Artigos científicos

BACKGROUND: The main objective of this study was to assess the correlation between three semiquantitative and one computerized method based on Agatston Score (AS), when measuring abdominal aortic calcification (AAC) in abdominal aortic aneurysm (AAA) patients. Secondary aim was to access differences in AAC upon clinical variables, when different methods of calcium scoring are used.

METHODS: This was an observational, retrospective, cross-sectional study. A database of AAA patients consecutively submitted to elective repair between 2008 and 2015 was used. Patients were excluded if they did not have preoperative imaging or presented scans incompatible with at least one of the whole set of calcification methods tested. Calcification measures were performed using AS, aortic calcification index (ACI), AAC-8 and AAC-24 methods. The Pearson’s correlation was used for primary analysis.

RESULTS: Study population comprised 102 patients, 95% males, with a median age of 71 (interquartile range, IQR 66-76) years. AAAs presented median aortic diameter of 60 (54- 70) mm. Pearson’s correlation with AS was 0.816 for ACI, 0.703 for AAC-8 and 0.648 for AAC-24. ACI also presented the highest ICC for intraobserver agreement (0.972) and for interobserver agreement (0.966). ACI was associated more often to demographic and clinical variables in the dataset that associated with the computerized method.

CONCLUSIONS: ACI is suggested as a fast and easy-to-use method of assessing AAC in AAA patients. Its use should be encouraged to study AAC in AAA over other semiquantitative methods, in research settings.

Author information:

(1)Department of Angiology and Vascular Surgery, São João Hospital Centre, Porto, Portugal – marina_f_neto@hotmail.com.

(2)Cardiovascular Research Centre, Faculty of Medicine, University of Porto, Porto, Portugal – marina_f_neto@hotmail.com.

(3)Cardiovascular Research Centre, Faculty of Medicine, University of Porto, Porto, Portugal.

(4)Faculty of Medicine, University of Porto, Porto, Portugal.

(5)Department of Pediatric Surgery, São João Hospital Centre, Porto, Portugal.

(6)Department of Angiology and Vascular Surgery, São João Hospital Centre, Porto, Portugal.

(7)Centre for Research in Health Technologies and Information Systems and Department of Community Medicine, Information and Health Decision, Faculty of Medicine, University of Porto, Porto, Portugal.

J Cardiovasc Surg (Torino). 2018 Feb 8. doi: 10.23736/S0021-9509.18.10132-7. [Epub ahead of print]

Introduction: In this paper it is presented a clinical report on intra-arterial thrombolysis of an acute thrombosed popliteal artery aneurysm. We report the technical aspects and discuss indications, principal advantages and contraindications of this form of treatment.

Author information:

(1)Serviços de Angiologia e Cirurgia Vascular do Hospital de São João, Porto e do Centro Hospitalar do Tâmega e Vale de Sousa, Penafiel, Portugal.

Rev Port Cir Cardiotorac Vasc. 2011 Apr-Jun;18(2):111-3.

Indexed for MEDLINE

Introduction: Success after endovascular abdominal aortic aneurysm repair (EVAR) is dependent on device positional stability. The quest for such stability has motivated different endograft designs, and the risk factors entailed remain the subject of debate. This study aims at defining the incidence, risk factors, and clinical implications of device migration after EVAR with the AneuRx endograft. In this study we included all consecutive 109 patients submitted to primary AneuRx placement for infrarenal aortic or aortoiliac aneurysms. Preoperative computed tomography (CT) scans were reviewed for the following anatomic characteristics: neck length, diameter, angulation, calcification, and thrombus load; and sac diameter and thrombus load. Percentage of device oversizing relative to the proximal neck diameter was determined. All postoperative CT scans were reviewed, and the distance between the lowest renal artery and the craniad end of the device was measured. A >/=5-mm increase in such distance was considered indicative of device migration. Migration cumulative incidence was estimated by the Kaplan-Meier method, and its association with any of the preoperative anatomical characteristics was tested using Cox proportional hazards models. Median follow-up time was 9 (range, 1-31) months. Migration occurred in nine patients, corresponding to a 15.6% estimated probability of migration at 30 months (SE = 5.1%). Migration was associated with the risk of proximal type I endoleak (hazard ratio = 3.39, 95% confidence interval = 1.46-7.87; p = 0.007). This type of endoleak occurred in three of the migration-affected patients (33.3%); all of them were resolved by additional cuff placement at the proximal landing zone. No other migration-related reinterventions were performed. The only significant associations between anatomic factors and device migration probability were the protective effects of longer necks (odds ratio [OR] = 0.71 for each additional 5 mm, p = 0.045) and longer overlapped portions of neck and device (OR = 0.56 for each additional 5 mm, p = 0.003). There was a trend toward higher probability of migration among reverse-tapered necks (OR = 1.75, p = 0.109). Percentage of device oversizing correlated with early neck dilation (between preoperative and first postoperative diameters, correlation coefficient = 0.4, p < 0.0001), but not with late neck dilatation (between first postoperative and 1.5-year scan diameters, correlation coefficient = 0.29, p = 0.112). There was a trend toward higher mean percentage of late dilation among migrators (11.4%, standard error of the mean [SEM] 2.6) than nonmigrators (5.7%, SEM = 1) (p = 0.08), but both groups had similar mean percentages of early dilation (3%, SEM = 1.6%, vs. 5.5%, SEM = 0.6%; p = 0.365). This result indicates that device migration is not a rare event after AneuRx implantation. This phenomenon is associated with proximal type I endoleaks. Deployment of the endograft immediately below the renal arteries might help to prevent migration, since use of greater lengths of overlapped device relative to the proximal neck has a protective effect. Migration seems to be independent of the degree of device oversizing.

Author information:

(1)Division of Vascular Surgery, Mayo Clinic, Rochester, MN, USA.

Ann Vasc Surg. 2005 Mar;19(2):178-85.

Indexed for MEDLINE

Introduction: Type II endoleaks are associated with the absence of aneurysm shrinkage after endovascular abdominal aortic aneurysm repair (EVAR). This study aims at determining the predictability of this complication, whose potential risk factors have been the subject of conflicting reports. Preoperative computed tomography (CT) scans of 178 patients who underwent EVAR for true infrarenal abdominal aortic aneurysms between January 20, and April 17, 2003, with a minimum follow-up of 30 days, were reviewed. The following information was retrieved: maximum aneurysm diameter, aneurysm thrombus load (maximum thickness, percentage of sac circumference wall coverage, percentage of maximum sac area occupancy); number, diameter, and nature (lumbar, inferior mesenteric, accessory renal, middle sacral) of patent aortic side-branch arteries; thrombus thickness at each aortic branch ostium, and aneurysm diameter at that level. Postoperative CT and duplex scans supplemented with angiography in selected cases were reviewed for the presence of a type II endoleak observable beyond the 30th postoperative day. Logistic regression was used to assess the association of each variable with this outcome. There were 38 (21.3%) patients with type II endoleaks after the 30th postoperative day. The median follow-up was 12 months (range 1-65 months). By univariate analysis, the following variables significantly decreased the risk of a type II endoleak: thrombus maximum thickness [odds ratio (OR) 0.77 for a 5 mm increase, p = 0.009], mean thrombus thickness at aortic side-branches ostia (OR 0.65 for a 1 mm increase, p = 0.0006), thrombus-occupied percentage of maximum aneurysm area (OR 0.72 for a 10% increase, p < 0.0001), percentage of thrombus-lined aneurysm wall (OR 0.53 for a 25% increase, p < 0.0001). The presence of a patent inferior mesenteric artery (OR 6.84, p < 0.01) and the number of patent aortic side-branches (OR 1.37 for each additional vessel, p =0.002) significantly increased the risk of detecting a late type II endoleak. Aneurysm and aortic side-branch diameters did not have any impact. In a multiple logistic regression model (whole model p < 0.0001), the thrombus-occupied percentage of maximum aneurysm area (OR 0.74 for a 10% increase, p < 0.0005) and the number of patent aortic side-branches (OR 1.31 for each additional vessel, p= 0.009) remained independent predictors of type II endoleaks. The simple measure of the proportion of maximum aneurysm area occupied by thrombus may be a useful way to identify patients at high risk of a persistent type II endoleak. Patients with low preoperative sac thrombus load should be followed with a high degree of suspicion for this complication.

Author information:

(1)Division of Vascular Surgery, Mayo Clinic, Rochester, MN, USA.

Ann Vasc Surg. 2005 May;19(3):302-9.

Indexed for MEDLINE

Introduction: Long-term durability after endovascular abdominal aortic aneurysm repair (EVAR) is dependent upon the maintenance of an effective seal between the endograft and the proximal landing zone. Continuous neck dilation might lead to the loss of such a seal. This study aims at evaluating the incidence, risk factors, and clinical consequences of post-EVAR aneurysm neck dilation in patients treated with two types of endografts: AneuRx and Ancure. We reviewed data concerning all consecutive patients submitted to primary EVAR using the AneuRx and Ancure devices. Preoperative neck anatomic characteristics (diameter, calcification, and thrombus load) were evaluated, and device oversize percentage was calculated. Postoperative same-level neck diameter was measured on all postoperative computed tomographic (CT) scans. Probabilities of neck dilation (> or = 10% and > or =15%) relative to preoperative diameter and first postoperative diameter were estimated with the Kaplan-Meier method and compared between patients using both types of endograft. The impact of anatomic characteristics on neck dilation incidence was evaluated using Cox proportional hazards models. Mean neck dilation was compared between patients with and without device migration and proximal type I endoleak. Both groups had similar probabilities of dilating > 10% relative to preoperative diameter and to first postoperative diameter. Proximal necks in AneuRx-treated patients had higher probabilities of dilating > or = 15% relative to preoperative diameter than Ancure-treated patients (45.5% vs. 18.7% at 1.5 years, p = 0.025), but the probability of such dilation relative to the first postoperative diameter was not different between the two groups (12.4% vs. 9.1% at 1.5 years, p = 0.832). None of the preoperative neck characteristics was associated with neck dilation risk. Device oversize percentage was correlated with the percentage of neck dilation at first postoperative CT scan relative to preoperative diameter in both the AneuRx (correlation coefficient = 0.469,    p <0.0001) and the Ancure (correlation coefficient = 0.464, p < 0.011) groups, but it was not correlated with the percentage of neck dilation at 1 or 1.5 years relative to first postoperative CT scan in either group. Patients with and without caudad device migration (> or = 5 mm) had similar percentages of neck dilation at 1.5 years relative to preoperative diameter, but migrators had higher mean percentages of dilation at 1.5 years relative to first postoperative neck diameter (11.4% vs. 5.6, p = 0.012). Two phenomena may be differentiated: an immediate postimplant dilation, strongly correlated with the percentage of oversize and more likely to reach values > or = 15% with an AneuRx device than with an Ancure graft, and a subsequent dilation, relative to the first postoperatively measured diameter, equally probable with either type of device, not correlated with the percentage of oversizing but associated with caudad device migration. Our study does not support any adverse role for the degree of oversize.

Author information:

(1)Division of Vascular Surgery, Mayo Clinic, Rochester, MN, USA.

Ann Vasc Surg. 2006 May;20(3):338-45. Epub 2006 May 19.

Indexed for MEDLINE

Introduction: As endografting technology advances, anatomical constraints limiting access and deployment have become less of a burden. While unsuitable candidates for endografting exist, these patients are becoming less frequent. To broaden the applicability of endovascular abdominal aortic aneurysm repair (EVAR), we have modified the bifurcated AneuRx device into a unilimb modular prosthesis, by placing an aortic extender cuff across the flow divider, thus excluding its contralateral limb. This technique was used with success in 3 groups of patients: with occlusion of 1 iliac artery, with a nontraversable iliac stenosis, or with a small calcific aortic bifurcation. In these patients, anatomy can make it difficult, if not impossible, to place a bifurcated stent graft. Whether as a planned preoperative procedure or as a ;;bail-out” maneuver, this procedure has been successful in avoiding open surgical conversion.

