RCAAP Repository

Introduction: Severe ilio-femoral occlusive disease can limit the endovascular treatment of aorto-iliac aneurysms. In high surgical risk patients, inventive and staged hybrid interventions can be the answer to achieve definitive treatment. Clinical Case: A 68-year-old male, with multiple comorbidities, presented with simultaneous occurrence of bilateral common iliac aneurysms and severe ilio-femoral occlusive disease associated with right critical limb-threatening ischemia. In order to exclude the iliac aneurysms, preserve pelvic flow and revascularize the threatened limb we decided for a three-staged hybrid intervention. First, we began with a right external iliac angioplasty with femoral endarterectomy to create adequate arterial access. In a second intervention, we implanted a bifurcated aortoiliac endograft through this access. In order to prevent pelvic ischemia, contralateral leg outflow was directed to the left internal iliac artery with a combination of self-expandable and balloon-expandable covered stents. Finally, a right femoro-posterior tibial artery bypass completed the revascularization. At 1,5-year follow-up, no complications are reported and the patient is asymptomatic. Conclusion: In patients with poor medical condition and complex aorto-iliac aneurysmal and occlusive disease, a staged hybrid approach like the one described in this case-report can be feasible and associated with durable midterm patency and excellent clinical outcome.

Introdução: Os falsos aneurismas da artéria renal são maioritariamente causados por lesões iatrogénicas ou por trauma renal. A incidência destes está a aumentar devido ao incremento do uso de procedimentos minimamente invasivos n o tratamento da patologia renal e, consequente aumento das lesões iatrogénicas. Devido à natureza da parede, estes apresentam um alto risco de rutura e, portanto, devem ser diagnosticados e tratados precocemente. Objetivo: Avaliar a experiência do Departamento de Angiologia e Cirurgia Vascular do CHUP na abordagem dos falsos aneurismas da artéria renal. Métodos e materiais: Foi realizada uma revisão retrospetiva com recurso aos registos clínicos e imagiológicos de 20 pacientes com diagnóstico de falsos aneurismas da artéria renal entre 2010 a 2018. Resultados: Em 95% dos casos a etiologia foi iatrogénica. Todos os pacientes apresentaram-se sintomáticos, 85% com hematúria macroscópica. O tempo médio entre a lesão e a manifestação clínica foi de 4,5 dias. O tratamento realizado em todos os casos consistiu na embolização da artéria alimentadora. O tempo entre a lesão e o tratamento foi de 18,1 dias. A taxa de salvamento do rim foi de 95%. Discussão/Conclusão: Neste estudo, a principal etiologia e a técnica cirúrgica utilizada estão de acordo com a literatura publicada. Esta taxa de salvamento do rim, reforça que o tratamento endovascular é um método eficaz. Embora não haja referências publicadas na literatura que permitam a comparação, neste estudo observou-se que o tempo entre a lesão e o tratamento foi elevado, o que se traduz num diagnóstico tardio. Neste sentido, a consciencialização dos urologistas em relação a esta complicação é extremamente importante.

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Caros colegas espero que se encontrem bem.  Na sequência da pandemia COVID-19, com início no nosso país em Março de 2020, houve um grande impacto nos cuidados de saúde prestados aos doentes. Este impacto foi consequência da alocação dos recursos para o tratamento da infeção pelo vírus SARS-CoV-2 e consequente diminuição dos recursos para o tratamento de outras patologias. A associação do medo sentido pelos doentes em recorrer às instituições de saúde levou ao adiamento dos cuidados médicos necessários.  A real dimensão do impacto da pandemia na saúde global da população, ainda não pode, neste momento, ser totalmente estimada. Após uma primeira fase em que o sistema de saúde foi apanhado desprevenido e teve que rapidamente se adaptar a esta nova realidade, surge agora uma segunda fase de agravamento, mais cedo que o previsto. Neste momento, a população afetada pela infeção engloba uma faixa etária mais jovem provocando um menor impacto em termos de internamento hospitalar e mortalidade. Contudo, graças a uma maior mobilidade e contactos sociais mais frequentes destes grupos etários, é previsível uma difusão da infeção mais rápida e mais intensa nos meses de Outono e Inverno.  Em face de um panorama que se avizinha preocupante, solicitei a todos os Diretores de Serviço de Angiologia e Cirurgia Vascular do Serviço Nacional de Saúde que colaborassem na publicação de um artigo, de estrutura livre, acerca da forma como os diferentes serviços geriram o tratamento do doente com doença vascular periférica e quais as repercussões da pandemia. Todos anuíram em colaborar e desta forma publicamos neste número todos os manuscritos que nos foram enviados. Com estas publicações poderemos perceber a forma como decorreu a gestão do tratamento da doença vascular periférica no país de 1 março a 31 de maio de 2020, analisar as diferenças institucionais e seus resultados e desta forma projetar o futuro próximo com novas e melhores metodologias.  Neste número iniciamos também a publicação de guidelines da European Society for Vascular Surgery traduzidas em língua portuguesa com o objetivo de alcançar um universo maior de leitores. Começamos por publicar a tradução das guidelines: “European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia”. É importante salientar que as referências a esta publicação devem ser as do artigo original. Um agradecimento ao Prof. Frederico Gonçalves responsável pela qualidade acrescida que estas publicações trarão à nossa revista permitindo alargar a sua difusão na comunidade lusófona.  Termino, desejando a todos, que cumpram os cuidados de proteção individual necessários e mantenham um comportamento familiar, social e profissional que minimize o risco de infeção e consigamos assim colaborar no tratamento de todos os doentes e em particular do doente com patologia vascular periférica.  Um abraço  Rui Machado 

