RCAAP Repository

Introduction: After surgical revascularization of the lower limb, antiplatelet agents are usually prescribed and anticoagulation is considered in cases of high risk of thrombosis. We conducted a systematic literature review of the existing evidence on long term prescription of anticoagulants in the postoperative. Material and methods: Systematic review of the literature available in the Pubmed database. Results: The studies selected for the final review consisted of: 6 randomized controlled trials (and 4 post-hoc analyzes), 1 prospective study with historical controls and 3 retrospective studies. Conclusion: The efficacy of hypocoagulation depends on the conduit used and its intrinsic factors. There is benefit of hypocoagulation in the autologous venous lower limb bypasses, but the INR range and risk factors for thrombosis may influence the results. In the non-venous grafts there may be benefit in those with reduced caliber and low average flow. The incidence of major bleeding is significant, and a careful evaluation of the risk-benefit ratio in the prescription of chronic hypocoagulation is essential.

Introduction: Iliac artery dissection without aortic involvement is a rare entity, with most cases associated with predisposing factors such as trauma, atherosclerosis, connective tissue disorders or vigorous exercise. The best treatment is not unanimous, and depends on the acuteness and severity of symptoms. Criteria for intervention include prevention of aneurysmatic degeneration, acute limb ischemia, inguinal pain and aneurysm rupture. Recent results using endovascular technique showed comparability with open repair, but there is paucity of data concerning long term results. Methods: Relevant medical data were collected from hospital database. Results: The patient is a 65 years old male, referred to the emergency department for abdominal pain in the left lower quadrant with inguinal irradiation. No signs or symptoms of acute limb ischemia were present. He had no previous history of connective tissue disease, cardiovascular risk factors, trauma or vigorous exercise. A CTA was performed, which identified an acute common left iliac artery dissection, with no evidence of vascular compromise of the ipsilateral limb He was submitted to surgical left femoral approach and percutaneous right femoral approach and dissection exclusion with two stentgrafts. Resolution of abdominal pain occurred immediately. Imagiologic follow-up with CTA was performed 12 and 24 months later with no signs of dissection or residual stenosis. Conclusion: In this case, an hybrid procedure with femoral surgical approach was performed for access site control. The use of bilateral femoral access was useful to identify the true lumen more accurately and to accommodate a more precise stent placement assuring adequate sealing. At 24 months follow-up, the patient maintains asymptomatic with no evidence of complications in the imagiologic follow-up. No signs or symptoms suggestive of connective tissue disease developed.

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Introdução: O pé diabético é uma complicação da Diabetes Mellitus (DM) responsável por 250 amputações em 2015 em Portugal1,2. É uma consequência da vasculopatia, imunopatia e neuropatia3,4, sendo esta última o mecanismo mais importante da Neuroartropatia de Charcot (NC)5. A radiografia convencional permite uma primeira abordagem imagiológica, identificando os “6 D’s”: Dense subchondral bones; Degeneration; Destruction; Deformity; Debris, Dislocation6,7. Deste modo, pretende-se relacionar os dados imagiológicos da radiografia simples do pé com a clínica e a fisiopatologia da entidade “Pé Diabético”, tendo como mote a descrição de um caso clínico. Caso clínico: Homem de 59 anos, com antecedentes de DM tipo 2 e amputação transmetatársica à direita recorreu ao Serviço de Urgência por dor, eritema e edema no pé e terço inferior da perna direita e úlcera plantar com exsudato purulento. Apresentava pulsos femorais e poplíteos. Pulsos distais ausentes. Foi internado para antibioterapia, descarga total, cuidados de penso e avaliação analítica, radiológica e multidisciplinar. Apesar do controlo da infeção associada foi impossível o realinhamento do pé e restituição das relações dos ossos pela grande destruição óssea. O doente foi submetido a amputação abaixo do joelho. Comentários: Na radiografia de perfil observou-se perda dos arcos plantares longitudinais medial e lateral e calcificação (encurtamento) do tendão de Aquiles (Figura 1, nº1), com aumento da pressão na face plantar que, associada à neuropatia sensitiva, contribuíram para a formação de úlcera, como observado neste caso8,9. A úlcera traduz-se neste exame do pé pela radio-lucência identificada na zona média plantar, patognomónica de Neuroartropatia de Charcot. (Figura 1, número 2)10. Verificou-se destruição óssea - fragmentos ósseos (Figura 1, nº3) com fratura da tuberosidade do calcâneo e colapso sub-astragalino (Figura 1, nº4). A localização desta fratura é das menos frequentemente observadas na Neuroartropatia de Charcot11. A neuropatia sensitiva permite submeter o pé a extremos de stress com consequentes fraturas indolores. A neuropatia autonómica, a abertura de “shunts” arteriovenosos e a hipervascularização óssea, acarretam osteopenia (Figura 1, nº5) e diminuição da resistência à fratura11,12. Observou-se edema (Figura 1, nº6) e enfisema subcutâneo (Figura 1, nº7), tradutor da presença de agentes microbiológicos anaeróbios, geralmente identificados em 90% das culturas13. Constatou-se calcificação da artéria tibial posterior (Figura 1, nº8), tipicamente uma mediocalcinose de Monckeberg, que está associada a elevada taxa de amputação e de mortalidade. Esta alteração vascular aumenta o grau de dificuldade técnica e compromete o prognóstico da revascularização11,14,15.  Conclusões: Apesar da grande variedade de técnicas imagiológicas, o custo-efetividade na deteção das principais alterações patológicas tornam a radiografia convencional a primeira linha de diagnóstico do pé diabético16.

