RCAAP Repository

Introduction: The evolution on aseptic technique and prophylactic antibiotherapy has been keeping a low incidence of prosthetic vascular graft infections (PVGI). However some patients are still at risk of a disease that compromises the graft function and the viability of the perfused organ, while threatening each individual with septic complications. The management of PVGI depends on the severity of infection, the culprit microorganism, the location of the infected prosthesis and the patient's overall status. Several treatment strategies are available, from radical explantation to graft preservation techniques and chronic antibiotherapy. The surgeon should then decide which leads to a better quality of life-adjusted outcome. The authors intend to present a clinical profile on the population with PVGI of their institution. Methods: Using the institution own system, all the discharge papers from in-hospital episodes concerning the department of Vascular Surgery, between 2000 and 2018, which mentioned the words “infection” and “graft”, were collected. All documents referring to non-related infections and vascular access graft infections were excluded. Also, documents failing to report essential data were excluded. Results: A total of 47 patients were included, aged between 46 and 84 years old (median 69 years), 89% male. Only 15% had diabetes and 2 patients were under immunosuppression. About half of all cases were aortobifemoral infected grafts. 13 cases had had urgent surgeries when the prosthesis were implanted. Late infections were more common than early ones, and more frequently infected by Gram positive bacteria. The anastomotic pseudoaneurysms were the most frequently seen presentations. Only 25% of the infected grafts were occluded. Antibiotic combinations using vancomycin were the most used, for 1 to 12 weeks in duration. Removal of the graft was performed in 85% of patients, of which 57% were submitted to revascularization procedures. Follow up was heterogeneously reported with a median duration of 26,5 months. During follow up, 20% of patients were submitted to major amputation, 18% died from complications related to the infected graft and in 29% a non-related mortality was reported. Discussion: There remains a challenge to approach PVGI, not only because the frailty of the individuals affected but also because the multisystemic implications of a vascular infection. The growing prevalence of multidrug resistant bacteria in an older population mandates the need to consider multidisciplinarity. PVGI affecting the Aorta by low-virulence bacteria and the demanding surgery for graft explantation with hemodynamic impact is a scenario that may force to change the therapeutic strategies in patients who are not fit for surgery. However, graft-preserving strategies are associated to infection recurrence and poorer outcomes. Conclusion: A multidisciplinary approach, sensitive and early diagnosis, and a sensible balance between the infection aggressiveness and the overall status of each patient, are needed for optimal outcomes.

Introduction: Type I Endoleak (EL1) is often associated with a high risk of aneurysmal expansion and consequent secondary rupture. The Heli-FX EndoAnchor system (Aptus Endosystems®) has emerged as an alternative for the treatment of EL1, whose mechanism consists of "anchoring" or "screwing" the prosthesis to the aortic wall in order to obtain better apposition /sealing. Objectives: The main objective of this study was to analyze the initial routine clinical experience of EndoAnchor's use in a tertiary institution and assess safety/effectiveness of its use. Methods: We selected all cases in which Endoanchors were applied since this technology was available in our Institution. We analyze the main indications as well as the outcomes of its use. Results: Since March 2017 until March 2019 (24 months), 12 patients underwent Endoanchors fixation. Endoanchors were implanted in 8 patients (66%) at the time of an initial EVAR procedure (primary use) and in 4 patients (33%) with an existing endograft and proximal aortic neck complications (secondary use). Regarding the primary use of Endoanchors, in 5 patients (62.5%) the indication was prophylactic due hostile aortic neck anatomy and in 3 patients (37.5%) the indication was early EL1, (75% elective cases and 25% urgent cases). Endoanchors were used in secondary procedures in 4 patients, in 3 cases (75%) the indication was late EL1 and in 1 case (25%) it was for REVAR, (50% elective cases and 50% urgent cases). In all cases, our institution presented a 100% technical success and 0% morbimortality in 30 days. There were no residual EL1 at the end of the procedure in angiography. During an average follow-up of 16.0 ± 7.7 months, no secundary procedures were perfomed, no related deaths to aneurysmal pathology or aneurysm ruptures were observed. Conclusion: From the experience of our institution, Endoanchors were used prophylactically in EVAR cases with hostile aortic anatomy and are a treatment option in EL1, with and without rupture with promising results.

