RCAAP Repository

Introduction: Endovascular repair of aortic aneurysms is widely established. However, aorto-iliac aneurysms pose a challenge, specifically regarding distal sealing. A frequent approach is extending the iliac limb to the external iliac artery (EIA) with occlusion of the internal iliac artery (IIA), often with varying degree of pelvic ischemia causing significant morbidity. Iliac branched devices (IBD) allow for the creation of distal landing zones in the EIA and IIA, maintaining pelvic perfusion. We performed a descriptive analysis and outcome evaluation of IBD use in a single center patient cohort. Methods: An observational, descriptive, retrospective cohort analysis of all consecutive patients intended to treat with IBDs from Jan-2008 to Dec-2020 was performed. Technical success was defined as correct implantation of the IBD with confirmed patency of both EIA and IIA. We included all patients where at least one IBD was deployed, irrespective of additional procedures.Statistical analysis was performed using STATA 16, for Mac. Results: Of the initial 54 patients, 53 were included, (technical success 98,1%). Fifty-two were men (98.2%), mean age 73.5 years (SD 8.1). Mean aortic diameter was 56.4mm (SD 13.4), mean CIA aneurysm diameter 37.0mm (SD 12.7).A total of 60 IBD’s were performed (CookÆ Medical’s ZBIS device), of which 5 as part of complex aortic treatment with fenestrated endografts, 32 EVAR with unilateral IBD, 7 EVAR with bilateral IBD, 6 EVAR with unilateral IBD and contra- lateral extension to the EIA with embolization of the IIA and 3 isolated IBD (for type 1B endoleaks following EVAR or isolated iliac aneurysm).Peri-operative complications included acute kidney injury (AKI) (11,3% - 5/44), paraparesis and intestinal ischemia (1,9% each), one embolic intra-operatory stroke (1,9%) and one acute myocardial infarction (MI) (1,9%). Median follow-up was 9 months (IQR:16, 1-80months), during which 4,9% (2/42) developed type IB endoleaks, 4,9% (2/42) iliac aneurysm enlargement, 2,4% (1/42) limb kinking, 4,9% (2/42) limb occlusion, with a 7,14% (3/42) re-intervention rate. We found no association between limb patency and single, dual-antiplatelet treatment or anti-coagulation (p=0,6). There was no significative difference in AKI incidence between bilateral or unilateral IBD (irrespective of contra-lateral procedure). No in-hospital mortality was registered. There was one case of in-hospital death post-MI (1,9%), overall mortality 17% (9/53). Conclusion: In this cohort we found that the most common complication is AKI, apparently not directly related to the technique itself. Follow-up complications were few and mainly associated to loss of distal seal or limb occlusion, but implying a considerable re-intervention rate.

Introduction: Clinical registries are fundamental tools to understand the reality and audit the treatment of abdominal aortic aneurysms (AAA). The Portuguese Society of Angiology and Vascular Surgery, promotor of the National Registry of Vascular Procedures (RNPV), has developed a AAA module that started in December 2019. The objective of this report is to present data of the first year of the AAA module from Portugal. Methods: The AAA module opened the possibility for voluntary registry since December 2019. After specific training of investigators, participating centres started registration in a progressive way throughout the year 2020. Registrations are performed in a specifically designed web-based tool. All degenerative AAA cases are registered (including juxta- or supra-renal), with or without iliac involvement. Thoraco-abdominal or isolated iliac aneurysms are excluded. Demographic, anatomical, risk factos, admission, treatment details and outcomes at 30-day/in-hospital are registered. One and five-year follow-up is optional. For the purpose of this report, only data referring to mode of admission and treatment, as well as perioperative mortality, are reported. Results: From December 2019 to December 2020, 350 patients were registred in the AAA module platform. Mean age is 74.3± 13.7 and 92.0% are male. Admission was elective in 76,9% of cases. Mean maximum aortic diameter was 63.9mm ± 19.9mm. Most patients presented with infra-renal aneurysms, in similar proportion for elective and urgent cases (79% vs 76%), p=0.16. Aortic diameter was the indication for repair in 59.4% of cases. Endovascular treatment (EVAR) was used in 68.9% of cases. In elective surgery, the proportion of EVAR was 75.7% and in urgent cases 45.7%, p < 0.01. In elective surgery, perioperative mortality was 3.3% (8 patients). For EVAR patients it was 2.8% and for open surgery 5.2%, p<0.01. In urgent surgery, perioperative mortality was 41.9%, lower for EVAR (20.0% vs. 61.6% for open surgery), p<0.01. Conclusion: In its first year, the AAA module of the RNPV produced important data that help understand the patterns of treatment of this pathology in Portugal. These data may help vascular centres in quality improvement by providing a benchmark for comparison.

