RCAAP Repository

The widespread use of various imaging modalities, allow that hypogastric aneurysms have been increasingly detected. Usually asymptomatic, but once clinical symptoms occur, it must be supposed immediately that the hypogastric aneurysms have ruptured or that is compressing neighboring abdominal structures. We describe a patient with a giant hypogastric aneurysm, after a AAA repair, compressing the ureter and spinal roots, treated by open surgery.

Introduction: Venous ulcer is the most advanced stage of chronic venous disease. Polidocanol foam sclerotherapy corresponds to a minimally invasive treatment, reproducible in cases of vessel recanalization. Objective: To correlate the severity of venous disease, quality of life and recanalization rates in patients with venous ulcers treated with polidocanol foam sclerotherapy. Methods: Forty patients with venous ulcers submitted to ultrasound-guided polidocanol foam sclerotherapy were evaluated. The patients were divided into four groups according to the post-procedure period (Group 6, Group 12, Group 24 and Group 36). Quality of life, severity of disease and vein recanalization were analyzed in all patients using the generic questionnaire SF-36, the Clinical Severity Scale of the Venous Symptoms and Doppler ultrasonography, respectively. Results: There was no statistically significant relationship between vein recanalization with the eight SF-36 domains or with the higher scores of the Clinical Severity Scale of Venous Symptoms in any of the groups studied. When comparing the domains of SF-36 between groups there was statistically significant difference in the domain limitations by emotional aspects (p<0.05). Conclusion: Vein recanalization does not affects negatively the quality of life and the severity of disease in patients submitted to polidocanol foam sclerotherapy.

The deep vein thrombosis (DVT) is a high morbility pathology if not properly diagnosed and treated at its aerly stage. The direct oral anticoagulants (doacs), which selectly inhibit factor IIa (dabigatran) or factor Xa (rivaroxaban, apixaban and edoxaban), have become an attractive alternative to conventional therapy due to their fixed doses, no food interactions and absence of monitoring.  The aim of this wrk is to procced with a revision on therapeutic use of DOACs and their risk/benefit correlation in comparison to conventional therapy in the DVT treatment and prevention.  It was conducted a search on Pubmed database of English-language articles that addressed the DOACs in treatment and secondary prevention of DVT. It were also included the major cinica trials and the atest guidelines for the treatment and prevention of Venous Thromboembolism (VTE). Large randomized studies sateted the non-inferiority of DOACs in the efficiency profile in comparison to conventional therapy, with the adventage of providing a higher safety profile. The improved risk/benefir ratio of DOACs combined with predictable pharmacokinetic properties and the absence of monitoring allow a better relation cost/efficiency. Athough not all patients benefit from this therapy, which should be individualized in each case, the DOACs have changed DVT treatment and prevention into a more practical and safer procedure, associated with a higher patient satisfaction and a decrease in recurrent events incidence, lauching a new paradigm in DVT treatment and prevention.

Paraplegia is a devastating and well recognized complication of thoracoabdominal aortic aneurysm repair surgery, with cerebrospinal fluid drainage systems emerging as an important measure to improve neurological outcome. The protocol elaborated by the authors consists of several documents that guide the placement of the drainage system, its maintenance, the handling and the hemodynamic goals for the intraoperative and postoperative period, the interventions to be taken in case of neurological deficit and the withdrawal of the drainage catheter with safety. It is imperative to familiarize the different members of the medical and nursing teams with the usage rules of this system. The main objective is to optimize the approach of these patients in order to improve their neurological outcome and to minimize the risk of complications.

