RCAAP Repository

Introduction: Increased percutaneous vascular procedures lead to a growth in access-related complications, the most common of which is pseudoaneurysm (PA). Nowadays, femoral PA first-line treatment is ultrasound-guided thrombin injection (UGTI). Methods: An observational retrospective study was designed. Patients who underwent UGTI on a tertiary hospital, from 2008 to 2018 were included. Data were collected from medical records. Primary endpoint was UGTI success (primary PA occlusion and after US revaluation PA occlusion). Secondary endpoints were procedure-related complications, reinterventions, hospitalization duration and survival. Results: 102 patients were included. 97% of PA had a confirmed iatrogenic etiology. 4% were diagnosed after a vascular procedure and 85% after cardiology procedure, 80% of which after coronary catheterization and 13% after TAVI (transcatheter aortic valve implantation). 58% of patients where on antiplatelets and 50% on anticoagulation therapy. 80% of PA was located on the right groin. 65% affected CFA and 35% affected SFA or PFA. PA mean diameter was 36,8mm. 29% of PA were lobulated (complex PA). Regarding PA neck, 58% had long neck (length ≥3mm) and 58% had narrow neck (width <3mm). Median time from iatrogenic trauma to UGTI was 6 days. 89% of PA showed primary occlusion after UGTI; this rate decreased to 73% after US revaluation. 16% of patients repeated UGTI, 5% more than once. We identified no procedure-related complications. Complex PA were associated with lower rates of PA occlusion on US revaluation (p=0,012). We found no association between occlusion rates and affected artery, antithrombotic medication, PA diameter, neck length or width. 6% of patients underwent femoral PA surgical procedure (most of them after more than 2 UGTI); one underwent an endovascular repair procedure. After UGTI, hospitalization median time was 3 days, longer after TAVI compared with coronary catheterization (p=0,006). Patients mean survival was 97±2% at 1 month, 86±4% at 1 year e 60±7% at 5 years, with no significant difference between different PA etiologies. Conclusion: UGTI is a safe and effective modality for PA treatment. We can expect that 1/6 of patients will need more than one UGTI to achieve expected success; this risk is higher in complex PA. Despite good results, some patients will continue to require surgical procedures.

Peripheral bypass grafting with autologous vein is the gold standard treatment of peripheral artery disease. In cases when the great saphenous vein is not available the arm veins or small saphenous veins are possible alternatives. The use of small saphenous vein as a bypass conduit is not a spread practice. We present two cases of revascularization procedures using the small saphenous vein as a conduit and a literature review on the theme.

OBJECTIVE: Renal graft dysfunction or worsened hypertension in renal transplanted patients may be a manifestation of graft hypoperfusion due to transplant renal artery stenosis (TRAS) or stenosis of iliac arteries proximal to renal transplant (pseudo-TRAS). Endovascular management of TRAS has been increasingly used to preserve renal graft function. With this study, we aim to evaluate the impact of endovascular treatment of TRAS on renal function in the short to medium term. MATERIAL AND METHODS: This is an observational, retrospective, single-center study that included all adult renal transplant patients who underwent endovascular intervention on TRAS between September 2017 and June 2020. Renal graft function was monitored by serum Creatinine (sCr) levels. RESULTS: Thirteen patients were included (53.8% female), with a median age of 57 (21-70) years. Eleven patients (84.6%) presented with graft dysfunction. Ten subjects (76.9%) underwent transluminal angioplasty and stenting of renal artery and three (23,1%) of donor iliac arteries. Most cases (69.2%) were interventioned in the first-year post-transplant. Overall technical success was 100%, with no periprocedural deaths. Overall 30-day morbidity was 15.4%. Median follow-up time was 20.2 (1,3 – 36,3) months. One patient died during follow up and other worsened graft dysfunction, requiring hemodi- alysis and nephrectomy. Reduction in sCr levels was statistically significant in the first postoperative month, compared to preoperative values, but sCR levels were still increased when compared to baseline levels (pre-TRAS diagnosis). CONCLUSIONS: The majority (12/13) of patients showed improvement or stabilization of renal graft function compared to the preoperative period, during the follow-up period, supporting the procedure’s safety. Despite this, most patients did not recover baseline sCr levels, reinforcing the importance of prompt graft revascularization. Delayed diagnosis of TRAS may compromise the benefit of revascularization and prevent full recovery of renal function.

