RCAAP Repository

A nossa sociedade vai fazer 18 anos de existência, uma maioridade que também traduz responsabilidade acrescida. Nesta englobamos evidentemente a necessidade de assegurar uma formação continuada de qualidade, abrangente e diversa para os sócios. Para fazer face a este desafio, demos início a um projeto educativo — a Academia SPACV — que visa coordenar as atividades formativas da Direção e Núcleos Temáticos. Os princípios que regem a Academia SPACV são três: qualidade, diversidade e transparência. A qualidade das ações formativas é assegurada pela Direção e Coordenadores dos Núcleos e avaliada pelos formadores e formandos no final de cada evento. Através de newsletter, informaremos os sócios sobre os detalhes destas avaliações. Tentaremos que as iniciativas formativas da Academia sejam abrangentes e úteis para todos, desde o recém-entrado interno de formação específica até ao assistente hospitalar mais experiente que procura atualização em áreas especificas da nossa atividade clínica. Pela primeira vez, em 2018, tivemos um curso de iniciação à Angiologia e Cirurgia Vascular dedicado aos mais novos. Procuramos apoiar os Núcleos em formações dedicadas a temas relevantes da especialidade e associámo-nos à Sociedade Espanhola de Angiologia e Cirurgia Vascular na realização do I Curso Internacional de Atualização em Angiologia e Cirurgia Vascular. Contamos com o imprescindível apoio da indústria, que nos permite concretizar todas estas iniciativas. Não obstante, pautamos todas as formações com isenção e transparência, evitando quaisquer conflitos de interesse. Só desta forma concebemos a formação, dignificamos a nossa Sociedade e servimos os interesses dos nossos doentes. Estamos empenhados, hoje e para o futuro, em oferecer aos associados uma qualidade e diversidade formativa que espelhe os valores que regem a SPACV. Bem hajam, Frederico Bastos Gonçalves Secretário Geral da SPACV

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Abdominal aortic aneurysm (AAA) occurs most often in older men, Caucasian, with history of smoking or family history of AAA. AAA seems to have indication for population screening for its prevalence (4-8%) and mortality (80-90%); existence of a latency period until aneurysm rupture; use of an efficient, economic and safe screening technique; and treatment with a low mortality rate. The objective of this work was to perform a critic analysis of the results of AAA population screening programs and their impact on mortality. It was also analyzed if the decrease in the prevalence in the last decade will have implications in the viability of these programs. The randomized trials MASS, Chichester and Viborg showed that the screening of AAA is feasible, even 13 to 15 years after the begging of the program. Two of the trials have proven that screening AAA is cost-effective. The trial performed in Australia revealed to be ineffective, probably due to a high incidental diagnosis. The meta-analysis of these studies has shown that population-based screening for AAA reduces the AAA-related mortality by 4 per 1000 men with 65 years or more and reduces all-cause mortality in the long-term, by 5 per 1000. A cohort study with 61,982 participants reported a reduction in the number of ruptured aneurysms and reduction of mean aortic diameter over 20 years. Recent studies suggest that screening of AAA is economically viable up to a prevalence of 0.5% in men and 1.1% in women. Statistical models have shown that screening of AAA has benefits comparable to other screening programs. The implementation of AAA population screening programs in the male population over 65 years-old is viable and clinically relevant, contributing to a reduction in mortality related to AAA. The screening in women, at least with history of smoking, appears to have legitimacy, but more evidence is needed to determine its viability. According to data of “Aorta não avisa” and “Aorta é Vida” programs the prevalence of AAA in Portugal is around 4%, which seems to justify the implementation of a population screening program in the country.