Introduction: Endovascular treatment of type B aortic dissection has focused on the covering of the proximal entry tear. However, recently, concern has emerged regarding the distal aortic remodeling and new techniques such as the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination (STABILISE) technique have gained more acceptance. We describe a technical note regarding the combination of the STABILISE technique in addition to the Covered Reconstruction of the Aortic Bifurcation (CERAB) technique to achieve complete aortic remodeling. Methods: The authors describe a stepwise approach regarding the endovascular repair of type B aortic dissections. A simple TEVAR is performed first. If the patient still shows signs of true lumen compression, a STABILISE technique is performed in order to achieve true lumen expansion and complete aortic remodeling. However, in some patients, false lumen perfusion and true lumen compression at the very distal aorta is maintained due to distal comunicating tears. In these patients, if there are still signs of infra-renal aortic or iliac compression/occlusion or distal thrombosis of the false lumen, a simultaneous CERAB is performed. Conclusion: By combining these techniques, we aim to cover both the proximal tear and the distal comunicating tears resulting in a complete flap apposition, false lumen obliteration, re-expansion of the true lumen and achieve optimal remodeling.

Vascular graft infections are still to date a complex medical challenge. The evolution of the hospital flora and development of the vascular surgery field has led to a change in the reality of these infections, making it important to know their current microbiological context in order to provide better care. These infections depend on endogenous and exogenous factors and vary according to the timing of infection, localization and microbiological environment of the patient. There is a high morbidity and mortality associated with these conditions and the treatment must be tailored to patient in question, making it necessary to know the underlying bacteria and the variety of treatment options available. The knowledge of predisposing factors, the high index of suspicion and correct diagnosis and prevention must be performed in all patients and in a multi- disciplinary matter. 

Introduction: The presence of multiple renal vessels is frequent in the general population and, when present in a donor, increases the complexity of renal transplantation surgery, increasing the risk of complications. Although transplantation of cadaver donor grafts with these characteristics is accepted, the same procedure in living donor remains controversial.  The objective of this work is to present the case of a living donor renal transplant surgery with complex vascular anatomy - two arteries and two renal veins.  Clinical case: 42-year-old woman with end stage renal disease due to IgA nephropathy, on regular hemodialysis program for 9 months, evaluated in more than one center for living donor renal transplantation and rejected by the complexity of the vascular anatomy of the donor - right kidney with two arteries and two short renal veins. In our center, where vascular surgery integrates the multidisciplinary team of renal transplantation, the transplant was accepted considering that the ex-vivo vascular reconstruction of the graft (back table) was technically feasible.  Arterial reconstruction was performed on a lateral-lateral anastomosis of the two renal arteries. Venous reconstruction included the stretching of the renal veins with the great saphenous vein of the recipient and its posterior lateral-lateral anastomosis. The kidney was implanted in the recipient's right iliac fossa.  Immediate diuresis after dislodging was observed, with a rapid decrease in creatinine values to normal and discharged on the 16th postoperative day.  Conclusion: Organ shortage is an important limiting factor for renal transplantation. Inclusion of donors with multiple renal vessels has shown good results and may increase organ availability. The integration of an experienced vascular surgeon in the multidisciplinary team of renal transplantation allows the accomplishment of complex arterial and venous reconstructions in grafts with less favorable vascular anatomy. 

Introduction: Lower limb lymphedema is a relatively common pathology that conditions a marked impact on the patient's quality of life. It may occur primarily or be secondary to an external factor. In most cases, its treatment is conservative through compression therapy. However, reconstructive surgery of the lymphatic system to improve lymphatic drainage have gained popularity. In the most severe cases, it may be necessary to perform excisional procedures for limb reduction. Methods: A review of a clinical case of severe lower limb lymphedema was performed, which was treated using a surgical procedure of debulking. Subsequently, a literature review was carried out using the MEDLINE database. Results: A 46-year-old male with a history of morbid obesity followed closely in the outpatient clinic by lymphedema praecox of the right lower limb that appeared in the second decade of life. The patient was observed at the vascular surgery consultation with complaints of lymphorragy, and conservative treatment with compressive therapy was instituted. Despite the initial improvement, a lymphedema worsening was observed with recurrence of lymphorragy in the thigh. He underwent debulking surgery with a favorable outcome and marked clinical improvement in the postoperative period. Conclusion: Lymphedema of the lower limbs is a poorly recognized condition that has a marked impact on patients' quality of life. Currently, there is no curative treatment and the results of conservative treatment are limited. Surgical treatment, especially excisional procedures, are used in the most serious cases, mainly to treat complications associated with the chronicity.