Este documento deve ser referenciado citando também a versão original em Inglês: Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg. 2020 Feb;59(2):173-218. Epub 2019 Dec 31. PMID: 31899099. Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. https://doi.org/10.1016/j.ejvs.2019.09.006

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Introduction: Tromboangiitis Obliterans or Buerguer's disease is one of the expresions of the peripheral arterial disease; its main feauture is the absence of average distal outflow that precludes direct revascularization surgery; lumbar sympathectomy was carried out to treat this condition with acceptable results but nowadays this technique is described as obsolete; many young vascular surgeons have not even heard about it and most of them have never seen a lumbar sympathectomy for the treatment of patients with critical limb ischemia. Case report: A 39-year-old woman admitted with critical limb ischemia due to popliteal artery occlusion without average distal outflow, treated by a lumbar sympathectomy as a resource technique. Discussion: Today, endovascular treatment is the first option for the critical limb ischemia in most cases; althoug tromboangiitis obliterans is less frequent nowadays, exists, and this is one of the situations where endovascular treatment does not work; what's more, direct surgery is also not possible. Conclusions: Lumbar sympathectomy can work not only in this scenary of Buerguer's disease; it can be used as resource technique when the first approach with direct surgery has failed and there is not more options to limb salvage; thus, lumbar sympathectomy should be part of the therapeutic arsenal of any vascular surgeon.

Introduction: Chronic Mesenteric Ischemia (CMI) resulting from an impaired blood flow of the splanchnic organs is characterized by an insidious clinical course and is often an underestimated and undertreated disease. The natural history is progressive, caused by atherosclerosis progression in a polymorbidity and aging society. Due to collateralization, diffuse stenotic lesions can remain asymptomatic for a long time and usually manifests when an acute medical or surgical event occurs. In those cases, the clinical suspicion is crucial to reach the diagnosis promptly, allowing to preserve the patients’ quality of life and, above all, the patients’ life. Clinical case 1: A 48-year-old woman with a history of smoking goes to the emergency department for hypogastric abdominal pain, nausea, and vomiting. A study was performed by computed tomography angiography (CTA) that demonstrated occlusion of the superior mesenteric artery (SMA) and significant stenosis of the celiac trunk associated with thickening of small bowel suggestive of ischemia. A thrombectomy of the superior mesenteric artery and retrograde stenting of the artery ostium was performed, followed by extensive enterectomy on 24-hour laparotomy. After hospital discharge, the patient had new abdominal complaints, and stent occlusion was documented in the SMA. She underwent an iliohepatic bypass with good results. Clinical case 2: A 76-year-old man previously submitted to a right axillofemoral and femoropopliteal sequential bypass to treat chronic limb-threatening ischemia (CLTI), went to the emergency department with complaints of abdominal pain, vomiting, and constipation. The diagnosis of a subocclusive intestinal syndrome was made, having performed a computed tomography (CT) scan where it was observed the Ileum adhered to the cecum, which was thickened; the celiac trunk and SMA had subocclusive stenosis. The patient underwent primary celiac trunk stenting with a balloon-expandable stent. After celiac artery revascularization, a right colectomy was performed with two segmental enterectomies. Conclusion: Mesenteric ischemia is a severe condition that is often underdiagnosed due to the lack of awareness of most physicians and nonspecific symptoms. The vascular intervention aims to prevent intestinal necrosis, which can lead to the patient’s death. Timely diagnosis is therefore essential, and revascularization must be performed before or at the same time as intestinal surgery. The close collaboration between the general and vascular surgery teams is essential to the success of these cases.