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Introduction: Over the past few decades management options of the acute limb ischaemia (ALI) have changed. Nowadays, catheter direct thrombolysis (CDT) is commonly used as an alternative to surgery in immediate management of the ALI and may offer certain advantages over surgery in appropriately selected patients. Objective: To evaluate CDT data for the treatment of acute ischaemia in lower extremity in different aetiologies. Materials and methods: All consecutive patients who underwent CDT for acute limb ischaemia in our vascular surgery department, between 1 January 2011 to 31 August 2017 were identified and reviewed. Outcome measures included primary patency at 30 days and one year, haemorrhagic complications, major amputation and mortality. Results: In total, 128 limbs from 106 patients were included. The median follow-up was 14 months [range: 6–31 months]. The aetiologies of ischaemia included in the study were native artery thrombosis, PTFE and GSV bypass thrombosis, intra-stent thrombosis, popliteal aneurysm and entrapment thrombosis and arterial embolism. The Stages of ALI according to the Rutherford classification were 12,5% in class I, 77,3% in class IIa and 10,2% in class IIb. Primary patency rates were 71.3% and 47.8% at one and three years, respectively. The requirement for re-intervention was 27.6% in the native artery thrombosis group, 65.2% in the PTFE graft thrombosis group, and 18.2% in the intra-stent thrombosis group. No re-interventions were verified for popliteal aneurysm or arterial embolism aetiologies. The overall amputation free survival was 83.3% at 27 months, and the cumulative incidence of death was 10.1% at 32 months. Complications occurred in 40 interventions (31.3%); the majority comprised minor bleeding from the access site, and one death due to haemorrhagic stroke. Conclusions: CDT although associated with an increased risk of bleeding complications, it is a feasible and safe therapy, with clinical outcomes that may reduce the need for open surgical treatment in many patients. Our findings support this therapeutic approach as a valid option in ALI, in different aetiologies.

Introduction: Representing 0.03% of all tumors, paragangliomas (PGLs) are extremely rare. During the past 15 years, there has been a significant progress in the knowledge of the genetics of PGLs. Germline mutations in succinate dehy- drogenase (SDH) genes are the commonest genetic cause of PGL. Objective: Given the high clinical relevance of the SDH status, we aimed to evaluate the diagnostic and prognostic value of SDH mutations in a Portuguese cohort with carotid body paragangliomas.We Report the experience of several departments of Angiology and Vascular Surgery in the management of carotid body tumors. Methods: Forty-six individuals were included in the present study, of which forty-two were index cases and four were familial cases. Clinical features and biochemical data were retrieved by a retrospective analysis of clinical files. DNA was isolated from peripheral blood samples obtained from all individuals following their written informed consent. For all the subjects recruited, the genetic analysis involved the mutation search on the entire coding region of the SDHD gene and was extended to the SDHB gene coding region, in a subgroup of patients with a more aggressive presentation. Results: Since 2016, genetic screening was offered to 46 patients with Carotid body PGL. The patients came from Angiology and Vascular Surgery Departments from all over the country.The genetic analysis identified seven different heterozygous mutations in the SDHD gene (p.Met1Val, p.Met1Ile, p.Gly12Ser, p.Pro53Leu, IVS3+4G>A, IVS3-2A>C, p.Leu139Phefs)In addition, one mutation in SDHB gene (p.Ser198Alafs) was present in one index case. The SDHD mutations were identified in eight of the 41 index patients (20%), and in three of the four familial cases studied (75%). Of these, one mutation, p.Met1Ile, was present in two apparently unrelated patients. The prevalence of the Familial type has varied between reported studies from as low as 5% to as high as 30%, in our study they represent 26% (12 cases) of the sample. This wide-ranging variability stems from the existence of hidden familial cases. Conclusion: Genetic screening allows the identification of familial cases and improves clinical decision-making and adequate management of patients and their relatives. The Present data contributes to a broader characterization of the molecular profile of European patients with PGL.