Author information:

(1)Division of Vascular Surgery, Mayo Clinic, Rochester, MN, USA.

Vasc Endovascular Surg. 2006 Mar-Apr;40(2):103-7.

Indexed for MEDLINE

OBJECTIVE/BACKGROUND: Several abdominal aortic aneurysm (AAA) screening programs have demonstrated a similar prevalence of this disease in Westerns countries, ranging from 1.2% to 2.8%. However, the annual rate of AAA repair is significantly less even, and its relationship to AAA prevalence is not clear. The objective was to perform a systematic review, describing an international overview in the yearly rate of AAA repairs.

METHODS: The number of elective and emergency AAA repairs was obtained via thorough review of publications indexed in PubMed and Scopus from 2010 to October 2018. Portuguese data were obtained from the national administrative database of health care. Data from the UK were extracted from the National Vascular Registry’s 2015 annual report. Each country’s population was assessed from published national censuses, thus allowing estimation of the number of AAAs treated per 100,000 habitants.

RESULTS: Data from 14 countries were obtained. The yearly number of elective operations per 100,000 habitants was 2.2 in Hungary, 3.8 in Portugal, 5.3 in Spain, 5.9 in Iceland, 6.5 in Finland, 7.0 in New Zealand, 7.8 in the UK, 10.0 in Denmark, 10.2 in Sweden, 13.3 in the USA, 14.8 in Norway, 15.3 in the Netherlands, 15.6 in Italy, and 17.3 in Germany. The yearly rate of ruptured repairs was 0.5 in Hungary, 1.5 in Portugal, 1.8 in Spain, 1.7 in Iceland, 1.7 in Finland, 1.3 in New Zealand, 1.8 in the UK, 3.3 in Denmark (2013), 2.7 in Sweden  (2013), 1.7 in the USA, 2.1 in Norway, 3.1 in the Netherlands, 2.3 in Italy, and  2.7 in Germany.

CONCLUSION: The rate of AAA treatment is highly variable, with a nearly eightfold variance between the countries with the highest and lowest rates of elective repair. Correlation between elective and ruptured repairs was not clear. A deeper understanding of the reasons for the disparities in AAA treatment among Western countries is of the utmost importance.

Author information:

(1)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário de São João, Porto, Portugal. Electronic address: cferreira.ricardo@gmail.com.

(2)Aortic and Vascular Centre, Clinic Hirslanden, Zürich, Switzerland.

(3)Kaiser Foundation Hospital, Honolulu, HI, USA.

(4)Centro de Investigação e Tecnologia de Informação em Sistemas de Saúde (CINTESIS) e Departamento de Ciências da Informação e da Decisão em Saúde, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.

(5)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

(6)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário de São João, Porto, Portugal; Centro de Investigação e Tecnologia de Informação em Sistemas de Saúde (CINTESIS) e Departamento de Ciências da Informação e da Decisão em Saúde, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.

Eur J Vasc Endovasc Surg. 2019 Aug;58(2):200-205. doi:10.1016/j.ejvs.2019.03.007. Epub 2019 Jun 11.

Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

OBJECTIVE: Presentation of a clinical case of an aorto-esophageal fistula secondary to thoracic aorta pseudoaneurysm, complicated by early type Ia endoleak after endovascular repair.

CLINICAL CASE: A 64 years old male patient, with a history of arterial hypertension, smoking, alcohol abuse and ischemic heart disease with previous coronary revascularization was observed because of chest pain and abundant hematemesis, with Angio-CT revealing a 77mm pseudoaneurysm of the descending thoracic aorta, close to the left subclavian artery, with mass effect on the esophagus and trachea and signs of fistulization. He was proposed to endovascular repair with sealing in zone 2 of the aortic arch after building a left carotid-subclavian bypass. In the first 24 hours there were two episodes of massive hematemesis, with new Angio-CT revealing a early distal migration of the prosthesis, conditioning a type Ia endoleak. A carotid-carotid right-left bypass with left carotid ligation was performed and a new endoprosthesis was implanted in the origin of the brachycephalic trunk (zone 1). The final angiography showed aneurysm exclusion with permeability of the supra-aortic trunks. Later contrasted esophageal examination and endoscopy revealed an ulcer of the posterior left lateral wall with clot suggestive of fistula, and an esophageal prosthesis was successfully implanted. It held seven days of antibiotic therapy with ceftriaxone and metronidazole with no evidence of mediastinal infection and with aneurysm exclusion in the CT follow-up.

CONCLUSION: The recognized biomechanical and anatomical complexity of the aneurysmatic thoracic aorta represents a considerable challenge to the endovascular treatment of aorto-esophageal fistulas, especially in aneurysmatic sealing of the aortic arch, with significant rates of type Ia and III endoleaks.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Centro Hospital de São João, Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2015 Jan-Mar;22(1):47-51.

Introduction: Substantial differences across genders have been documented for the natural history and clinical course of cardiovascular diseases. This study’s objective is to compare preoperative characteristics, intraoperative events, and postoperative outcomes in men and women undergoing endovascular abdominal aortic aneurysm repair (EVAR). We hypothesized that despite gender anatomic specificities, EVAR may achieve similar results across genders. We included 241 consecutive patients  who underwent elective EVAR at our institution from December 1996 through May 2003. Demographic variables and comorbidities were collected by chart review, and intraoperative events were from surgical notes. Baseline anatomic characteristics were evaluated on the last preoperative computed tomography (CT) scan. Radiologic outcomes were evaluated on all postoperative CT scans, and clinical follow-up information was abstracted from charts. Women constituted 12% (n = 29) of our cohort and were older than men (79.9 vs. 74.9 years, p = 0.0003). When compared to men, they had aneurysms with similar diameter (54.1 vs. 55.5 mm, p = 0.491) but narrower (23.1 vs 25.5 mm, p < 0.0001) and shorter (18.9 vs. 30.4 mm, p <0.0001) proximal necks. Female iliac arteries were narrower (9.6 vs. 11.4 mm, p <0.0001), with higher calcification scores (2.5 vs. 2.3, p = 0.047) but lower tortuosity indexes (1.2 vs. 1.3, p = 0.0001). Additional access maneuvers were more frequent in women: iliac access angioplasty (31% vs. 10.9%, = p = 0.007), uni-iliac conversion (13.8% vs. 1.4%, p = 0.005), and iliac “chimney” conduit (12.1% vs. 1.2%, p = 0.0001). There was a trend toward longer fluoroscopy time in women (34.6 vs. 26.9 min, p = 0.056). The following postoperative outcomes at 24 months were similar in women and men: freedom from endoleak (63.4% vs. 72.7%, p = 0.74), reintervention rate (28% vs. 24.5%, p = 0.878), aneurysm shrinkage (24.3% vs. 68.7%, p = 0.199), aneurysm expansion (0% vs. 3%, p = 0.213), and survival (92.9% vs. 84.3%, p = 0.341). There was a trend toward higher rates of neck dilation relative to preoperative diameter in women (48.5% vs. 16% at 12 months, p = 0.059) and toward lower limb patency rates in men (100% vs. 92.8%, p = 0.098). In sum, women have shorter proximal necks and smaller and more calcified iliac arteries, which increases the necessity of access-related additional maneuvers. Despite being older and having a less favorable anatomy, women can expect similar technical and clinical outcomes after EVAR.

Author information:

(1)Division of Vascular Surgery, Mayo Clinic, Rochester, MN, USA.

Ann Vasc Surg. 2004 Nov;18(6):653-60.

Indexed for MEDLINE

OBJECTIVE: To evaluate the effectiveness and clinical outcomes of endovascular aneurysm repair in a single regional centre Methods: The medical records one hundred consecutive patients who underwent elective endovascular repair of nonruptured infra-renal abdominal aortic aneurysm were retrospectively reviewed. The assessed outcomes were all-cause mortality, aneurysm-related mortality, incidence of perioperative complications and reinterventions. Patient demographics and procedure characteristics were also analysed.

RESULTS: The patient’s mean age was 74.4 years-old. There was a male preponderance, with only 5 women treated. Two-thirds were American Society of Anesthesiologists (ASA) class ≥3. Loco-regional blockade was the anaesthetic technique most commonly used (65%). There were no perioperative deaths. Medical complications occurred in 10.3% of cases, pulmonary and cardiac being the most frequent. The 30-day reintervention rate was 6.1% (SE: 2.4%). The overall median hospital length of stay was 5 days. At 8 years, all cause mortality was 28.5%(SE: 8.5%) and aneurysm-related death was 1.3% (SE: 1.3%). During the follow-up period, 87.9% (SE: 3.7%) of patients remained free from reintervention

CONCLUSIONS: In our institution, EVAR is associated with no early mortality and significantly good perioperative outcomes such as low rate of systemic complications, minimal blood loss, low rate of postoperative mechanical ventilation use and short hospital stay. Although the high reintervention rate for EVAR has been confirmed in several studies, our study did not find such a high need for secondary procedures. We found a durable benefit since aneurysm-related mortality is very low and late overall survival is similar to other reports. In this study’s setting, our findings support endovascular management of large AAAs.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Hospital de São João e Centro de Bioestatística e Informática Médica, Faculdade de Medicina da Universidade do Porto; Centro de Investigação em Tecnologias e Sistemas de Informação em Saúde (CINTESIS).

Rev Port Cir Cardiotorac Vasc. 2010 Jul-Sep;17(3):157-61.

Indexed for MEDLINE

Introduction: A 22-years old male patient, with a history of renovascular hypertension, was evaluated in the emergency department for abdominal pain of acute onset, interpreted as acute appendicitis. During surgery, we identified an extensive haemoperitoneum which required conversion to laparotomy without identifying focal hemorrhage. A peri-operative angiography disclosed a parietal irregularity of the upper rectal artery, without active bleeding. The patient remained stable until the 15th postoperative day, when there was clinical deterioration and hemoglobin decrease. Angio-CT revealed the presence of an upper rectal artery pseudoaneurysm with an extensive retroperitoneal and organized hematoma. The patient was proposed for surgical correction which was not carried out due to extensive inflammatory and fibrotic changes, being referred for endovascular exclusion, performed by selective catheterization and coil embolization. The procedure went without complications. Catheterization was performed upstream and downstream of the pseudoaneurysm, with microcatheter, and embolization performed with coils. Control angiography showed no filling of the aneurysm. The patient remained asymptomatic after the procedure, with clinical and analytical stability. Inferior mesenteric artery primary pseudoaneurysms are rare but potentially fatal, with formal indication for treatment, given the risks of free rupture. The use of endovascular techniques allows a minimally invasive approach, with exclusion of the PA, with high rates of primary success. Doubts remain regarding the functionality of the involved organ and long-term recurrence rates; therefore high importance is given to proper follow-up of these patients.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Centro Hospital de São João, Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2012 Oct-Dec;19(4):221-4.

Indexed for MEDLINE

OBJECTIVE: Presentation of a case of endovascular repair of aorto-bronchial fistula secondary to thoracic aortic aneurysm.

MATERIAL AND METHODS: 67 years old male patient, former smoker, with a history of arterial hypertension, dyslipidemia, coronary artery disease, chronic renal insufficiency and carotid endarterectomy, followed in outpatient department with recent diagnosis of descending TAA. The patient presented to the emergency department due to 2 episodes of cough and self-limited abundant hemoptysis. The thoracic angio-CT revealed a rupture of the aneurysm, with 77mm, to the lung parenchyma with aorto-bronchial fistula to the left main bronchus. Patient was submitted to endovascular repair using a Valiant Thoracic endoprosthesis by Medtronic®, via right femoral approach.