Introduction: The May Thurner syndrome (MTS), results from compression of left common iliac vein (LCIV) between the fifth lumbar vertebra, posteriorly, and the right common iliac artery (RCIA), anteriorly. This phenomenon can cause venous stasis in the pelvis and in the left lower limb. The Nutcracker syndrome (NCS) result from compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta, called Anterior NCS, or more rarely by compression of the LRV between the aorta and the lumbar vertebra, when the vein passes behind the aorta, called posterior NCS. The association of the two anomalies can occur when a circunaortic renal vein exists. This phenomenon can cause stasis in the kidney and in the pelvis. The MTS and NCS are rare clinical entities and the association of the two pathologies is extremely rare. Clinical Case: A 29-year-old female, complaints of bilateral leg pain, predominantly on the left side, left malleolar edema which increases in the end of the day, and dyspaneuria. These complaints interfere severely with the quality of life of the patient. The physical examination reveals collateral varices in the posterior aspect of the left tight, a right side vulvar varicose vein and mild left malleolar edema.  A phlebography of the ilio-cava system and the ovarian vein reveal a compression of LCIV by the RCIA with an extensive collateral pathway communicating the left and the right vein iliac system, the origin of a right side vulvar varicose vein in the right internal iliac vein and the compression of a posterior LRV by the aorta. A transluminal angioplasty with sequential dilatation with a 12, 14 and 16 mm balloon was done and an Optimed stent 16/100 mm was implanted in the LCIV.At 3 months of follow up, the patient called and informed that she was pregnant, so she stopped the rivaroxabane and maintained the elastics stockings. The pregnancy and the child birth had no intercurrences. An abdomino-pelvic control CT at 12 months follow-up was done, showing the stent in a good position and patent, and posteriorly she was submitted to stab avulsion of varicose veins in the left thigh. At 18 months follow-up, the patient was clinically asymptomatic. Discussion/Conclusion: Insufficient knowledge about the natural history of NCS and MTS results from the   uncertainty in the diagnostic criteria and treatment selection, particularly in the rare association of both. This association can be responsible for the amplification of the symptomatology of the venous obstruction.  In our case, we have seen the resolution of the complaints by treating only one of the obstructive lesion (MTS) and we haven’t seen any effect of the pregnancy in the structure and patency of the ilio-caval stent. 

Paragangliomas (PGLs) are neuroendocrine neoplasms that can occur throughout the body wherever there is paraganglia. Representing 0.03% of all tumours, PGLs are extremely rare. Although predominantly benign and amenable to cure by surgical ressection, up to 6% can be malignant. To date, three genes have been identified that are associated with Familial PGLs. All three encode subunits (D, B and C) of the enzyme succinate dehydrogenase complex (SDH), which is part of the Kreb's cycle and the electron transport chain. We report a novel causative frameshift mutation in the subunit D of SDH (SDHD) in a family with Carotid Body Paragangliomas. This finding contributes for extending the known mutational spectrum of SDHD, and to help the genetic counseling of this family. Noteworthy, is now possible to offer to other relatives, still sub-clinical, a predictive test that would eventually aid an early surveillance/intervention for a better prognosis.

Peripheral mycotic aneurysms are rare complications of infective endocarditis. The case of a 49-year-old man with a radial artery aneurysm in a context of infective endocarditis caused by Streptococcus bovis in the postoperative period of mechanical aortic valve replacement by homograft is reported. After diagnostic confirmation by Doppler scan, we chose to resect the aneurysmal sac with termino-terminal anastomosis. At 2 years of follow-up he presented asymptomatic, with palpable radial pulse and thriphasic flow in the palmar arch and ulnar artery.

Introduction: Benign superior vena cava syndrome (SVCs) is rare and may be related to a totally implantable vascular access device (TIVAD). In the past 20 years, percutaneous endovascular placement of a stent has been rising as a viable option for SVCs treatment. Case Report: We report the case of a 42-year-old woman with the diagnosis of classical Hodgkin lymphoma who presented a SVCs one year after placement of a TIVAD. After failure of conservative treatment, we placed an auto-expansible stent through the TIVAD with good radiologic and clinical result. Conclusion: Endovascular treatment for TIVAD-related SVCs is safe and may be considered a first line approach.