Introduction: Despite significant advancements, ruptured abdominal aortic aneurysm (rAAA) remains a life-threatening condition, and the decision whether or not to proceed with surgical intervention is extremely difficult in daily practice. Previous risk prediction models of rAAA mortality developed before EVAR was an option, had their validity questioned in an era where both open repair (OR) and EVAR are available. In 2017, Healey CT et al and von Meijenfeldt GC et al (Dutch Aneurysm Score) published two new mortality prediction models, both based on easily obtained clinical variables and validated in a population submitted to either OR or EVAR. The purpose of this paper was to describe the evolving experience in rAAA management in our centre, and to validate the applicability of the aforementioned scores in our practice. Methods: The clinical data of all patients admitted in our hospital from 2010 to 2016 with the diagnosis of rAAA were retrospectively reviewed and statistical analysis using SPSS V.22 was performed. Results: A total of 71 patients were considered, including 19 EVARs and 52 ORs. There was a significant increase over time in repairs performed by EVAR, and in 2015 the annual rate of EVAR exceeded that of OR. The population of patients submitted to EVAR and OR were comparable in gender, age and co-morbidities with the exception of smoking, more common in the EVAR group (73.7% Vs 36.5%; p=0.005). No cases of intra-operative mortality were registered in the EVAR group, as opposed to 17% in the OR group (p=0,049). 30-day mortality reached 49% in the OR group and 31,6% in the EVAR group (p>0.05). Several pre-operative predictors of outcome were identified: smoking (p=0.005), pre-operative hemodynamic instability (p=0.003) and international normalized ratio (INR) at admission (p<0.0001). As for post-operative preditors of outcome, hemodynamic instability in the ICU was statistically significant (p<0,0001). Binary logistic regression concluded elevated INR and post-operative instability were independent risk predictors of outcome (p<0.05). The mortality score prediction models aforementioned were applied to our population and estimated mortality significantly correlated with real mortality (estimated mortality 41% and 45.3% Vs real mortality 45%; both p<0.0001). Pearson correlation was applied to compare scores and concluded a correlation coefficient of 0.775 (p<0.001), describing a significant positive linear correlation between scores. Conclusions: In recent years, EVAR has increasingly become the procedure of choice for rAAA in our institution. With this evolving approach to rAAA, both score prediction models were retrospectively applied and both accurately predicted mortality in the study population (p<0.001).

Axillary and subclavian artery injuries due to penetrating trauma, excluding those occurring in war theatre, are relatively rare and few cases are described in the literature. However, if not diagnosed in a timely manner, these lesions may be associated with high morbidity and mortality. The difficulty and complications often associated with the open surgery approach have made endovascular treatment a more attractive alternative, particularly in cases of pseudoaneurysm or arteriovenous fistula formation. The authors describe a clinical case of a 24-year-old man admitted for an axillary artery injury in the context of penetrating trauma and that undergone successful endovascular correction.