RESULTS: The procedure went without complications. There was no paraplegia or acute arterial lesion. Postoperatively, there were registed two episodes of self-limited hemoptysis and developed cough that progressively reversed after 2 months. The patient held antibiotic prophylaxis during hospitalization and for 2 months after discharge. 12 months after procedure, no complications were observed and patient remains asymptomatic.

CONCLUSION: The advance of endovascular approach in the treatment of complicated AAT brought a new therapeutic solution, giving a reduction in morbidity and mortality (± 3%), particularly for control of active aorto-bronchial fistula. As regards to success rate and long-term antibiotic prophylaxis, present studies are inconclusive. Concerned to infection risk and fistula recurrence (± 10%), long-term antibiotic administration was the chosen treatment.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Centro Hospital de São João, Porto. Portugal.

Rev Port Cir Cardiotorac Vasc. 2011 Jul-Sep;18(3):173-6.

Indexed for MEDLINE

INTRODUCTION: Hepatic artery aneurysms (HAAs) are rare, representing about 0.1-2% of all arterial aneurysms. They are the second most common splanchnic aneurysms, after splenic artery aneurysms. They have the highest rate of rupture among all splanchnic artery aneurysms and frequently become symptomatic.

METHODS: To present a case of a hepatic artery aneurysm treated by endovascular technique.

RESULTS: A 65-year old man who had a medical history of hypertension, dyslipidemia and smoking, with an incidental finding on a CT imaging of a hepatic artery aneurysm (maximum diameter 75mm) was admitted for selective arteriography and treatment. He was asymptomatic. We proceeded to aneurysm exclusion with a self-expandable covered stent (Viabahn®) 6x100mm. Final angiography revealed permeability of right hepatic artery, splenic artery and gastroduodenal artery, and no visible endoleaks. He was discharged on the 4th postoperative day, asymptomatic and without analytic changes. On a 6 months follow-up, CT-angio confirmed a fully patent stent with no visible endoleaks and complete aneurysm exclusion.

CONCLUSION: HAAs should be diagnosed before rupture. Abdominal pain, bleeding or compression may be the first symptoms. Exclusion by endovascular techniques, namely through covered- stent use, may be a good option.

Author information:

(1)Centro Hospitalar São João, Portugal.

(2)Centro Hospitalar São João; Faculdade de Medicina da Uiniversidade do Porto, MEDCIDES, Portugal.

Rev Port Cir Cardiotorac Vasc. 2017 Jul-Dec;24(3-4):171.

Indexed for MEDLINE

Author information:

(1)Serviço de Cirurgia Vascular do H. S. João, Porto.

Rev Port Cir Cardiotorac Vasc. 2009 Oct-Dec;16(4):237-8.

Indexed for MEDLINE

BACKGROUND: The incidence of abdominal aortic aneurysm (AAA) repairs in Portugal is one of the lowest mentioned in the literature. This phenomenon can be justified either by a low prevalence of the disease or by its low detection rate. To date, the prevalence of the pathology is unknown. The objective of the study was to estimate the prevalence of AAA and its associated risk factors, in men aged ≥65 years and to evaluate the population’s disease awareness.

METHODS: All males aged ≥65 years registered in a Portuguese primary health care unit were invited to participate. The abdominal aorta was measured by ultrasound (inner to inner method). Concomitant risk factors and patient’s AAA awareness were also assessed. An aortic diameter >30 mm was considered aneurysmatic.

RESULTS: Nine hundred thirty-three patients were invited for the screening. Of these, 715 participated in the study (participation rate of 76.6%). The AAA prevalence in this sample was 2.1%. Eighty-five percent of the evaluated patients had never heard of the disease before. The mean age of the assessed population was 72.3 years; Multiple logistic regression analysis showed a positive association between AAA and history of smoking (odds ratio [OR] 8.8, P = 0.037) and history of dyslipidemia (OR 9.6, P = 0.035). A negative association was found between diabetes and AAA (OR 0.33, P = 0.045).

CONCLUSIONS: The found prevalence shows that a significant number of potentially fatal AAAs remains to be diagnosed in Portugal. These results highlight the need for an effective program of AAA detection in Portugal. The lack of awareness in the Portuguese population for this pathology should also prompt reflexion.

Author information:

(1)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, Porto, Portugal. Electronic address: cferreira.ricardo@gmail.com.

(2)Unidade de Saúde Familiar de Valongo, ACES Maia-Valongo, Porto, Portugal.

(3)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, Porto, Portugal.

(4)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, Porto, Portugal.

(5)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, Porto, Portugal; Centro de Investigação e Tecnologia de Informação em Sistemas de Saúde (CINTESIS) e Departamento de Ciências da Informação e da Decisão em Saúde, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.

(6)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

Ann Vasc Surg. 2019 Aug;59:48-53. doi: 10.1016/j.avsg.2018.12.091. Epub 2019 Feb 22.

Copyright © 2019 Elsevier Inc. All rights reserved.

OBJECTIVE: Endoleaks are critical complications of endovascular abdominal aortic aneurysm repair (EVAR). This study sought to determine the frequency and nature of intraoperative endoleaks and their impact on postoperative endoleak-related events.

METHODS: A retrospective chart review was performed of all patients who underwent EVAR at our institution. The impact of intraoperative endoleaks on postoperative endoleak rates and endoleak-related reintervention rates were assessed.

RESULTS: From December 18, 1996, to May 21, 2003, 241 patients underwent EVAR. An endoleak was observed during 126 (52.3%) procedures. Type I endoleaks were observed in 63 (26.1%) cases: 35 proximal and 31 distal endoleaks (3 cases at both attachments). Angioplasty, additional cuff placement, or stenting corrected 59 (89.4%) of these endoleaks. A total of 71 type II intraoperative endoleaks (29.5%) and 8 type IV endoleaks (3.3%) were observed without any attempted corrective maneuvers. Ten type III endoleaks (4.2%) occurred but all resolved with angioplasty or additional cuff placement. In all, 86 (35.7%) endoleaks persisted on completion angiogram. Patients with a type I or type II intraoperative endoleak were more likely to have an endoleak at 1.5 years (31.4% vs. 21.6%, P=.018). Reinterventions were required more often after an intraoperative type I endoleak (10% vs. 4%, P=.003). Patients with intraoperative endoleaks demonstrated a trend toward less postoperative aneurysm diameter reduction at 2 years (43.8% vs. 74.5%, P=.104).

CONCLUSION: The presence of a type I or a type II endoleak during EVAR significantly increases the likelihood of a postoperative endoleak and should prompt a high degree of suspicion during follow-up.

Author information:

(1)Eastern Virginia Medical School, and Division of Vascular Surgery, Sentara Heart Hospital, Norfolk, Virginia, USA.

Vasc Endovascular Surg. 2009 Aug-Sep;43(4):352-9. doi: 10.1177/1538574409333581. Epub 2009 Apr 7.

Indexed for MEDLINE

OBJECTIVE: Results on the management of infrarenal abdominal aortic aneurysm (AAA) from Mediterranean countries are scarce. The aim of this study was to evaluate trends in rate of and mortality after repair of intact AAA (iAAA) in Portugal.

METHODS: iAAA repairs registered in the hospitals administrative database of the National Health Service from 2000 to 2015 were retrospectively analyzed regarding demographics (age and gender) and type of repair (open surgery [OS] or endovascular repair [EVAR]). Rate and mortality were compared among three time periods: 2000-2004, 2005-2009 and 2010-2015.

RESULTS: Age-standardized rate of iAAA repair increased consistently across the time periods under analysis from 3.6±0.6/100,000/year in 2000-2004, to 5.6±0.4/100,000/year in 2005-2009 and to 7.1±0.9/100,000/year in 2010-2015 (p<0.001). The percentage of EVAR among all iAAA repairs rose steeply from 0 to 21±19% and then to 58±7% (p<0.001). The rate of OS also increased from the first  to the second period, but there was a decrease in the third period (p<0.001). The in-hospital mortality after iAAA repair decreased from 7.5±1.3% to 6.6±1.6% and then to 5.1±1.9% (p<0.001). This variation corresponded to a decrease in-hospital mortality after EVAR (from 4.0±3.5% to 2.8±0.9%, p<0.001) and increased in-hospital mortality after OS (7.5±1.3% to 7.4±1.1% to 8.3±3.7%, p<0.001). Low-volume centers (<15 repairs/year) did not present higher mortality rates. The number of EVARs per year in a centre presented a positive association with EVAR mortality (Spearman correlation of 0.696, p=0.004).

CONCLUSION: The rate of repair of iAAA continues to grow, especially in patients ≥ 75 years old, and did not reach an inflection point yet. This is happening along with decreased repair mortality mainly due to the increased use of EVAR. Hospital mortality for iAAA repair is still a matter of concern, warranting further investigation and planning of vascular surgical services.

Author information:

(1)Department of Angiology and Vascular Surgery, São João Hospital University Center, Porto, Portugal; Department of Surgery and Physiology, Cardiovascular Research Unit, Faculty of Medicine, University of Porto, Portugal. Electronic address: marina_f_neto@hotmail.com.

(2)Department of surgical sciences, Section of vascular surgery, Uppsala University.

(3)Department of Surgery and Physiology, Cardiovascular Research Unit, Faculty of Medicine, University of Porto, Portugal.

(4)Center for Health Technology and Services Research (CINTESIS) and Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Portugal.

(5)Department of Angiology and Vascular Surgery, São João Hospital University Center, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS) and Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Portugal.

Ann Vasc Surg. 2020 Jan 6. pii: S0890-5096(19)31056-8. doi: 10.1016/j.avsg.2019.12.013. [Epub ahead of print]

Copyright © 2019. Published by Elsevier Inc.

Introduction: The parallel grafting technique (PGT) is a valuable alternative to prefabricated branched or fenestrated endovascular aortic repair. An often overlooked advantage of PGT is its unique adaptability to different anatomical challenges that might appear intra-operatively.

Report: A 72 year old male patient presented with a 60 mm thoracic aneurysm, 59 mm juxtarenal abdominal aortic aneurysm, and 32 mm common iliac aneurysm (CIAA). Thoracic endovascular aortic repair plus endovascular aortic repair with bilateral renal artery chimneys and CIAA exclusion applying the sandwich technique was proposed. Because of unfavourable angulation it was not possible to achieve selective left renal catheterisation via axillary access. Changing to a femoral approach allowed successful retrograde catheterisation. The procedure ended with a chimney for the right renal artery and a periscope for the left renal artery. The final angiogram showed no endoleaks and renal and hypogastric patency. The patient was discharged three days after the procedure and remains under ultrasound surveillance after 40 months because of a small type two endoleak.

CONCLUSION: When using a prefabricated branched device, the possibility of selectively catheterising a visceral branch often has no straightforward solution. However, parallel grafting is an extremely flexible technique, which was of paramount importance for the surgical outcome of the present case.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Porto, Portugal.

(2)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal.

(3)Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina da Universidade do Porto, Portugal.

(4)Instituto de Cirurgia Vascular e Endovascular de São Paulo, Brazil.

EJVES Short Rep. 2019 Apr 8;43:37-40. doi: 10.1016/j.ejvssr.2019.03.002. eCollection 2019.