Introdution: Aneurismal disease involving the thoracoabdominal segment adds significant complexity to endovascular aortic repair.  Objective: Evaluate institutional experience of a tertiary center in fenestrated and branched aneurysm repair for throracoabdominal or juxtarenal aortic aneurysms Methods: Retrospective analysis of a consecutive series of patients treated by endovascular repair using fenestrated or branched stent grafts between October 2010 and May 2016. Results: Twenty-six patients underwent endovascular repair with fenestrated and/or branched stent grafts (mean age 68±7years; 1 female). Eleven patients had history of previous aortic intervention. Seventeen throracobdominal aneuryms had the following anatomic distribution: Type I: n=1; Type III: n=5; Type IV: n=6 and Type 5: n=5. Additionally nine pararenal aneuryms were treated. Mean maximum aneurym diameter was 72±25mm. There were 3 types of stent graft configuration based on aortic anatomy and aneurysm morphology:  21 custom-made (14 fenestrated and 7 fenestrated/branched) and 5 off-the-shelf multibranched (T-branch). The median number of fenestrations/branches per stent graft was 4(2-4). The total target visceral vessels involved was 88. In 88% another planned endovascular procedure was performed: EVAR n=15; TEVAR n=4 and EVAR+TEVAR n=4. The technical sucess rate was 96% (25/26) (1 case of ostial stenosis of the celiac trunk with unssucessfull catetherization). The 30 day mortality rate was 7,7% (2/26). Spinal cord ischemia occurred in 12% (N=3; acute onset N=1; delayed N=2) There was no difference between the pre- and post-operative (p=0,777). The mean follow-up time was 10±15 months. There were 2 endoleaks, and no late re-interventions nor late aneurismatic ruptures during the follow-up time. Conclusion: Fenestrated/branched devices development allowed the treatment of complex high risk aneurismatic disease in a less invasive manner. These procedures are technically demanding, but safe and effective in prevention of aneurysm rupture in our experience. Despite the relatively low number of patients, our results are in line with other international contemporary endovascular series.

The popliteal artery entrapment syndrome (PAES) is a major cause of claudication and acute ischemia of lower limb in young athletes without risk factors for atherosclerosis. We present a 39 years-old female patient with no relevant past history and no sport activity, admitted to our emergency department with acute disabling claudication in the right lower limb caused by retrogeniculate popliteal artery occlusion. Computed tomography scan confirmed a type II popliteal entrapment syndrome with popliteal artery occlusion. The patient was submitted to surgery that consisted in myotomy of the medial head of the gastrocnemius muscle, division of the anomalous fibrous band, resection of the diseased popliteal artery and interposition of a reverse ipsilateral saphenous vein graft. The patient recovered distal pulse on the right foot. Previously considered as a rare disease, the growing number of publications about PAES in the medical literature show the opposite. However, little is known about the prevalence of this syndrome and some studies report a prevalence of 0.165–3.5%. PAES is more common in males and in almost 60% is bilateral. The best treatment results are obtained with replacement of the popliteal artery with graft interposition, preferably venous. Currently, this approach is advocated in all patients with entrapment with the exception of early stages with arterial disease confined to the adventitia. PAES is not as rare as previously admitted and therefore it is important to maintain a high index of suspicion in these age group.

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Abdominal aortic aneurysm (AAA) has shown an epidemiological transition in Western countries. The standard of the XX century characterized by increasing incidence and mortality has been replaced by decreasing incidence and mortality due to AAA. The decrease in deaths from AAA observed since the 90s seems to have been motivated by reduced exposure to risk factors, increased use of cardioprotective drugs, increased availability of diagnostics and improved treatment modalities. This epidemiological transition could have an impact on the screening strategy (both in organized or opportunistic screening) as well as in the management of resources related to the treatment of AAA. The objective of this review is to scrutinize the magnitude of these epidemiological changes, the possible underlying causes and its potential impact.

Pulmonary artery pseudoaneurysms may be caused by infection, trauma, neoplasm or iatrogenic lesions, such as pulmonary artery rupture during right heart artery catheterization. Clinical presentation can range from an incidental finding to a life-threatening bleeding with massive hemoptysis. We present a case of a 67 year old woman with systemic sclerosis that developed massive hemoptysis after right heart catheterization. Computer tomography angiography showed a pulmonary artery pseudoaneurysm in the posterior basal segmental branch of the left lower lobe. Computer tomography angiography usually allows pseudoaneurysm diagnosis, localization and characterization and can aid in therapeutic procedure planning. Without treatment pseudoaneurysms may enlarge or rupture. Although a rare complication, pulmonary artery pseudoaneurysms are associated with high morbidity and mortality, and should not be missed.

The thoracic outlet syndrome can occur from the compression of the neurovascular bundle of the upper limb in the segment below the clavicle. In this case, the responsible one for the situation is the minor pectoralis muscle, referred in the literature as "pectoralis minor syndrome" (PMS). Although probably present in pediatric ages, these syndromes are uncommon and often undiagnosed. We describe a 14-year-old handball practitioner, with an unusual presentation of PMS, whose diagnosis was confirmed by arteriography. Considering his age, he underwent physiatric therapy and sport’s restriction. We observed a substantial clinical improvement within six months, and no changes at the axillary-subclavian axis were found two years after. According to the literature this is a rare case, being its etiology related to the handball practice.