Popliteal vein aneurysm is a rare but potentially fatal entity due to possible thromboembolic complications. The purpose of this paper is to describe two institutional cases and to review the literature. In one case the diagnosis was made after the occurrence of symptomatic pulmonary embolism and in another, incidentally. In both cases the treatment was by conventional surgery without perioperative complications. From the literary review, a total of 43 popliteal vein aneurysms published between 206 and 2016 were analyzed.

Introduction: Mortality rates after lower limb amputation are notoriously high and age is associated with increased mortality. The aim of this retrospective study was to determine mortality rates after a first major lower limb amputation in a cohort of patients older 80 years old. Methods: We performed an analysis of factors affecting early and late outcome after major lower limb amputation for peripheral vascular disease or diabetic complications at a tertiary referral vascular center between 2008 and 2015 in patients older than 80 years old. Results: 557 patients underwent a major amputation (54% female), of median age 86.3 ± 4.4 years and 20% had bilateral amputations during the study period. Median follow-up was 4.8 [0.8; 16.4] months. 30-day and 2-year mortality rates were 27% and 77%. Age adjusted 1-year mortality rate after trans-femoral amputation (TFA) was 68%, almost double that of trans-tibial amputation (TTA) (36%, p= .04). The rate of re-operation was substantially greater after TTA (36% vs 17%, p< .01). Survival and Cox regression analysis demonstrated that long-term mortality was associated with hospital re-admission (HR: 2.00, p <.05) cerebrovascular and chronic kidney disease (HR: 1.22 and 1.24 respectively, p <.05), acute ischemic amputation (HR 1.21 p <.05). Previous revascularized amputees and TTA survived longer (HR 0.65 and 0.51 respectively, p <.01). Conclusions: This study adds prognostic information for a well-defined population of people with a first amputation at or proximal to a transtibial level, due to a vascular or a infection related cause. Mortality rates after lower limb amputation are notoriously high, with only 23% of these cohort patients living longer than two years.

Objective: Type 2 endoleak occurs in up to 30% of endovascular aneurysm repair (EVAR), but its long-term significance continues to be one of the most controversial topics. We reviewed our experience to evaluate late outcomes associated with type 2 endoleak. Methods: Between January 2008 to December 2014, 57 patients undergoing EVAR were enrolled in the presenting study. Computed tomography (angioCT) scan assessment was performed to evaluate aneurysm sac evolution. Primary end points included type 2 endoleak incidence, aneurysm sac growth, abdominal aortic aneurysm (AAA) related rupture and death. Secondary endpoints included conversion to open repair, reintervention rate, type 2 endoleak persistence and failure to shrinkage > 5mm and abdominal aortic aneurysm (AAA) rupture. Results: We identified 10 (17.5%) patients with type 2 endoleaks (6 early at the first follow-up CT scan). Median followup was 39.0 ± 31,6 months. Endoleaks persisted in 7 patients (12,2% of total patients; 70,0% of type 2 endoleaks) for >6 months. Overall survival rate was 100%, 98% and 80% at 1, 2 and 5 years. Spontaneous sealing occurred in 6/10 (60%): 3/3 (100.0%) transient type 2 endoleaks and 3/7 (43%) persistent type 2 endoleak. Transient type 2 endoleak (those that resolved <6 months of EVAR) weren´t associated with adverse late outcomes. In contrast, persistent endoleak was associated with several adverse outcomes. When evaluating patients with transitory endoleak vs persistent endoleak, freedom from sac expansion at 1, 3, and 5 years was 100% (transitory) vs 85%, 65%, e 40% (persistent) (P < .001). Patients with persistent endoleak were at increased risk for aneurysm sac growth vs patients without endoleak (odds ratio [OR], 36.0; 95% confidence interval [CI] 2,15 - 79; P < .02). The only reintervention occurred in a persistent endoleak). There was no aneurysm rupture or AAA-related death. Conclusion: Small sample size have limited this study ability to evaluate the impact on endoleak on adverse outcomes. Persistent type II endoleaks led to significant aneurysm sac enlargement, but without increased mortality or rupture rate.