Introduction: Abdominal aortic aneurysm (AAA) remains a relevant cause of mortality in Western countries. There is a need for continuous identification of risk factors for aneurysmal progression and predictors of treatment response to optimize the therapeutic strategy to be offered to these patients. Vascular calcification has been studied in several capillary beds as a cardiovascular risk factor. However, the importance of abdominal aortic calcification (AC) in AAA remains incompletely clarified, and the available evidence is scattered and heterogeneous. The objective of this review is to describe the possible impact of AC on aneurysmal progression and rupture, as well as on the response to endovascular correction. It should be noted that the establishment of a validated, quick and easy to use method for assessing AC would be of great clinical and/or research utility.

Publisher: O aneurisma da aorta abdominal (AAA) permanece uma causa relevante de mortalidade nos países ocidentais. É premente a contínua identificação de fatores de risco de progressão aneurismática bem como de preditores de resposta ao tratamento na otimização da estratégia terapêutica a oferecer a estes doentes. A calcificação vascular tem sido estudada em diversos leitos capilares como um fator de prognóstico cardiovascular. Contudo, a importância da calcificação da aorta abdominal (CA) no AAA permanece incompletamente esclarecida, sendo a prova científica disponível dispersa e heterogénea. O objetivo desta revisão é descrever o eventual impacto da CA na progressão e rutura aneurismática, bem como na resposta à correção endovascular do AAA. Salienta-se que o estabelecimento de um método validado, rápido e fácil de usar para avaliar a CA seria de grande utilidade clínica e/ou investigacional.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Porto, Portugal; Departamento de Cirurgia e Fisiologia e Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal, Portugal.

(2)Departamento de Cirurgia e Fisiologia e Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal.

(3)Faculdade de Medicina da Universidade do Porto, Portugal.

(4)2Departamento de Cirurgia e Fisiologia e Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal; Serviço de Cirurgia Cardiotorácica, Centro Hospitalar de São João, Porto, Portugal.

(5)Departamento de Cirurgia e Fisiologia e Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal; 5 Serviço de Cirurgia Pediátrica, Centro Hospitalar de São João, Porto, Portugal.

(6)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Porto, Portugal; 5Serviço de Cirurgia Pediátrica, Centro Hospitalar de São João, Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2018 Jan-Jun;25(1-2):55-60.

Article in Portuguese; Abstract available in Portuguese from the publisher

Introduction: Hepatic artery aneurysms are a rare condition that can be fatal if rupture happens. Often, they are incidentally identified in routine imaging. Intervention is indicated when symptomatic, if they reach 2cm or more of size, in patients presenting with multiple hepatic artery aneurysms and in all pseudoaneurysms. We describe the case of a 57 year-old female, to whom a post-traumatic hepatic artery aneurysm was diagnosed. Open surgical repair was successfully accomplished.

Author information:

(1)Hospital Privado da Boa Nova, Departamento de Ciências da Informação e da Decisão em Saúde (CIDES) e Center for Health Technology and Services Research (CINTESIS) da Faculdade de Medicina da Universidade do Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2014 Oct-Dec;21(4):237-239.

INTRODUCTION: Type B aortic dissection (TBAD) affects mostly men with an estimated annual incidence between 2.9 and 4.0 per 100,000, and it appears to be  increasing. DISSECT classification was published in 2013 aiming to reunite clinical and anatomical characteristics of interest to clinicians involved in TBAD management. In Portugal, the incidence of the condition, as well as its characteristics and outcomes, are not well documented. The aim of this paper is to describe the reality of a tertiary institution with a referral area of about 0,6 million habitants.

METHODS: It is a retrospective study that included all patients with TBAD admitted from March of 2006 to 2016. The patients were categorized according to their demographic and clinical characteristics. For each patient, the computerized tomography scan that enable the TBAD diagnosis was classified using DISSECT classification. Overall mortality rates and aorta-related mortality rates were estimated using Kaplan-Meier method. Cox regression was used to study determinants of mortality.

RESULTS: We included 35 patients, estimating a TBAD incidence of approximately 0.6 per 100,000 person-year. The majority were men (83%) with a mean age of 60±12 years-old; 71% were hypertensive, 56% were ex-smokers or active smokers and 13% had diabetes. As to DISSECT classification, 76% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum trans-aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental extent), 26% presented with Complications, being rupture and branch vessel malperfusion the most frequent, and 28% had partial Thrombosis of false lumen (versus 66% with permeability of false lumen). Eight patients underwent surgery (24%), 6 of them in acute phase and 2 of them in subacute phase. At 12 months, overall survival of whole series was 73,1%±8,3% and survival free from aortic-related mortality was 83±6,7% (Figure 1 A and B). The presence of complications was identified as an independent risk factor of overall mortality but not to aortic-related mortality.

CONCLUSION: The incidence of TBAD verified was lower than what has been described in literature. DISSECT classification can be easily applied to TBAD cases. The presence of complications predicts higher mortality. Further studies are needed to characterize TBAD in Portugal.

Author information:

(1)Departamento de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Portugal.

(2)Faculdade de Medicina do Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2017 Jul-Dec;24(3-4):168-169.

Indexed for MEDLINE

Introduction: Proximal type I endoleaks after endovascular abdominal aortic aneurysm repair (EVAR) are associated with a high risk of rupture. Risk factors for developing this complication are not fully elucidated. We aimed to define preoperative predictors for proximal type I endoleak and describe its clinical outcome. From a consecutive series of 257 patients who underwent EVAR, we selected 202 who had available pre- and postoperative CT scan studies. Proximal neck diameter, length, angulation, calcification, thrombus load (thickness, percentage of neck circumference coverage, percentage of neck area occupancy), and maximum aneurysm diameter were evaluated on preoperative CT scans. All postoperative CT and duplex ultrasound scans, supplemented with angiograms in selected cases, were reviewed for the presence or absence of endoleak. Device overlap and oversizing (relative to the proximal neck) were also determined. Type I proximal endoleak rates were estimated using the Kaplan-Meier method. The associations between the variables listed above and proximal type I endoleak were evaluated by use of Cox proportional hazards models. Proximal type I endoleak occurred in eight patients, corresponding to a 3-year incidence rate of 4% (SE = 1.5%). The median follow-up was 340 days (range, 22-1954). Univariate analyses found significant associations between proximal type I endoleak and the following variables: percentage of calcified neck circumference (hazards ratio = 2.19 for a 25% increase, p = 0.019), aneurysm maximum diameter (hazards ratio = 1.98 for a 1-cm increase, p = 0.006) and proximal neck and device overlap (hazards ratio = 0.53 for a 5-mm increase, p = 0.007). The mean overlap among cases with and without type I proximal endoleak was 15.6 mm and 29.3 mm, respectively. When these variables were included in a multivariate model, all remained statistically significant. No significant association could be documented for neck thrombus-related variables. Thirty-nine (19.3%) patients had a beta neck angle inferior to 120 degrees. There was a trend toward a higher incidence of proximal type I endoleaks in these patients (p = 0.057). Device oversize relative to proximal neck diameter did not affect the probability of this type of endoleak. One patient survived an emergency open repair of a ruptured aneurysm after significant expansion. Six patients underwent endovascular reinterventions (4 additional proximal cuff placements, 2 proximal angioplasties). The mean interval for reintervention was 389 days. Distal migration (>or=5 mm) was identified in four cases (50%). Proximal type I endoleak is a rare complication after EVAR, but it is associated with a high number of reinterventions and potentially serious consequences. Patients with short and heavily calcified aneurysmal necks and large aneurysms are at increased risk of proximal type I endoleaks.

Author information:

(1)Division of Vascular Surgery, Mayo Clinic, Rochester, MN, USA.

Ann Vasc Surg. 2004 Nov;18(6):621-8.

Indexed for MEDLINE

J Vasc Surg. 2011 Nov;54(5):1552; author reply 1552. doi: 10.1016/j.jvs.2011.04.065.

Indexed for MEDLINE

J Vasc Surg. 2012 Jul;56(1):282; author reply 282-3. doi: 10.1016/j.jvs.2012.02.056.

Indexed for MEDLINE

Introduction: A 59-year-old man was referred with complicated chronic type B aortic dissection. Despite the false lumen’s being dominant in terms of caliber and limb perfusion, visceral arteries originated in a 9-mm true lumen. A staged approach was performed: open aortobi-iliac bypass with preservation of both lumens to the infrarenal aorta, with reinforcement of the aorta and anastomosis with Dacron (wrap technique); exclusion of the dissection by endografting all of the false lumen with three successive thoracic endoprostheses; and maintenance of true lumen perfusion using two periscopes with self-expanding nitinol stents. The patient remains asymptomatic after 1 year of follow-up.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Porto, Portugal.

(2)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

(3)Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

(4)Universitätsspital Zürich, Zürich, Switzerland.

J Vasc Surg Cases Innov Tech. 2018 Aug 29;4(3):226-230. doi: 10.1016/j.jvscit.2018.03.006. eCollection 2018 Sep.

Introduction: Spinal cord ischemia remains the Achilles’ heel of thoracic and thoracoabdominal diseases management. Great improvements in morbidity and mortality have been obtained with the endovascular approach TEVAR (Thoracic Endovascular Aortic Repair) but this devastating complication continues to severely affect the quality of life, even if the primary success of the procedure – dissection/aneurysm exclusion – has been achieved. Several strategies to deal with this complication have been published in the literature over the time. Knowledge and technology have been evolving from identification of the risk factors associated with spinal cord ischemia, including lessons learned from open surgery, and from developments in the collateral network concept for spinal cord perfusion. In this comprehensive review, the authors cover several topics from the traditional measures comprising haemodynamic control, cerebrospinal drainage and neuroprotective drugs, to the staged-procedures approach, the emerging MISACE (minimally invasive selective segmental artery coil-embolization) and innovative neurologic monitoring such as NIRS (near-infrared spectroscopy) of the collateral network.

Author information:

(1)1 Department of Angiology and Vascular Surgery, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal.

(2)3 Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Alameda Professor Hernani Monteiro, Portugal.

(3)2 Department of Anaesthesiology, São João Hospital Center, Alameda Professor Hernani Monteiro, Portugal.

(4)4 Faculty of Medicine, Department of Information and Decision Sciences in Health (CIDES), Research Center in Health Technologies and Information systems (CINTESIS), University of Porto, Alameda Professor Hernani Monteiro, Portugal.

Vascular. 2017 Jun;25(3):307-315. doi: 10.1177/1708538116671235. Epub 2016 Sep 30.

Indexed for MEDLINE

OBJECTIVE: To assess endovascular treatment of thoracic aorta diseases in a national centre of angiology and vascular surgery. To quantify the national registry of TEVAR’s.

MATERIAL AND METHODS: This unicentric and retrospective study included patients submitted to TEVAR until the end of 2012. Twenty-seven patients were considered high-risk for conventional surgery: 14 degenerative thoracic aorta aneurysms or pseudoaneurysms (10 assymptomatic), 1 ruptured thoracoabdominal aneurysm, 5 aortabronchial/aortoesophageal fistulas, 3 complicated dissections, 2 penetrating atherosclerotic ulcer/intramural hematoma, 1 traumatic laceration and 1 embolization from aortic plaque. Eighteen (67%) were emergent/urgent procedures.

RESULTS: At the institutional level, immediate technical success was achieved in all cases; average follow up was 24 months (0-97). Thirty days and 24 months global mortality was, respectively, 4% (6% for emergent/urgent procedures and 0% for elective procedures) and 13%. Aortic-related mortality was similar. One case of paraplegia and 2 of case of stoke were registered. Endoleak was present in 4 patients. Survival free from aneurysmal sac expansion (aneurysm, pseudoaneurysm or dissection, n=16) was 88% at 30 days. Survival free from aortic reintervention was 93% at 30 days and 81% at 24 months. Nationally, TEVAR registries triplicated from 2007 top 2010.