Axillary artery injury after a shoulder dislocation is an extremely rare condition. Open surgery is the classical treat- ment of such lesions, consisting of direct suture at the site of the rupture or arterial reconstruction with a patch or a bypass. We report the case of a 74-years-old man who suffered a vascular and neurological injury after a recurrent glenohumeral joint dislocation and was treated with a covered stent.

INTRODUCTION: Inferior vena cava agenesis is one of the most uncommon anomalies of this vessel, with an estimated prevalence of 0.0005–1% in the general population. However, around 5% of the patients younger than 30 years with a diagnosis of deep vein thrombosis have this anomaly. METHODS AND MATERIAL: Report of two clinical cases of inferior vena cava agenesis with different clinical presentations. CLINICAL CASE 1: A 40-year-old man was admitted with a 3 days history of unilateral lower limb swelling and pain, gradually progressing to the inability to walk. On physical examination he had swelling, bruising and tenderness involving leg and thigh and prominent engorged superficial abdominal collateral veins.Venous Doppler Ultrasound showed left deep venous thrombosis extending from popliteal vein to common iliac vein. A computed tomography angiogram showed agenesis of the infrarenal vena cava and patent renal veins draining in to the azygous system and hemiazygous systems. The patient as discharged with rivaroxaban and compression stockings. At 2 months follow up he was asymptomatic and still anticoagulated. CLINICAL CASE 2: A 35 year- old woman, with a previous history of recurrent lower limb varicose veins surgery and left internal malleolar ulcer at 30 years presented at medical department 3 years later with complains of ulcer recurrence. A computed tomography angiogram revealed an absent infrahepatic vena cava, prominently dilated azygos and hemiazygos veins with enlarged retroperitoneal collaterals. The patient initiated dressing care with oxide zinc and oral rivaroxaban. DISCUSSION/CONCLUSION: The majority of cases remain asymptomatic. However, when symptomatic, the majority present as proximal DVT involving the iliac and femoral veins. CT or MRI should be the imagiological methods used to diagnose this anomaly. No clear consensus has been reached on therapeutic strategy, other than long-term antico- agulation and elastic stockings.

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INTRODUCTION: Surgical site infections are associated with devastating consequences in vascular surgery patients but the data on Methicillin Resistant Staphylococcus aureus (MRSA) infection among those remains scant and conflicting. Most vascular surgery antibiotic prophylaxis assume that all patients submitted to surgery are tested prior to the intervention or that all patients with risk factors for MRSA are presumed to be colonized. However, the costs associated with testing all patients are not negligible, and most of the vascular surgery patients have risk factors for MRSA colonization. The purpose of this study was to evaluate the burden of MRSA clinical infection and its outcome and to adjust clinical practice accordingly. METHODS: A retrospective analysis of clinical data from all patients with MRSA isolations that were submitted to vascular surgery in the year 2019 was conducted. The primary endpoint was in-hospital mortality. Secondary endpoints were timing of infection (pre-existent infection or post-surgical infection), need for ICU and length of hospital stay. RESULTS: Out of 1681 patients admitted for surgery in the year 2019 in the vascular surgery ward, only 21 had clinical infection with positive MRSA isolates. All the patients had risk factors for MRSA colonization. Seventeen were admitted for PAD (Rutherford grade 5 or 6). Eight patients had post-operatory infections, whilst the remaining presented with MRSA infection prior to the intervention. Post-operatory infections ranged from superficial incisional in three patients, deep incisional in one patient, and organ/space/prosthesis infection in four patients (of the last group, two had prosthesis infection). There were five deaths, of which two were unrelated to the infection. Of the three deaths probably infection-related, all were post-operatory surgical site infections, and all were organ/space/prosthesis infections (one with prosthesis infection). There was no patient admitted to the ICU that survived. The mean hospital stay was increased by 26 days (31 days, 95% CI, 19-43). CONCLUSION: Infection by MRSA was less frequent than expected in our population, which may mean that colonization might be smaller than expected. Pre-operative infection was almost always related to chronic wounds and did not increase the risk of post-operative wound infection or death, contrary to post-operative infection, which seems to significantly increase mortality.