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Introduction: Ever since the first positive case was identified on March 2nd in Lousada, a region close to the border of our catchment area, we reacted immediately by systematically repurposing our surgical wards.  Objective: Describe the changed made by our Vascular Surgery Department from March 13 to May 14.  Methods: We collected clinical, operative, and consultation volume data from March 13 to May 14 and we compared it with the historical averages. We also reviewed the documents related to the planification activity.  Results: At the peak of the outbreak, we adopted a split-team policy and encouraged complete team segregation to reduce the risk of intradepartmental cross-contamination. Non-ambulatory surgical volume decreased by 54.8% (from 31 cases to 14 cases), and the ambulatory surgical activity was cancelled. Our in-person consultation volume decreased 86.4%; 73 consultations were completed by phone, in which the patient was never evaluated in-person. In the emergency room the main difference between the pre-pandemic to the pandemic was in the number of patients observed without vascular pathology (82 versus 28).  Conclusions: The adaptation to COVID-19 pandemic reduced significantly the surgical production of our Vascular Surgery Department.

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With the onset of the SARS-CoV-2 pandemic in early 2020, health services and personnel adapted their resources to mitigate and control the outbreak. These needs inevitably led to adaptations in most medical and surgical departments, including in our Vascular Surgery department. As we are facing a second outbreak of this pandemic, with unpredictable outcomes and repercussions in health services, it is crucial to learn from previous experiences and share strategies to perform the best care to our patients, despite the restrictions that have been imposed. Through this paper, we review the adaptations in Centro Hospitalar Universitário Lisboa Norte and particularly in our department to overcome the pandemic. We also assess the impact of these changes in our activity and compare with the experience of other fellow surgeons. With an upcoming second outbreak, it is crucial to learn from this and other departments’ experiences to overcome a potential health crisis.

Introduction: Transplant renal artery kinking is an unusual post-kidney transplant complication usually associated with early graft dysfunction. Methods: We present an unusual clinical manifestation of post-transplant renal artery kinking. A review of the clinical process was made with patient consent. Results: A 52-year-old male with end-stage renal disease secondary to IgA nephropathy was submitted to cadaveric donor kidney transplant. The patient had good renal function postoperatively, however, after three months the patient began a gradual reduction of diuresis and worsening of renal function, needing to remain in a “squatting position” 5 hours a day to maintain a normal urine output. A bypass between the left external iliac artery and the graft renal artery with an ipsilateral autologous great saphenous vein was made to correct a renal artery kinking and the patient fully recovered. Conclusion: Renal artery kinking commonly manifested as renal graft dysfunction may have a singular form of presentation. Early intervention is essential to preserve graft viability.

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Cystic lymphangioma is a rare and benign malformation of the lymphatic system, with retroperitoneal location accounting for only 1% of all lymphangiomas. Clinical presentation is frequently nonspecific. Authors present a case report of a 38 years old woman with persistent abdominal pain refractory to treatment that required imaging investigation (abdominal ultrasound and thoraco-abdominopelvic computed tomography scan) unveiling a cystic retroperitoneal mass suggesting lymphangioma. Abdominal laparotomy was performed for complete excision of the tumor. Histopathological exam of surgical specimen confirmed the cystic lymphangioma diagnosis. Complete surgical excision is considered gold-standard therapy and allow definite diagnosis.

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Introduction: The analysis of administrative databases, using administrative data from hospital codification, is an important tool to improve knowledge and management of healthcare. Through this, it is possible to evaluate tendencies as well as monitor and evaluate generic outcomes. Method: The present report is a result of a collaboration protocol between the Portuguese Society of Angiology and Vascular Surgery and the NOVA National School of Public Health, based on the analysis of data resulting from hospital codification by homogeneous diagnostic groups gathered by the Portuguese Central Administration of Health System. It was an observational, retrospective, transversal study. It presents the tendencies observed in hospital admissions and interventions in the three main groups of arterial pathology (abdominal aneurysm, peripheral arterial disease and cerebrovascular disease) handled by Angiology and Vascular Surgery in Portugal. Results: Data from hospital admissions within the Portuguese National Health Service in Continental Portugal was obtained from 2009 to 2017. The large majority of patients were in the range of 65 to 84 years-old and male sex was predominant. A significant proportion of admission were non-elective. Total number of admissions increased over the years. Globally, there was a gradual increase in the use of endovascular techniques, which were dominant in the majority of fields of intervention. However, conventional surgery remained relevant as a therapeutic modality and was dominant in the case of symptomatic carotid disease. Conclusion: A tendency in increasing number of admissions as well as increasing proportion of endovascular treatment was noted, which has important implications in the National Healthcare System management and in the planning of activity by surgical departments. The use of administrative data has important limitations in the analysis, in obtaining patient characteristics and operative details, and represents only the reality of the National Healthcare System of Continental Portugal. Never the less, it has been the basis for better understanding the characteristics of patients and procedures in different areas of care and to support clinical and governance decisions.