CONCLUSION: These results favour the actual tendency to consider TEVAR as a first-line solution for several thoracic aortic diseases.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar de S. João, Center for Research in Health Technologies and Information Systems (CINTESIS), Departmento de Ciências de Informação e Decisão em Saúde (CIDES) da Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2014 Jan-Mar;21(1):43-54.

Indexed for MEDLINE

OBJECTIVE: To evaluate and compare the effectiveness and clinical outcomes of abdominal aortic aneurysm treatments.

METHODS: The medical records of all patients who underwent elective open or endovascular repair of nonruptured infra-renal abdominal aortic aneurysm from January 2001 to April 2009 were retrospectively reviewed. The assessed outcomes were all-cause mortality, aneurysm-related mortality, incidence of perioperative complications and reinterventions. Patient demographics and procedure characteristics were also analysed.

RESULTS: One hundred and eighty four consecutive patients were included: 107 ( 58% ) had open surgery and 77 ( 42 % ) had endovascular repair ( EVAR ). Medical complications were more frequent after open surgery ( 24 % vs 10 %; p=0.025 ). There was no perioperative mortality in the EVAR group, whereas in open surgery 9 deaths occurred ( 8.4 % in-hospital mortality; p=0.011 ). At 7 years, all cause mortality was similar in the two groups ( 27 vs 30 %; p=0.34 ). There was, however, a persistent difference in aneurysm-related mortality ( Kaplan-Meier estimates were 9.5 % in the open repair group and 1.5 % in the EVAR group; p=0.023 ). Reintervention rates for EVAR were not higher than those for open surgery ( at 5 years, 21.2% vs 21.4 %; p=0.70 ).

CONCLUSIONS: In our institution, EVAR is associated with lower early mortality and morbidity compared to open repair. Despite equivalent late overall survival, endoluminal repair offers an aneurysm-related mortality 6 times inferior to open repair. The need for reintervention was similar after EVAR or open surgery. In this study setting, our findings support endovascular management of large AAAs, even in patients fit for open repair.

Author information:

(1)Departamento de Angiologia e Cirurgia Vascular do Hospital de S. João e da Faculdade de Medicina da Universidade do Porto, Departamento de Ciencias da Informação em Saúde e Decisão da Universidade do Porto e Centro de Investigação em Tecnologias da Saúde e Sistemas de Informação ( CINTESIS ).

Rev Port Cir Cardiotorac Vasc. 2010 Oct-Dec;17(4):245-50.

Indexed for MEDLINE

INTRODUCTION: Brachial artery aneurysms are relatively uncommon and generally due to infectious, post-traumatic or iatrogenic etiology. They seem to affect 4.5% of arteriovenous fistula. The usual manifestation is an accidental finding of a pulsatile, painless, and asymptomatic mass. Complications include sac thrombosis, thromboembolic ischaemic events, and disruption with profuse bleeding.

METHODS: The aim of this study is to present a case of true brachial artery aneurysm in end-stage renal disease patient after arteriovenous fistula creation.

RESULTS: Sixty-six-year-old men with a past medical history of hypertension, dyslipidemia, smoking and poliquistic renal disease. He started a hemodialysis program in March 2006, using a brachiocephalic fistula on the left upper limb, built in February 2005. Submitted to kidney transplant in June 2010 and subsequent fistula ligation in December 2012. He goes to the emergency service in June 2016 with a pulsatile mass on the medial aspect of the left arm. Pain, redness and heat were present. Radial pulse was palpable. Inflammatory parameters were high and ultrasound revealed a fusiform aneurysm of the brachial artery with partial thrombosis and triphasic flow. An MRI was performed, documenting a brachial artery aneurysm, with 44mm greatest diameter and an extension of 17.5cm. Patient was hospitalized under antibiotic therapy and submitted to a reversed great saphenous vein interposition graft. Discharge from hospital occurred on the 7th postoperative day, with no sensitive or motor deficits and a present radial pulse.

CONCLUSION: Arterial aneurysm is a rare, but significant complication long after the creation of a hemodialysis access. High flow, immunosuppression and increased resistance following ligation of the AV fistula may accelerate this process.

Author information:

(1)Centro Hospitalar São João, Portugal.

Rev Port Cir Cardiotorac Vasc. 2017 Jul-Dec;24(3-4):182.

Indexed for MEDLINE

BACKGROUND: Type B aortic dissection (TBAD) is associated with high morbidity and mortality. The DISSECT classification aims to reunite clinical and anatomical characteristics of interest to clinicians involved in its management. This paper aims to characterize a cohort of patients admitted for type B aortic dissection in a tertiary institution.

METHODS: This is a retrospective study that included all patients admitted to the hospital due to TBAD from 2006 to 2016. The computerized tomographic angiography that enabled the TBAD diagnosis were reevaluated using DISSECT classification.

RESULTS: Thirty-two patients were included in this case series. As to DISSECT classification, 79.3% were acute (Duration), 66% had a primary Intimal tear location in aortic arch, the maximum aortic diameter was 44±13mm (Size), 60% extended from aortic arch to abdomen or iliac arteries (Segmental Extent), 28% presented with Complications, and 28% had partial Thrombosis of false lumen. Six patients underwent intervention during the follow-up period. At 12 months, overall survival was 75.4%±8.3% and survival free of aorta-related mortality was 87.0±6.1%. Survival free of aortic dilatation was 82.6±9.5%. In univariate analysis, the presence of complications and chronic kidney disease associated with increased overall and aorta-related mortality rates. Hypertension was associated with aortic dilatation.

CONCLUSION: The outcomes after TBAD in a Portuguese center are reported. All interventions in TBAD were performed due to complications. The presence of complications and chronic kidney disease was associated with overall mortality and aorta-related mortality and hypertension with aortic dilatation. DISSECT classification was possible to apply in all patients.

Author information:

(1)Faculty of Medicine, University of Porto, Portugal.

(2)Faculty of Medicine, University of Porto, Portugal; Department of Angiology and Vascular Surgery, São João Hospital, Porto, Portugal.

(3)Faculty of Medicine, University of Porto, Portugal; Department of Angiology and Vascular Surgery, São João Hospital, Porto, Portugal; Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2019 Apr-Jun;26(2):131-137.

INTRODUCTION: Digital subtraction angiography (DSA) was considered the gold standard method for peripheral artery disease (PAD) evaluation. Notwithstanding,  recent developments of computed tomography angiography (CTA) have improved the specificity and sensibility of this method. The main objective of this study is to characterize a cohort of patients with lower limb PAD and clarify if there are differences upon groups using different preoperative imaging methods (DSA or CTA).

METHODS: This retrospective study focused on patients with PAD that underwent surgical intervention (endovascular revascularization or open surgery). CTA group included all patients submitted to this method as their pre-operative exam, between March 2009 and April 2017. DSA group included patients submitted to DSA as their pre-operative exam within the same period. The groups were compared regarding intervention details, ankle-brachial index (ABI) variation, reintervention, major amputation and mortality rates, and hospital length of stay.

RESULTS: One hundred and two patients were included (33 CTA and 69 DSA). DSA group presented more below the knee lesions with TASC C or D classification (p=0.002), as well as runoff vessels scarcity (p=0.001). There were no differences in the endovascular/open surgery ratio (p=0.308), ABI alteration with intervention (p=0.860), reintervention rates (p=0.236), major amputation (p=0.999), mortality (p=0.574), or hospital length of stay (p=0.933).

CONCLUSION: CTA seems to achieve equivalent performance to DSA for morphological and therapeutic planning of PAD. Nevertheless, extrapolation to patients with TASC C or D distal lesions cannot be performed. Publisher: Introdução: A Angiografia de Subtração Digital (ASD) era considerada o gold-standard para avaliação da Doença Arterial Periférica (DAP). O desenvolvimento da angiotomografia computadorizada (ATC) melhorou a sensibilidade e especificidade deste método. O objetivo principal deste trabalho é caraterizar uma coorte de doentes com DAP dos membros inferiores e perceber se há diferenças clínicas entre os doentes avaliados pré-operatoriamente por ASD ou ATC. Métodos: Este estudo retrospetivo incidiu sobre doentes com DAP submetidos a intervenção cirúrgica (revascularização endovascular ou cirurgia aberta). No grupo ATC foram incluídos todos os doentes que realizaram ATC como exame de avaliação pré-operatória, entre março de 2009 e abril de 2017. O grupo ASD incluiu doentes submetidos a ADS como exame pré-operatório durante o mesmo período. Os grupos foram comparados quanto a detalhes da intervenção, alteração do índice tornozelo-braço (ITB) com a intervenção, taxas de reintervenção, de amputação major e de mortalidade, bem como tempo de internamento. Resultados: Foram incluídos 102 doentes (33 ATC e 69 ASD). O grupo ASD apresentou mais lesões no setor distal com classificação TASC C ou D (p=0.002) e maior escassez de vasos de runoff (p=0.001). Não se registaram diferenças no rácio intervenção endovascular/cirurgia aberta (p=0.308), na alteração do ITB com a intervenção (p=0.860), nas taxas de reintervenção (p=0.236), de amputação major (p=0.999) ou de mortalidade (p=0.574), nem no tempo de internamento (p=0.933). Conclusão: Os resultados deste trabalho sugerem que a ATC possa ter um desempenho semelhante à ASD no estudo morfológico e planeamento terapêutico da DAP. Contudo, estes resultados não podem ser extrapolados para os doentes com lesões graves do setor distal.

Author information:

(1)Medicine Faculty, University of Porto, Portugal.

(2)Medicine Faculty, University of Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital São João, Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2018 Jul-Dec;25(3-4):133-140.

Indexed for MEDLINE

OBJECTIVE: Presentation of 3 consecutive cases of coronary-subclavian steal syndrome, with special attention to clinical evolution, diagnosis, treatment strategies and outcomes.

MATERIAL AND METHODS: We present three consecutive cases of male patients, aged 60 to 69 years (average: 63 years) with hypertension, dyslipidemia, and smoking as the most prevalent cardiovascular risk factors. The 3 cases had a history of previous coronary revascularization using the left internal mammary artery to the anterior descending coronary, with an interval of 4 months to 4 years before the onset of symptoms, 2 of the cases with stable angina, 1 with V4 to V6 ST segment  depression in the exercise test and 1 with myocardial infarction with no ST segment elevation. None of the patients had left upper limb claudication. In 2 patients, no left radio-cubital pulse was detected at rest being weak in the third. All patients had atherosclerotic obliteration of the left subclavian artery, 2 with occlusion and 1 with stenosis >90%. Cardiac catheterization was the diagnostic exame in all cases. The interval between diagnosis and intervention was 6 to 13 weeks (median of 9 weeks). We chose the endovascular treatment with balloon expandable stent. The preferred access route was the left humeral artery in 2 cases and the femoral artery in the third.

RESULTS: In all patients the revascularization was achieved, without residual stenosis. Angiography after revascularization, disclosed antegrade flow in all patients through the left internal mammary artery. Recovery of the symmetry of pulses was noticed in all the patients, no signs or symptoms of myocardial ischemia were presented in two of them, with nonspecific pre-cordial symptoms remained in the third, after effort. All patients were discharged with dual antiplatelet therapy for a period not less than 3 months.

CONCLUSION: The coronary-subclavian steal syndrome is a rare cause of myocardial ischemia after coronary revascularization (0.1% to 6%), as a result of proximal arterial occlusive disease, with subsequent hemodynamic, being atherosclerosis the main etiology. Although the surgical route has been the treatment of choice in the past, endovascular revascularization emerged nowadays as the first-line treatment, with recent studies demonstrating high patency at the 2nd and 5th year after angioplasty (100% and 85% to 95%) and low morbidity and mortality. Further doubts arise about the role of double antiplatelet therapy, having been chosen, in this series, treatment of at least 3 months.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Centro Hospital de São João, Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2012 Jul-Sep;19(3):163-6.