Doente do sexo masculino, 82 anos, fumador e com fibrilhação auricular, internado noutra instituição hospitalar por pneumonia adquirida na comunidade. Transferido para o nosso hospital após colocação de catéter venoso central na veia jugular interna esquerda a qual foi complicada de punção transfixiva e cateterização acidental da artéria carótida primitiva ipsilateral com progressão para o arco aórtico (Figura 1 e 2). O doente foi operado confirmando-se o diagnóstico pré-operatório (Figura 3) e sendo realizada a remoção cirúrgica do catéter por abordagem cervical seguida de venorrafia e arteriorrafia primárias. O pós-operatório decorreu sem complicações pelo que o doente foi transferido para o hospital da área de residência no 4º dia de pós-operatório.

Relatamos um caso clínico de um doente submetido a recessão cirurgica de tromobo tumoral da veia cava inferior e posterior recontrução vascular.

Blunt thoracic aortic injury is a highly lethal injury both in the prehospital and in hospital setting.Survival of this injury is rare and therefore there is few data on the long term prognosis of these patients.We report a case of a patient who underwent primary repair of a traumatic thoracic aorta laceration and presented 29 years later with an aortic aneurysm in the same location as the initial repair. The patient was submitted to endovascular repair of the aneurysm. The techniques for repair of traumatic aortic lacerations and the available evidence on the prognosis of these patients are reviewed, with a focus on the incidence of secondary injuries after initial repair and proposed follow-up plans.

The role of visceral obesity in atherosclerosis is well recognized by the medical community. On the contrary, the importance of skeletal muscle is almost unknown. Muscle is nowadays understood as an endocrine organ producing myokines with direct action in several physiological and pathological pathways, including atherosclerosis. The myokines reduce the formation of neointima, expression of inflammatory mediators, the recruitment of inflammatory cells and the formation of foam cells. Epidemiological studies are demonstrating the association between reduced muscle mass and cardiovascular atherosclerotic disease. Low muscle mass is associated with an increased prevalence of coronary heart disease, aortic calcification, carotid atherosclerosis, carotid intima-media thickness, intracranial artery stenosis and endothelial dysfunction. In this way resistance training, which increases the muscle size and strength may have a key role in atherosclerosis while endurance training alone might not. The time and type of protein intake by older adults may be critical to the maintenance of muscle mass and to the increase survival. The objective of this paper was to perform a review about the published literature in the last 13 years about the role of skeletal muscle in atherosclerosis. 

Aims Inflammation is common in clinical practice and often results in significant complications. The study was performed in search of a novel anti-inflammatory agent for inflammation modulation which would be useful for cardiovascular disorders and various clinical scenarios. Materials and methods A crushed red rose extract was prepared from the petals, and it was processed for analysis. The extract was tested on HUVEC cells at various concentrations. By microscopic analysis of cells, a safe concentration was identified, and the levels below the safe limit were tested at 72 hours and seven days for selected cytokines secretion. Results Majority of the tested Inflammatory cytokine secretion was reduced by the treatment of red rose extract on the cells. VEGF and angiogenic cytokine levels were reduced, but VEGF-R2 levels were maintained after the cell treatment. Below the safe concentration limit (0.5%) there were only minimal changes in the cytokines levels tested at various dilutions. Conclusion There is potential for a red rose extract treatment in the regulation of inflammatory cytokines secretion. Further studies need to be performed to identify the benefits.  

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Purpose: The e!cacy of endovenous stenting for ileofemoral stenosis or occlusion in post-thrombotic syndrome (PTS) is gaining momentum with studies reporting improved clinical outcome. This study analyses the outcomes of venous stenting in PTS for patients in whom conservative and/or prior surgical treatment modalities had failed. Materials and Method: Operative and clinical records were retrospectively analysed in all patients who had endovenous stenting for PTS. Baseline demographics, procedural details and symptom severity based on CEAP and Villalta scores were collected. Stent patency was assessed by follow-up duplex ultrasound. Clinical follow-up included Villalta score and a subjective assessment of improvement. Results: Fifteen patients with a mean Villalta score of 11 were treated. Two were lost to follow-up. Technical success was 100% with no major complication. Two minor complications (self-limiting bleeding) occurred. At follow-up, stent patency, by Duplex ultrasound, was 71.4% at 13 (range 5–54) weeks. 53.8% (n=7) of patients reported subjective improvement in their symptoms, 30.8% (n=4) of patients reporting no improvement and 15.4% (n=2) of patients reporting worsening of their symptoms. The mean Villalta score at follow-up was 8.5; a signi"cant reduction (p=0.049) from the pre-procedural score. Conclusion: Endovenous stenting for PTS can be performed safely and with a high technical success rate. Patency rates are reasonable and are associated with a signi"cant reduction in Villalta scores.

