Scielo RSS http://scielo.pt/rss.php?pid=1646-706X20230002&lang=es vol. 19 num. 2 lang. es http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200054&lng=es&nrm=iso&tlng=es http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200056&lng=es&nrm=iso&tlng=es http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200057&lng=es&nrm=iso&tlng=es http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200058&lng=es&nrm=iso&tlng=es Abstract Introduction: The progression of diabetes mellitus to a global epidemic resulted in an increased prevalence of tibioperoneal disease in chronic limb threatening ischemia (CLTI). Distal disease still poses an enormous challenge to vascular surgeons. Crural angioplasty was formerly restricted to patients with short stenotic lesions or to high-risk patients for bypass surgery. Nevertheless, endovascular treatment has been used preferentially over bypass surgery in most centres. The aim of this study is to analyse the results of open ultra-distal revascularization in a single-centre with a limb preservation program for CLTI. Methods: The present study consists in a single-centre retrospective analysis of all patients with CLTI submitted to below the ankle bypass. The end points were limb-based patency (LBP), primary patency (PP) and secondary patency (SP) rates, freedom from CLTI, freedom from new CLTI, freedom from major index limb amputation, amputation free-survival, and overall survival. Patients were categorized in subgroups based on age (above or below 75 years), dialysis status, wound and infection grade (0 and 1 vs 2 and 3 in WIfI classification). Statistical analysis was carried out using Stata 12.1 (StataCorp®, Lakeway Drive, College Station, Texas, USA). Time-to-event end points were presented with Kaplan-Meier estimates, censored at major amputation, death, or last follow-up, and compared with the log rank test. Results: A total of 134 limbs in 122 patients with CLTI (83% male, median age of 68 years) were submitted to below the ankle bypasses. The median follow-up was 33.7 months. LBP, PP and SP were, respectively, 78%, 78% and 92% at 1 year, 73%, 73% and 88% at 2 years, and 62%, 62% and 79% at 4 years. At 1 year, 83% of the limbs were free from CLTI. Of these patients, 89% and 74% remained free from new CLTI at 2 and 4 years, respectively. Eighty-two percent of the patients were free from major index limb amputation at 4 years. Thirty-day mortality was 1.6% (2 patients) and 1-year and 2-year survival was 90% and 81%, respectively. Age, dialysis status and wound/infection grade (WIfI classification) did not influence patency rates. Conclusion: Below the ankle bypass is safe and has excellent clinical outcomes. The present study emphasizes the value of open surgery in a challenging territory, with high rates of patency, limb salvage, freedom from CLTI and from new CLTI. These results were not affected by patient status or clinical severity factors. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200070&lng=es&nrm=iso&tlng=es Abstract Introduction: Guidelines state that ruptured abdominal aortic aneurysms should be treated shortly after the diagnosis and ideally within 90 minutes. The main aim of this study is to assess the referral pattern of our centre regarding the intervals between the diagnosis of ruptured AAA and the surgical repair, considering the geographical referral areas of our hospital. Methods: We conducted an observational, retrospective cohort study from a single centre. The study population included all patients with the diagnosis of symptomatic or ruptured abdominal aortic aneurysm referred to Centro Hospitalar e Universitário Lisboa Norte (CHULN) between 2012 and 2021. The moment of diagnosis was assumed to be the time of the CT angiography and the moment of treatment was assumed as the time of entering the operating room (OR). Results: During the study period a total of 150 patients (90.7% men, mean age 78.3, SD 8.7) were treated. Of these, 86% presented as ruptured aneurysms while 14% presented as symptomatic aneurysms. The median time between the diagnosis and the initiation of surgical treatment was 150 (+/- 132) minutes. Only 22% of patients were treated within 90 minutes of diagnosis and this remained unchanged throughout the study period. No statistically significant difference was observed between the median time intervals registered for survivors and deceased patients at 24 hours (p = 0.907), 48 hours (p = 0.743) and 30 days (p = 0.605) post-surgery. Conclusion: In our study, only 22% of patients with ruptured or symptomatic abdominal aortic aneurysms are treated within the recommended time frame. Although there is no significant impact on mortality, the authors recognize unavailability of information regarding patients that died before arrival to our hospital as a relevant limitation. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200075&lng=es&nrm=iso&tlng=es Abstract Introduction: Vascular Surgery is a demanding specialty with vast technological and research advances in the last decades. This has led to an increasing complexity of providing adequate training programs for the modern Vascular Surgeon. Our aim was to understand the current satisfaction rates and perceived limitations of the Vascular Surgery residency program in Portugal by performing an online survey to residents. Methods: A survey study was conducted between April and June 2021 targeting Angiology and Vascular Surgery Residents in Portugal. Residents were contacted by e-mail from the National Portuguese Society of Angiology and Vascular Surgery to answer the survey. The survey was anonymized, and all residents from the 1st to 6th year were invited to