Indexed for MEDLINE

INTRODUCTION: For several years, digital subtraction angiography (DSA) was considered the gold standard method for the evaluation of PAD patients. This is an invasive technique and allows a good evaluation of collaterals and the vessel lumen, even in cases with associated calcification. Nevertheless, recent technical development of computed tomography angiography (CTA) has improved its specificity and sensibility, besides the fact that CTA is a fast and non-invasive procedure.

OBJECTIVE: To characterize a cohort of lower limb PAD patients and clarify if there are differences among the patients preoperatively evaluated by DSA or CTA.

METHODS: This retrospective study focused on PAD patients with a Rutherford classification ≥ 3 and submitted to intervention (endovascular revascularization or open surgery). The CTA group included all patients submitted to this method as their preoperative exam, between March 2009 and April 2017. In the same period of time, patients submitted to DSA as their preoperative exam, were randomly selected. The exclusion criteria were: realization of the exam for a different diagnosis than PAD, amputation not preceded by revascularization, absence of intervention during a period of 1 year after the realization of the exam. The groups were compared upon the type of surgery (open vs endovascular), number of revascularization sectors, reintervention, amputation, mortality and length of hospital stay.

RESULTS: 34 CTA patients and 71 DSA patients were included. The groups were demographically and clinically homogeneous. In what regards to arterial lesions, the DSA group showed more often lesions of the distal sector with TASC C or D classification (25% in DSA group and 0% in CTA group; p=0,001), as well as scarcity of runoff vessels (0 or 1 in 72% of DSA patients group and 26% in CTA group; p=0.001). There were no differences about the endovascular and open surgery ratio (1.8 to CTA and 1.4 to DSA; p=0.305), reintervention rates (21% CTA and 16% DSA; p=0.517), major amputation (9% CTA and 11% DSA; p=1), minor amputation (9% CTA and 16% DSA; p=0.541), mortality (18% CTA and 23% DSA; p=0,602), or length of hospital stay (median and (interquartile range) of 14 (27) for CTA and 14 (17) for DSA; p=0.933).

CONCLUSION: CTA seems to be a method for morphological and therapeutic planning of PAD that is non-inferior to DSA.

Author information:

(1)Departamento de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Portugal.

(2)Faculdade de Medicina do Porto, Portugal. Rev Port Cir Cardiotorac Vasc. 2017 Jul-Dec;24(3-4):174.

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PURPOSE: We describe the outcomes of femoro-distal bypass procedures used to treat peripheral arterial occlusive disease (PAOD). The aim of this retrospective analysis was to evaluate primary patency and limb salvage at 5 years.

METHODS AND PATIENTS: We retrospectively studied 122 consecutive patients who underwent femoro-distal bypass surgery from 1999 to 2002. Information was collected from clinical charts at S. João Hospital, Porto, Portugal. Kaplan-Meier curves were used to calculate primary patency and limb salvage rates; groups were compared using Cox proportional hazards models.

RESULTS: Five-year cumulative primary patency was 67,1% and limb-salvage rate was 71,1%. Major amputation risk for diabetics was significantly higher – 49% – compared with 18% in non-diabetics patients (p=0,0001). There were trends associating major amputation with women and smokers; there were also trends associating hypertension and in situ saphenous vein bypass with lower risk of major amputation .

CONCLUSION: Our preliminary results support the view that infrainguinal revascularization can be safely performed, with acceptable five-year cumulative primary patency and major amputation rates. The risk of major amputation, however, is significantly increased in diabetic patients.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Hospital de S. João, Porto.

Rev Port Cir Cardiotorac Vasc. 2008 Jul-Sep;15(3):151-5.

Indexed for MEDLINE

INTRODUCTION: Infragenicular multisegmentar atherosclerotic disease is prevalent in diabetic and chronic renal failure (CRF) patients and associated with critical ischemia ulcera related. Distal angioplasty revascularization is an option allowing wound healing and improvement of life quality. Objectives Identification and impact determination of independent factors related to limb salvage and mortality in patients submitted to distal angioplasty.

METHODS: Between January 2010 and December 2012, 31 balloon angioplasties were performed in 25 patients with critical limb ischemia. Overall survival and limb salvage were determined by Kaplan- Meier analysis. Independent impact on the “primary endpoints” factors was evaluated using log rank test or Cox regression.  The rate of complications and reintervention was analyzed.

RESULTS: Mean age was 68 ± 11 years, 17 diabetic patients (68%) and 9 patients on hemodialysis (36 %). Mean follow-up was 380 days. Mean C-reactive protein was 75 mg / L. Overall survival was 97, 88 and 74 % at 3, 6 and 12 months, and remained stable at last observation. The limb salvage was 67 % at 3 months, 55 % at 6 months and 30 % at last observation. Diabetic and ASA 2 patients had a more satisfactory last observation limb salvage, respectively 61 and 75%, p value close to significance. There was statistically significant relationship between mortality and CRF (p = 0.004). One non-succeded reintervention occurred and there was one transient post contrast renal acute failure.

CONCLUSION: In this sample, although survival is high, long term limb salvage is low justified by the very sick population and anatomical issues. ASA classification and diabetes can be an additional prognostic factor of limb salvage.

Author information:

(1)Serviços de Cirurgia Vascular II e de Nefrologia do Centro Hospitalar Lisboa Norte, Portugal.

Rev Port Cir Cardiotorac Vasc. 2013 Oct-Dec;20(4):221-6.

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Introduction: Vascular lesions, although quite rare, are one of the most devastating complications in the context of a hip prosthesis. Therefore, the correct diagnosis is crucial to prevent irreversible damage to the patient. The authors present the case of a 70-year-old Caucasian woman with an ischemic lower limb as consequence of a late perforation of external iliac artery due to an acetabular screw. The issue was resolved by simply cutting part of the screw, avoiding other surgical options that would be much more aggressive for the patient. Careful clinical evaluation allowed for a correct diagnosis and a timely creative treatment, preventing further consequences to the patient.

Publisher: As lesões vasculares, embora muito raras, são uma das complicações mais devastadoras no contexto de uma prótese do quadril, pelo que o seu diagnóstico correto é fundamental para evitar danos irreversíveis ao paciente.Apresentamos o caso de uma mulher caucasiana de 70 anos de idade com um membro inferior isquêmico causado por uma perfuração tardia da artéria ilíaca externa devido a um parafuso acetabular.O problema foi resolvido simplesmente cortando parte do parafuso, evitando outras opções cirúrgicas que poderiam ser muito mais agressivas para o paciente.A avaliação clínica cuidadosa permitiu um diagnóstico correto e um tratamento criativo a tempo de prevenir outras consequências para o paciente.

Author information:

(1)Centro Hospitalar São João, Porto, Portugal.

Rev Bras Ortop. 2016 Jul 19;52(3):359-362. doi: 10.1016/j.rboe.2016.05.004. eCollection 2017 May-Jun.

OBJECTIVES: Compare the results of surgical thrombectomy (ST) and catheter directed thrombolysis (CDT) in the treatment of acute ischemia due to peripheral prosthetic bypass occlusion.

METHODS: Retrospective single center analysis of the electronic clinical data on two groups of patients with acute lower limb ischemia due to prosthetic bypass occlusion: in one ST was performed (data collected between June-2006 ahd September-2011) and the other was treated with CDT Qui2 test (categorical variables) and independent samples t test (continuous variables) were used for comparisons between groups. The Kaplan-Meier method was used to estimate rates of freedom from reintervention and limb salvage, with the Log Rank test used for comparisons.

RESULTS: Twenty-six bypass were included in the ST group and 11 bypass were included in the CDT group. There were no statistically significan differences between groups regarding gender age and type of occluded bypass. The median time for freedom from reintervention was 275 days for the CDT group and three days for the ST group (p = 0.0029 when comparing survival curves). The median time for limb salvage was 468 days for the CDT group and 17 days for the ST group (p = 0.03 when comparing survival curves).

CONCLUSION: These results support the choice for CDT as the local first line therapy for acute ischemia due to bypass occlusion, despite the limitations arising from the sample size. The results of ST need to be urgently addressed.

Rev Port Cir Cardiotorac Vasc. 2014 Apr-Jun;21(2):121-4.

Indexed for MEDLINE

INTRODUCTION: The aim of this study is to evaluate the outcome of catheter directed thrombolysis (CDT) in acute lower limb ischaemia depending on the underlying etiology.

METHODS: Retrospective single center analysis of electronic clinical data on patients with acute lower limb ischaemia treated with CDT. Between January 2011 and September 2017, 128 procedures in 106 patients were included. The etiology of ischaemia was native artery thrombosis in 39 procedures (30,5%), PTFE graft thrombosis in 56 (43,8%), intra-stent thrombosis in 11 (8,6%), emboly in 9 (7%), popliteal aneurysm thrombosis in 9 (7%), vein graft thrombosis in 2 (1,6%) and popliteal artery entrapment in 2 (1,6%).

RESULTS: Median follow-up time was 14 months [range: 6-31], during which 22% needed further intervention. The need for reintervention was 27,6% in native artery thrombosis group, 65,2% in PTFE graft thrombosis group, 18,2% in intra-stent thrombosis group. No reinterventions occurred neither in popliteal aneurysm group or emboly group. Amputation free survival was 83,3% (SE 4,6%) at 27 months and cumulative incidence of death was 10,1% (SE 5,2%) at 32 months, with no differences between the groups.

CONCLUSION: Intra-arterial thrombolytic therapy achieves good mid-term clinical outcomes, reducing obviating the need to open surgical treatment in many patients. These results support the choice for CDT as a valid option in acute limb ischaemia of several etiologies.

Author information:

(1)Centro Hospitalar São João, Portugal.

(2)Centro Hospitalar São João; Faculdade de Medicina da Universidade do Porto, MEDCIDES, Portugal.

Rev Port Cir Cardiotorac Vasc. 2017 Jul-Dec;24(3-4):108.

Indexed for MEDLINE

OBJECTIVES: Evaluation of graft thrombectomies performed at our department, during a five years’ consecutive period.

METHODS: Charts of all consecutive graft thrombosis treated with surgical thrombectomy at our department between June/2006 and September/2011 were retrospectively reviewed. Thrombectomy primary patency, limb salvage and mortality rates were estimated by the Kaplan-Meier method. Differences among subgroups were tested by the Log-Rank test for time-dependent outcomes.

RESULTS: A total of 57 cases were studied. Median follow-up time was 387 days. Survival rate was 84,2% at 358 days (SD=6,1%). Thrombectomy primary patency rates were 17,9 % at 1 year (SD=6,5%). Limb-salvage rates were 56,6% at 1 month (SD=6,9%) and 40,3% at 4,5 years (SD=7,1%). Re-intervention rates were 52,2% at 4,5 years and among those who were reoperated on, limb-salvage rates were 71,4% at 12 days (SD=9,9%). To assess the differences according to the type of graft operated on, cases were placed into two groups: one group included those thrombectomies performed by occlusion of any bypass for aorto-iliac revascularization (aortobifemoral, femoro-femoral, femoro-popliteal crossover, axilo-unifemoral and axilo-bifemoral) and the other group included all the others (for infra-inguinal revascularization). The first group exhibited lower survival rates (85,1% vs 96,3% at 11 days, SD<10%, p=0.024). On the other hand, this group presented higher patency rates comparing to infra-inguinal revascularization group (58,5% vs 81,3% %, SD<10%, p=0,006). Regarding limb-salvage and re-intervention rates, there were no significant differences between these two groups. Interval time between bypass surgery and thrombectomy for its occlusion had no impact on patency, neither the additional measures used along with thrombectomy for revascularization after occlusion.