Introduction: Chronic venous disease is a prevalent condition that worsens with age and is associated with poor quality of life.The treatment of varicose veins (VV) has multiple alternatives, and different practices across Europe.The aim of this article is to analyze the treatment of very elderly patients with severe forms of chronic venous disease using the VenaSeal technique. Method, Material and Results: Report of 5 very old patients with severe venous insufficiency treated with Vena- Seal in 2021. Clinical case 1: A 86-year-old woman, with untreated bilateral varicose veins and recurrent ulcers, was observed in consultation, complaining of severe pain in left leg with an doppler ultrasound (DUS) showing bilateral great saphenous vein (GSV) insufficiency.An outpatient basis treatment of the left great saphenous vein with VenaSeal associated with phlebectomies was performed in the left side. After 6 months of follow-up, she is asymptomatic with small areas of repermeabilization of the proximal trunk of GSV. Clinical case 2: A 85-year-old man was observed in consultation describing two episodes of varicorrhagia in his right leg and and DUS with bilateral great saphenous vein insufficiency.An outpatient basis treatment of the right great saphenous vein with VenaSeal associated with varicose veins foam esclerotherapy DUS guided was performed. After a 3-month follow-up, the patient is asymptomatic with the imaging control showing occlusion of the trunk of the great saphenous vein. Clinical case 3: A 97-year-old woman was observed in consultation complaining of severe pain in left leg associated with an ulcer with severe interference with her quality of life and a DUS with bilateral great saphenous vein insufficiency. An outpatient basis treatment of the left great saphenous vein with VenaSeal associated with varicose veins foam esclerotherapy DUS guided was performed. After a 2-month follow-up, the patient is asymptomatic with a healed ulcer, with the DUS control showing occlusion of the great saphenous trunk. Clinical case 4: A 95-year-old woman was observed in consultation describing bilateral severe pain and ulcers in both legs and DUS with bilateral great saphenous vein insufficiency.An outpatient basis treatment of bilateral great saphenous vein with VenaSeal associated with varicose veins foam esclerotherapy DUS guided was performed. After 1-month follow-up, she is asymptomatic with healed ulcers and has occlusion of the right GSV ́s trunk and areas of repermeabilization of left GSV ́s trunk. Clinical case 5: An 84-year-old woman was observed in consultation with severe pain and severe pruritus of the left leg and a DUS with left GSV insufficiency.An outpatient basis treatment of the left GSV with VenaSeal associated with phlebectomies was performed.After 1 month of follow-up, the patient is asymptomatic with occlusion of the proximal left GSV ́s trunk. Discussion/Conclusion: Treatment with Venaseal is not considered in the 2015 Guidelines of the ESVS, however the VeClose Study compared VenaSeal with radiofrequency ablation and reported equivalent improvement in symptoms scores and GSV occlusion.VenaSeal treatment doesn ́t require use of elastic compression after surgery and allows return to routine activity immediately, so it may be a good therapeutic option in this age group of patients with high clinical risk. In our experience, VenaSeal resulted in complete resolution of the symptoms and ulcers in the short term. However, a complete occlusion of GSV was not observed in all cases, so new studies and protocols doses can be necessary.

Introduction : May Thurner Syndrome (MTS) is a clinical condition as a result of an anatomical compression of the left common iliac vein by the fifth lumbar vertebra posteriorly, and by the right common iliac artery anteriorly associated with symptomatology. Affirming the diagnosis can be difficult and intravascular ultrasonography (IVUS) can help in the definitive decision. Clinical Case: A 43 years old man with a past history of a deep venous thrombosis of the left lower limb presented at our clinical appointment with a 5 months history of left limb edema and inability to stand up for long periods of time, disabling him from working.A venous-CT scan was obtained to diagnose the condition but was inconclusive. It was proposed to the patient to carry out a phlebography and an IVUS to eliminate the doubt and increase the diagnosis acuity, which was accepted.A phlebography and IVUS confirmed a significant compression of the left common iliac vein (image 1).The patient was treated by endovenous placement of an Abre 16/80 medtronic stent followed by dilatation with a 16/40 balloon Boston scientific. The phlebography and IVUS control showed complete resolution of the compression. (Image 2) Discussion/Conclusion: The diagnosis of MTS can be difficult and implies a high degree of clinical suspicion.The TC scan alone may not be diagnostic. The phlebography, and especially the more recent IVUS technology increases the accuracy of the diagnosis.Emergence of endovascular surgery revolutionized the treatment of obstructive venous disease, and became the gold standard of treatment. However, the implantation of stents in a young population implies additional cautions due to the lack of knowledge about their behavior over the long term.In this clinical case, the IVUS allowed us to reach the diagnosis and to increase the therapeutic accuracy of the ilio- cava stenting. We recommend the routine use of IVUS in the management of MTS.