participate. The survey was carried out using the Google® Forms platform and using Portuguese language. Questions were developed with two main objectives, the first being to analyze the satisfaction rates with the current residency program and the second to understand current limitations and possible areas of improvement. Results: Overall, 33 (65%) out of 51 invited residents participated in the survey, with equally distributions regarding the year of residency. Nineteen residents were male (57.6%). Most residents considered that the current one-year General Surgery rotation should be reduced and replaced by other specialties such as Radiology. Main surgical limitations were found with open aortic surgery. However, when compared to other European countries, residents considered that the main current limitation was scientific/academic training. Most residents were satisfied with their residency and felt professional fulfillment, however, most also reported having an unhealthy work-life balance and lack of time for academic and scientific research. When comparing the survey answers between younger and older residents, older residents reported more often having considered quitting and having experienced bullying or harassment. Conclusion: The findings from this study provide insight into the perceptions of the trainees regarding current training limitations and satisfaction rates with the residency program and may provide a base for improvement and development strategies in the residency programs in Portugal. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200087&lng=es&nrm=iso&tlng=es Resumo A doença quística adventicial é uma patologia que afeta principalmente o leito arterial, porém, em raros casos pode envolver o sistema venoso. O objetivo desta revisão foi padronizar a marcha diagnóstica, tratamento e vigilância de doentes com suspeita de doença quística adventicial venosa. Para cumprir os objetivos supracitados, uma revisão narrativa sumarizando os principais achados da literatura usando as bases de dados PUBMED e EMBASE foi feita. Um total de 33 artigos foram selecionados traduzindo-se num total de 41 casos de vACD. Após analise dos dados, foi possível concluir que o vaso mais frequentemente atingido é a veia femoral comum, e a maior parte dos doentes refere edema unilateral de membro com tempo de evolução variável. Quando perante um doente com edema unilateral de membro, em que a TVP foi excluída, é necessário proceder a outros meios complementares de diagnóstico de forma a confirmar, ou excluir, a vACD. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200091&lng=es&nrm=iso&tlng=es Abstract Introduction: Blunt thoracic aortic injuries (BTAI) are defined as a tear in the thoracic aorta caused by a high energy blunt trauma. The most common reported mechanism of injury is motor vehicle accidents, and it can be potentially lethal. The Society for Vascular Surgery (SVS) and the European Society for Vascular Surgery (ESVS) guidelines recommend thoracic endovascular aortic repair (TEVAR) as the first line treatment for BTAI. Other controversies regarding BTAI management were reported in the literature, such as the best treatment for minimal aortic injuries with intimal tear, ideal stent graft oversizing, best timing for treatment and necessity to cover the left subclavian artery (LSA). The purpose of this review is to identify and analyze appropriate studies published so far about the management of BTAI. Methods: We performed a thorough electronic search of the literature using PubMed and Embase databases. We used the following combination of key words in our search strategy ((aortic injury) AND (blunt thoracic trauma)) AND (vascular surgery* OR treatment* OR TEVAR*). Articles not in English were excluded. The primary subject was results of endovascular treatment. Secondary subjects were indications and results of OSR, best timing for intervention, ideal graft oversizing, need for left subclavian artery (LSA) coverage, and management of BTAI grade I (intimal tear). Results: Data related to our primary and secondary subjects were extracted from the selected articles. TEVAR is considered the primary treatment for BTAI, if the patient has suitable anatomy, with good short and mid-term outcomes, with lower mortality and paraplegia rates at short and mid-term follow-up, compared to OSR. Despite good term results at short-term follow-up after TEVAR, long-term outcomes are still a concern. OSR is still a valid option in selected cases, and it should be considered for patients whose injury location is unsuitable for the endovascular approach. In most patients with BTAI, it is recommended around 10% of graft oversizing. However, a more aggressive approach with oversizing between 10-20% should be considered for patients with considerable hypotension and even >20% for patients presenting with severe hypotensive hemorrhagic shock. A necessity of LSA coverage has been reported in 30% of TEVAR for urgent treatment of BTAI, and it seems to be well tolerated. We should considered expectant approach with serial follow-up CT scans in patients with BTAI grade I injuries with asymptomatic intimal aortic tear. Conclusions: This literature review reports and synthetizes published data about the management strategies for BTAI. TEVAR seems to be effective in the treatment of BTAI, with few complications and good outcomes at short and mid-term follow-up, and it should be the first-line treatment for these patients. OSR should be an option when a patient’s injury is not suitable for endovascular approach. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200094&lng=es&nrm=iso&tlng=es Abstract Introduction: Endovascular reconstruction of the thoracoabdominal aorta is highly complex due to the need to preserve the main visceral branches. Optimal treatment with fenestrated and branched aneurysm aortic repair (F/B-EVAR) is usually not possible in urgent situations. Parallel grafting technique as an “off-the-shelf” solution have been described with good short and medium-term results. Case report: A 44-year-old male, born in Guinea Bissau, presents to the emergency department with epigastric pain radiating to the dorsum. The patient had a history of large vessel vasculitis secondary to Bechet’s disease (HLA B51 allele positivity) and previous thoracic aneurysm aortic repair (TEVAR) to treat a paraceliac aortic pseudoaneurysm. Computed tomography angiography (CTA) demonstrated a pseudoaneurysm with approximately 10 cm diameter at zone 6 immediately distal to the previous endoprosthesis. The pseudoaneurysm was excluded with a parallel grafting technique using a 31mm aortic endoprosthesis with a periscope graft for the right renal artery in a “sandwich-like” configuration and a chimney graft for the superior mesenteric artery (SMA). Postoperative CTA confirmed the exclusion of the pseudoaneurysm and permeable bridging stents. Conclusion: The pathology of the thoracoabdominal aorta is technically demanding, requiring experience and detailed planning. The complexity increases in emergency cases. Our case highlights that the parallel grafting technique should be encouraged in life-threatening scenarios as a readily available solution for complex aortic repair, even in a reconstructed aorta. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200098&lng=es&nrm=iso&tlng=es Resumo Introdução: A disseção aórtica aguda tipo B (DAAB) é uma síndrome aórtica aguda que apresenta elevada taxa de mortalidade. Atualmente, na fase aguda, preconiza-se o tratamento médico nos casos de DAAB não complicada, ficando a cirurgia reservada para os casos de DAAB complicada (rutura, síndrome de malperfusão, dor/hipertensão refratária, expansão rápida ou progressão proximal/distal). A cirurgia endovascular, por apresentar taxas de morbi-mortalidade francamente inferiores à cirurgia aberta, está recomendada sempre que possível. Caso clínico: Apresentamos um caso de DAAB complicada de falso aneurisma, rotura e malperfusão visceral, submetida de urgência a tratamento endovascular (TEVAR + PETTICOAT) e drenagem torácica. O pós-operatório foi complicado de AVC isquémico do hemisfério direito, com recuperação quase completa dos défices durante o internamento. A angio-TC de controlo, aos 2 meses, mostrou exclusão do falso aneurisma, expansão do verdadeiro lúmen (com adequada perfusão das artérias viscerais) e trombose parcial do falso lúmen (exceto em focos de preenchimento retrógrado à custa de artérias lombares e intercostais). http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200103&lng=es&nrm=iso&tlng=es Abstract Introduction: The development of a uretero-arterial fistula (UAF) is a rare and life-threatening condition. Owing to its low prevalence, diagnosis and management remains a challenge for both urologists and vascular surgeons and UAF’s high mortality rates may be at least partially attributed to delayed diagnosis. We present a case of UAF in a patient with previous pelvic surgery and indwelling ureter catheter. Case report: An 82-year-old male presented to the emergency department with haemodynamic instability and gross haematuria that started one hour prior to admission. The laboratory study performed showed an acute anaemia of 7.5g/dl and a contrast enhanced computed tomography revealed a ureteral fistula between the stented left ureter and the common iliac artery. The patient was taken to the angiography suit and a balloon-expandable stent-graft (GORE® VIABAHN® VBX - 11mm diameter and 59mm in length) was deployed. Following the procedure, the haematuria resolved, and the patient had an uneventful post-operative stay. He was discharged two weeks after admission, following a course of large spectrum antibiotic therapy. The patient remained asymptomatic at 3 month follow up. Conclusions: Uretero-arterial fistula is an uncommon condition but with an increasing prevalence, at least in part due to improved pelvic cancer treatment. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2023000200106&lng=es&nrm=iso&tlng=es Abstract Introduction: The development of a uretero-arterial fistula (UAF) is a rare and life-threatening condition. Owing to its low prevalence, diagnosis and management remains a challenge for both urologists and vascular surgeons and UAF’s high mortality rates may be at least partially attributed to delayed diagnosis. We present a case of UAF in a patient with previous pelvic surgery and indwelling ureter catheter. Case report: An 82-year-old male presented to the emergency department with haemodynamic instability and gross haematuria that started one hour prior to admission. The laboratory study performed showed an acute anaemia of 7.5g/dl and a contrast enhanced computed tomography revealed a ureteral fistula between the stented left ureter and the common iliac artery. The patient was taken to the angiography suit and a balloon-expandable stent-graft (GORE® VIABAHN® VBX - 11mm diameter and 59mm in length) was deployed. Following the procedure, the haematuria resolved, and the patient had an uneventful post-operative stay. He was discharged two weeks after admission, following a course of large spectrum antibiotic therapy. The patient remained asymptomatic at 3 month follow up. Conclusions: Uretero-arterial fistula is an uncommon condition but with an increasing prevalence, at least in part due to improved pelvic cancer treatment.