Introduction: The Fellow of the European Board of Vascular Surgery (FEBVS) examination is a comprehensive exam for Certified Vascular Surgeons or General Surgeons with Vascular Certification. It comprehends a thorough assessment of vascular pathology knowledge, and includes critical analysis of diverse clinical cases and vascular subjects (Clinical Viva), critical review of an academic paper and direct open and endovascular skills examination in independently validated simu- lators. It is, therefore, increasingly seen as a standard of quality for International Vascular Specialists, so that it currently represents the final exam for Vascular Surgery Certification in countries such as Netherlands and Switzerland. Through this work, we aim to perform a critical review on the results of the past ten FEBVS examinations. Methods: A review of the results from the past ten consecutive FEBVS examinations was performed. Data on the results of open technical skills assessment (aortic anastomosis, distal anastomosis and carotid endarterectomy), endovascular technical skills assessment, clinical viva and academic paper analysis were collected. Candidates demographic character- istics were also reviewed. A review on both global and specific failure rates, as well as their behavior throughout the years was performed. Results: Three-hundred consecutive candidates, who have performed their Vascular Training in twenty-six different countries, were assessed in 10 different examinations performed in the last 5 years (2014–2018). Most candidates were male (77,7%), with a mean age of 36 years old. The majority of candidates were from the Netherlands (24,1%), although Germany (13,4%), Spain (12,4%) and the United Kingdom (11,4%) had a significant representation as well. Global failure rate was 28,3%, and 5,3% of the candidates were granted “honours” due to outstanding performance (global score > 90%). 21,2% of the failed candidates repeated the exam, with a global pass rate of 56,1%. Among each of the individual assessments that constitute the exam, failure rate was significantly higher in the academic paper review (24,7%), when comparing to technical open (16%), technical endo (14%) and clinical viva assessments (15,5%). Regarding each of the individual skills evaluated in the open technical section, failure rate was significantly higher in the aortic anastomosis (29,3%), when comparing with distal anastomosis (16%) and carotid endarterectomy (17,6%). More importantly, a progressive increase of failure rate in aortic anastomosis assessment was observed throughout the years (Fig.1), in accordance to the known perception of progressive loss of open aortic skills among young physicians. Portugal represents only 4,2% of all FEBVS candidates, with a pass rate of 100%. Conclusion: The FEBVS examination is a comprehensive exam, that independently assesses both theoretical and technical knowledge. Failure rate is high, although the existence of “honours” confirms a balanced difficulty level. An alarming loss of open aortic skills is noticeable and reinforces the need of simulation training in such territory.

Introduction: Chronic occlusive venous disease manifests mainly at the level of the iliofemoral vein, and its treatment has been revolutionized by the emergence of endovascular techniques. Venous system stenting has evolved from the existing treatments of arterial occlusive disease. Some arterial stents were used in the venous system with good results, however, the need to improve the characteristics of these devices led to the development of stents dedicated exclusively to venous pathology. In recent years several dedicated endoprostheses have been approved, however, there are few studies comparing their characteristics and results. Objectives: Update on the venous stents available and comparison of their characteristics and results. Methodology: The bibliographic research was performed in database "Natural Library of Medicine PubMed - Medline". Articles from the last 20 years with language in Portuguese and English were included. Greater relevance was given to research articles, but books and review articles relevant to the topic were also included Results/Discussion There are currently 7 devices used in iliofemoral occlusive disease Wallstent™ Endoprosthesis, Zilver® Vena ™, Sinus-Venous®, Sinus Obliquus®, Vici® Venous Stent, Venovo® Venous Stent, Sinus Obliquus®and Abre™ Venous. The short-term outcomes show high rates of technical success, primary and secondary patency, null mortality and low rates of periprocedural complications. Conclusion: Existing stents for venous use appear to be effective and safe in the treatment of iliofemoral occlusive venous disease. None of the devices stand out in terms of effectiveness, however, dedicated stents appear to have lower complication rates. Long-term studies are needed to confirm these results.