Introduction: Endovascular aortic repair (EVAR) has significantly altered the therapeutic strategy for abdominal aortic aneurysm (AAA), due to less invasiveness and lower perioperative morbi-mortality. However, specific complications such as type 1a endoleak (T1aE) and persistent type 2 endoleak (pT2E) have been associated with adverse outcomes including aneurismal rupture. We present a case of AAA rupture due to both T1aE and pT2E treated in our institution. Case Report: The patient is a 73-year-old male, submitted to EVAR at another institution for infra-renal AAA with no apparent complications. He was admitted in the emergency department, 7 years post-EVAR, with abdominal pain and loss of consciousness with spontaneous recovery. A CTA was performed and revealed aneurysmal sac growth, spontaneous hiperdensity of the thrombus, high density in the fat in the right retroperitoneum and a pT2E. Intra-operatively, after opening the aneurysmal sac, both pT2E and T1E were detected. He was submitted to partial aneurismectomy, suture of the ostia of the lumbar arteries, filling of the aneurysm sac with prothrombotic products and closure of the aneurysm sac with adjustment of the proximal sealing zone. The patient was discharged 15 days post-procedure. CTA performed 1 month after the procedure revealed no endoleak, aneurismal sac stability filled with prothrombotic products. At 2-year follow-up the patient remained asymptomatic and the CTA findings remained unchanged. Discussion: Rupture post-EVAR is a significant therapeutic challenge for vascular surgeons. In this case, pre-operative CTA findings lead to plan an open surgery with endoaneurismorrhaphy of collaterals. Intra-operative finding of T1aE in the context of aneurismal rupture and hemodynamic instability, forced us into an inventive solution aiming to regain proximal sealing. This was essentially a variant of previously described proximal banding for T1aE. Endoprosthesis explantation was considered too time-consuming and aggressive in an already unstable patient. Results at 2-year follow-up were encouraging.

Desmoplastic fibroblastoma (DF), also known as collagenous fibroma, is a rare benign fibrous tumor, recently described. It occurs predominantly in trunk and upper limbs, and can appear at any age. The authors describe a case of a 42-yearold female patient with DF, with upper limb neurovascular compromise. Patient was submitted to block excision of the tumor mass and brachial artery, with arterial reconstruction (autologous interposition graft). The anatomopathological analysis was consistent with DF and the diagnosis was validated by an international external laboratory1. This is the first description in the literature of an DF involving an arterial segment.

Aorto-iliac aneurysms involve both common iliac arteries in 30% of cases. Endovascular treatment can be performed using combined revascularization and embolization techniques, but in selected cases, the preservation of the two hypogastric arteries appears to offer a clear advantage. Thus, in order to accomplish this goal, it is necessary to use bilateral iliac branch devices (IBD), which require specific technical strategies. In this paper, the authors report two clinical cases, describe the technique and discuss its peculiarities.

Abdominal aortic aneurysm (AAA) is a cumbersome pathology, with catastrophic consequences when not properly diagnosed and treated. Nowadays, EVAR became an established treatment option for AAA, with better perioperative outcomes when compared to open surgery, and is quickly gaining a position of preference among the patients. However, the occurrence of endoleaks is described as the most common adverse event associated to EVAR. Consequently, we review the definition and classification of endoleaks as well as their potential risks and management. Nonetheless, according to the current follow-up protocols of ESVS, this technique requires an extensive imaging follow-up, usually by means of computed tomographic angiography (CTA), which carries increased economic cost and leads us to discuss related great radiation hazards. Concerning the latter, we also review the selected studies and we concluded that the first month CTA is the single most important imaging exam for patients’ prognosis and, once no complications are found, other reviewed imaging follow-up strategies should be undertaken to minimize radiation exposure and yet further risks for the patients. Therefore, this article establishes an overview about the current evidence and future strategies on EVAR imaging follow-up.

