=41), all in the endovascular group. 92 patients (68.1%) were transferred from other hospitals, with a mean distance of 113±88 km. In this cohort, in-hospital mortality was 31.5% in transferred patients and 34.9% in not transferred patients. Subgroup analysis revealed that there were no significant differences between transferred and not transferred patients' groups concerning main outcome (p=0.35), baseline characteristics (age and gender), type of surgery and anesthesia, weekend presentation, ICU admission, length of ICU and hospital stay. Logistic regression analysis revealed that the variables associated with mortality were female gender (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.40-3.70; p<0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p<0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p<0.01). CONCLUSION: Our study revealed that transfer of patients for urgent repair of AAA was not associated with an increased mortality. The hypothetical increased mortality due to transfer might have been compensated by endovascular treatment and local anesthesia in some cases. Further studies must be carried out, particularly comparing endovascular and open repair in emergency setting.

In the Current Era of Endovascular Surgery, What is the Role of Axillofemoral Bypass?

INTRODUCTION: Nowadays, axillofemoral bypass is viewed as an end-of-line solution for lower limb revascularization, owing to its classically described poor long-term patency, and recent advances in endovascular options for patients with complex aortoiliac anatomy not suitable for open reconstruction. There is a marked difference in patient profiles in published series of axillofemoral bypass, reflecting changing procedures indications due to technical innovations. The objective of this study is to determine the contemporary profile of patients treated with axillofemoral bypass and their outcome. METHODS: Patients who underwent axillofemoral bypass surgery in a tertiary hospital from April 2011 to September 2017 were identified. Surgical indication, patency, amputation and death rates were recorded. Patients were grouped in axillouni vs axillobifemoral, 1st revascularization procedure vs reintervention, and primary aortoiliac occlusive disease vs primary aneurysmal disease, and were compared using Kaplan-Meier survival analysis. RESULTS: 54 patients were included. 80% underwent an axillobifemoral bypass. Median age was 67 years; 96% were male. The most prevalent cardiovascular risk factors were HTA (81%) and history of smoking (76%). Primary vascular disease was aneurysmal in 24% of patients. The remaining group had peripheral occlusive arterial disease. In 53%, axillofemoral bypass was the first revascularization performed (naif group). On these, indications for this procedure were aorto-iliac occlusive disease (89%) and AA thrombosis (19%). In patients previously submitted to revascularization (47%), the most common first procedures were aortobifemoral bypass (56%), femoro-femoral bypass (44%) and EVAR (36%). Indications for axillofemoral bypass on this group were: prosthesis thrombosis (64%), secondary aorto-enteric fistulae (28%) and prosthesis infection (8%). Primary patency of axillofemoral bypass was 93% at 1 month and 80% at 5 years (Graphic 1). Differences were not significant regardless the vascular surgery status (naif vs reintervention), but axillobifemoral bypass and aneurysmal disease groups had a higher patency than axillounifemoral bypass and occlusive disease groups, respectively. No patient with aneurysmal disease required amputation over a 5-year follow-up. In primary occlusive disease group, 88% of patients were free-of-amputation at 1 month and 83% at 5 years. Patients who underwent this procedure had a survival rate of 78% at 1 month and 59% at 5 years (Graphic 2). No major difference was recorded between study groups. CONCLUSION: Axillofemoral bypass, although being an increasingly uncommon procedure, still allows acceptable rates of patency and limb salvage. As patients with aortoiliac disease usually have multiple comorbidities and a short life- -expectancy, axillofemoral bypass is attractive owing to its less invasive character.

Infrarenal Abdominal Penetrating Aortic Ulcer, an Atypical Location of a Rare Disease.

INTRODUCTION: Penetrating aortic ulcer (PAU) is classically included in acute aortic syndromes, together with aortic dissection and intramural hematoma. These three disorders are considered different stages of the same disease. PAU is the result of medial degeneration with disruption of the intima, mainly due to atherosclerotic risk factors. Most of them are located on descending thoracic aorta and only a few small series and case reports demonstrate location on infrarenal abdominal aorta. Clinical presentation varies in spectrum, from asymptomatic to fatal aortic rupture. Treatment options include medical therapy, particularly strict blood pressure control, and surgical approach. Nowadays endovascular exclusion is commonly performed, although open surgical reconstruction remains the gold standard. METHODS: Report a case of endovascular repair of an infrarenal abdominal PAU. RESULTS: A 72-year-old man, with hypertension, type 2 diabetes, hypercholesterolemia, lumbar osteoarthrosis, was referred to Vascular Surgery outpatient clinic with the diagnosis of infrarenal abdominal PAU on a Computed Tomography Angiography (CTA). This exam was performed due to chronic lumbar complaints from lumbar osteoarthrosis. The patient denied any other complaint. Physical examination was normal. A thoraco-abdomino-pelvic CTA revealed two sites of PAU in the infrarenal aorta with 10mm and 21mm of depth and associated aortic enlargement of 39mm maximum diameter. This exam revealed an enlargement of the depth of the PAU and the aorta diameter in 2 and 3mm, respectively, in the course of 2 months. An EVAR was performed, in a standard aorto-biiliac fashion. The post-operative period was uneventful and the patient discharged 3 days later. 1 month after the surgery, patient remained asymptomatic and the follow-up CTA demonstrated exclusion of both PAU, no endoleaks and stability of aortic diameter. A long term follow-up should be maintained, as for regular EVAR. CONCLUSION: PAU is a rare clinical entity, with infrarenal abdominal aorta location even scarcer. Asymptomatic patient must be regularly followed and threshold to treatment low, bearing in mind the possible catastrophic evolution of the disease. Endovascular approach should be considered as a first approach, considering the technical feasibility and the comorbidities associated with this elderly population.

Acute Iatrogenic Limb Ischaemia, a Report of 2 Late Presentation Cases.

INTRODUCTION: With increasing use of percutaneous vascular procedures, access complications that present to a vascular surgeon increase. The most limb-threatening condition is acute limb ischaemia. Acute limb ischaemia is the most common vascular surgical emergency. In spite of recent advances in vascular surgery, it continues to carry a poor prognosis, if not early diagnosed and managed. METHODS: This is a case-report of 2 patients referenced to a vascular surgery emergency department of a tertiary hospital with late acute limb ischaemia. RESULTS: Patient 1: Male, 42 years, alcoholic, autonomous, presented with pain with elbow active movements in a secondary hospital. Excluded acute orthopaedic injury, doctor recorded signs of acute limb ischaemia and referenced patient to a tertiary hospital, where vascular surgeon diagnosed an acute advanced upper limb ischaemia. Bed-side Eco-Doppler showed an echogenic linear material on a thrombosed umeral artery, surgically confirmed to be a guidewire (Fig.1. Surgical extraction of intra-umeral guidewire). Reviewing patient history, this guidewire should have been missed over 6 months, by the time the patient was hospitalized on an ICU for alcoholic coma. Patient underwent umeral, radial and ulnar thromboembolectomy and had a no-reflow status. However, poor persistent global status, with limited mobilization, pressure forces and prolonged vasotropic support, promoted progression of a cyanotic leg plaque to a necrotic evolving leg ulcer with septic response, despite persistent good perfusion of the foot (Fig.2. Necrotic evolving leg ulcer). Unfortunately, the two reported patients underwent urgent major limb amputation, patient 1 above the elbow, and patient 2 above the knee. CONCLUSION: Acute limb ischaemia continues to carry a poor limb and life prognosis if not early diagnosed. We should be alert for the increasingly prevalence of iatrogenic acute limb ischaemia, and regularly evaluate perfusion status of limbs after any percutaneous procedure.