INTRODUÇÃO: Nas últimas duas décadas, a abordagem de tratamento de aneurisma da aorta abdominal (AAA) mudou drasticamente de cirurgia aberta para cirurgia endovascular. A diminuição de cirurgia de AAA convencional , open aneurysm repair (OAR), levanta preocupações relativamente à competência dos futuros cirurgiões vasculares para executar este procedimento complexo e de alto risco. O principal objetivo deste estudo foi avaliar as tendências de tratamento de AAA entre internos de Cirurgia Vascular, ao longo de 15 anos, a nível nacional. MÉTODOS: Identificação dos médicos que terminaram o internato de Angiologia e Cirurgia Vascular entre 2002 e 2017, inclusive, a nível nacional e colheita dos dados através da consulta dos currículos para a prova final de conclusão do internato complementar. Foram avaliados o total de cirurgias por AAA, tanto por OAR e por EVAR e contabilizadas aquelas realizadas como 1o cirurgião. A correlação entre o número de cirurgias abertas de AAA e o ano de conclusão do internato complementar foi testada usando o coeficiente de correlação de Spearman. RESULTADOS: Em Portugal, de 2002-2017, apesar de não se verificar variabilidade no número total de OAR realizados, verificou-se um decréscimo marcado naqueles realizados como 1o cirurgião (rho=-0,363; P<0.02). No final do internato em 2007, um interno de Cirurgia Vascular realizava em média 15 casos de OAR e em 2007 a média foi de apenas 7 casos. Por outro lado, constatou-se um aumento marcado no número total de procedimentos de EVAR (rho=0,478; P<0.02) bem como aqueles realizados como 1ocirurgião (rho=0,540; P<0.01). CONCLUSÃO: O presente estudo revela que os internos de Cirurgia Vascular, a nível nacional, se encontram expostos a progressivamente menos casos de OAR e verifica-se uma diminuição significativa nos procedimentos de OAR como 1o cirurgião.  