Introduction: Iatrogenic vascular lesions are rare but potential complications of any surgical intervention at cervical level, with catastrophic consequences when not properly contained. Despite the importance of the vascular structures located at this level, literature on this subject is scarce, fact which reinforces its rarity. In a decade in which endovascular options became the standard treatment modalities in a wide range of pathologies, proper open surgical skills are still essential for the resolution of this type of problems. Methods: The authors present a case report of iatrogenic laceration of the brachiocephalic, right subclavian and common carotid arteries during a cervical lymphadenectomy, successfully controlled and corrected by means of open surgery. Results: Female patient, 49 years old, with previous medical history of total thyroidectomy and right cervical lymphadenectomy due to thyroid papillary carcinoma. Regular assessment in outpatient consultation was maintained, and at 5 years’ follow-up, bilateral profound lymph node metastasis was diagnosed, and re-intervention was planned. During the right cervical surgical dissection, heavy arterial hemorrhage from the carotid sheath was noted, with no possibility for proper vascular control. Due to lack of access for tissue dissection and vascular control, sternotomy of the sternal manubrium was performed, and access to the upper mediastinum was granted. Laceration of the brachiocephalic trunk, and proximal segments of both the right subclavian and common carotid arteries were noted. Vascular dissection, isolation and control were rapidly assured. Taking into account nature of the lesion and the fibrosis and the frailty of the surrounding tissues, direct suture was not possible, and so vascular reconstruction was performed by means of prosthetic grafts. In order to do so, interposition graft between the brachiocephalic trunk and the right subclavian artery was performed, after which new interposition graft was sutured between the right common carotid artery and the previous one. In both cases, PTFE grafts were used. Once arterial flow was restored, lymph node excision was performed as planned. Post-operation evolution was favorable, with no neurological deficits to report nor right arm ischemia, as the right radial pulse was present and strong. Doppler ultrasound evaluation performed at one-month follow-up revealed total integrity of the vascular grafts, with no anastomotic stenosis. Conclusion: Iatrogenic vascular lesions are important surgical challenges, due to their seriousness, unpredictability, and need for quick intervention and control. In this endovascular era, proper domain of open classic surgical techniques is still essential to the daily practice of any vascular surgeon.

Introduction: The inadvertent arterial puncture in the placement of dialysis catheters is uncommon, occurring in 4.2% - 9.3% of the cases, and it may be difficult to recognize immediately in previously unstable and in shock patients. It is a serious situation that occurs more frequently in the femoral region in relation to the subclavian and there is no recommended standard treatment. The purpose of this study is to present the treatment method used in a case of inadvertent placement of a dialysis catheter in the subclavian artery.Clinical Case: A 58-year-old woman with a history of hypertension and CRF on hemodialysis, admitted in the infecciology service in septic shock clinic with a starting point in a central venous dialysis catheter (CVCd) placed in the left femoral vein and associated with endocarditis. After the beginning of empirical antibiotic therapy with vancomycin and gentamicin, the CVCd of the left femoral vein was removed and an attempt was made to place a new catheter in the left subclavian vein. On suspicion of intra-arterial localization of the catheter, the patient performed an angio-CT that confirmed the presence of CVCd in the left subclavian artery without contrast extravasation or thrombosis. On observation, the patient was intubated and ventilated, with normal humeral, radial and ulnar pulses, with no evidence of hematoma, false aneurysm or thrum at the puncture site. The patient underwent surgical treatment and a Viabahn® 8 x 50 mm self-expandable covered stent was deployed in the left subclavian artery, distal to the emergence of the vertebral and internal mammary arteries (excluding the site of the CVCd puncture). The covered stent was placed in the correct location and deployed immediately after the removal of the CVCd by the anesthesiologist, with control and resolution of the hemorrhage. Intraoperatively, a new CVCd was placed in the right femoral vein. There were no vascular intercurrences and an Enterobacter Cloacae sensitive to ertapnem was later isolated in the blood cultures. The patient was discharged on the 24th day with pulses kept in the left upper limb and without complications of the access.Conclusion: Removal and immediate compression of CVCd when introduced into the arterial sector may result in uncontrollable hemorrhage, pseudoaneurysm or AV fistula, especially if the entrance site is in a zone of difficult access to compression, as it is the case of the subclavian artery. The endovascular positioning of a covered stent at the entrance site of the CVCd and its opening immediately after the removal of the CVCd constitutes an interesting, innovative technical aspect whose disclosure may be useful in similar cases.