CONCLUSION: RESULTS of surgical thrombectomies after graft thrombosis are discouraging. Other techniques such as thrombolysis must be kept in mind in order to achieve better outcomes. In some patients one must decide wether to proceed with an attempt to salvage the initial procedure or to amputation, which may speed the patient toward the best possible outcome.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Hospital de S. João e Faculdade de Medicina da Universidade do Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2013 Apr-Jun;20(2):93-6.

Indexed for MEDLINE

Author information:

(1)Serviço de Angiologia do Hospital de S. João, Porto. We report two cases of severe trauma of the upper limb requiring arterial revascularization. A brachio-brachial inverted saphenous bypass graft was done in both cases. Graft rupture attributed to local infection occurred at fourth post-operative week. Pseudomonas aeruginosa was isolated from the surgical wound in the first case and Acinetobacter baumanni in the second. The first case ended up with arm amputation mostly owing to extensive destruction of soft tissue, the patient being discharged home without any other sequel. In the second case the patient was successfully resuscitated after cardiopulmonary arrest, secondary to hemorrhagic shock. He underwent new brachio-brachial venous bypass graft avoiding the contaminated area. Irreversible ischemic signs plus growing overt infection led to arm amputation later on. This patient developed multi-organ failure and died by the fifth post-operative week. Acinetobacter baumannii and Pseudomonas aeruginosa are gram-negative bacilli widely present in hospital environment. Most of them are resistant to commonly used antibiotics. Their association with vascular conduit infections might have dreadful consequences as it happened in these cases.

Rev Port Cir Cardiotorac Vasc. 2006 Apr-Jun;13(2):93-7.

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Author information:

(1)Cardiology Department, Centro Hospitalar de São João, Porto, Portugal. sofiakorreia@gmail.com

Rev Port Cardiol. 2012 Jul-Aug;31(7-8):527-8. doi: 10.1016/j.repc.2012.02.013. Epub 2012 Jun 21.

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Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Hospital de S. João, Porto. We report a retrospective study of patients submitted to supragenicular femoro-popliteal bypass surgery in our department between 1998 and 2002. A SPSS package was used for statistical analysis. Eighty bypasses were performed in 74 patients with a median follow up of 19,6 months [1-71 (+/- 22,5 months)]. Leriche-Fontaine stage IV chronic ischemia was the main indication for surgery accounting for 68,8% of cases, followed by stage III (25%) and stage IIb (6,2%). The most prevalent vascular conduit was PTFE (87,5%), with great saphenous vein and Dacron being used on 7,5 % and 5% of cases. Ten patients (12,5 %) later required major amputation and limb salvage at 12, 24 and 36 months was 91,6 %, 87,7 % and 82,8 %. The primary patency rates were 81,7 %, 78,9 % and 71 % at the end of the first, second and third year of follow up. Patient survival was 92,8%, 92,8 % e 88,6 % at 12, 24 e 36 months of follow up. A large proportion of patients (61,7 %) required an accessory procedure. Our results might be considered acceptable in face of other published results, though care must be taken given the intrinsic limitations of this retrospective study.

Rev Port Cir Cardiotorac Vasc. 2006 Jan-Mar;13(1):37-40.

Indexed for MEDLINE

OBJECTIVES: Carotid angioplasty and stenting (CAS) has been proposed as an alternative to carotid endarterectomy (CEA) in patients excluded from the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study and in those considered at high risk for CEA. In light of recently released CAS data in patients at high risk, we reviewed our experience with CEA.

METHODS: The records for consecutive patients who underwent CEA between 1998 and 2002 were retrospectively reviewed, and risk was stratified according to inclusion and exclusion criteria from a “high-risk” or CAS-CEA trial, The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial.

RESULTS: Of 776 CEAs performed, 323 (42%) were considered high risk, on the basis of criteria including positive stress test (n = 109, 14%), age older than 80 years (n = 85, 11%), contralateral carotid occlusion (n = 66, 9%), pulmonary dysfunction (n = 56, 7%), high cervical lesion (n = 36, 5%), and repeat carotid operation (n = 27, 3%). Other high-risk criteria included recent myocardial infarction (MI), cardiac surgery, or class III or IV cardiac status; left ventricular ejection fraction less than 30%; contralateral laryngeal palsy; and previous neck irradiation (each <1.5%). Clinical presentation was similar in the high-risk and low-risk groups: asymptomatic (73% versus 73%), transient ischemic attack (23% vs 22%), and previous stroke (4% vs 5%). The overall postoperative stroke rate was 1.4% (symptomatic, 2.9%; asymptomatic, 0.9%). Comparison of high-risk and low-risk CEAs demonstrated no statistical difference in the stroke rate. Factors associated with significantly increased stroke risk included cervical radiation therapy, class III or IV angina, symptomatic presentation, and age 60 years or younger. Overall mortality was 0.3% (symptomatic, 0.5%; asymptomatic, 0.2%), not significantly different between the high-risk (0.6%) and low-risk groups (0.0%). Non-Q-wave MI was more frequent in the high-risk group (3.1 vs 0.9%; P <.05). A composite cluster of adverse clinical events (death, stroke, MI) was more frequent in the symptomatic high-risk group (9.3% vs 1.6%; P<.005), but not in the asymptomatic cohort. There was a trend for more major cranial nerve injuries in patients with local risk factors, such as high carotid  bifurcation, repeat operation, and cervical radiation therapy (4.6% vs 1.7%; P <.13). In 121 patients excluded on the basis of synchronous or immediate subsequent operations, who also would have been excluded from SAPPHIRE, the overall rates for stroke (1.65%; P =.69), death (1.65%; P =.09), and MI (0.83%; P=.71) were not significantly different from those in the study population.

CONCLUSIONS: CEA can be performed in patients at high risk, with stroke and death rates well within accepted standards. These data question the use of CAS as an alternative to CEA, even in patients at high risk.

Author information:

(1)Division of Vascular Surgery, Mayo Clinic and Mayo Medical School, Rochester, Minn, USA. Comment in J Vasc Surg. 2004 Sep;40(3):595-6; author reply 596.

J Vasc Surg. 2004 May;39(5):958-65; discussion 965-6.

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Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Hospital de S. João, Porto. The aim of this study was to report the initial experience with eversion carotid endarterectomy technique at our department. We undertook a retrospective analysis of prospectively collected data on all carotid endarterectomies performed since January 2004 to March 2006. A comparison between both groups – eversion endarterectomy (EE) and conventional endarterectomy (CE) – was done using a statistical software package. A total of 150 consecutive carotid endarterectomies were performed, 26 (17 %) of them being done using EE. Median age for all patients was 69 [52 – 89] years old with a clear male predominance (n=119; 79,3%). Cardiovascular risk factors were distributed as follows: hypertension,126 (84%); diabetes, 40 (26,7%); dyslipidaemia, 105 (70%); tobacco smoking, 44 (29,3%). There were proportionately more patients on the EE group submitted to simultaneous CABG (30,8 % vs. 8,8 %; p=0,043) and asymptomatic for previous neurological events (53,9 %vs. 27,3%; p=0,05). There was one case of cervical haematoma reported for the EE technique. Neither neurological morbidity nor deaths were reported within this group. In the CE group the mortality was 0,8 % (1 patient) and the neurological morbidity (either stroke or TIA) was 2,4 % (3 patients). The overall stroke and death rate combining both groups was 2,7 %. Outcome differences between EE and CE patients were nonsignificant, even on multivariate analysis. Eversion carotid endarterectomy is a safe procedure that might be considered as a valid option to conventional endarterectomy.

Rev Port Cir Cardiotorac Vasc. 2006 Oct-Dec;13(4):211-5.

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Author information:

(1)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Portugal.

(2)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, São João, Portugal.

(3)Departamento de Ciências da Informação e da Decisão em Saúde, Centro de Investigação e Tecnologia de Informação em Sistemas de Saúde (CINTESIS) Faculdade de Medicina, Universidade do Porto, Portugal.

Vascular. 2019 Oct;27(5):468-474. doi: 10.1177/1708538119841451. Epub 2019 Apr 2.

Indexed for MEDLINE

OBJECTIVES: Estimate the frequency and risk factors of restenosis after carotid endarterectomy, contralateral carotid disease development, neurologic symptoms (ipsi or contralateral) and new endarterectomy (ipsi or contralateral) in patients who underwent previously endarterectomy.

METHODS: Retrospective single center analysis of the electronic clinical data and of duplex ultrasound results of 293 consecutive patients who underwent carotid endarterectomy between 2002 and 2008. The study included risk factors, procedure and patient’s characteristics. All outcomes, since time-dependent, were estimated by the Kaplan-Meier method. The association between outcomes and risk factors was evaluated with the Log Rang test.

RESULTS: The proportion of patients with restenosis/occlusion during follow up was 16% (EP=0,04), at 8,5 years. The rate of patients with restenosis was much higher in patients that underwent direct closure when compared to all other (16% Vs 2% at 3,4 years; P=0,02). At 9 years, 26% (EP=0,05) of the patients without previous contralateral internal carotid artery stenosis showed progression of the disease.

CONCLUSION: Findings during duplex ultrasound follow up in patients who underwent carotid endarterectomy reach a somewhat unexpected high frequency. However, most of these changes do not mean hemodynamic or clinical significance. Direct arterial closure was associated with higher restenosis frequency. The disease progression in contralateral side occurred in a considerable proportion of cases, in particular in those patients who had already hemodynamically significant stenosis. These findings emphasize the potential benefits of duplex ultrasound follow up in patients who undergo carotid endarterectomy.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar de S. João, Departamento de Ciências de Informação e da Decisão em Saúde (CIDES) e Center for Health Technology and Services Research (CINTESIS) da Faculdade de Medicina da Universidade do Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2014 Oct-Dec;21(4):223-227.

BACKGROUND: Primary hyperhidrosis is defined as excessive sweating of idiopathic etiology, associated with sympathetic hyperactivity, which greatly impacts patients’ quality of life (QoL). The definitive treatment for palmar and axillary hyperhidrosis (PAH) is video-assisted thoracic sympathectomy (VATS). The objective of this study was to evaluate the quality of life of patients with PAH before and after VATS according to the level of sympathectomy performed, as well as the presence of compensatory hyperhidrosis (CH) and other complications.

METHODS: All patients who underwent VATS in our vascular surgery department between January 2011 and December 2016 were included in the analysis. From 120 contact attempts, 88 interviews were carried out. Patients were divided into 2 groups according to the intervened thoracic level: high thoracic ganglion (HTG; T2, T2-T3, T2-T3-T4; n = 68) and low thoracic ganglion (LTG; T3, T3-T4, T4; n = 20). The questionnaire evaluated preoperative PAH severity, the presence of CH, preoperative and postoperative QoL, and postoperative satisfaction.

RESULTS: The median age of patients was 29 years, and the median follow-up period was 32 months (IQR of 34 months). Most patients had severe or very severe PAH (97.7%) and preoperative QoL was bad or very bad (95.5%). Postoperatively, QoL was significantly improved in all domains evaluated, with no differences observed between the groups. The overall percentage of complications was 11.4%, mostly pneumothorax, but there was a significantly lower incidence of complications in the HTG group (P = 0.029). Compensatory hyperhidrosis developed in 85.2% of cases, but it was only considered intolerable in 10.2%. The incidence of CH was 82.4% in the HTG group and 95% in the LTG group, with no statistically significant differences between the groups (P = 0.147).

CONCLUSIONS: Palmar and axillary hyperhidrosis severely affects QoL, and video-assisted thoracic sympathectomy was proven to be effective regardless of the target ganglion resected. Although CH was frequent, it was tolerated in most cases.