Introduction and Objectives: Heparin administration is a standardized step in carotid surgery due to the reduced thromboembolic complication rate during perioperative period. This practice is not free of risks since hemorrhagic complications are associated with a larger number of reinterventions. Historically, protamine, as an agent capable of reverting the anticoagulant effects of heparin has raised controversy due to its association with carotid thrombosis and stroke. This article aims to review the published literature about the role of protamine reversal in carotid surgery. Methods: Using Pubmed, 10 articles published from January 2010 until the present date were selected, including two meta-analysis, one systematic review and six large-scale multicentric observational studies. The aim of this study was to identify the risk of myocardial infarction, stroke and death, as well as hemorrhagic complications after the administration of protamine. Results: Six of the selected articles focused on the effects of protamine during carotid endarterectomy, three on transfemoral carotid stenting and one on transcarotid stenting (TCAR). All the studies related to patients undergoing carotid endarterectomy where protamine had been administered, showed a statistically significant reduction in bleeding rate with a reduction in the number of patients undergoing surgical reintervention and the number of blood transfusions required. There was no statistical difference in the rate of myocardial infarction, stroke and death. The only study that analyzed the use of protamine on TCAR showed similar results to endarterectomy. Observational studies showed no differences in the incidence of stroke, myocardial infarction, death and bleeding complications with the use of protamine on transfemoral carotid stenting, yet a systematic review identified protamine as a risk factor for higher 30-day stroke rate. Patients submitted to surgical reinterventions showed higher rates of stroke, myocardial infarction and death, independently of the administration of protamine. Conclusion: The scientific data published on the last decade supports the safety of protamine reversal during carotid surgery, lowering hemorrhagic complications without showing an increase in thrombotic events. This is supported by meta-analysis and large-scale observational studies, going against the historical controversy surrounding protamine usage based on small sample analysis and local experience.

Introduction: The risk of peripheral arterial disease (PAD) is significantly increased in patients with type 1 diabetes mellitus who have developed chronic kidney disease. Pancreas kidney transplantation seems to be a promising option for these patients as it corrects both dysfunctions. The traditional risk factors for PAD are well defined in the general population. However, in patients undergoing simultaneous pancreas kidney transplant (SPKT) its influence is not well characterized. Objective: The aim of this study was to identify possible risk factors that influence the development and progression of PAD in pancreas-kidney transplanted patients and assess the outcomes of PAD on this population. Methods: We made a retrospective observational study of a group of 229 patients with type I diabetes mellitus and end stage renal disease who underwent pancreas-kidney transplantation. Demographic data, years of diabetes prior to transplant, months of dialysis prior to transplant, smoking, antihypertensive drugs intake, statins intake, cerebro- vascular disease, myocardial ischemia, cholesterol levels and serum levels of creatinine, cystatin C, C-reactive protein and albumin were analyzed. Analysis of patients as well as kidney and pancreatic grafts survival was performed. Data were analyzed by SPSS version 27with significance at p < 0.05. Results: Of the total of 216 patients included in the analysis with mean age of 46.01 ± 0.48 years, 32 patients (14,8%) devel- oped symptomatic PAD and 23 patients (10,6%) critical limb ischemia. The major amputation rate in this subgroup was 26,1%. Patients with PAD were characterized by higher levels of LDL-C prior to transplant (p = 0.040), which were associated with a 1.011-fold higher risk of developing the disease. Higher levels of HbA1c 6 months and 3 years after transplant were also present among PAD patients (p = 0.033 and p = 0.022), associated with a respectively 1.512- fold and 1.334-fold higher risk of developing the disease. Patients with PAD had also higher levels of Cystatin C 5 years after transplant (p = 0.015) providing a 2.405-fold higher risk of developing the disease. Additionally, myocardial ischemia was also more prevalent among patients with PAD (p = 0.037) inducing a 3.220-fold higher risk of developing the disease. Survival analysis demonstrated a trend towards lower survival and lower renal graft survival in patients with PAD. Conclusion: Poor metabolic control appears to be associated with the development of symptomatic PAD. Elevated levels of cystatin C were also associated with PAD and this can be an independent marker of progression of disease. Also, this study demonstrated that patients with myocardial ischemia were at higher risk of developing PAD.