INTRODUCTION: Phlegmasia cerulea (PC) is a severe form of deep vein thrombosis. In the setting of massive venous thrombosis and severe ischemia, catheter-directed thrombolysis (CDT) or trombectomy is mandatory. We report three cases of women with PC managed with venous thrombectomy after failure of CDT. CASE REPORTS: 1: 20 years-old, with recent intake of oral contraceptive, referred with acute onset of limb swelling, pain and a cold left lower extremity associated with foot pallor, paresthesia and numbness. Doppler ultrasound revealed occlusive thrombosis of the entire deep venous system and the great saphenous vein (GSV). Anticoagulation (AC) and CDT were started. However due to increasing levels of transaminases, creatine kinase and myoglobin, CTD was stopped and venous thrombectomy was proposed. A retrievable inferior vena cava filter (IVC) was implanted and venous surgical trombectomy. The completion venography showed a Cockett compression that was treated with stenting of the left iliac vein. Thrombophilia tests were positive for anticardiolipin antibodies an hyperhomocysteinemia. At 3-years follow-up, the patient is asymptomatic and under AC. The 3-year Doppler showed normal patency for the iliac stent and a mild femoropopliteal vein insuffiency. 2: 19 year-old, taking oral  contraceptives, with acute onset of PCD with acute thrombus in the left iliac, femoral, popliteal veins. CDT was started at admittance but stopped after two days because of very low values of serum fibrinogen and persistence of occlusive thrombus in the iliac vein. A retrievable IVC filter was placed and the thrombus removed with surgical thrombectomy. Phlebography showed no significant residual thrombus and no signs of compression were present. At 1 month follow-up, the patient presented without leg edema or venous claudication symptoms. Thrombophilia testing is awaited. 3: 54 year-old who presented with low back pain, worsening left leg pain and swelling with a cyanosed and colder foot. At doppler ultrasound there were monophasic arterial flow in the left leg. After exclusion of arterial embolism, the first therapeutic approach was CDT, but it was also stopped due to very low fibrinogen levels and an ineffective thrombus lysis in venography controls. After implantation of a retrievable IVC, surgical thrombectomy via femoral vein was performed, with successful thrombus removal. Venography showed Cockett syndrome and a stent was implanted. At 6 months the patient remained without major symptoms, and Doppler confirmed stent patency with non residual obstruction or venous insufficiency. CONCLUSION: Awareness and timely diagnosis of phlegmasia cerulea is necessary to ensure prompt intervention to prevent loss of limb. When CDT is not effective, surgical thrombectomy remains successfully alternative. Iliac venous stenting complement is also crucial to treat associated Cockett syndrome. Endovascular thrombectomy devices may be a reasonable alternative to surgical thrombectomy.

Introdução: Apesar dos esforços das equipas de saúde, a taxa da amputação em doentes com Isquémia Crítica Ameaçadora de Membro (CLTI) é bastante elevada. Cada vez mais se torna relevante um tratamento individualizado do doente por forma a melhorar a sua qualidade de vida. Contudo, não existe uma escala de qualidade de vida validada para doentes amputados por isquémia crítica. Os autores propõem uma revisão sistemática da literatura com vista a sumarizar as escalas de avaliação de qualidade de vida após amputação. Métodos: Foi feita uma pesquisa por todos os estudos relacionados com avaliação funcional e da qualidade de vida após amputação na base de dados Pubmed. Resultados: Dos 228 artigos foram incluídos 28. Dos artigos analisados apenas 3 avaliaram exclusivamente doentes vasculares com CLTI. 24 escalas diferentes foram usadas 44 vezes: 11 escalas (44%) de avaliação de saúde e 14 escalas (56%) de qualidade de vida, das quais 2 escalas (18%) de avaliação de saúde e 4 das escalas (29%) de qualidade de vida são específicas para doentes amputados e uma escala para doença arterial periférica. Conclusões: A heterogeneidade de escalas torna difícil uma comparação de resultados. Na população de doentes amputados vasculares, escalas gerais podem não ser representar corretamente os domínios mais valorizados por esta população. Escalas específicas para protetisados ou de avaliação da progressão de doença arterial periférica também parecem não ser as mais adequadas para este subtipo de doentes mais idosos e com limitações prévias. São essenciais novos estudos para validar uma escala específica para esta população.