Introduction and Purpose: Endograft migration after EVAR is rare. There are even fewer reports in the literature describing endograft migration treatment in the thoracic aorta. We report a successful treatment of a migrated endograft after TEVAR. Methods and Results: We report the case of a patient previously submitted to TEVAR, about 15 years ago. He was admitted in the Emergency Department for chest pain. After detecting the endograft migration with detachment from the neck, he was submited to a new endovascular procedure. We performed a partial repositioning of the proximal segment of the endograft with endotraction maneuvers using a balloon and a through-and-through guidewire, and we placed a proximal extention. The procedure was uneventful. Up to eight months of follow-up no complications were reported. Discussion and Conclusion: Treatment of an endograft migration, specially when related to a type Ia endoleak or detachment from the neck, can be regarded as a vascular emergency as well as a technical challenge.

Abstracts of the Communications and Posters of the 17th SPACV Congress

Deep venous sector injuries during lower limb varicose vein surgery are rare. They can have serious repercussions in terms of the patient’s quality of life, so reconstructive interventions are strongly recommended. We report a case of a patient referred to our Institution after an extensive lesion of the femoral venous sector. We performed a reconstructive surgery, through mechanical thrombectomy, as he presented an extensive deep vein thrombosis, and by performing an interposition graft bypass. After two years of follow no complications were reported. The patient is asymptomatic, with no significant signs or symptoms of post thrombotic syndrome. The interposition graft is still patent.

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Introduction: Abdominal aortic aneurysm (AAA) and carotid stenosis (CS) are manifestations of atherosclerotic disease. Besides common risk factors, both diseases have an identical genetic expression related to oxygen transport and the erythrocyte membrane.Objectives: Studying the association between AAA and CS≥50%; estimating the prevalence of aneurysmal disease in patients with CS; determining the prevalence of risk factors more frequently associated with CS. Material and Methods: We executed a transversal, retrospective and observational study. We studied a population of 526 men who realized carotid ultrasound from January 2013 to December 2014. We evaluated the following variables: presence and characteristics of AAA; smoking; SC degree and history of carotid endarterectomy and a score of risk for AAA. The statistical analysis was obtained by IBM SPSS Statistics 21 software.Results: The mean age was 68,7 ± 8,84 years and 329 patients (62,5%) were more than 65 years. Concerning risk factors, 298 (56,7%) were smokers. Of the 526 patients, 191 (36,3%) had CS≥50% or had made carotid endarterectomy. The prevalence of AAA in patients with CS≥50% was 19,4%. We verified the statistical evidence to affirm the association between AAA and CS≥50% (p=0,009). We didn’t verify evidence between AAA and the different levels of CS≥50% (p=0,115). We observed an association between advanced age and AAA (p=0,034). We didn’t verify the statistical evidence to affirm an association between AAA and smoking (p=0,783). We didn’t find association score of risk and the prevalence of AAA (p=0,300).Conclusion: This study highlights the importance of excluding aneurismal disease in patients with CS.

Introduction: Acute mesenteric ischemia (AMI) and colonic ischemia (CI) may be quite intricate and appear in the same patient simultaneously or in different time frames. However, in the majority of patients with CI a specific occlusive vascular lesion cannot be identified, as opposed to AMI. According to the American College of Gastroenterology (ACG), CT angiography should be performed in all patients with severe CI in order to exclude AMI. The main purposes of this study were to stratify CI severity to determine if there was an association with the presence of AMI, and to identify determinants of AMI in severe CI. Methods: The clinical data of all patients admitted with the diagnosis of CI from 2010 to 2014 were retrospectively reviewed. Results: A total of 241 patients were included, 213 with isolated CI and 28 with CI+AMI. CI was stratified according to ACG severity classification. No cases of concomitant AMI were found in mild CI, 1.5% of patients with moderate CI and 56.8% of patients with severe CI had simultaneously AMI. The severe isolated CI was compared with the severe CI+AMI group. Hematochezia was found more frequently in isolated CI (p<0.001) whereas constipation and isolated right CI were more common in the CI+AMI group (p=0,021). At admission haemoglobin level was significantly higher in the CI+AMI (13.8±1.9 Vs 11.4±2.2; p<0.001) as was lactate level (7.6±4.6 Vs 2.4±1.3; p=0.001). Atrial fibrillation, coronary disease and isolated right colon ischemia were more common in the CI+AMI group (p<0.05). Other clinical findings were evaluated with no significant difference between groups. Conclusions: The knowledge of an association between CI and AMI prompts to look for underlying occlusive disease in patients with severe CI. Our results based on the analysis of 241 patients with CI support the ACG recommendation for CT angiography in all patients with severe CI. Elevated lactate level, right isolated CI, atrial fibrillation and coronary disease are predictors of AMI in patients with severe CI in this study.