Author information:

(1)Angiology and Vascular Surgery Unit, Centro Hospitalar São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal. Electronic address: tiagojoaosoares@hotmail.com.

(2)Angiology and Vascular Surgery Unit, Centro Hospitalar São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Alameda Prof. Hernâni Monteiro, Porto, Portugal.

Ann Vasc Surg. 2019 Oct 16. pii: S0890-5096(19)30753-8. doi: 10.1016/j.avsg.2019.07.018. [Epub ahead of print]

Copyright © 2019 Elsevier Inc. All rights reserved.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de S. João e CINTESIS e CIDES da Faculdade de Medicina da Universidade do Porto, Portugal. Pelvic congestion syndrome is a common disorder that occurs mainly in young multiparous women. It is characterized by a variable combination of chronic (up to 6 months) not cyclical pain, dyspareunia, dysmenorrhea, urinary symptoms and constipation, that may be associated to perineal and lower limbs varicose veins, with pelvic origin. We report the clinical case of a 26 year-old female, G0P0, with lower limbs varicose veins. During the investigation of chronic pelvic pain associated to pelvic heaviness and dyspareunia, a MR was performed and pelvic varicose veins were diagnosed. Findings were confirmed by venography. Imaging findings and symptoms severity mandated treatment and we proceeded to left ovaric vein embolization. Therapeutic success was then reached and patient remains asymptomatic 10 months after treatment.

Rev Port Cir Cardiotorac Vasc. 2015 Jan-Mar;22(1):53-56.

OBJECTIVE: Presentation of Onyx outcomes in the embolization of extracranial vascular malformations, regarding the clinical efficacy and safety.

MATERIAL AND METHODS: A 29 years old female patient, with a vascular malformation of the right upper thigh complicated with skin ulcer, healed in 2011, referred for light pain and tension at the site of the lesion. Physical examination revealed a scar of a previous ulcer, extensive venous collateral network and tenuous expandability of the malformation. Angiography revealed a high flow vascular malformation, with arterial and venous component, through branches of the internal iliac, common and profunda femoral arteries, involving the right thigh, from the root to the middle third, on the lateral side. Patient was proposed for arterial catheterization and endovascular embolization, which consisted in five embolization sessions with an interval of 3 weeks, through contralateral femoral catheterization, firstly with coils; in the remaining, it was decided to embolize with Onyx, through distal catheterization of the sinus with microcatheter.

RESULTS: All sessions coursed without major complications, registering pain complains on the first post-procedure day which reversed with anti-inflammatory medication. There was no skin necrosis or significant elevation of tissue necrosis markers. Distal embolization of malformation sinus with Onyx was achieved in all sessions without significant reflux or recurrence of the embolized branch, with decreased of the sinus size, no pain complaints and the lack of expandability after the 5 sessions.

CONCLUSION: Used primarily in intracranial vascular malformations, there is now a growing utilization of Onyx in the embolization of extracranial malformations, given the physical properties, with promising initial results, particularly in high-flow injuries. A recent study demonstrated a significant reduction of the malformation sinus, low rate of recanalization and re-expansion, with high clinical safety. The clinical result of this patient demonstrated the high efficacy and safety in the use of embolic agent, making its use promising in the treatment of a wide range of vascular malformations.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Centro Hospital de São João, Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2013 Oct-Dec;20(4):233-8.

Indexed for MEDLINE

AIM: Retrospective analysis of suspected deep venous thrombosis (DVT) of the lower limbs admitted to an emergency unit and subsequently scanned in the vascular lab.

METHODS: Clinical and demographic details of patients were retrieved from clinical files and collected in a database. The statistical software SPSS was used for statistical analysis.

RESULTS: Between January 2011 and September 2013, 407 venous scans were performed for ruling out DVT. Two hundred sixty-nine (66%) patients were female. Average age was 60.1 years-old (16-93). One hundred thirty-four scans (32.9%) were positive for the diagnosis of recent DVT (simultaneous DVT and superficial thrombophlebitis in six patients of this group). In 194 exams (47.6%) there was any sign of venous thrombosis, whether recent or remote. The remaining cases showed up signs of remote DVT in 22 (5.4%) patients, and superficial thrombophlebitis in 50 (12.2%) patients.

CONCLUSION: Suspected DVT was confirmed in only a third of patients, using ultrasound scan. Local implementation of guidelines for the evaluation of patients with suspected DVT may reduce the amount of unnecessary scans.

Author information:

(1)Serviços de Urgência e de Angiologia e Cirurgia Vascular do Centro Hospitalar Tâmega e Sousa e Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar S. João, Porto, Portugal.

Rev Port Cir Cardiotorac Vasc. 2014 Apr-Jun;21(3):167-170.

OBJECTIVE: To determine the incidence of deep venous thrombosis (DVT) recurrence in young people, and its association with some genetic polymorphisms (FV G1691A, FII G20210A, MTHFR C677T, PAI-1 4G/5G). DESIGN: Prospective cohort study.

METHODS: A database was established prospectively to follow-up a cohort of unselected patients who had had a first episode of objectively proven DVT under the age of 40 years. All patients had DNA analysis for heritable thrombophilia. We excluded patients with deficiency of antithrombin, protein C or protein S, malignant disease, antiphospholipid syndrome, or a requirement for long-term antithrombotic treatment. The end-point was objective evidence of symptomatic DVT recurrence.

RESULTS: Eighty-seven patients were enrolled in the study. Mean duration of follow-up was 4.07 years. At 2 years, the cumulative recurrence rate was 19.3%. The risk of risk was not related to presence or absence of laboratory evidence of genetic polymorphisms: FV G1619A (HR 1.26 [95%CI: 0.64-2.46]; p = 0.51), FII G20210A (HR 0.81 [95%CI: 0.35-1.89]; p = 0.62), MTHFR C677T (HR 1.26 [95%CI: 0.56-2.81]; p = 0.58), PAI-1 4G/5G (0.84 [95%CI: 0.35-2.05]; p = 0.71).

CONCLUSION: In this study, the risk of recurrent deep venous thrombosis in young people was not related with the presence of FV G1691A, FII G20210A, MTHFR C677T or PAI-1 4G/5G polymorphisms.

Author information:

(1)Department of Vascular Surgery, S. João University Hospital, Porto, Portugal. mansilha@netcabo.pt

Eur J Vasc Endovasc Surg. 2005 Nov;30(5):545-9. Epub 2005 Aug 1.

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Author information:

(1)Serviço de de Angiologia e Cirurgia Vascular do Hospital de São João, Porto.

Rev Port Cir Cardiotorac Vasc. 2011 Jan-Mar;18(1):61-2.

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Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Centro Hospitalar de S. João, Porto, Portugal. Paradoxical embolism may occur in patients with acute pulmonary thromboembolism, when a patent foramen ovale(PFO) coexists with a right to left shunt associated to pulmonary hypertension. We presented the case of a 83 year old woman with paradoxical embolism to both legs, in the setting of pulmonary embolism. She was successfully treated with peripheral thrombectomy and anticoagulation. Patent foramen ovale closure wasn’t performed because of its small size and right to left shunt absence after clinical stability.

Rev Port Cir Cardiotorac Vasc. 2012 Jan-Mar;19(1):45-6.

Indexed for MEDLINE

BACKGROUND: In the last decade, endovascular radiofrequency obliteration has been used as a safe and feasible method, alternative to conventional vein-stripping surgery.

METHODS: Data were collected from our center between January 2009 and June 2011. Pretreatment examination included lower limb assessment using CEAP classification and VCSS (Vein Clinical Severity Score). Ultrasound examination was performed at first follow-up visit (one week to one month after surgery) and the last-one in September 2011.

RESULTS: The study enrolled 30 patients (33 legs), their mean age was 41.4 ± 10.4 and 76,7% (n=23) were female. Mean follow-up time was 240 days. Treated veins included 32 great saphenous vein above-knee segments, and one small saphenous vein. Only 8% of patients were free of pain before treatment and at last follow-up 61% reported no pain. Edema rate also improved from 52% (before surgery) to 9% at last control. During follow-up, two treated vessels were identified as patent, albeit competent: one a small saphenous vein and the other a segment of a great saphenous vein. Two cases of paresthesias and one of hyperpigmentation were observed at stab avulsion site. The mean VCSS score was 5,6 ±3.11before surgery and 1,4±1.34 at last follow-up.

CONCLUSION: Radiofrequency segmental thermal ablation effectively reduced symptoms of venous insufficiency, with a significant reduction at VCSS score, and was a well tolerated and safe method, with few complications.

Author information:

(1)Serviço de Angiologia e Cirurgia Vascular do Hospital São João, Porto. Portugal.

Rev Port Cir Cardiotorac Vasc. 2011 Apr-Jun;18(2):123-7.

Indexed for MEDLINE

OBJECTIVE: Varicose vein (VV) surgery is frequently performed by surgeons without formal vascular training. We aimed to compare the outcomes of the procedure based on the background of the surgeon.

METHODS: All patients registered with VV surgery between 2004 and 2016 in Portuguese public hospitals were included in the study. Intrahospital outcomes were assessed from this administrative database. A random multicenter sample of 315 patients submitted to saphenous high ligation and stripping (175 patients from six vascular surgery departments and 140 patients from five general surgery divisions) were further queried over the phone, whereby additional nonregistered outcomes were evaluated: preoperative venous ultrasound, impact on quality of life by the 14-item Chronic Venous Insufficiency Quality of Life Questionnaire, visual analogue scale evaluation (score of 1 to 5) of the aesthetic results and general satisfaction, work absence days, and time to return to physical activities.

RESULTS: In 13 years, there were 153,382 patients submitted to VV surgery. Of these, 49% were operated on by general surgeons and 40% by vascular surgeons; in 11%, it was not possible to identify the specialty performing the operation. Twenty-three deaths were registered (no differences between groups). In the general surgery group, 14% of patients were hospitalized for more than one night compared with 3% in the vascular group (P < .001). Reintervention rate during the period analyzed was significantly higher in the general surgery group (13.5% vs 8.2%; P < .001). Rate of outpatient surgery was higher in the vascular surgery group (60% vs 36%;        P <.001). Phone query revealed similar overall satisfaction and improvement in quality of life in both groups (4.2 vs 4.0 [P = .275] and 35% vs 36% [P = .745], respectively). However, patients operated on by general surgeons reported worse surgical scars (2.8 vs 2.1; P = .007), higher number of residual VVs (2.4 vs 1.7;          P = .006), and higher number of days absent from work (40 vs 27 days; P = .005) and took longer to resume physical activities (60 vs 41 days; P = .001).

CONCLUSIONS: Despite that the majority of VV surgery in Portugal is executed by general surgeons, this study highlights important advantages when it is performed by surgeons with vascular training.

Author information:

(1)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, Porto, Portugal. Electronic address: cferreira.ricardo@gmail.com.

(2)Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

(3)Centro de Investigação e Tecnologia de Informação em Sistemas de Saúde (CINTESIS) e Departamento de Ciências da Informação e da Decisão em Saúde, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

(4)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Tãmega e Sousa, Penafiel, Portugal.

(5)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Lisboa Norte, Centro Hospitalar Lisboa Central, Lisboa, Portugal.

(6)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

(7)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Lisboa Central, Lisboa, Portugal.

(8)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de Vila Nova de Gaia e Espinho, Espinho, Portugal.

(9)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, Porto, Portugal.

(10)Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar São João, Porto, Portugal; Centro de Investigação e Tecnologia de Informação em Sistemas de Saúde  (CINTESIS) e Departamento de Ciências da Informação e da Decisão em Saúde, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.

J Vasc Surg Venous Lymphat Disord. 2019 Sep;7(5):732-738. doi: 10.1016/j.jvsv.2019.01.060. Epub 2019 May 5.

Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.