Background: LLL is characterized by protein-rich interstitial fluid accumulation due to lymphatic system insufficiency, resulting in progressive non-pitting edema. Primary and secondary lymphedema are distinguished by the absence or presence of an external trigging factor, respectively. Diagnosis is based on clinical examination combined with imaging modalities. The non-surgical approach of LLL is based on preventive measures, lifestyle interventions and life-long compression modalities, aiming to reducethe edema congestion and to improve patient quality of life.Objectives: The present literature review aims to compile current scientific knowledge on the various domains of the non-surgical treatments of LLL.Methods: Search was performed in PubMed database, using the following medical subjects heading (MeSH) terms: “lymphedema”, “lower limbs” and “medical treatment”. Research and review articles indexed in the last 10 years and written in English language were selected. Animal experimentation works and single case-reports were excluded. Other materials searched comprised reference books in the area of Vascular Surgery, namely Rutherford Vascular Surgery — 9th Edition, 2018. Development: The non-surgical treatment of LLL is characterized by a multifaceted approach, including mechanical reduction of limb swelling, alternative medical devices and pharmacological therapy. Complex decongestive therapy is recognized as the standard of treatment and its compression modalities include drainage massages, pneumatic compression, bandaging systems, compression garments and physical exercise. Compression therapies differ in the degree and time of pressure applied and can be performed by healthcare professionals or by the patient himself. The duration of treatment stages varies and it mayinclude hospital and outpatient regimens. Positive treatment outcomes include increased skin elasticity, limb volume reduction, pain relief, increased functional capacity and improved quality of life.Conclusions: Compression modalities have been shown to be effective in reducing limb volume, increasing tissue elasticity and improving the physical, psychological and aesthetic aspects of patient life. However, sustained volume reductions depend mostly on patient diligence. Intensive and outpatients approaches do not compromise treatment efficacy and high pressures therapies are effective and well tolerated. Current lymphedema non-surgical treatment lacks long-term results and urges more effective therapeutic alternatives.

Introduction:  A number of guidelines for the management of carotid disease are available to help clinicians in therapeutic decision and provide useful guidance for the best care of the patients. They stated that carotid endarterectomy (CEA) has some benefit in symptomatic patients with carotid stenosis of 50-69% and is highly beneficial in stenosis of 70-99%, with mortality/ stroke rate less than 6%. The maximum benefit is observed when surgery is performed within two weeks after the cerebrovascular event. CEA in asymptomatic patients should be offered to patients with life expectancy higher than 5 years, stenosis of >70%, and perioperative complications should be less than 3%. The aim of this study is to analyse our clinical practice, review treated patients and referral times and compare the outcomes of our institutional practice with published guidelines. Material and methods: Retrospective study of patients undergoing carotid endarterectomy at Centro Hospitalar Universitário do Porto between 2010 and 2015. Results: Between 2010 and 2015, 404 patients underwent CEA, 76% men, and mean age 69 years for both sexes. The degree of stenosis was usually evaluated by ultrasound. The use of complementary study with angio-CT was required in 20% and angiography in 2.2% of the cases. The majority of patients (54.2%) were symptomatic (stroke/ TIA <6 months). In patients with a cerebrovascular event diagnosed at our institution, the time to surgery was 10 days (median). All CEA were performed under general anaesthesia and for arterial closure, a Dacron patch was systematically used. Shunt was used in 4.6% of cases (n=18). The mean surgery time was 101 minutes and the mean clamping time was 40 minutes. Reversal of antioagulation with protamine was performed in 48.3% patients. Morbimortality: 9 post-operative sequelae events (major stroke), 8 minimal / transient deficit (minor stroke) and 4 deaths. In symptomatic patients (n = 219), the rate of postoperative major stroke was 3.6%. In asymptomatic patients (n = 185), a major and a minor stroke was observed (1.1%). Other complications: haematoma 5.9% (n=24); infection 0.2% (n=1); peripheral nerve dysfunction 8.7% (n=35); false aneurysm 0.5% (n=2). Conclusions: Our results are within the reference values. This study allowed us to know our reality, our ability to give an effective answer for our patients, and to serve as a basis for improving ways of acting.

Superficial femoral artery (SFA) aneurysms are rare clinical disorders, with few case reports and small series published concerning atherosclerotic aneurysms. We report a clinical case a giant aneurysm of the SFA, in a patient previously submitted to extensive SFA endarterectomy and vein angioplasty.A 73-year-old man presented at a routine vascular surgery consultation. The patient had been submitted to a right SFA endartectomy and vein patch angioplasty, sixteen years ago, for intermittent claudication. Physical examination demon- strated a large pulsatile mass of the right thigh. His right pedal pulse was palpable. Ultrasound and computed tomography scan confirmed a 78x71x240mm aneurysm of the right superficial femoral artery. He was proposed to aneurysmectomy and femoro-popliteal bypass. During operative intervention, proximal and distal control was obtained and the aneurysm opened. A large amount of thrombus was removed and a femoro-popliteal bypass was performed using the ipsilateral great saphenous vein. The postoperative period was uneventful, as was the patient recovery. In our report, the aneurysmal area matched precisely to the endarterectomised area and no other aneurysms were found. So we are facing an uncommon case of a SFA degeneration into a giant aneurysm after extensive endarterectomy and vein angioplasty.