Introduction: Splenic artery pseudoaneurysms (SAP) represent a rare clinical entity typically caused by sequelae of pancreatitis or abdominal trauma. Unprovoked, spontaneous SAP are exceedingly rare, with only two other case reports in the literature up to date. In this paper we pretend to present a case of a ruptured idiopathic SAP successfully treated endovascularly.Methods: Relevant medical data were collected from hospital database.Results: The patient is a 75-year-old male with no past history of pancreatitis, abdominal trauma or abdominal surgery. He was admitted in the emergency department with thoracalgia with interscapular irradiation with few hours of evolution. He referred food intolerance with vomiting for approximately 7 days.In the diagnostic work-up, a computed tomography angiogram (CTA) was performed and revealed a previously unknown voluminous hiatus hernia and a ruptured 25 mm SAP with active bleeding into a 104x98 mm perigastric collection in the left hypochondrium extending to the thorax, a 34 mm peri-pancreatic and a 35 mm pararenal collection. Urgent treatment was planned in the angiography suite, and after selective catheterization of the splenic artery, pseudoaneurysm origin was identified and embolized both proximally and distally with coils. The end result angiogram was apparently successful. CTA was repeated and revealed complete embolization of the pseudoaneurysm, with no evidence of bleeding. Peri-aneurysmaticcollections remained unchanged in size and splenic infarction was evident in 50% of parenchyma. He was discharged 10 days after the initial procedure.Conclusions: Endovascular surgery seems a good option for SAP even in rupture, with good short-term results. In this case, it was admitted that it could be a bridge to open surgery with aneurysmectomy and splenectomy. However, given the good clinical recovery post-embolization, no further surgery was considered. Nowadays there is little consensus on follow-up, and long term results are largely unknown.

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Objective: Evaluate our experience with treated patients with the diagnosis of Nutcracker Syndrome, literature review and proposal of a new classification for the Nutcracker Syndrome Introduction: The Nutcracker syndrome (NCS) can result from the left renal vein (LRV) compression between the superior mesenteric artery and the aorta (Anterior NCS), or more rarely by compression of the LRV between the aorta and the lumbar vertebra when the vein passes behind the aorta, (posterior NCS). The association of the two anomalies can occur when a circunaortic renal vein exists. The prevalence of NCS is unknown, but it appears to be rare and under diagnosed. Methods and Materials: A retrospective descriptive analysis case by case, based on the clinical and imagiological records related to seven patients diagnosed with Nutcracker Syndrome, in the period between January-2011 and March- 2017, in our center . The diagnosis was made by clinical suspicion, after exclusion of other more common etiologies, and the observation of a significant hemodynamic stenosis of the venous kidney drainage by computed tomography. We observed 7 patients, 57,1% (4 patientes) females, with a mean age of 21,7 years with 85,7% in their second or third decade of life. Posterior NCS were observed in 42,9% (3 patients), anterior NCS in 28,6% (2 patients), antero-posterior NCS in 14,3% (1 patient), and compression of a left side vena cava by the aorta when it crosses to right side in 14,3% (1 patient). The most common symptom was macroscopic hematúria (71,4%), followed by flank pain exacerbated by exercise (28,6%) and congestion pelvic syndrome in 14,3%. Tree patients were submitted to surgery, two were treated with a renal auto transplant and one a left ilio-caval stenting. One patient submitted to an auto transplant necessitated a nephrectomy secondary to a renal venous thrombosis. The other four patients followed a conservative management and surveillance. After a mean follow-up of 2,7 years, five patients were asymptomatic, one had a self-limited haematuria episode, and another kept asymptomatic proteinuria. Discussion/Conclusion: The diagnosis of NCS can be made at any age, particularly in the second and third decade of life and is reported to be more frequent in females. In our experience we observed a female/male ratio of 1,3, and a high proportion of posterior NCS (42,9%). The posterior NCS type was the most common type of NCS, going against the literature that reports only 19 cases since 2017. We describe a fourth type of Nutcracker Syndrome, that we call other anatomic type of NCS and we propose a new anatomical classification of NCS. A policy of wait and see, decreased the necessity of surgery to near one half of the patients (42,9%). The choice of renal auto transplant was due to our long and good experience in kidney transplantation, with more than 2500 cases done. The nephrectomy was done by laparoscopy to reduce the invasiveness, and we should pay attention to the tension of the renal vein, as it can result in thromboses as was one of our cases. Despite the recent reports of good results with stenting of the renal vein, we keep concern about the durability of the stents in this young population and it isn’t our first choice.