Introduction: The degeneration of arterial aneurysms is a common manifestation of atherosclerosis, a process that involves the arterial vasculature, occurring in several arterial territories. With the increase of life expectancy, the number of patients with arterial aneurysms has increased, since its prevalence raises with age. Society of Vascular Surgery classifies arterial aneurysms according to their etiology. The most common form is the degenerative aneurysm, which can result from arterial wall degeneration due to several factors - genetic, inflammatory and/or environmental. Multiple aneurysms are more common in patients with arterial aneurysms of the lower limbs, especially in the popliteal artery. These aneurysms are associated with a high risk of morbidity, ischemic symptoms and a poor prognosis. A relationship between abdominal aortic aneurysms and lower extremities aneurysms will be discussed in this review. Objectives: Recent studies report new possible etiologies for multiple aneurysmal disease. The purpose of this review is to report what’s new concerning causes, epidemiology, diagnosis and treatment of the multiple aneurysmal disease of the abdominal aorta and the lower extremities’ arteries. Methods: An initial search was conducted in PubMed that gathered articles, written in English and Portuguese, within a time period from 1960 to 2019. Only the articles containing information about the main topics covered by this review were selected and an effort was made to cite the most recent ones (from 2001 to 2018). Development: Multiple aneurysmal disease is rare and affects mainly the male sex. Multiple arterial aneurysms manifest as a systemic vascular disease and have been associated with multiple disorders. Atherosclerosis, vasculitis (polyarteritis nodosa and Behçet’s disease, infectious mycotic aneurysms and hereditary conditions, such as Marfan’s syndrome and Ehlers-Danlos are some of the most involved. The incidence of femoral and popliteal aneurysms in persons with abdominal aortic aneurysms appears higher than that noted previously. Ultrasound scanning is appropriate to the recognition of these peripheral aneurysms among patients with abdominal aortic disease. Because the complications can be serious, the early diagnosis assumes great importance for the prevention of complications associated with great morbidity. The role and the challenges associated with genetic tests to determine susceptibility for multiple aneurysmal disease are discussed in this review. Conclusion: Multiple aneurysmal disease is rare, and in most cases, symptoms are vague. New methods for early diagnosis and surgical reconstruction are needed to allow adequate intervention and to prevent complications. Also, multiple arteries should be surveyed when an aneurysm is suspected or detected at one site, especially in patients with risk factors and in those who present with an isolated aneurysm in the lower extremities.