Introduction: Traumatic popliteal artery injury is a rare clinical entity, but it is the most common cause of amputation in injured extremities.The aim of this study was to report the incidence of popliteal artery injury after knee trauma and report therapeutic management and results. Methods and material: ICD-10/ ICD-9 codes (S85.0/904.41; S83.1/836.5; S83.4; S83.5; S72,4/821.2; S82,1/823.0) were used to identify patients admitted with popliteal artery injury and/or knee trauma at our tertiary center from 1/1/2010 to 31/5/2021. A statistical analysis was realized using the SPSS program version27. Results: At our center from 1/1/2010 to 31/5/2021 535 patients were admitted due to knee trauma (28 with knee dislocation and 507 with fracture close to the knee) and 9 patients with popliteal artery injury (seven males, median age 39.0 years) The mechanism of PAI was motorcycle (4) or bicycle (1) or work (1) accidents (4); one fall, one running over and one iatrogenic injury.The incidence of PAI after knee trauma was 1.5%, after knee dislocation 17.9% and 0.8% after fracture close to the knee. Regarding associated injuries, four patients had severe soft tissue damage, two had venous injuries and two had nerve disruptions.The median ischemic time was 6.0 hours and mean vascular surgical time was 2.4 hours.Regarding vascular treatment, eight patients were submitted to bypass surgery and one was treated conservatively. Therapeutic fasciotomies were performed in three patients.No primary amputations were performed. A secondary major amputation was performed in one patient.The mean hospital length of stay was 24.9 days and mortality was 0%.Three patients returned to their normal activity level and six were limited in their daily activity. Discussion/Conclusion: The risk of PAI after knee dislocation is higher than after knee fracture (17,9% vs 0.8% in our study, and 3,4-8,2% vs 0,2 % in Swedish registration), so orthopedic surgeons must be aware of that increased risk, to avoid missing this diagnosis.The amputation rate in our serie was lesser than the Swedish registration and the United States National Trauma Data Bank (11% vs 28% and 14,5%, respectively). However, it ́s still a high rateconsidering that it mostly affects a young and active population and only 33.3% patients return to a normal life.A multidisciplinary approach is essential to decrease ischemia time and to promote a holistic treatment.

Introduction: Renal artery aneurysms are rare clinical entities whose treatment criteria are not fully established. Endovascular treatment has gained acceptance in the case of renal artery trunk aneurysms. However, in the case of aneurysms of the renal artery branches, such procedures are often impossible due to high morbidity, so the question remains about the best treatment modality. We present a clinical case of multiple bilateral aneurysms of the renal artery branches in a young patient adequately treated with ex-vivo reconstruction and renal autotransplantation. Case-presentation: A 35-year-old woman was diagnosed with bilateral renal artery aneurysms during an investigation of secondary arterial hypertension (AHT). The patient underwent surgical treatment with renal autotransplantation, and the right kidney was initially treated. Transperitoneal laparoscopic nephrectomy was performed. She underwent ex vivo repair of aneurysms, on the bench, with aneurysmectomy and aneurysmorrhaphy. The graft was implanted in the right iliac fossa with anastomoses to the external iliac artery and vein. After three months, an identical procedure was performed on the left. Upon inspection, a large aneurysm was observed in the renal artery bifurcation and another small aneurysm in one of the branches; both corrected with aneurysmec- tomy and aneurysmorrhaphy. Ex-vivo angiographic control ensured the preservation of graft arteries patency without evidence of residual aneurysms. The kidney was implanted in the left external iliac vessels uneventfully. A study with renal scintigraphy confirmed the adequate function of both kidneys. The patient is asymptomatic at nine months of follow-up with serum creatinine and glomerular filtration rate within normal values. Conclusion: Renal autotransplantation with ex vivo arterial repair seems to be a good solution in treating aneurysms of the renal artery, particularly in complex cases with multiple aneurysms.