Introduction: Infectious celiac artery aneurysm (ICAA) is an extremely rare diagnosis, and only a few cases have been reported in the literature to date. We aimed to review this rare clinical entity, focusing on diagnosis and treatment strategies.Methods: A systematic literature review was performed using MEDLINE database according to the PRISMA guidelines.Results: A total of 11 cases of ICAA were identified in the literature to date. Treatment options were extremely variable and included both open and endovascular surgery. Open surgery included aneurysm ligation or aneurysmectomy with or without revascularization with bypass. Endovascular options are increasingly used and include embolization of the aneurysm and collaterals, stentgraft exclusion of the ICAA and in one case report, Chimney technique was used to exclude the aneurysm maintaining celiac trunk patency. Unsurprisingly, antibiotherapy was consistently an essential part of the treatment strategy.Conclusions: Due to the rarity of ICAA, natural history is unclear. Still, surgical treatment is unanimous regardless of aneurysm size. Short term results of endovascular treatment are encouraging, but endovascular implantation of prosthetic material in an infected environment is a concern, so lifelong antibiotherapy and close monitoring are advisable.

Introduction: The European Society for Vascular Surgery (ESVS), following the most validated data published by North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trial (ECST) and Symptomatic Veterans Affairs Co-operative Study Trial (SVACS), determina, regarding symptomatic carotid endarterectomy, designated carotid endarterectomy (CEA) to be considered for patients reporting carotid territory symptoms within the preceding 6 months and diagnosed with moderate (50–69%) carotid stenosis (MCS)(1). Aims: Analyse the admitted patients with MCS, scrutinise the therapeutic orientation and evaluate its adequacy. Materials and methods: The authors retrospectively studied all consecutive patients admitted at one single Institution with symptomatic MCS between 2011–2016. After data collection, patients that were guided to best medical treatment (BMT) were encompassed in Group I, those allocated to carotid endarterectomy (CEA) plus BMT were on Group II and those allocated to carotid stenting (CAS) plus BMT were on Group III. Afterwards we proceeded with a statistical analysis of the results obtained concerning outcomes during follow-up. Results: Group I included 38 patients, 25 males, with a mean age of 74,5 years old. During first year follow-up, was regis- tered one stroke and two transient ischemic attack (TIA) accounting three events (7,9%). Relatedly, 8 patients (21%) died of non-related cause. Group II included 29 patients, 24 males, with a mean age of 72 years old. As peri-operative outcomes was registered two strokes, one causing the death of the patient, accounting two events (6,5%). Finally, in Group III were included 19 patients, 14 males, with a mean age of 76,3 years old. As peri-operative outcomes were registered two strokes, one leading to the death of the patient, accounting two events (10.5%). Discussion/Conclussion: We found a significant statistical difference (p=0,038) favouring BMT plus CEA in place of Stenting plus BMT in accord with already published evidence. Despite higher events registered in the BMT Group, the difference, when compared to CEA plus BMT was not substantial (p=0,67).Despite the reduced pool of patients analysed requiring further studies, according to these results, we believe that once presented with a patient with symptomatic MCS, CEA plus BMT should be offered whenever possible. Still, we consider that there may exist some high risk for CEA patients in whom we should allocate to BMT alone and repetitive re-evaluation considering CEA when neurological stabilization.