Arteriovenous malformations are the least common vascular anomalies, but they can have a worst prognosis when compared with other vascular anomalies. In this way, the authors present a case of young female with arteriovenous malformation on the left shoulder. The indication and the treatment options were discussed within national and international experts at the Conference of Vascular Anomalies in Lisbon in 2018. The authors shared their opinions and made a revision on this topic.

Introduction: Stroke is a major health problem. Overall, 10–15% of all strokes are related to a previous asymptomatic carotid stenosis >50%. Carotid endarterectomy (CEA) is e!ective in stroke prevention; risk/benefit assessment is less apparent for elderly. The authors evaluate department CEA outcomes in elderly population aged 75 years and older, focusing in perioperative outcomes and long term survival. Material and methods: Retrospective unicentric analysis was performed, encompassing 156 surgeries in 149 patients aged 75 years and older, between January 2010 and December 2017. Results: Perioperative stroke/mortality was 2.6% (4.0% for symptomatic, 0% for asymptomatic); perioperative morbidity was 6.4%; estimated "ve-year survival was 71.9%. Conclusion: CEA continues to be a low-risk approach to treat carotid bifurcation atherosclerosis, even in elderly population, with perioperative morbidity and mortality resembling international standards for general population. Long term survival is quite good and age alone should not be a reason to refrain from offering carotid endarterectomy to this patients.

 Endovascular aneurysm sealing (EVAS) was a relatively new concept that aimed to reduce the incidence of complications after endovascular aneurysm exclusion. However, EVAS device was recently recalled from market due to high risk of graft failure beyond two years after implantation(1,2). The aim of this paper is to report a case of a post-EVAS ruptured abdominal aortic aneurysm. A 72 year-old-man underwent EVAS and a bilateral sandwich technique of the iliac bifurcation for an aorto-bi-iliac aneurysm in 2015 in another institution. Follow-up CTA at three years showed a type Ib endoleak in the left iliac bifurcation and the patient was kept under clinical and imagiological surveillance (protocol unkown, again at another institution). Four years after the initial procedure the patient was admitted in the emergency department of our hospital after syncope and with abdominal pain. The CT-angiography (CTA) revealed a post-EVAS rupture in the distal aorta suggesting an endobag rupture (Fig 1). The patient underwent open surgical repair with explantation of the EVAS device (Fig 2 and 3) and an aorto-bifemoral interposition with a Dacron graft. The procedure was uneventful and the post-operative CTA showed a patent aorto-bifemoral graft without evidence of any complications (Fig. 4). One week later the patient was discharged home in good clinical condition. Post-operative surveillance is important in any aortic aneurysm endovascular procedure. However, since the last EVAS studies, all patients submitted to this technology must be under strict surveillance to identify complications like endobag rupture that can lead, as in the reported case, to aneurysm rupture which in turn can lead to stent graft explantation in an emergency setting

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Introduction: Ischemic stroke is a predictable complication of cardiac surgery specially in patients with previous diagnosed carotid stenosis. On the other side, patients undergoing carotid endarterectomy with concomitant significant valvular or coronary artery disease, may face worst peri-operative outcomes.  Objective: Analyzing outcomes from a pool of patients with both comorbidities wondering which procedure should be conducted first.  Material and Methods: Retrospective analysis of a group of patients submitted to carotid endarterectomy (Group I) between January 2011 and December 2017 that concomitantly presented coronary artery or valvular disease. Outcomes comparison with a group of patients submitted to cardiac surgery (Group II) that concomitantly presented carotid stenosis.  Results: There was no statistically significant difference in patient stroke risk-factors between groups.  Adverse events rate difference between groups did not reach statistical significance (stroke 1,7% vs 2,8% p=0,698; Acute myocardial infarct 1,7% vs 2,8% p=0,698, death 0% vs 4,6% p=0,073).  Discussion: Handling these specific pools of patients is still debatable. Both interventions demand a multidisciplinary approach so as an experienced surgery and anaesthesiology team to individually select which approach fits each patient better. 

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Visceral artery aneurysms are rare, with an estimated incidence of less than 2% in the general population. Left gastric artery aneurysm are particularly uncommon, accounting for 4% of all visceral aneurysms. Usually an incidental finding, they can manifest with rupture and be life threatening. The authors present a case of an 83 year-old male with haemorrhagic shock caused by a ruptured left gastric artery aneurysm. Coil embolization of afferent and efferent arteries was performed with good morphologic results. Management of a ruptured visceral aneurysm is aimed at controlling life-threatening bleeding usually by embolisation in the emergency setting.

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