Introduction: Subclavian arterial puncture is a relatively frequent complication of attempted placement of central venous catheters (CVC). The placement of a CVC in the artery is rarer, but with potential serious complications especially in its withdrawal. Anticipating these complications, control of potential bleeding in catheter withdrawal is usually performed by surgical or endovascular approach with endoprosthesis release. Our goal is to present the treatment with a percutaneous arterial closure device.  Materials / Methods: Presentation of a clinical case of a CVC placed in the subclavian artery treated with a percutaneous arterial closure device.  Results: A 51-year-old man hospitalized for acute myocardial infarction. On the first day of hospitalization, the introduction of a CVC into the right subclavian vein was attempted. In view of the suspected intraarterial position, CT angiography scan demonstrated that the CVC had been introduced into the subclavian artery with a point of entry proximal to the passage under the clavicle and with a path to the brachiocephalic trunk. Hypocoagulation with UFH was initiated given the risk of pericateter thrombosis and embolization. The use of percutaneous closure device ProGlide® was planned using the CVC pathway. As predictable difficulties for this option was the long CVC path to the arterial entry point, raising questions about the extent of the suture mechanism of the device and the progression of nodes in this path. Under fluoroscopic control, an angioplasty balloon was progressed until the CVC point of entrance for temporary bleeding control in case of ProGlide® failure; in which case the procedure would be completed with a covered endoprosthesis; the subclavian artery had a diameter of 12 mm and was ipsilateral to a brachiocephalic fistula. It was decided to retrograde puncture the fistula and progress the balloon to the subclavian artery. The rigid guide wire was then placed through the CVC and the CVC removed. Two Proglide® closure devices (positioned at 10 p.m. and 2 p.m.) were released. The complete resolution of clinical and imaging hemorrhage was verified.  Discussion/Conclusions: Placement of CVC in the subclavian artery is a potentially serious complication since its removal can be complicated with severe haemorrhage. Depending on the point of entry, there may be additional complexities due to the proximity of the vertebral and carotid arteries. In this case we left open several hypotheses (endovascular and ultimately surgical), but our preference was ad initium the percutaneous introduction of closure device given the feasibility, simplicity, less aggressiveness, non-interference with the vertebral ostium, and lower cost compared to a covered endoprosthesis. 

Objective: To analyze the experience in the treatment of bilateral complex arterial aneurysms of the renal arteryIntroduction: Renal artery aneurysms are a rare clinical entity and the epidemiology, pathophysiology and best treatment are not clearly defined in the literature.Material and Methods: Retrospective analysis of the database of patients with the diagnosis of renal artery aneurysms. A total of 3 patients with bilateral aneurysms were surgically treated and a descriptive analysis was applied on a case-by-case basis. ResultsClinical case 1: A 46-year-old female patient with arterial hypertension with incidental diagnosis of two saccular aneurysms of the right renal artery and two saccular aneurysms of the left renal artery. A left nephrectomy was performed laparoscopically and an aneurysmectomy and angioplasty with internal saphenous vein and kidney implant were performed in the left iliac fossa. Four months later, the right kidney was treated with laparoscopic nephrectomy, aneurysmorrhaphy associated with aneurysmectomy and bypass with internal saphenous vein, renal vein extension with internal saphenous vein spiral prosthesis and implantation of the kidney in the right iliac fossa.Case report 2: Female patient, 38 years old, arterial hypertension with incidental diagnosis of two saccular aneurysms of the right and left renal arteries. A left nephrectomy was performed laparoscopically and the aneurysms were excluded with Yasergil titanium clips associated with aneurismorrhaphy and left iliac fossa implant. Four months later, a right laparoscopic nephrectomy was performed and aneurysms were treated with aneurysmorrhaphy and renal vein extension, with spiral vein prosthesis of the internal saphenous vein, and implantation in the right iliac fossa.Clinical case 3: A 33-year-old male patient with the incidental diagnosis of two fusiform aneurysms of the right renal artery and two saccular aneurysms of the left renal artery. A right nephrectomy was performed laparoscopically, and the renal polar artery was ligated because of the impossibility of reconstruction and the kidney was implanted in the right iliac fossa. Seventeen months later, a left nephrectomy was performed laparoscopically and aneurysmectomy was performed in association with two renal bypasses with internal saphenous vein and implantation of the kidney in the left iliac fossa.Discussion and conclusion: The treatment of bilateral aneurysms is rare and, in 2014, the first case of autotransplant treatment was published. There are, however, no randomized trials comparing in situ, ex vivo and endovascular surgery. At our center, the treatment of complex renal artery aneurysms, which we defined as those requiring greater than 45 minutes of renal artery clamping time or located in artery areas not accessible to in situ reconstruction, is performed through ex-vivo surgery and autotransplantation in the iliac fossa. This therapy represents an excellent option with zero morbidity and mortality. Experience in renal transplantation and vascular surgery is a key requirement for successful treatment.