INTRODUCTION: People infected with the human immunodeficiency virus (HIV) - People living with HIV/AIDS (PLWHA) - seem to have an increased risk of incidence and prevalence of cardiovascular diseases, namely stroke of ischemic nature. Additional etiological mechanisms, in addition to aging, appear to lie in chronic virus-mediated inflammation as well as in antiretroviral therapy (ART). The aim of this study was to carry out a retrospective review with descriptive analysis of cases of PLWHA and with a diagnosis of carotid atherosclerotic disease in a tertiary referral center as well as a non-systematic review of the literature. METHODS: All patients diagnosed with HIV infection and concomitantly diagnosed with carotid atherosclerotic disease, in a tertiary center, between October 2007 and December 2019, were selected. A descriptive analysis of the sample and additionally a non-systematic review of the literature using the MEDLINE database, were performed. RESULTS: Nine patients who met the inclusion criteria were selected, 7 (78%) being male. The mean age at diagnosis of carotid disease was 59 years. The diagnosis of HIV infection preceded, on average, 12 years before the diagnosis of carotid disease, while the start of ART preceded this diagnosis by about 11 years. The most common cardiovascular risk factors are dyslipidemia (89%), high blood pressure (56%) and smoking (56%). Approximately 33% had peripheral arterial disease and 22% had coronary artery disease. Only two (22%) patients underwent carotid endarterectomy over a median follow-up of 5 years, both for asymptomatic stenosis. Since the diagnosis of carotid disease, there have been no major cardiovascular events (stroke or acute myocardial infarction). During follow-up there were two deaths. CONCLUSION: PLWHA have a high prevalence of multisite artery disease, manifesting it at a relatively earlier age compared to the general population. These patients benefit from multidisciplinary follow-up for therapeutic optimization in order to obtain better results. However, larger prospective studies are needed to clarify the results in these patients and to improve the therapeutic approach, particularly in those with concomitant carotid disease.

INTRODUCTION: Inferior vena cava (IVC) agenesis is a rare pathology, associated with an increased risk of iliofemoral deep venous thrombosis (DVT), a frequent cause of disabling post-thrombotic syndrome (PTS). CASE REPORT: Authors present a case of bilateral iliofemoral thrombosis in a patient with IVC agenesis, successfully treated at a European reference center. Patient was submitted to an endovascular Y reconstruction of the IVC and iliac veins.

INTRODUCTION: Contralateral carotid occlusion (CCO) is considered a high-risk condition for patients undergoing carotid artery endarterectomy (CEA). Patients with a CCO may be intolerant to carotid cross-clamping during CEA, thus prone to postoperative adverse neurological outcomes. Patients with CCO may also have a higher burden of atherosclerotic disease, leading to a higher rate of cardiovascular events. METHODS: A Medline search was performed in order to identify publications focused on the impact of CCO on outcomes after CEA. RESULTS: Patients with CCO present a higher incidence of intolerance to carotid cross-clamping. The rates of shunt use are higher in patients with CCO. In the postoperative period, patients with CCO show a higher rate of stroke. Evidence regarding the effect of CCO on long-term outcomes remains controversial, with most studies reporting a lack of association between CCO and adverse long-term outcomes after CEA. CONCLUSION: Patients with CCO have an increased risk of postoperative adverse outcomes. The best strategy for this group of patients should be based on a case-by-case approach.

INTRODUCTION: Chronic intestinal ischemia accounts for approximately 1:1,000,000 admissions in some epidemiological studies. This condition usually affects individuals with known atherosclerotic lesion in other territories. Although typically found in female patients in their seventh decade of life with established arterial disease, chronic intestinal ischemia may manifest itself in younger patients. In the latter case, unusual causes, such as vasculitis, must be included in the differential diagnosis. CASE REPORT: We report the case of a 31-year-old man with a known history of intermittent left and right upper limb claudication and smoking. He complained of postprandial epigastric pain in the previous year, with unvoluntary weight loss (6kg in the previous 6 months) and fear of eating. An angio CT scan was performed, which showed occlusion of the celiac trunk and superior mesenteric artery at its origin. The diagnosis of chronic intestinal ischemia was formulated, and the patient was submitted to an antegrade bypass from the supraceliac aorta to the superior mesenteric artery and common hepatic artery, with a bifurcated Dacron graft. DISCUSSION: Given the inflammatory nature of the collected fragment of aorta, the onset of intestinal ischemia at a young age and the remaining peripheral arterial manifestations, a presumptive diagnosis of Takayasu’s arteritis was formulated. This vasculitis is typically found in patients in their third decade and is associated with diffuse arterial thickening. Mesenteric manifestations in this condition can occur up to 30%.

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