Scielo RSS http://scielo.pt/rss.php?pid=1646-706X20230001&lang=es vol. 19 num. 1 lang. es http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100002&lng=es&nrm=iso&tlng=es http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100005&lng=es&nrm=iso&tlng=es http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100007&lng=es&nrm=iso&tlng=es Abstract Introduction: The Abdominal aortic aneurysm (AAA) module of the Portuguese National Vascular Registry (RNPV) is a prospective, voluntary, population-based registry, that encompasses more than 90% of portuguese vascular departments. The aim of this study was to evaluate the results of the first 1000 infra-renal AAA included in the Portuguese RNPV. Methods: Data were collected from November 2019 to December 2022 and analyzed for demographic aspects, treatment indication, aneurysm anatomic characteristics, type of intervention (EVAR and open surgical repair - OSR), outcome at 30-days and 1-year. EVAR and OSR were compared within elective and urgent settings. Results: A total of 1122 patients were included in the period of study. After applying the exclusion criteria, we analyzed the first consecutive 1000 patients with infra-renal aneurysm submitted to EVAR or OSR, in elective or urgent settings. Elective procedures were perfomed in 79.2% of cases. Patients were predominantly male (91.8%), with a mean age of 74.1 ± 10.6 years. The overall 30-day mortality was 2.7% (EVAR 1.8% and OSR 5.9%; p=0.003). Pos-operative complications were more frequent in the OSR group, with significant repercussion in hospital length, reinterventions and early mortality. Baseline AAA diameter was identified as a predictor of 30-day mortality. Intra-hospital mortality was inversely related with the caseload of the center (p=0.032), mainly due to higher mortality in OSR (p=0.04). The center caseload did not impact the intra-hospital mortality in elective standard EVAR procedures. Urgent repair was performed in 205 patients with significantly larger AAA-diameter (70.5 ± 21.5 mm versus 57.5 ± 14.3 mm, p<0.001). The preponderance of EVAR was less pronounced comparing to OSR (53.7% versus 46.3%). The 30-day mortality rate was 34% (EVAR 28.8% and OSR 44.4%, p=0.024). A multivariate analysis identified age (p < 0.001) and 30-day pulmonary failure (p<0.001) to be independent risk factors for mortality. Conclusion: Vascular registries reflect real-world practice and offer the advantage of rapid feedback of current practice. Portuguese results with AAA treatment are generally favourable and comparable to existing literature from other countries in Europe and North America. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100015&lng=es&nrm=iso&tlng=es Abstract Introduction: Renal angioplasty emerged as an alternative for renal artery stenosis (RAS). In 2009 and 2014, two clinical trials (ASTRAL and CORAL) led to a paradigm shift in renovascular disease. Neither showed a clear benefit over best medical treatment, although there were methodological flaws. This study aims to evaluate the impact of these trials in clinical practice. Methods: We designed a retrospective cross-sectional study from patients submitted to renal artery angioplasty between 1999 and 2021 in a tertiary center. Patients were selected from the center’s surgical records. Diagnostic arteriograms, open interventions and renal graft failures were excluded. Patients were divided in two cohorts: a historical group from 1999 to 2013 and a contemporary cohort, from 2014 to 2021. We compared the number of angioplasties per year and patient comorbidities, preoperative lesion severity, renal function, and the number of antihypertensive drugs. Results: 152 patients were included: 104 patients between 1999-2013 (7 cases per year [5-8]) and 48 patients between 2014-2021 (6.5 cases per year [4.5-7]), with no significant difference between medians (p=0.53). Patients included between 2014-2021 were taking more antihypertensive drugs (3 [2-4] vs. 2 [1-3]; p=0.001) with a worse renal function (eGFR 44,2 ± 25,9 vs. 68,6 ± 29,2; p<0.001). Comparing with the results from the CORAL trial, patients included in the whole cohort had a significantly higher degree of stenosis (84.2 ± 7.52 vs. 72.5 ± 14.6; p < 0.001) and a higher proportion of patients in stage ≥3 chronic kidney disease (56.6% vs. 49.6%; p 0.002). While there was a benefit in renal function improvement, no difference was found in blood pressure control. Conclusion: Renal artery angioplasties emerged as a first-choice therapy in hemodynamically significant stenoses in patients with difficult-to-control hypertension with or without renal failure. The CORAL trial in 2014, by showing no clear benefit over best medical treatment, led to a paradigm shift. Although the annual number of procedures remained unchanged, patients treated after 2014 had more severe lesions, worse preoperative renal function and blood pressure control. Further studies should assess who truly benefits from this procedure. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100020&lng=es&nrm=iso&tlng=es Abstract Introduction: Fenestrated/branched EVAR (f/bEVAR) are associated with lower peri-operative major complications, when compared to open repair in complex aortic pathologies. However, f/bEVAR is limited by the waiting time for customized graft production and has specific anatomic limitations. Alternatively, adapting outside instructions-for-use, readily available off-the-shelf devices has been used with variable success. Among these options is the Octopus technique, which consists of parallel stent grafts originating inside a larger external stent graft. Despite being an off-label combination of devices, it can play a role when f/bEVAR is unavailable or inapplicable. Methods: Single center retrospective study, including all consecutive patients treated with the Octopus technique. Baseline characteristics, peri-procedural and follow-up data was obtained. Primary endpoint is clinical success. Secondary endpoints are complications and secondary interventions in follow-up. Results: Between 2015 and February 2022, six patients with a mean of 74±9 years were identified. Treatment indications included three type 1A endoleaks and 3 thoracoabdominal aortic aneurysms (TAAA) without prior intervention, one of which was mycotic. Four procedures were elective and the remaining two emergent. In the elective cases, the Octopus technique was chosen due to anatomical constraints and because waiting time for customization was considered excessive. Excluder and Incraft endografts were used in 5 and 1 cases, respectively. Thirteen visceral branches were revascularized (6 superior mesenteric, 4 renal and 3 celiac arteries). Gutter endoleaks were observed in 2 patients. Mean blood loss, surgery and hospitalization duration was 483 (300) mL, 288 (73) minutes and 26 (19.5) days. One perioperative death occurred, in a patient treated in the context of post-EVAR rupture due to type 1A endoleak. The most frequent postoperative complications were temporary acute renal failure (2/6), paraplegia (2/6) of which one was completely resolved, and non-graft related infection (2/6). One early reintervention, consisting of branch relining due to kinking and gutter embolization was necessary. On follow-up, there were no new endoleaks or endoleak-related interventions. Four patients died within two years, one with an aneurysm-related complication (spondylodiscitis in the context of a mycotic TAAA). The remaining deaths were not aneurysm related. Conclusion: The Octopus technique may offer a valuable off-the-shelf solution for complex aortic diseases, particularly due to anatomical constraints or in the emergent setting. Despite a high technical success rate, there is significant early morbidity and high mid-term mortality. In our series, durability was reasonable for this challenging group of patients, and our outcomes are in accordance with other reports. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100027&lng=es&nrm=iso&tlng=es Abstract Introduction: Recently published studies on peripheral arterial occlusive disease (PAOD) have revealed marked sex disparities in patient selection and treatment outcomes. In a recent retrospective study with data from 11 different countries, Portugal was highlighted as one of the countries with greater sex discrepancies related to PAOD treatment. We aimed to analyze sex specific differences in the treatment of symptomatic PAOD, concerning different variables, in a single hospital center, in Portugal. Methods: Data on treatment of symptomatic PAOD patients from October 1st, 2020, to December 31st, 2021, were retrospectively collected from clinical registries from a single hospital center in Portugal. Different variables and post-operative outcomes were analyzed dichotomized by sex, with descriptive statistics. Statistical analyses were conducted using the IBM Statistical Package for Social Sciences (SPSS) software v28. Results: A total of 220 patients, 15,9% female and 84,1% male, were treated for PAOD, in the selected period, in a hospital center from Portugal. Female patients were older (mean age of 73.8 years versus 69.5 years in male); were less likely to be treated for intermittent claudication (3% versus 6% of men); more often treated at a more advanced stage of the disease with trophic lesions (91% versus 74% of men); more likely to be offered primary major amputation (14% versus 3% of male patients); less likely to be taking statins as part of PAOD medical management (65.7% versus 77.8% of male); and had a higher 90-day mortality rate (17.1% versus 6.5% in men). They were also more frequently treated with endovascular procedures (40%) than with OSR (26%). Conclusion: Remarkable sex discrepancies in the treatment of PAOD were found in our hospital center. This study brings awareness to the scientific medical community for sex disparities in the management of patients with PAOD. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100033&lng=es&nrm=iso&tlng=es Abstract Acute aortic dissections are unpredictable aortic catastrophes. Although significant recent improvements have been accomplished in the treatment and management of aortic dissections, a significant amount is still not fully understood regarding this deadly condition. Comprehension of aortic dissections is especially important due to the impact of the disease, since a lot of patients die before reaching the hospital and a significant number of the ones who do survive the initial event end up dying during follow-up. The epidemiology and disease characteristics of these conditions are still under investigation and not completely clear. In this article we aim to review the current knowledge on the epidemiology and clinical characteristics of aortic dissections. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100038&lng=es&nrm=iso&tlng=es Abstract Introduction: Kidney autotransplantation (KAT) is a versatile surgical technique used to treat multiple diseases affecting the kidney. This procedure allows the reconstruction of the renal artery or vein with optimal surgical exposure reducing warm ischemia time compared to open direct repair. Although infrequently reported nowadays and despite the growing use of endovascular treatments, KAT still has a place in treating complex kidney vascular conditions. Methods: We performed a literature review using the MEDLINE®, SCOPUS, and Web of Science databases with the combination of the terms: “kidney autotransplantation,” “renal artery,” “renal vein,” “aorta,” “aneurysm,” and “nutcracker syndrome.” All relevant English-language studies published between January 1990 and June 2022 reporting the outcomes of the KAT technique in vascular disorders were included. Results: A total of 32 articles were included. Ex-vivo repair and KAT is widely described in treating renal artery aneurysms (RAA), with a reported technical success rate of 99.9%, a complication rate ranging from 6.9 to 9.4%, and a graft loss rate of up to 4.1%. The use of the laparoscopic technique for harvesting the kidney was variable throughout the series published, and heterotopic KAT was performed in most treated patients. Ex-vivo repair and KAT was successfully used after failed endovascular therapy and is a viable option in women of childbearing age with bilateral complex RAA. Concerning renal artery stenosis associated with different etiologies (fibromuscular dysplasia, Takayasu's arteritis, and neurofibromatosis type 1), significant reduction of blood pressure and the number of anti-hypertensive drugs have been reported in most patients after KAT. Results of arterial hypertension improvement associated with RAA after KAT are more variable. The use of KAT in treating nutcracker syndrome is reported with good results, even after left renal vein transposition or venous stenting failure. Other reports exist on the successful use of KAT for treating renal vein aneurysms and as an adjunct in open surgical or hybrid aortic reconstructions. Conclusion: Renal autotransplantation is a useful technique in the treatment of kidney vascular disorders with good overall results reported in the literature. It may be an essential adjunct in open surgical or hybrid treatments for abdominal and thoracoabdominal aortic diseases. Defining the patients who would benefit from this technique as a preferential treatment choice in different renal vessel disorders would be necessary. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100044&lng=es&nrm=iso&tlng=es Abstract Introduction: Aortic aneurysms affect 3.3% of adults and there is a growing burden of small aneurysms detected, which may grow to need surgical repair. Still, we rely only on surgical therapy for this disease, left to monitor patients until they are candidates for treatment. Pharmacologic therapies have long been proposed and studied and still we have no evidence supporting drug therapy in small aneurysms. In this report we make a narrative review of basic molecular aspects of aneurysm disease and of evidence behind drug therapies that have been proposed and studied throughout the last decades. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100047&lng=es&nrm=iso&tlng=es Abstract Introduction: Mycotic or primary infected aortic aneurysms comprise aproximately 1.3% of all aortic aneurysms and may be caused by septic emboli to the vasa vasorum, by haematogenous spread during bacteraemia or by direct extension of an adjacent infection leading to an infectious degeneration of the arterial wall and aneurysm formation. The objective of this report is to describe a clinical case of a complicated mycotic aortic aneurysm. Case report: A male, 69-year-old patient, with medical background of diabetes, hypertension and a bladder carcinoma (surgically ressected 5 years before, complicated at the time with an E.coli septicaemia), presented at the ER with generalised malaise, asthenia, anorexia, abdominal pain, diarrhea and fever, with 1 week of evolution. At admission, clinical examination revealed poor general condition, fever (39ºC), noral blood pressure, and the abdominal examination showed no abnormalities. Laboratory results revealed an stable haemoglobin of 13 g/dL, leukocytosis (19850/UI) and neutrophilia (90%), an a C Reactive Protein of 350mg/dl. A Computed Tomography Angiography (CTA) revealed a 3,5 cm saccular juxtarenal AAA, with peri and intra-aortic gas, strongly suggestive of an mycotic AAA (MAA). Hospitalization was indicated and a septic and immunologic screening was perfomed. The patient started a broad-spectrum antibiotic with meropenem and vancomycin and clinical, laboratory and hemodynamic surveillance. Blood and urine cultures revealed a E.Coli infection, and directed antibiotic was started. After 10 days os hospitalization, the patient was haemodinamic stable, presented no fever or abdominal pain, however inflammatory parameters remained elevated, and a new CTA that showed a daunting increase of 4 cm of the AAA (7,5 cm) with signs of contained ruture. An emergency intervention was decided and the patient underwent an thoracophrenolaparotomy and aorto-aortic interposition with bovine pericardium patch. After 24h of surgery the patient died of septic shock. Conclusion: MAA is a rare and threatening disease with rapid progression and high mortality. Even with broad-spectrum antibiotic and rapid surgical response, the tragic outcome is often the unavoidable result http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000100050&lng=es&nrm=iso&tlng=es Abstract Introduction: Mycotic or primary infected aortic aneurysms comprise aproximately 1.3% of all aortic aneurysms and may be caused by septic emboli to the vasa vasorum, by haematogenous spread during bacteraemia or by direct extension of an adjacent infection leading to an infectious degeneration of the arterial wall and aneurysm formation. The objective of this report is to describe a clinical case of a complicated mycotic aortic aneurysm. Case report: A male, 69-year-old patient, with medical background of diabetes, hypertension and a bladder carcinoma (surgically ressected 5 years before, complicated at the time with an E.coli septicaemia), presented at the ER with generalised malaise, asthenia, anorexia, abdominal pain, diarrhea and fever, with 1 week of evolution. At admission, clinical examination revealed poor general condition, fever (39ºC), noral blood pressure, and the abdominal examination showed no abnormalities. Laboratory results revealed an stable haemoglobin of 13 g/dL, leukocytosis (19850/UI) and neutrophilia (90%), an a C Reactive Protein of 350mg/dl. A Computed Tomography Angiography (CTA) revealed a 3,5 cm saccular juxtarenal AAA, with peri and intra-aortic gas, strongly suggestive of an mycotic AAA (MAA). Hospitalization was indicated and a septic and immunologic screening was perfomed. The patient started a broad-spectrum antibiotic with meropenem and vancomycin and clinical, laboratory and hemodynamic surveillance. Blood and urine cultures revealed a E.Coli infection, and directed antibiotic was started. After 10 days os hospitalization, the patient was haemodinamic stable, presented no fever or abdominal pain, however inflammatory parameters remained elevated, and a new CTA that showed a daunting increase of 4 cm of the AAA (7,5 cm) with signs of contained ruture. An emergency intervention was decided and the patient underwent an thoracophrenolaparotomy and aorto-aortic interposition with bovine pericardium patch. After 24h of surgery the patient died of septic shock. Conclusion: MAA is a rare and threatening disease with rapid progression and high mortality. Even with broad-spectrum antibiotic and rapid surgical response, the tragic outcome is often the unavoidable result