Introduction: Involvement of the ascending/aortic arch in the thoracic aorta pathology can preclude thoracic endovas- cular aortic repair (TEVAR) due to the absence of an adequate proximal landing zone. Hybrid interventions combining ascending/aortic arch replacement with TEVAR of the descending thoracic aorta (DTA) are associated with good outcomes. Despite the existence of dedicated devices (E-vita®, Thoraflex®), they may not be available in good time in emergent cases that might require inventive solutions, like the one we present. Case Report: A 53-year-old hypertensive, active smoker male was admitted due to a non-A-non-B acute aortic dissection, complicated with a contained rupture at the aortic isthmus and a left haemothorax. Considering the absence of a secure proximal landing zone we decided on an aortic arch replacement and frozen stented elephant trunk using off-the-shelf devices. Debranching of the innominate and left common carotid arteries was performed with a 16×8mm bifurcated graft. The aortic arch replacement was performed with a 28 mm Dacron, under hypothermic circulatory arrest. A 30×30×157mm stent graft was anterogradely advanced to the DTA, under direct vision, with its proximal part parked at the level of the Dacron anastomosis. The proximal arch anastomosis was completed at the level of the sinotubular junction. Completion angiography revealed appropriately reconstructed aortic arch, successful exclusion of the entry tear and rupture site, as well as adequate renal and visceral perfusion. The patient had an uneventful postoperative course, being discharged on postoperative day 23. Control CTA demonstrated successful arch reconstruction, true lumen expansion and no signs of complications. Conclusion: This hybrid approach with off-the-shelf devices was successful and avoided the cumulative morbidity of an additional left thoracotomy as the technical difficulty of a full open surgery in this setting. In the absence of readily available dedicated devices, hybrid techniques will undoubtedly play a role in the treatment of acute aortic syndromes. The existence of an “Aortic Team” available to evaluate, decide and combine the expertise of cardiothoracic and vascular surgery was essential in this case.

Introduction: The development of aneurysms in iliac arteries excluded from high-pressure direct flow from the aorta is very uncommon. We report a case of successful treatment of bilateral metachronous iliac artery aneurysms (MIA), found 10 years after an aortobifemoral bypass, with perfusion only by retrograde flow from the common femoral arteries (CFA). Case Report: A 76-year-old man came for consultation after incidental finding of bilateral MIAs, 10-years after aorto- bifemoral bypass for treatment of an aortic abdominal aneurysm (AAA). Computed tomography angiography (CTA) showed a right internal iliac artery (IIA) aneurysm of 43-mm diameter and a left common iliac artery (CIA) aneurysm of 45-mm diameter that were not present 10-years before. Exclusion of the left CIA aneurysm was achieved with a left IIA to external iliac artery (EIA) endograft using two covered stents (“banana” technique). The right IIA aneurysm was excluded with embolization of the distal internal iliac branches and aneurysm sac with coils and occlusion of the proximal EIA with an occluder. There were no postoperative complications. A CTA two months after surgery showed total exclusion of the left CIA aneurysm and normal filling of the left IIA, as well as complete occlusion of the right IIA aneurysm. Conclusion: This case highlights that aneurysmal degeneration of iliac arteries can be generated by retrograde blood flow after treatment of AAAs with aortobifemoral grafts. An endovascular approach using the “banana” technique proved to be effective in treating MIAs while maintaining patency of one IIA.

Introduction: Chronic venous disease (CVD), particularly if severe, can have significant psychopathologic consequences and major changes in quality of life. Anxiety and humor disturbances are often already present when the patient with CVD searches the vascular surgeon. This study aims to identify and characterize psychopathology in CVD and its relation with quality of life. Methods: A transversal study included all patients seen in the first appointment with two vascular surgeons of a tertiary university hospital, with the CVD diagnosis, from December 2019 to January 2021. Five Portuguese language-validated questionnaires were used: EQ-5D (Euro quality of life – 5 Dimensions), EQVAS (Euro QoL visual analogue scale), CIVIQ20 (chronic venous insufficiency questionnaire), BAI (Beck Anxiety Inventory) and BDI (Beck's Depression Inventory). The primary endpoints were anxiety and humor disturbances’ suggestive scores, evaluated on BAI and BDI question- naires, respectively. The secondary endpoints were quality of life, evaluated on EQ-5D, EQVAS and CIVIQ20 questionnaires. The findings were correlated according to the clinical class (C) of the CEAP classification (clinical, etiological, anatomical and pathophysiological). Results: Fifty-nine patients were included. The median age was 58 years. 73% were female. 20% was under psychiatric pills. The CEAP clinical classification was as follows: C1 7%; C2 64%; C3 10%; C4 15%; C5 2%; C6 2%. The median CIVIQ20 and EQVAS scores were 48 and 75, respectively. The median BAI score was 16; 40% of the patients stated moderate or potentially worrying anxiety levels. The median BDI score was 7; 31% of the patients stated at least mild levels of depression. There was a positive correlation between the clinical class CEAP and the BAI score (p=0,049) and the BDI score (p=0,039). There was no correlation between the clinical class CEAP and the EQVAS score. The patients with higher CIVIQ20 scores have chosen lower scores on EQVAS (p<0,001). There was a positive correlation between the CIVIQ20 score and BAI score (p<0,001) and the BDI score (p=0,003). The patients with worse ascertained health on EQVAS displayed higher anxiety (p=0,009) and depression scores (p<0,001). There was a positive correlation between BAI and BDI scores (p=0,002). Conclusion: Anxiety and depression disturbances commonly coexist and are prevalent in symptomatic CVD patients. The relation between severe clinical signs of CVD, lower quality of life and the presence of psychopathology was demonstrated in this study, which suggests the need for an adjunctive psychological approach to CVD patients.

Introduction: Isolated abdominal aortic dissection (IAAD) is a relatively rare event and precise indications for treatment aren't clearly defined. Its natural history is not fully understood due to the rarity of the disease and to the fact that most surgeons have a low threshold to intervene in these patients. Open surgery represents the classical treatment but endovascular intervention has gained wide acceptance in most centers and is now the most frequently adopted treatment option. The largest series of treated patients are from Asian centers with the largest of them comprising only 33 cases whereas in western surgical centers the largest series contains only 21 patients. Methods: Single center, retrospective, observational, study of patients with IAAD who were treated with open or endovascular surgery. Results: We describe eight patients with IAAD who underwent treatment in our institution (four males and four females). Median age at presentation was 78 years and all patients were asymptomatic. Median aortic diameter at presentation was 30mm (14-85mm). All but one patient underwent endovascular treatment. Three patients were treated with bifurcated aortic endografts, three patients had a single stent-graft (iliac limbs of aortic endografts) implanted and one patient underwent a CERAB procedure for coexistent stenotic disease of the aortic bifurcation. There were no perioperative deaths. Median follow-up was 6,2 years (2 months-13 years). Late reintervention was needed in one patient, 8 years after initial surgery, due to a type 1 endoleak. Conclusion: According to our experience, endovascular intervention represents a safe and durable treatment option in IAAD, however, long-term follow-up is mandatory. Larger studies with longer follow-ups are needed to understand this disease.

INTRODUCTION: In situ lesser saphenous vein (LSV) graft has been advocated in cases of lower limb revascularization where target arteries are confined to the lower leg and the greater saphenous vein (GSV) is neither available nor suitable. This often occurs in diabetic or end-stage renal diseased patients, whose occlusive disease pattern typically affects the tibioperoneal vessels, sparing the femoropopliteal segment. In situ technique offers the potential advantages of decreased surgical trauma to the vein, better size-matching and improved hemodynamics. The posterior approach simplifies the surgical procedure; it achieves similar graft patency and limb salvage rates compared to standard procedures. CASE REPORT: We report a case of an 89 years-old male diabetic patient with previous attempts of endovascular revascularization of the posterior tibial and peroneal arteries; he presents with a nonhealing ulcer of the first toe of the right foot. Ultrasonographic vein mapping revealed varicose GSV in both limbs and a linear, ~3mm diameter, LSV in the right leg. The patient underwent right limb retrogeniculate popliteal to distal posterior tibial artery bypass with in situ LSV through a posterior approach. Post-operative bypass thrombosis occurred after seven days; it was resolved with surgical thrombectomy, vein angioplasty and arteriovenous shunt ligation. During follow-up at the outpatient clinic, the bypass remains patent and skin lesions healing without complications. CONCLUSION: In situ LSV is a safe and viable option conduit for popliteal to distal arteries bypasses. Vascular surgeons should be aware of the posterior approach, which simplifies and comfortably exposes the anatomic structures required for this surgery.

Paclitaxel molecule has been on the market since 1991 and is indicated for the treatment of multiple neoplasms. Since 2012 has been used in endovascular devices for the treatment of peripheral artery disease and have become a mainstay in the treatment of symptomatic femoro-popliteal lesions, in particular for preventing arterial restenosis. They have a proven benefit in patency and freedom-from re-intervention up to 5 years. A recent meta-analysis of RCT showed an increased late-mortality rate, however, real-life cohorts analyses presents contradictory results. RCT meta-analysis is comprised mainly by claudicants, and CLTI patients are underrepresented. Further studies are needed to clarify this matter, in particular with a higher percentage of CLTI presentation. For now, patients should be advised about risks and benefits of paclitaxel exposure and a shared decision-making process should be followed.